[
  "--- Page 1 ---\n371\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nIntrapartum Fever\nJ Karunasinghea on behalf of the Sri Lanka College of Obstetricians and Gynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2021; 43: 371-382\na Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo, Sri Lanka\nSLCOG Guideline\n1. Scope and background\nThis guideline is focused on the aetiologies, manage-\nment, and potential consequences of intrapartum fever.\nManagement of some of the specific causes of\nintrapartum fever will be briefly discussed. Note that\nthe scope of this guideline is restricted only to intra-\npartum care.\nThe guideline will not provide information about\nmanagement of septicaemia and Group B streptococcal\n(GBS) infection in pregnancy (refer relevant guidelines).\nFor detailed management of Dengue fever and\nCOVID-19, please refer to the National Guidelines.\n2. Summary of key recommendations\n2.1  Definition\nIntrapartum fever is defined as the elevation of\nmaternal oral temperature ≥39°C (≥102.2°F) on\none reading or temperature between 38°C\n(>100.4°F) to 39°C (102.2°F) on two readings 30\nminutes apart in a woman in labour1.\nHealthcare worker should measure oral temperature\nof all women in labour 4 hourly or whenever they\nshow signs and symptoms of febrile illness.\nTemperature should be recorded in the partogram\nroutinely. Whenever high temperature is detected,\nit should be recorded in a separate temperature chart.\n2.2  Aetiology\nIntraamniotic infection (IAI) and neuraxial\nanaesthesia are the most common causes for\nintrapartum fever2. Aetiology of the intrapartum\nfever is classified into two categories.\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v43i4.8032\na. Infectious causes\nb. Non-infectious causes\na. Most common infection related aetiologies are\n• Intraamniotic infection (IAI)\n• Urinary tract infection\n• Respiratory tract infection including H1N1\ninfluenza\n• Any other pre-existing infection which could\npresent as fever during labour\n• Dengue fever and COVID-19 infection\nwhich should be given special consideration\nduring pandemics\nb. Non-infectious causes\n• Use of neuraxial anaesthesia is the most\ncommon cause of non-infectious cause of\nfever at term.\n• Increased metabolism (eg: thyrotoxicosis),\npoor ventilation, delivering in an overheated\nroom and drug fever are considered as some\nother causes for intrapartum fever.\nPatients with following factors are considered high\nrisk for intrapartum fever –\n• Nulliparity\n• Labour induction\n• Prolonged labour\n• Premature labour\n• Prolonged membrane rupture\n• Multiple digital vaginal examinations\n• Exposure to intrauterine devices: – Intrau-\nterine pressure devices/ Foetal scalp\nelectrodes\nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.",
  "Most common infection related aetiologies are\n• Intraamniotic infection (IAI)\n• Urinary tract infection\n• Respiratory tract infection including H1N1\ninfluenza\n• Any other pre-existing infection which could\npresent as fever during labour\n• Dengue fever and COVID-19 infection\nwhich should be given special consideration\nduring pandemics\nb. Non-infectious causes\n• Use of neuraxial anaesthesia is the most\ncommon cause of non-infectious cause of\nfever at term.\n• Increased metabolism (eg: thyrotoxicosis),\npoor ventilation, delivering in an overheated\nroom and drug fever are considered as some\nother causes for intrapartum fever.\nPatients with following factors are considered high\nrisk for intrapartum fever –\n• Nulliparity\n• Labour induction\n• Prolonged labour\n• Premature labour\n• Prolonged membrane rupture\n• Multiple digital vaginal examinations\n• Exposure to intrauterine devices: – Intrau-\nterine pressure devices/ Foetal scalp\nelectrodes\nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\n\n--- Page 2 ---\n372\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n3.  Diagnosis and investigations\nCareful history and systemic examination are required.\nSpecial consideration should be given for abdominal\ntenderness, vaginal examination including characteristic\nof amniotic fluid and odour.\nInvestigations\nInvestigations are based on suspected aetiology.\nHowever, there are no specific investigations for\nintrapartum fever. Usually full blood count (FBC), blood\nculture, urine full report (UFR) and urine culture are\nperformed according to the suspected aetiology. High\nvaginal swab culture is usually done when there is\nevidence of premature rupture of membranes (PROM).\nIn endemic situations, rapid antigen for Dengue fever,\nH1N1 influenza and COVID-19 are vital for immediate\nmanagement.\nBiological markers – Many systemic reviews done in\nintra-partum fever concluded that, measurement of\nC-Reactive Protein (CRP) is unreliable for detecting\nintrauterine infection3.\n4.  Management\n•\nSenior obstetrician’s opinion should be obtained\nin the management of all patients with\nintrapartum fever. It may be beneficial to have\na multidisciplinary team approach involving the\nObstetrician, Microbiologist, Physician and the\nAnaesthetist.\n•\nNeonatology team should be notified and\ninvolved for every case of intrapartum fever.\nThe presence of a senior medical officer from\nthe neonatology team at the time of delivery is\nthe minimum requirement.\n•\nAntibiotics – Usually broad-spectrum antibiotics\nwith coverage of GBS (Group B streptococcus)\nis initiated in all patients except those with pre-\nexisting infection.  Different antibiotic regimens\nare used according to the hospital/unit policy\n(See Table 1).\n•\nAll patients with intrapartum fever should have\ntheir pulse rate, blood pressure and respiratory\nrate checked every 15 minutes throughout the\nlabour and the postpartum period. All healthcare\nprofessionals should have the knowledge to\nidentify the signs and symptoms of sepsis. In\ncase of suspected sepsis, a Modified Obstetric\nEarly Warning Signs (MOEWS) chart should\nbe maintained and the patient may need HDU or\nICU care during the process of labour.\n•\nCTG (cardiotocograph) – All patients with\nintrapartum fever should have a continuous\nfoetal monitoring with CTG.\n•\nGeneral measures should be taken to reduce the\nbody temperature by adequate hydration (IV/\noral fluids), removing blankets and clothing,\napplying a cool wet towel to the skin, lowering\nthe room temperature, and providing anti-\npyretics like paracetamol.\n•\nMode of delivery and timing of delivery –\nDecisions for timing and mode of delivery\nshould be made by the senior consultant\nobstetrician considering the following factors\na)\nSeverity of maternal infection\nb) Duration and stage of labour\nc) Gestational age\nd) Foetal viability\n•\nThere is no indication to deliver the foetus\nimmediately unless the cause of the fever is\nsuspected chorioamnionitis.\n5.  Management of specific infections\nManagement of Intraamniotic infection (Chorio-\namnionitis or IAI)\nIAI is defined as infection or inflammation of the\namniotic fluid, membranes, placenta and/or decidua4.\nDiagnosis is based on maternal pyrexia 38°C\n(100.4°F) orally, and at least the presence of two of\nthe following findings5.\n•\nMaternal tachycardia (>100bpm)\n•\nFoetal tachycardia (>160bpm)\n•\nUterine tenderness\n•\nFoul odour of the amniotic fluid\n•\nMaternal leukocytosis (>15,000cells/mm3)\nOnce the diagnosis of the IAI is made, commencement\nof broad-spectrum antibiotics and delivery is indicated.",
  "In\ncase of suspected sepsis, a Modified Obstetric\nEarly Warning Signs (MOEWS) chart should\nbe maintained and the patient may need HDU or\nICU care during the process of labour.\n•\nCTG (cardiotocograph) – All patients with\nintrapartum fever should have a continuous\nfoetal monitoring with CTG.\n•\nGeneral measures should be taken to reduce the\nbody temperature by adequate hydration (IV/\noral fluids), removing blankets and clothing,\napplying a cool wet towel to the skin, lowering\nthe room temperature, and providing anti-\npyretics like paracetamol.\n•\nMode of delivery and timing of delivery –\nDecisions for timing and mode of delivery\nshould be made by the senior consultant\nobstetrician considering the following factors\na)\nSeverity of maternal infection\nb) Duration and stage of labour\nc) Gestational age\nd) Foetal viability\n•\nThere is no indication to deliver the foetus\nimmediately unless the cause of the fever is\nsuspected chorioamnionitis.\n5.  Management of specific infections\nManagement of Intraamniotic infection (Chorio-\namnionitis or IAI)\nIAI is defined as infection or inflammation of the\namniotic fluid, membranes, placenta and/or decidua4.\nDiagnosis is based on maternal pyrexia 38°C\n(100.4°F) orally, and at least the presence of two of\nthe following findings5.\n•\nMaternal tachycardia (>100bpm)\n•\nFoetal tachycardia (>160bpm)\n•\nUterine tenderness\n•\nFoul odour of the amniotic fluid\n•\nMaternal leukocytosis (>15,000cells/mm3)\nOnce the diagnosis of the IAI is made, commencement\nof broad-spectrum antibiotics and delivery is indicated.\n\n--- Page 3 ---\n373\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n6. Maternal and neonatal consequences of\nintrapartum fever\n6.1  Maternal consequences\n• Dysfunctional labour\n• Greater likelihood of caesarean delivery\n• Uterine atony\n• Postpartum haemorrhage\n• Postpartum endometritis\n• Septic pelvic thrombophlebitis\n6.2  Neonatal consequences\n• Meconium Aspiration Syndrome\n• Hyaline Membrane Disease (HMD)\n• Neonatal Seizures\n• Intrapartum stillbirth\n• Early neonatal or infant death\n• Birth asphyxia\n• Neonatal encephalopathy  cerebral palsy\n• Needing assisted ventilation\n7.  Postpartum period\nAntibiotics started for confirmed or suspected\nintraamniotic infection should not be continued auto-\nmatically in the postpartum period. Continuation of the\nantibiotic treatment should be decided on case-by-case\nbasis considering the clinical state and the investi-\ngations. Continuation of the temperature monitoring\nchart and close observation of the neonate is recom-\nmended4.\n7.1   Introduction\nFever during labour (intrapartum fever) is an important\nclinically relevant obstetric event associated with a\nrange of maternal and neonatal complications. The\nprevalence of intrapartum fever has increased recently\ndue to increase use of neuraxial anaesthesia. Studies\nindicate 6.8 percent or 1 in 15 women in labour have\nfever6.\nEven though there can be both infectious and non-\ninfectious contributing causes, most pregnant women\nwith intrapartum fever are presumed to have an\nintraamniotic infection (IAI) and are managed with\nbroad spectrum antibiotics. IAI and neuraxial\nanaesthesia administration are the two most common\ncontributing causes of intrapartum fever. Many risk\nfactors such as nulliparity, prolonged labour and\npremature rupture of membranes are common to both.\nAn individualised approach involving a senior\nobstetrician is recommended for management of\nlabour. In addition, some pre-existing conditions may\nrequire involvement of a multi-disciplinary team\nmanagement.\n8. Recommendations and discussions\n8.1 Definition\nIntrapartum fever is defined as elevation of maternal\noral temperature 39°C (102.2°F) on one reading\nor temperature between 38°C (>100.4°F) to 39°C\n(102.2°F) on two readings 30 minutes apart in a\nwoman in labour.\nHealth care worker should measure oral temperature\nof all women in labour 4 hourly or whenever they show\nsigns and symptoms of febrile illness. Temperature\nshould be recorded in the partogram routinely.\nWhenever high temperature is detected, it should be\nrecorded in a different temperature chart.\nElevated body temperature will occur when the\nhypothalamic thermo regulator is reset at the higher\ntemperature by the endogenous pyrogens produced\nby specific host cells in response to infection, inflam-\nmation, injury or antigenic challenge. In some\ninstances, due to the inability to reset the thermo-\nregulatory centre, hyperthermia may occur. For\nexample, recreational drugs like ecstasy can lead to\nincrease in the core temperature by blocking the\nsweating or vasodilatation. In this chapter the term\nfever will be used to describe the rise in maternal\nintrapartum temperature by any mechanism. Obser-\nvations of normal parturient shows a diurnal\ndistribution of temperature with a peak from midnight\nto 2am and a nadir from 11am to noon7.\nThe temperature should be measured in the oral\nsublingual pocket with an electronic thermometer,\nsince this is an accurate and convenient method for\ndetecting maternal fever. Mouth breathing, hyper-\nventilation, ingestion of ice or hot beverages and\noxygen administration can affect the oral temperature.\nTemperature measurement should be undertaken at\nleast 15 minutes after consuming hot or cold\nbeverages8. Measurement of axillary temperature will\nhave an error of 1°C-2°C lower than the oral\ntemperature9.",
  "Mouth breathing, hyper-\nventilation, ingestion of ice or hot beverages and\noxygen administration can affect the oral temperature.\nTemperature measurement should be undertaken at\nleast 15 minutes after consuming hot or cold\nbeverages8. Measurement of axillary temperature will\nhave an error of 1°C-2°C lower than the oral\ntemperature9.\n\n--- Page 4 ---\n374\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nOral temperature is correlated better with intrauterine\ncore temperature according to one study. Foetal/\nintrauterine temperature is 0.2°C-0.9°C (0.4°F-\n1.6°F) higher than maternal oral temperature8,10-13.\n8.2  Aetiology and risk factors\nIAI and neuraxial anaesthesia are the most common\ncauses for intra-partum fever.\nAetiology of the intrapartum fever is classified into\ntwo categories.\na. Infectious causes\nb. Non-infectious causes\na. Most common infection related aetiologies are\n•\nIntra-amniotic infection (IAI)\n•\nUrinary tract infection\n•\nRespiratory tract infection\n•\nAny other pre-existing infection which could\nbe present as fever during labour\n•\nSpecial consideration should be given to dengue\nfever and COVID-19 infection\nb. Use of neuraxial anaesthesia is the most common\nnon-infectious cause of intrapartum fever.\nIncreased metabolism (eg: thyrotoxicosis), poor\nventilation, delivering in an overheated room and drug\nfever are also considered as some other causes for\nintrapartum fever.\nThe pathophysiology of the intra-partum fever\nassociated with neuraxial anaesthesia is not well\nunderstood. It has been attributed to –\n•\nDirect effect of local anaesthetics on endothelial\ncells, trophoblast cells or leukocytes to induce\nproinflammatory or inhibit anti-inflammatory\ncytokines release, which will act on thermo-\nregulatory centre to reset the temperature14-18.\n•\nBoth neuraxial anaesthesia and IAI share same\nrisk factors.\n•\nReduced heat loss – parturient with epidural\nanaesthesia have less pain induced hyper-\nventilation and less perspiration because of\nsympathetic block2.\nIn general, increased in temperature >38°C is usually\nobserved 4 hours following insertion of epidural\nanaesthesia19,20. Nulliparous are more likely to have\nlonger labour and likely to have intrapartum fever than\nmultiparous (risk 13-33%)21. There is no difference in\nthe maternal temperature elevation in parturient who\nreceive CSE (combined spinal and epidural anaesthesia)\ncompared to epidural alone. There is no known\neffective method to prevent neuraxial anaesthesia\nrelated temperature elevation.\nPatients with following factors are considered high\nrisk for intrapartum fever –\n•\nNulliparity\n•\nLabour induction\n•\nProlonged labour\n•\nPremature labour\n•\nProlonged membrane rupture\n•\nMultiple digital vaginal examinations\n•\nExposure to intrauterine devices: – Intrauterine\npressure devices – Foetal scalp electrodes\nHowever above-mentioned conditions are risk factors\nfor both IAI and neuraxial anaesthesia. Since there are\nno intrapartum clinical or laboratory findings that can\nreliably distinguish IAI and neuraxial anaesthesia related\nelevated maternal temperature, broad spectrum anti-\nbiotics are usually administered in this situation,\nresulting in overtreatment of mothers.\nOther sources of fever could be due to urinary tract\ninfection, respiratory tract infection, influenza, pneu-\nmonia and appendicitis that began during the\nantepartum period.\n8.3  Diagnosis and investigations\nCareful history and systemic examination are required.\nSpecial consideration should be given for abdominal\ntenderness, vaginal examination including characteristic\nof amniotic fluid and odour.\nInvestigations are based on suspected aetiology.\nHowever, there are no specific investigations for intra-\npartum fever. Usually full blood count (FBC), blood\nculture, urine full report (UFR) and urine culture are\nperformed according to the suspected aetiology. High\nvaginal swab culture is usually done when there is\nevidence of premature rupture of membranes (PROM).\nIn endemic situations, rapid antigen for Dengue fever,\nH1N1 influenza and COVID-19 are vital for immediate\nmanagement.",
  "Usually full blood count (FBC), blood\nculture, urine full report (UFR) and urine culture are\nperformed according to the suspected aetiology. High\nvaginal swab culture is usually done when there is\nevidence of premature rupture of membranes (PROM).\nIn endemic situations, rapid antigen for Dengue fever,\nH1N1 influenza and COVID-19 are vital for immediate\nmanagement.\n\n--- Page 5 ---\n375\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nBiological markers – Many systemic reviews done\nin intra-partum fever concluded that, measurement of\nC-Reactive Protein (CRP) is unreliable for detecting\nintra-uterine infection3.\n•\nWhite Blood Cell count/ Differential count\n(WBC/DC) – It is recommended to take WBC/\nDC in labouring women who are clinically ill or\nhaving a high temperature. Since elevated WBC\ncount is a normal physiological occurrence in\nlabour, the value of this is limited. The mean\nvalues of WBC count vary from 10,000 - 29,000\ncells/microlitre. Usually, the mean count\nincreases linearly throughout the labour22. With\nother evidence of infection, the presence of\nleukocytosis will support the diagnosis,\nespecially when accompanied by a left shift.\n•\nBlood culture – Even though there is no imme-\ndiate benefit of doing blood culture in intrapartum\nwomen, it will be useful for the subsequent\nmanagement as appropriate antibiotic therapy is\nimportant in patients with bacteraemia, for the\nprevention of progressing to sepsis and shock.\nIt is highly recommended to obtain the blood\ncultures from the patients with following\nfeatures23,24.\n•\nFever >39°C (102.2°F)\n•\nChills\n•\nHypothermia\n•\nLeukocytosis with left shift\n•\nNeutropenia\n•\nDevelopment of otherwise unexplained organ\ndysfunction\nUsually, blood cultures are not routinely performed in\npatients with suspected IAI as delivery and empirical\nantibiotic therapy is effective in 80-90% of these\npatients.\n•\nUrine tests – Urinary dipstick is important in a\nlabouring woman for the rapid diagnosis of a\nurinary tract infection. This is easy to perform,\nconvenient and low cost. Sample could be\nobtained from a clean catch midstream urine,\nstraight catheter, or an indwelling catheter. Urine\nculture is important when the patient is clinically\nill, but not practical as a first line diagnosis test.\n•\nRapid antigen test – In dengue fever detecting\nthe NS1 antigen is important since early\nintervention with proper fluid management is\nnecessary.\nIn suspected COVID-19 infection, rapid antigen\ntest is strongly recommended, because symp-\ntomatic or asymptomatic patients in endemic\nsituation need early isolation in the management.\nReal time PCR has a value if available, for patients\nwho are found to be having fever despite negative\nRapid antigen.\n•\nHigh vaginal swab – It is routinely taken in\nwomen with PROM. Positive culture for\npotential pathogens does not correlate well with\nthe risk, or developing chorioamnionitis; how-\never, they are useful in determining the organisms\nwhen the chorioamnionitis is diagnosed and\ndirecting the antibiotic therapy.\n8.4  Management of intra-partum fever\nSenior obstetrician’s opinion should be obtained in the\nmanagement of all patients with intrapartum fever. It\nmay be beneficial to have a multidisciplinary team\napproach involving the Obstetrician, Microbiologist,\nPhysician and the Anaesthetist.\nNeonatology team should be notified and involved for\nevery case of intrapartum fever. The presence of a\nsenior medical officer from the neonatology team at\nthe time of delivery is the minimum requirement.\nAntibiotics – Usually broad-spectrum antibiotics with\ncoverage of GBS (Group B streptococcus) is initiated\nin all patients except those with pre-existing infection.\nDifferent antibiotic regimens are used according to the\nhospital/unit policy.\nAll patients with intrapartum fever should have their\npulse rate, blood pressure and respiratory rate checked\nevery 15 mins throughout the labour and the postpartum\nperiod. All healthcare professionals should know the\nsigns and symptoms of sepsis. In case of sepsis, patient\nmay need HDU or ICU care. In case of suspected\nsepsis, a Modified Obstetric Early Warning Signs\n(MOEWS) chart should be maintained and the patient\nmay need HDU or ICU care during the process of\nlabour.\nClinical signs and symptoms of sepsis are – pyrexia,\nhypothermia, tachycardia, tachypnoea, hypoxia,\nhypotension, oliguria, impaired consciousness and",
  "In case of sepsis, patient\nmay need HDU or ICU care. In case of suspected\nsepsis, a Modified Obstetric Early Warning Signs\n(MOEWS) chart should be maintained and the patient\nmay need HDU or ICU care during the process of\nlabour.\nClinical signs and symptoms of sepsis are – pyrexia,\nhypothermia, tachycardia, tachypnoea, hypoxia,\nhypotension, oliguria, impaired consciousness and\n\n--- Page 6 ---\n376\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nfailure to respond to treatment. These signs including\npyrexia, may not always be present and are not\nnecessarily related to the severity of the sepsis25. Refer\nto quick Sequential Organ Failure Assessment (qSOFA)\nscore for early detection of suspected patients with\nsepsis Table 2.\nCTG (cardiotocograph)\nAll patients with intrapartum fever should have a\ncontinuous foetal monitoring with CTG.\nIntrauterine infection is associated with abnormal foetal\nheart trace, but there is no specific CTG pattern that\nindicate early onset neonatal sepsis.\nFoetal tachycardia may occur due to maternal pyrexia\nor intrauterine infection. If Foetal tachycardia occurred\nsecondary to maternal pyrexia, foetal tachycardia will\nsubside once the normalisation of the maternal tem-\nperature is achieved.\nChanges in baseline variability or new onset decele-\nrations must prompt measurement of maternal mean\narterial pressure (MAP), hypoxia and acidaemia.\nGeneral measures\nMeasures should be taken to reduce the body tem-\nperature by adequate hydrations (IV/oral fluids),\nremoving blankets and clothing, applying a cool wet\ntowel to the skin, lowering the room temperature and\nproviding anti-pyretics like paracetamol.\nMode of delivery and timing of delivery – Decisions\nfor timing and mode of delivery should be made by\nthe senior consultant obstetrician considering the\nfollowing factors\na) Severity of maternal infection\nb) Duration and stage of labour\nc) Gestational age\nd) Foetal viability\nThere is no indication to deliver the foetus immediately\nunless the cause of the fever is suspected chorioa-\nmnionitis.\nExpediting the delivery with maternal instability may\nincrease the risk of maternal and foetal mortality unless\nthe infection is intrauterine.\n8.5  Management of specific infections\nManagement of Intra-amniotic infection (Chorioa-\nmnionitis or IAI).\nIAI is defined as infection or inflammation of the\namniotic fluid, membranes, placenta and/or decidua.\nDiagnosis is based on maternal pyrexia 38°C\n(100.4°F) orally, and at least the presence of two of\nthe following findings\n• Maternal tachycardia (>100bpm)\n• Foetal tachycardia (>160bpm)\n• Uterine tenderness\n• Foul odour of the amniotic fluid\n• Maternal leukocytosis (>15,000cells/mm3)\nOther clinical and laboratory criteria are insensitive for\nIAI.\n“Triple I” is another terminology proposed by an\nexpert panel in 2015, replacing IAI, which indicate\nintra uterine infection, inflammation or both1, 27. The\norganisms involved in the chorioamnionitis usually\npresent in the lower genital tract.\nUsually, a presumptive diagnosis is made depending\non the above findings. However, for the definitive\ndiagnosis of IAI amniotic fluid gram stain, culture or\nplacental histology showing features of an infection is\nnecessary.\nEven though the positive amniotic fluid culture is the\ngold standard for the diagnosis, it is of limited value in\nclinical practice as the results may not be available for\nup to 3 days from sampling. Maternal C-Reactive\nprotein and Leukocytosis have low sensitivity and\nspecificity to detect the chorioamnionitis. Combination\nof maternal blood and amniotic fluid biomarkers\n(interleukin 6 >7.9ng/ml, Glucose <15mg/dl) could\nimprove the accuracy of the diagnosis. Ultrasono-\ngraphic evaluation of the foetal thymus is more\nsensitive to diagnose chorioamnionitis than the foetal\nbiophysical profile26. Foetuses complicated with\nchorioamnionitis were found to have small thymus in\nultrasound scan.\nDelivery is indicated once the diagnosis of intraamniotic\ninfection is made. It is also important to treat with\nbroad-spectrum antibiotics with the coverage of group",
  "Foetuses complicated with\nchorioamnionitis were found to have small thymus in\nultrasound scan.\nDelivery is indicated once the diagnosis of intraamniotic\ninfection is made. It is also important to treat with\nbroad-spectrum antibiotics with the coverage of group\n\n--- Page 7 ---\n377\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nB streptococcus to reduce the maternal and neonatal\nmorbidity. Patient should initially be started on intra-\nvenous antibiotics2. See the Table 1 below for regimens\nof antibiotic combinations.\nUsually, the IAI is associated with labour abnormalities,\ncaesarean section, uterine atony, PPH, endometritis and\nseptic pelvic thrombophlebitis. Chorioamnionitis is very\nimportant as it can lead serious maternal complications\nsuch as septic shock, postpartum haemorrhage, adult\nrespiratory syndrome, intensive care admissions and\nrarely maternal death. Forty – seventy percent of pre-\nterm birth and 1-13% of term births with preterm\nrupture of membranes or spontaneous labour are\ncomplicated with chorioamnionitis28. Early onset\nneonatal meningitis, neurodevelopment delay,\npneumonia, respiratory distress, sepsis and death are\nsome of the neonatal complications of IAI.\nManagement of UTI\nUrinary tract infections are common during pregnancy.\nThe presence of fever, flank tenderness, nausea,\nvomiting, costo-vertebral angle tenderness, with or\nwithout lower urinary tract symptoms like – dysuria,\nfrequency, urgency, suprapubic pain and haematuria,\nmay indicate the presence of upper or complicated\nurinary tract infection. Simple cystitis may present\nwithout fever. Empirical antibiotic treatment is indicated\nfor UTI. Commencement of the antibiotic regimen is\ncustomised according to the unit/hospital policy. This\nmay need to be changed according to the sensitivity\npattern of the urine culture and clinical response later.\nManagement of respiratory tract infection\nUpper respiratory tract infections will present with\nnasal congestion, rhinorrhoea, sore throat, malaise and\ncough. Fever, if present is usually of low grade. These\npatients do not need any specific antibiotics, except\nfor symptomatic management and simple antipyretics.\nIf the patient present with sudden onset rigors followed\nby fever, productive cough, purulent sputum and\npleuritic chest pain high possibility of pneumonia\nshould be considered. Treatment and management are\nsimilar to the non-pregnant individual, but chest\nX-Ray could be delayed until after delivery. Pregnant\nmothers can be treated safely with Azithromycin or/\nand Ceftriaxone.\nAntiviral prophylaxis should commence immediately\nif indicated for mothers suspected to have H1N1\ninfluenza.\nPatient with severe lower respiratory tract infection\nmay need to be positioned comfortably in propped-up\n(Fowler’s) position. They need close monitoring of\nvital signs, especially the respiratory rate and oxygen\nsaturation.  Patients with severe respiratory failure may\nneed transferring to intensive care unit (ICU) and early\ndelivery.\nManagement of dengue fever\nThe management of dengue fever depends on the phase\nof the fever. Patients in the critical or leaking phase,\nare considered in the high-risk category and need to\nbe managed in an ICU setting during labour. (See\nNational guidelines on dengue fever in pregnancy).\nManagement of COVID-19\nIn a pandemic situation patient may present without\nany symptoms or fever. Therefore, all patients presen-\nting to labour suite may need a COVID-19 screening\nwith Rapid antigen or Real time PCR.\nEarly diagnosis and patient isolation at the appropriate\nsetting is of paramount importance, with adequate\npersonal protective equipment (PPE). Maternal pulse\nrate, blood pressure, respiratory rate and oxygen\nsaturation should be monitored throughout the labour.\nDecision making in labour should be precise to avoid\nobstetric emergencies, since the delay is anticipated in\ntransferring, organising and performing procedures\nwith adequate isolation and personal protective\nequipments (PPE). Patients who are on prophylaxis\nenoxaparin should be discontinued of it, 12 hours before\nthe onset of labour or induction. (see the national\nguideline on Management of COVID-19 infection in\npregnancy).\n8.6  Maternal and neonatal consequences of\nintrapartum fever\nNeonatal consequences\n• Meconium Aspiration Syndrome\n• Hyaline Membrane Disease (HMD)\n• Neonatal Seizures\n• Intrapartum stillbirth\n• Early neonatal or infant death",
  "Patients who are on prophylaxis\nenoxaparin should be discontinued of it, 12 hours before\nthe onset of labour or induction. (see the national\nguideline on Management of COVID-19 infection in\npregnancy).\n8.6  Maternal and neonatal consequences of\nintrapartum fever\nNeonatal consequences\n• Meconium Aspiration Syndrome\n• Hyaline Membrane Disease (HMD)\n• Neonatal Seizures\n• Intrapartum stillbirth\n• Early neonatal or infant death\n\n--- Page 8 ---\n378\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n• Birth asphyxia\n• Neonatal encephalopathy and cerebral palsy\n• Needing assisted ventilation\nWhen the labouring woman is having fever, peripartum\ntransfer of the infection to the fetus is one the major\nconcerns. The presence of intraamniotic infection can\ngive rise to short term effects to the new-born like\nsepticaemia, meningitis and pneumonia. Long term\noutcomes are cerebral palsy and neurodevelopmental\ndelay.\nOnce the micro-organisms enter the foetal mucosa, it\ninduces a localised and subsequently a systemic\ninflammatory response called foetal inflammatory\nresponse syndrome (FIRS). FIRS affect multiple organ\nfunctions including the hematopoietic system, immune\nsystem, thymus heart, adrenal glands, skin, lung, brain\nand gut29,30.\nThere is no definite method to differentiate intrapartum\nfever due to neuraxial anaesthesia from chorio-\namnionitis. Hence, there is increased tendency for\nneonatal sepsis screening and treating with antibiotics.\nHowever, fever due to neuraxial anaesthesia is not\nassociated with increased rate of proven sepsis. But,\neven in the absence of documented infection, neuraxial\nanaesthesia related intra-partum pyrexia may be\nassociated with adverse neonatal outcome. When the\nmother is having temperature during labour, neonate\nshould be closely observed for sepsis. Especially\nneonates with low birth weight, prematurity, and\nhypothermia at birth, maternal Group B streptococcal\ncolonization, preeclampsia and maternal hypertension\nshould have a full septic screening31.\nMaternal consequences\n• Labour abnormalities (dysfunctional labour)\n• Greater likelihood of caesarean delivery\n• Uterine atony\n• Postpartum haemorrhage\n• Postpartum endometritis\n• Septic pelvic thrombophlebitis\nMaternal outcome depends on the causes of the\nintrapartum fever. Almost all the women with\nintrapartum fever are likely to receive antibiotics. One\nstudy indicated that even low risk nulliparous women\nwith intrapartum fever have double the chance of\nrequiring a caesarean delivery or assisted vaginal\ndelivery than those without intrapartum fever regardless\nof receiving neuraxial anaesthesia32.\n9.  Clinical governance\nPossibility of chorioamnionitis should be suspected\nwhenever a woman in labour develop fever as it is a\ncondition associated with high perinatal morbidity and\nmortality. All measures should be taken to prevent the\noccurrence of chorioamnionitis.\n• Optimum sterility should be maintained during\nvaginal examinations and procedures like artificial\nrupture of membranes, membrane sweeping,\nFoley catheter insertion etc.\n• Minimise the number of vaginal examinations,\nespecially for those with prelabour rupture of\nmembranes and those who are in labour.\n• Plan the vaginal examination in such a way that\nonly the decision-making staff member will\nperform it. Avoid repeated vaginal examinations\ndone by different categories of staff in short\nintervals.\nAll mothers with intrapartum fever should have their\nmanagement discussed with the senior obstetrician and\nshould also get neonatal team involvement.\nAll mothers who are suspected of having\nchorioamnionitis should be counselled regarding their\nmanagement and possible neonatal consequences.\nMaintenance of partogram and MOEWS chart in\nsuspected sepsis are of paramount importance in the\nmanagement.",
  "All measures should be taken to prevent the\noccurrence of chorioamnionitis.\n• Optimum sterility should be maintained during\nvaginal examinations and procedures like artificial\nrupture of membranes, membrane sweeping,\nFoley catheter insertion etc.\n• Minimise the number of vaginal examinations,\nespecially for those with prelabour rupture of\nmembranes and those who are in labour.\n• Plan the vaginal examination in such a way that\nonly the decision-making staff member will\nperform it. Avoid repeated vaginal examinations\ndone by different categories of staff in short\nintervals.\nAll mothers with intrapartum fever should have their\nmanagement discussed with the senior obstetrician and\nshould also get neonatal team involvement.\nAll mothers who are suspected of having\nchorioamnionitis should be counselled regarding their\nmanagement and possible neonatal consequences.\nMaintenance of partogram and MOEWS chart in\nsuspected sepsis are of paramount importance in the\nmanagement.\n\n--- Page 9 ---\n379\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nAnnexure 1. Intrapartum fever management algorithm",
  "4, December 2021\nSLCOG Guideline\nAnnexure 1. Intrapartum fever management algorithm\n\n--- Page 10 ---\n380\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nRegimen\nDoses\n1. Ampicillin and Gentamycin\nAmpicillin IV 2g every 6 h and Gentamicin 2mg/kg\nIV load followed by 1.5mg/kg 8 h or 5mg/kg IV\nevery 24 h\n2. Cefuroxime + Metronidazole\nCefuroxime 750mg IV 8 h + Metronidazole 500mg\nIV 8 h\n3. Ceftriaxone, Metronidazole and clarithromycin\nCeftrixone 1g IV every 24 h, Metronidazole IV\n500mg every 8 h, and clarithromycin 500mg oral\nevery 12 h\n4. Ampicillin and Azithromycin\nAmpicillin 1.5g IV every 6 h and Azithromycin oral\n500mg every 24 h\n5. Ampicillin\n3g IV every 6\n6. Piperacillin-Tazobactum\n4.5g IV every 8 h\n7. Ertapenem\n1g IV every 24 h\n8. Mild penicillin allergy – Cefuroxime and\nCefuroxime 1.5g loading dose,750mg 8 h and\nGentamycin\nGentamicin 2mg/kg IV load followed by 1.5mg /kg\nevery 8 h or 5mg/kg IV every 24 h\n9. For severe penicillin allergy – Clindamycin\nClindamycin 600-800mg IV every 8h or Vancomycin\nor Vancomycin and Gentamicin\n1g IV every 12h (slow infusion over 1 hr) and\nGentamycin 2mg/kg IV load followed by 1.5 mg/kg\nevery 8 h or 5mg/kg IV every 24 h\nIV- Intravenous, h - hourly\nTable 1. Different antibiotic regimens to be used in intrapartum fever\nParameter\nValue\nScore\nBlood pressure\n< 100mmHg\n1\nRespiratory rate\n> 22 bpm\n1\nLevel of consciousness\nGCS < 15\n1\nScore of 2 or more: suggestive of sepsis\nTable 2. qSOFA scoring",
  "Different antibiotic regimens to be used in intrapartum fever\nParameter\nValue\nScore\nBlood pressure\n< 100mmHg\n1\nRespiratory rate\n> 22 bpm\n1\nLevel of consciousness\nGCS < 15\n1\nScore of 2 or more: suggestive of sepsis\nTable 2. qSOFA scoring\n\n--- Page 11 ---\n381\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nReferences\n1.\nHiggins RD, Saade G, Polin RA, Grobman WA,\nBuhimschi IA, Watterberg K, et al. Evaluation and\nmanagement of women and newborns with a\nmaternal diagnosis of chorioamnionitis: Summary\nof a Workshop. Obstet Gynecol. 2016; 127(3):\n426-36.\n2.\nKatherine TC. Intrapartum fever. In: Up To Date,\nVincenzo B (Ed), David LH (Ed), Up To Date,\nWaltham, MA. (Accessed on July 20, 2021.)\n3.\nEvers AC, Nijhuis L, Koster MP, Bont LJ, Visser\nGH. Intrapartum fever at term: diagnostic markers\nto individualize the risk of fetal infection: a review.\nObstet Gynecol Surv. 2012; 67(3): 187.\n4.\nCommittee on Obstetric. Practice Committee\nOpinion No. 712. Intrapartum management of\nintraamniotic infection. Obstet Gynecol 2017;\n130(2): e95-e101.\n5.\nNewton ER. Chorioamnionitis and intraamniotic\ninfection. Clin Obstet Gynecol 1993; 36: 795.\n6.\nTowers CV, Yates A, Zite N, et al. Incidence of\nfever in labor and risk of neonatal sepsis. Am J\nObstet Gynecol 2017; 216: 596.e1.\n7.\nAcker DB, Schulman EB, Ransil BJ, et al. The\nnormal parturient’s admission temperature. Am J\nObstet Gynecol 1987; 157: 308.\n8.\nBanerjee S, Cashman P, Yentis SM, Steer PJ.\nMaternal temperature monitoring during labor:\nconcordance and variability among monitoring\nsites. Obstet Gynecol 2004; 103: 287.\n9.\nWartzek T, Mühlsteff J, Imhoff M. Temperature\nmeasurement. Biomed Tech (Berl) 2011; 56: 241.\n10. Sciscione AC, Zainia T, Leet T, et al. A new device\nfor measuring intrauterine temperature. Am J\nObstet Gynecol 2001; 184: 1431.\n11. Macaulay JH, Randall NR, Bond K, Steer PJ.\nContinuous monitoring of fetal temperature by\nnon-invasive probe and its relationship to maternal\ntemperature, fetal heart rate, and cord arterial\noxygen and pH. Obstet Gynecol 1992; 79: 469.\n12. Adamson SK Jr, Towell ME. Thermal Homeostasis\nin the fetus and newborn. Anesthesiology 1965;\n26: 531.\n13. Walker D, Walker A, Wood C. Temperature of the\nhuman fetus. J Obstet Gynaecol Br Commonw\n1969; 76: 503.\n14. Smulian JC, Bhandari V, Vintzileos AM, et al.\nIntrapartum fever at term: serum and histologic\nmarkers of inflammation. Am J Obstet Gynecol\n2003; 188: 269.\n15. Goetzl L, Evans T, Rivers J, et al. Elevated maternal\nand fetal serum interleukin-6 levels are associated\nwith epidural fever. Am J Obstet Gynecol 2002;\n187: 834.\n16. De Jongh RF, Bosmans EP, Puylaert MJ, et al.\nThe influence of anaesthetic techniques and type\nof delivery on peripartum serum interleukin-6\nconcentrations. Acta Anaesthesiol Scand 1997; 41:\n853.\n17. Sultan P, David AL, Fernando R, Ackland GL.\nInflammation and epidural-related maternal fever:\nproposed mechanisms. Anesth Analg 2016; 122:\n1546.\n18. Wohlrab P, Boehme S, Kaun C, et al. Ropivacaine\nactivates multiple proapoptotic and inflammatory\nsignaling pathways that might subsume to trigger\nepidural-related maternal fever. Anesth Analg 2020;\n130: 321.\n19. Lieberman E, Lang JM, Frigoletto F Jr, et al.\nEpidural analgesia, intrapartum fever, and neonatal\nsepsis evaluation. Pediatrics 1997; 99: 415.\n20. Goetzl L, Rivers J, Zighelboim I, et al. Intrapartum\nepidural analgesia and maternal temperature\nregulation. Obstet Gynecol 2007; 109: 687.\n21. Goetzl L. Epidural analgesia and maternal fever: a\nclinical and research update. Curr Opin\nAnaesthesiol 2012; 25: 292.\n22. Acker DB, Johnson MP, Sachs BP, Friedman EA.\nThe leukocyte count in labor. Am J Obstet Gynecol\n1985; 153: 737.\n23. Bates DW, Sands K, Miller E, et al. Predicting\nbacteremia in patients with sepsis syndrome.\nAcademic Medical Center Consortium Sepsis\nProject Working Group. J Infect Dis 1997; 176:\n1538.\n24. Smith-Elekes S, Weinstein MP. Blood cultures.\nInfect Dis Clin North Am 1993; 7: 221.\n25. Royal College of Obstetricians and Gynaecologists.\nBacterial Sepsis in Pregnancy. Green-top Guideline\nNo. 64a. London: RCOG; 2012.",
  "64a. London: RCOG; 2012.\n\n--- Page 12 ---\n382\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n26. Catańo Sabogal CP, Fonseca J, Garcķa-Perdomo\nHA. Validation of diagnostic tests for histologic\nchorioamnionitis: systematic review and meta-\nanalysis. Eur J Obstet Gynecol Reprod Biol 2018;\n228: 13-26.\n27. Ona S, Easter SR, Prabhu M, et al. Diagnostic\nvalidity of the proposed eunice kennedy shriver\nnational institute of child health and human\ndevelopment criteria for intrauterine inflammation\nor infection. Obstet Gynecol 2019; 133(1): 33-9.\n28. Tita AT, Andrews WW. Diagnosis and management\nof clinical chorioamnionitis. Clin Perinatol 2010;\n37(2): 339-54.\n29. Kim CJ, Romero R, Chaemsaithong P, et al. Acute\nchorioamnionitis and funisitis: definition, pathologic\nfeatures, and clinical significance. Am J Obstet\nGynecol 2015; 213(4 Suppl): S29-S52.\n30. Gotsch F, Romero R, Kusanovic JP, et al. The\nfetal inflammatory response syndrome. Clin Obstet\nGynecol 2007; 50(3): 652-83.\n31. Paules C, Moreno E, Gonzales A, et al. Amniotic\nfluid sludge as a marker of intra-amniotic infection\nand histological chorioamnionitis in cervical\ninsufficiency: a report of four cases and literature\nreview. J Matern Fetal Neonatal Med 2016; 29(16):\n2681-4.\n32. American Association of Pro-Life Obstetricians\nGynecologists. AAPLOG practice bulletin no. 3:\npreviable induction of labor for chorioamnitis.\nIssues Law Med 2018; 33(2): 247-56.",
  "--- Page 1 ---\n259\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nManagement of thrombocytopaenia in pregnancy\nD L W Dasanayakea, Y Costab, A Weerawardana c  on behalf of Sri Lanka College of Obstetricians and\nGynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2021; 43:  259-268\na Consultant Obstetrician and Gynaecologist, Mahamodara Teaching Hospital, Galle, Sri Lanka\nb Consultant Haematologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nc Consultant Haematologist, De Zoysa Maternity Hospiatl for Women, Colombo, Sri Lanka\n1.  Scope and background\nThis guideline aims to describe the diagnostic approach\nto investigating thrombocytopaenia found in pregnancy,\nfollowed by a brief discussion on managing specific\ncauses of thrombocytopaenia. This provides evidence-\nbased information to health professionals to formulate\na rational care pathway.\nA platelet count of less than 150×109/L is defined as\nthrombocytopenia. Maternal thrombocytopaenia is in\nmost cases mild and has no adverse outcome for both\nmother and fetus. Rarely a platelet count may be the\npresenting feature of a significant disorder with life\nthreatening complications. Therefore management of\nthrombocytopaenia during pregnancy is challenging in\nboth diagnostic as well as management of delivery.\n2. Summary of key recommendations\n2.1 Initial assessment\nA platelet count below 150×109/L should warrant\nassessment for thrombocytopaenia during\npregnancy. Errors during blood collection and\nautomated haematology analysis may yield falsely\nlow values. Hence low platelet counts should be\nreconfirmed with a repeat Full Blood Count (FBC)\nand a request for a manual platelet count.\n2.2  Diagnosis of specific causes for thrombo-\ncytopaenia\nA multidisciplinary approach with the haematologist\nand the obstetrician is required for optimal care.\nIf thrombocytopenia is confirmed, careful history,\nexamination and laboratory workup is essential for the\ndiagnosis.\nA blood picture examination is vital to find the cause\nfor thrombocytopenia. Microangiopathic hemolytic\nanaemia (MAHA) in the blood picture, which is a\nhemolytic process with red cell fragmentation and\nthrombocytopenia, can be associated with severe\nPreeclampsia(PE), HELLP syndrome, TTP (Throm-\nbotic Thrombocytopaenic Purpura), aHUS (atypical\nHaemolytic Uraemic Syndrome), AFLP(Acute Fatty\nLiver in Pregnancy) and Disseminated Intravascular\nCoagulation (DIC).\nTo differentiate between above conditions apart from\na good clinical assessment, serum creatinine, lactate\ndehydrogenase (LDH), Prothrombin Time (PT),\nActivated Partial Thromboplastin Time (APPT), liver\nfunction tests (bilirubin direct/ indirect, albumin, total\nprotein, transferases, and alkaline phosphatase) and\nultrasound scan of abdomen are required.\nSLCOG Guideline\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v43i3.8020",
  "Microangiopathic hemolytic\nanaemia (MAHA) in the blood picture, which is a\nhemolytic process with red cell fragmentation and\nthrombocytopenia, can be associated with severe\nPreeclampsia(PE), HELLP syndrome, TTP (Throm-\nbotic Thrombocytopaenic Purpura), aHUS (atypical\nHaemolytic Uraemic Syndrome), AFLP(Acute Fatty\nLiver in Pregnancy) and Disseminated Intravascular\nCoagulation (DIC).\nTo differentiate between above conditions apart from\na good clinical assessment, serum creatinine, lactate\ndehydrogenase (LDH), Prothrombin Time (PT),\nActivated Partial Thromboplastin Time (APPT), liver\nfunction tests (bilirubin direct/ indirect, albumin, total\nprotein, transferases, and alkaline phosphatase) and\nultrasound scan of abdomen are required.\nSLCOG Guideline\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v43i3.8020\n\n--- Page 2 ---\n260\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nGestational Thrombocytopaenia (GT) is the most\ncommon reason for low platelets in pregnancy. It is a\ndiagnosis of exclusion. GT commonly develops in the\nlatter half of the pregnancy, and the platelet count is\nusually above 70×109/L. The diagnosis of GT is less\nlikely if the platelet count falls below 70×109/L.\nIncidence of Immune-Thrombocytopaenic Purpura\n(ITP) is approximately in 1/1000-1/10 000 pregnancies.\nIt is the commonest cause of a low platelet count\npresenting in the first and second trimesters.\nPE is the most common cause of thrombocytopenia\nassociated with MAHA presenting in the late second\nor the third trimester of pregnancy. Infrequently, it\nmay appear during the first week postpartum.\nHELLP syndrome may be a variant of PE characterized\nby more severe thrombocytopenia, more fulminant\nMAHA and profoundly elevated liver function tests.\nEven though it is rare, microangiopathies such as TTP,\naHUS and AFLP should be carefully looked into when\nthe woman presents with acute clinical features.\nPatients with Antiphospholipid Syndrome (APLS) and\nSystemic Lupus Erythematosus (SLE) may also present\nwith thrombocytopenia.\nAntinuclear Antibodies (ANA), thyroid function test,\nantiphospholipid antibodies and viral screening should\nbe considered if clinically indicated.\n2.3 Management of GT\nAntenatal platelet count should be monitored every 2\nto 4 weeks.\nNo special management is required.\nWhen the platelet count is less than 100×109/L, the\nwoman should be referred to an anaesthetist prior to\ndelivery.\nGT is not associated with neonatal thrombocytopenia.\n2.4  Management of ITP in pregnancy\nIn ITP, a multidisciplinary approach involving the\nobstetrician, haematologist, anaesthetist, transfusion\nphysician and neonatologist are required for optimal\ncare.\nFBC should be monitored at 2-4 weeks intervals or\nmore frequently if indicated.\nIf the platelet count is less than 30×109/L or bleeding\nmanifestations are present, first-line therapy is oral\ncorticosteroids, and if a rapid platelet increment is\nrequired as in impending delivery or significant blee-\nding, intravenous immunoglobulin (IVIg) should be\nadministered.\nTreatment to increase the platelet count for delivery is\ninitiated by 36 weeks or earlier if early delivery is\nplanned.\nDelivery should be planned in a setting where 24 hours\nblood bank facilities and ICU care are available.\nThe obstetric team should liaise with the haematologist,\nthe transfusion physician and the anaesthetist when\nplanning delivery.\nPlatelets count of at least 50×109 /L should be obtained\nfor safe delivery.\nIf platelet count of less than 50×109/L, platelet\nconcentrate should be available on-site for transfusion\nif necessary.\nCaesarean delivery is reserved for obstetric indications\nonly.\nAt a platelet count of ≥ 80×109/L, in the absence of\nother hemostatic abnormalities, regional anaesthesia\ncan be performed.\nIgG antibodies in ITP are known to cross the placenta,\ncausing thrombocytopenia in the fetus and neonate.\nThe occurrence of intracranial haemorrhage (ICH) is\na major neonatal concern. Measures should be taken\nto avoid traumatic delivery to the baby and the mother\nduring delivery. Scalp electrodes, fetal blood sampling,\nvacuum and difficult forceps delivery should be\navoided. If instrumental delivery is indicated, forceps\nis the choice.\nProphylactic measures should be taken to prevent\nPostpartum Haemorrhage (PPH), which includes active\nmanagement of the third stage of labour, oxytocin\ninfusion and intravenous tranexamic acid.\nPregnant women who are on long term steroids should\nhave regular blood sugar monitoring with PPBS and\nblood pressure monitoring.",
  "Scalp electrodes, fetal blood sampling,\nvacuum and difficult forceps delivery should be\navoided. If instrumental delivery is indicated, forceps\nis the choice.\nProphylactic measures should be taken to prevent\nPostpartum Haemorrhage (PPH), which includes active\nmanagement of the third stage of labour, oxytocin\ninfusion and intravenous tranexamic acid.\nPregnant women who are on long term steroids should\nhave regular blood sugar monitoring with PPBS and\nblood pressure monitoring.\n\n--- Page 3 ---\n261\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nNon-Steroidal Anti-Inflammatory drugs (NSAIDs)\nshould be avoided for postpartum or postoperative\nanalgesia in women with thrombocytopenia due to\nincreased hemorrhagic risk.\n2.5  Management of thrombocytopaenia due\nto PE, HELLP syndrome and AFLP\nUrgent delivery should be arranged as it is the mainstay\nof treatment.\nMaternal corticosteroids should be administered\nconsidering fetal maturity to reduce fetal respiratory\nmorbidity.\nIf DIC present, supportive care with FFP, platelet and\ncryoprecipitate should be administered with advice\nfrom the haematologist.\n2.6 Management of thrombotic thrombo-\ncytopaenic purpura/atypical hemolytic uraemic\nsyndrome\nDespite the diagnostic challenge, plasma exchange\n(plasmapheresis) needs to be commenced as soon as\nTTP/aHUS is suspected. Management requires a\nmultidisciplinary approach with the transfusion\nphysician, the obstetrician and the haematologist.\nPlasma transfusions should be given if there is any\ndelay in plasmapheresis.\nIn TTP, plasmapheresis should continue daily until\nthe platelet count is maintained in the normal range\n(>150×109/L) for a minimum of 2 days.\nPlatelet transfusions are contraindicated as they are\nknown to precipitate or exacerbate thrombosis.\n3.  Introduction\nThrombocytopenia is a common haematological\ncondition affecting 7-10% of the pregnant population1.\nIt occurs four times more frequently in pregnancy than\nin non-pregnant women and is the second leading cause\nof blood disorders in pregnancy after anaemia2.\nThrombocytopaenia is defined as a platelet count of\nless than 150×109/L.\nGT accounts for 70-80% of all cases of thrombo-\ncytopaenia in pregnancy. Hypertensive disorders\nexplain approximately 20% of thrombocytopenia, and\nimmune thrombocytopenia accounts for about 3-4%.\nOther etiologies such as TTP and HUS are considered\nrare in pregnancy but carry high morbidity and\nmortality for both the mother and fetus3.\n4.  Recommendations and discussion\n4.1  Initial assessment\nA platelet count below 150×109/L should warrant\nassessment for thrombocytopaenia during pregnancy.\nErrors during blood collection and automated\nhaematology analysis may yield falsely low values.\nHence low platelet counts should be reconfirmed with\na repeat FBC and a request for a manual platelet count.\nAll new patients presenting with thrombocytopenia\nneed reconfirmation of the low platelet number with a\nrepeat FBC and a manual platelet count. The repeat\nFBCsample should be taken from a direct, uncom-\nplicated venipuncture and added into an EDTA tube\nand mixed well. This will prevent minute clot formation\nin the sample leading to erroneously low platelet values.\nAssessing the manual platelet count will exclude any\nerrors in automated platelet analysis.\nIf large platelet aggregates are detected in the blood\nsmear taken from an EDTA sample with thrombo-\ncytopenia reported in the automated FBC results, it is\nconsidered as EDTA induced pseudo thrombocytopenia.\nIf it is necessary to obtain the accurate platelet number,\nblood should be collected into acitrated tube and sent\nto the laboratory for analysis within 15 minutes of\ncollection. As the platelets can undergo deterioration\nin a citrated sample, immediate analysis is vital, and\nthe laboratory should be informed of the procedure\nbefore collecting blood from the patient to a citrated\nsample. When thrombocytopenia is confirmed, careful\nhistory, examination, and laboratory workup are needed\nto arrive at a diagnosis.\nHistory should include.\n• recent history of fever (to exclude viral infections\nsuch as dengue fever)\n• the presence of severe headaches and other\nneurological manifestations (seen in PE and TTP)\n• past history of thrombocytopenia (favouring ITP)\n• symptomatic anaemia and recurrent infections\n(bone marrow failure/haematological malignancy)\n• past history of pregnancy-associated thrombo-\ncytopenia\n• history of connective tissue disorders (SLE and\nAPLS)",
  "As the platelets can undergo deterioration\nin a citrated sample, immediate analysis is vital, and\nthe laboratory should be informed of the procedure\nbefore collecting blood from the patient to a citrated\nsample. When thrombocytopenia is confirmed, careful\nhistory, examination, and laboratory workup are needed\nto arrive at a diagnosis.\nHistory should include.\n• recent history of fever (to exclude viral infections\nsuch as dengue fever)\n• the presence of severe headaches and other\nneurological manifestations (seen in PE and TTP)\n• past history of thrombocytopenia (favouring ITP)\n• symptomatic anaemia and recurrent infections\n(bone marrow failure/haematological malignancy)\n• past history of pregnancy-associated thrombo-\ncytopenia\n• history of connective tissue disorders (SLE and\nAPLS)\n\n--- Page 4 ---\n262\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n• hypothyroidism\n• liver disease\n• drug history\n• past and family history of bleeding disorders (rare\ninherited bleeding disorders such as type IIB Von\nWillebrand disease).\nOn examination, it is uncommon to detect bleeding\nmanifestations unless the platelet count is significantly\nlow. It is vital to check the blood pressure (PE, HELLP\nsyndrome), abdominal tenderness (PET, HELLP syn-\ndrome, AFLP), anaemia, lymphadenopathy, hepatos-\nplenomegaly (haematological malignancy) and\nneurological manifestations (severe PE, TTP).\nReduction of serum platelet counts is arbitrarily\nconsidered mild if the count is <150×109/L, moderate\nat 50-100×109/L and severe at <50×109/L.\n4.2  Diagnosis of specific causes for thrombo-\ncytopaenia\nA multidisciplinary approach with the haematologist\nand the obstetrician is required for optimal care.\nIf thrombocytopenia is confirmed, careful history,\nexamination and laboratory workup is essential for the\ndiagnosis.\nA blood picture examination is vital to find the cause\nfor thrombocytopenia. MAHA in the blood picture, a\nhemolytic process with red cell fragmentation and\nthrombocytopenia, can be associated with severe PE,\nHELLP syndrome, TTP, aHUS, AFLP and DIC4.\nTo differentiate between above conditions apart from\na good clinical assessment, serum creatinine, lactate\ndehydrogenase (LDH), Prothrombin Time (PT),\nActivated Partial Thromboplastin Time (APPT), liver\nfunction tests (bilirubin direct/ indirect, albumin, total\nprotein, transferases, and alkaline phosphatase) and\nultrasound scan abdomen are required.\nGT is the most common reason for low platelets in\npregnancy5. It is a diagnosis of exclusion. GT\ncommonly develops in the latter half of the pregnancy,\nand the platelet count is usually above 70×109/L. The\ndiagnosis of GT is less likely if the platelet count falls\nbelow 70×109/L.\nThe incidence of ITP is approximately in 1/1000-\n1/10 000 pregnancies. It is the commonest cause of a\nlow platelet count presenting in the first and second\ntrimesters6.\nPE is the most common cause of thrombocytopenia\nassociated with MAHA presenting in the late second\nor third trimester of pregnancy. Infrequently, it may\nappear during the first week postpartum7.\nHELLP syndrome may be a variant of PE characterized\nby more severe thrombocytopenia, more fulminant\nMAHA and profoundly elevated liver function tests5.\nEven though it is rare, microangiopathies such as TTP,\naHUS and AFLP should be carefully looked into when\nthe woman presents with acute clinical features.\nPatients with APLS and SLE may also present with\nthrombocytopenia.\nANA, thyroid function test, antiphospholipid antibodies\nand viral screening should be considered if clinically\nindicated.\nGT is a condition with mild to moderate platelet drop\nand is a diagnosis of exclusion. The platelet count in\nGT is usually above 70×109/L. The patient is asymp-\ntomatic, and thrombocytopenia is commonly detected\nin the second half of pregnancy. The platelet count\nspontaneously reverts to normal within the first two\nmonths of postpartum but can recur in subsequent\npregnancies.\nThe incidence of ITP is approximately in 1/1000-1/10\n000 pregnancies. It is the commonest cause of a low\nplatelet count presenting in the first and second\ntrimesters6. Despite improved understanding of the\npathophysiology, there is no specific diagnostic test,\nand, like GT, it is a diagnosis of exclusion. The presence\nof other autoimmune phenomena or a low platelet count\nduring pre-pregnancy can help to diagnose.\nThrombocytopaenia associated with hypertensive\ndisorders is the most frequent causes in the late second\ntrimester onwards8.Therefore PE screening should be\ncarried out to rule out hypertensive variants (HELLP,\nAFLP).\nHELLP syndrome, which affects 0.6% of pregnant\nwomen, is a severe variant of pre-eclampsia. However,\nin 15-20% of cases of HELLP syndrome, neither\nhypertension nor proteinuria is present9.",
  "The presence\nof other autoimmune phenomena or a low platelet count\nduring pre-pregnancy can help to diagnose.\nThrombocytopaenia associated with hypertensive\ndisorders is the most frequent causes in the late second\ntrimester onwards8.Therefore PE screening should be\ncarried out to rule out hypertensive variants (HELLP,\nAFLP).\nHELLP syndrome, which affects 0.6% of pregnant\nwomen, is a severe variant of pre-eclampsia. However,\nin 15-20% of cases of HELLP syndrome, neither\nhypertension nor proteinuria is present9.\n\n--- Page 5 ---\n263\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nAFLP occurs in 1 in 5000 to 10 000 pregnancies and\nis more common with multiple gestations than in\nsingletons. Up to 75% of women present with nausea\nor vomiting, and 50% have abdominal pain or signs\nand symptoms similar to PE. Although it is often\ndifficult to differentiate HELLP from AFLP, evidence\nof hepatic insufficiency, including hypoglycemia, DIC,\nor encephalopathy, is seen more often in AFLP5.\nTTP is an acute life-threatening disorder associated\nwith thrombocytopenia, MAHA and microvascular\nthrombosis. It results from a deficiency of the\nenzymeADAMTS13, required to cleave secreted ultra-\nlarge von Willebrand factor molecules (ULVWF). An\ninherited deficiency or acquired reduction of\nADAMTS13 due to IgG autoantibodies to ADAMTS13\nleads to persistence of ULVWF molecules resulting in\nabnormal platelet aggregation and microvascular\nthrombosis. Pregnancy is an important precipitant of\nacute TTP, accounting for approximately 5-10% of all\ncases of TTP in women4. TTP classically consists of\na pentad of thrombocytopenia, MAHA, neurological\nsigns, renal impairment and fever. However, TTP\ncommonly presents without the full spectrum of the\npentad. Laboratory features indicating a diagnosis of\nTTP are MAHA with many schistocytes in the blood\npicture, increased Lactate dehydrogenase (LDH),\nwhich is often out of proportion to the degree of\nhaemolysis due to associated tissue ischemia, normal\nPT/APTT and possibly elevated serum creatinine\nlevel10.\naHUS is a rare MAHA associated with pregnancy. The\nmajority of cases occur during the postpartum period.\nThe patient has MAHA, thrombocytopenia and severe\nrenal impairment. The outcome is severe, with two-\nthirds of cases developing end-stage renal failure within\none month4.\n4.3  Management of GT\nAntenatal platelet count should be monitored every 2\nto 4 weeks.\nNo special management is required.\nWhen the platelet count is less than 100×109/L, the\nwoman should be referred to an anaesthetist prior to\ndelivery.\nGT is not associated with neonatal thrombocytopenia.\nGT does not require treatment except periodic moni-\ntoring of platelet count. The thrombocytopenia resolves\nspontaneously. If the thrombocytopenia persists\nbeyond 6 to 8 weeks, the patient should undergo further\nhaematological investigations.\n4.4  Management of ITP in pregnancy\nIn ITP, a multidisciplinary approach involving the\nobstetrician, haematologist, anaesthetist, transfusion\nphysician and neonatologist, is required for optimal\ncare.\nFBC should be monitored at 2-4 weeks intervals or\nmore frequently if indicated.\nIf the platelet count is less than 30 ×109/L or bleeding\nmanifestations are present, first-line therapy is oral\ncorticosteroids, and if a rapid platelet increment is\nrequired as in impending delivery or significant bleeding,\nIVIg should be given.\nTreatment to increase the platelet count for delivery is\ninitiated by 36 weeks or earlier if early delivery is\nplanned.\nDelivery should be planned in a setting where 24 hours\nblood bank facilities and ICU care are available.\nThe obstetric team should liaise with the haematologist,\nthe transfusion physician and the anaesthetist when\nplanning delivery.\nPlatelets count of at least 50×109 /L should be obtained\nfor safe delivery.\nIf platelet count of less than 50×109/L, platelet\nconcentrate should be available on-site for transfusion\nif necessary.\nCaesarean delivery is reserved for obstetric indications\nonly.\nAt a platelet count ≥ 80×109/L, regional anaesthesia\ncan be performed in the absence of other hemostatic\nabnormalities.\nIgG antibodies in ITP are known to cross the placenta,\ncausing thrombocytopenia in the fetus and neonate.\nThe occurrence of intracranial haemorrhage (ICH) is\na major neonatal concern. Measures should be taken\nto avoid traumatic delivery to the baby and the mother",
  "If the thrombocytopenia persists\nbeyond 6 to 8 weeks, the patient should undergo further\nhaematological investigations.\n4.4  Management of ITP in pregnancy\nIn ITP, a multidisciplinary approach involving the\nobstetrician, haematologist, anaesthetist, transfusion\nphysician and neonatologist, is required for optimal\ncare.\nFBC should be monitored at 2-4 weeks intervals or\nmore frequently if indicated.\nIf the platelet count is less than 30 ×109/L or bleeding\nmanifestations are present, first-line therapy is oral\ncorticosteroids, and if a rapid platelet increment is\nrequired as in impending delivery or significant bleeding,\nIVIg should be given.\nTreatment to increase the platelet count for delivery is\ninitiated by 36 weeks or earlier if early delivery is\nplanned.\nDelivery should be planned in a setting where 24 hours\nblood bank facilities and ICU care are available.\nThe obstetric team should liaise with the haematologist,\nthe transfusion physician and the anaesthetist when\nplanning delivery.\nPlatelets count of at least 50×109 /L should be obtained\nfor safe delivery.\nIf platelet count of less than 50×109/L, platelet\nconcentrate should be available on-site for transfusion\nif necessary.\nCaesarean delivery is reserved for obstetric indications\nonly.\nAt a platelet count ≥ 80×109/L, regional anaesthesia\ncan be performed in the absence of other hemostatic\nabnormalities.\nIgG antibodies in ITP are known to cross the placenta,\ncausing thrombocytopenia in the fetus and neonate.\nThe occurrence of intracranial haemorrhage (ICH) is\na major neonatal concern. Measures should be taken\nto avoid traumatic delivery to the baby and the mother\n\n--- Page 6 ---\n264\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nduring delivery. Scalp electrodes, fetal blood sampling,\nvacuum and difficult forceps delivery should be\navoided. If instrumental delivery is indicated, forceps\nis the choice.\nProphylactic measures should be taken to prevent\nPostpartum Haemorrhage (PPH), which includes active\nmanagement of the third stage of labour, oxytocin\ninfusion and intravenous tranexamic acid.\nPregnant women who are on long term steroids should\nhave regular blood sugar monitoring with PPBS and\nblood pressure monitoring.\nNon-Steroidal Anti-Inflammatory drugs (NSAIDs)\nshould be avoided for postpartum or postoperative\nanalgesia in women with thrombocytopenia due to\nincreased hemorrhagic risk.\nIn ITP, a multidisciplinary approach involving the\nobstetrician, haematologist, transfusion physician,\nanaesthetist and neonatologist, is required for optimal\ncare.\nWomen with no bleeding manifestations and platelet\ncounts above 30×109/L do not require any treatment\nuntil 36 weeks gestation9.\nIf the platelet count is <30×109/L or bleeding mani-\nfestations are present, first-line therapy is oral\ncorticosteroids 0.25-1mg/kg daily (dose to be adjusted\nto achieve a safe platelet count) or if a rapid platelet\nincrement is required as in impending delivery or\nsignificant bleeding, IVIg 1g/kg9.\nIVIg has a relatively rapid therapeutic response (within\n1-3 days). Prednisolone shows a therapeutic response\nwithin 2-14 days11.\nCurrent recommendations aim for a platelet count of\n≥ 50×109/L prior to labour and delivery as the risk of\ncesarean delivery is present with everylabour9.\nFor spinal anaesthesia, the British Committee for\nHaematology and Anaesthetic Guideline standards\nrecommends a threshold of >80×1012,13. An anaesthetic\nconsultation in the third trimester to discuss options\nfor delivery is required.\nWhile platelet transfusion alone is generally not effective\nin ITP, if an adequate platelet count has not been\nachieved and delivery is emergent, or if there is blee-\nding, platelet transfusion in conjunction with IVIg can\nbe considered9.\nAfter delivery, close monitoring of the neonate is\nrequired as 21% to 28% will develop thrombocytopenia\npresumably from passive transfer of maternal auto-\nantibodies (IgG) against platelet antigens13. Less than\n1% of neonates develop intracranial hemorrhage14. Risk\nfor thrombocytopenia is increased if siblings had\nthrombocytopenia at delivery. Maternal platelet count\nduring pregnancy does not impact the risk of\nthrombocytopenia in the neonate15. The mode of\ndelivery is determined by the obstetric indications, with\navoidance of procedures associated with an increased\nhaemorrhagic risk to the fetus, such as fetal scalp\nelectrode/fetal blood sampling and operative vaginal\ndelivery14. A cord blood sample should be taken to\ncheck neonatal platelet count. Intramuscular injection\nof vitamin K should not be given if the platelet count is\nnot available, but intravenous or subcutaneous vitamin\nK can be administered.\n4.5  Management of thrombocytopaenia due\nto Pre-eclampsia/HELLP/AFLP\nUrgent delivery should be arranged as it is the mainstay\nof treatment.\nMaternal corticosteroids should be administered\nconsidering fetal maturity to reduce fetal respiratory\nmorbidity.\nIf DIC present, supportive care with FFP, platelet and\ncryoprecipitate should be administered with advice\nfrom the haematologist.\nPET affects 4% of all first pregnancies16. Thrombo-\ncytopenia is the commonest abnormality, occurring in\nup to 50% of women with pre-eclampsia. HELLP\nsyndrome is a serious complication specific to preg-\nnancy characterized by haemolysis, elevated liver\nenzymes, and low platelets. It occurs in about 0.5-\n0.9% of pregnancies and 10-20% of cases with severe\npre-eclampsia17. As delivery is the definitive mode of\ntreatment for maternal concerns, steroid should be\nadministered for fetal lung maturity. Supportive care\nwith the correction of clotting derangement following\ndelivery should be arranged. Careful observation is\nneeded to detect DIC as a complication in 20% of\nwomen with HELLP syndrome18. AFLP treatment\nconsists of supportive management and resuscitation\nof the mother and prompt delivery of the fetus, irres-\npective of the gestational age.",
  "Careful observation is\nneeded to detect DIC as a complication in 20% of\nwomen with HELLP syndrome18. AFLP treatment\nconsists of supportive management and resuscitation\nof the mother and prompt delivery of the fetus, irres-\npective of the gestational age.\n\n--- Page 7 ---\n265\nVol. 43, No. 3, September 2021\nSLCOG Guideline\n4.6 Management of thrombotic thrombo-\ncytopaenic purpura and atypical haemolytic\nuraemic syndrome\nDespite the diagnostic challenge, plasma exchange\n(plasmapheresis) needs to be commenced as soon as\nTTP/aHUS is suspected. Management requires a\nmultidisciplinary approach with the transfusion\nphysician, the obstetrician and the haematologist.\nPlasma transfusions should be given if there is any\ndelay in plasmapheresis.\nIn TTP, plasmapheresis should continue daily until\nthe platelet count is maintained in the normal range\n(>150×109/L)for a minimum of 2 days.\nPlatelet transfusions are contraindicated as they are\nknown to precipitate or exacerbate thrombosis.\nPlasmapheresis is the first-line therapy in TTP and\naHUS. Plasmapheresis removes substances promoting\nplatelet-aggregation and is successful with TTP but is\nless successful with HUS. Plasma infusion should be\nconsidered if there is any delay in plasmapheresis.\nClinical governance\nAccording to the national recommendation, all pregnant\nwomen should have a FBC at booking and repeated at\n26 to 28 weeks of gestation. Haemoglobin and platelet\ncount should be recorded in maternity notes.\nReferences\n1.\nVerdy E, Bessous V, Dreyfus M, Kaplan C,\nTchernia G, Uzan S. Longitudinal analysis of\nplatelet count and volume in normal pregnancy.\nThrombosis and Haemostasis 1997; 77: 806-7.\n2.\nGernsheimer T, James AH, Stasi R. How I treat\nthrombocytopenia in pregnancy blood 2013;\n121(1): 38-47.\n3.\nBurrows RF, Kelton JG. Thrombocytopenia at\ndelivery: a prospective survey of 6715 deliveries.\nAmerican Journal of Obstetrics and Gynecology\n1990; 162: 732-4.\n4.\nMari R. Thomas, Susan Robinson, Marie A. Scully:\nHow we manage thrombotic microangiopathies in\npregnancy: British Journal of Haematology 2016;\n(173): 821-30.\n5.\nDouglas B. Cines, Lisa D. Levine: Thrombo-\ncytopenia in pregnancy: Blood 2017; 130(21):\n2271-7.\n6.\nGill KK, KeltonJG Management of idiopathic\nthrombocytopenic purpura in pregnancy, Semin\nHematol. 2000; 37(3): 275-89.\n7.\nTerry Gernsheimer, Andra H. James,Roberto Stasi:\nHow I treat thrombocytopenia in pregnancy: Blood\n2013; 12(1): 38-47.\n8.\nProvan D and et al. International consensus report\non the investigation and management of primary\nimmune thrombocytopenia. Blood 2010; 115(2):\n168-86.\n9.\nRajasekhar A, Gernsheimer T, Stasi R, James AH.\nClinical Practice Guide on Thrombocytopenia in\nPregnancy. American Society of Hematology.\nAvailable at http://www.hematology.org/Clinicians/\nGuidelines-Quality/Quick-Reference.aspx. 2013;\nAccessed on 14.04.2021.\n10. Scully M, Hunt BJ, Benjamin S, Liesner R, Rose\nP, Peyvandi F, Cheung B, Machin SJ; British\nCommittee for Standards in Haematology.\nGuidelines on the diagnosis and management of\nthrombotic thrombocytopenic purpura and other\nthrombotic microangiopathies. Br J Haematol 2012;\n158(3): 323-35.\n11. Ciobanu AM, Colibaba S, Cimpoca B, Peltecu G,\nPanaitescu AM. Thrombocytopenia in Pregnancy.\nMaedica (Bucur) 2016; 11(1): 55-60.\n12. Gill KK, Kelton JG. Management of idiopathic\nthrombocytopenic purpura in pregnancy. Semin\nHematol. 2000; 37(3): 275-89.\n13. Eslick R, McLintock C. Managing ITP and\nthrombocytopenia in pregnancy. Platelets 2020; 31:\n300-6.\n14. Provan D, Arnold DM, Bussel JB, et al. Updated\ninternational consensus report on the investigation\nand management of primary immune thrombo-\ncytopenia. Blood Adv 2019; 3(22): 3780-817.\n15. Payne SD, Resnik R, Moore TR, et al. Maternal\ncharacteristics and risk of severe neonatal thrombo-\ncytopenia and intracranial hemorrhage in preg-\nnancies complicated by autoimmune thrombo-\ncytopenia. Am J Obstet Gynecol 1997; 177: 149-55.\n16. HernÃindez-DÃaz S, Toh S, Cnattingius S. Risk of\npre-eclampsia in first and subsequent pregnancies:\nprospective cohort study BMJ 2009; 338: b2255\ndoi:10.1136/BMJ.b2255, assessed on 14.04.2021.\nThrombosis and Haemostasis,1997; 77: 806- 807.\n17. Kirkpatrick CA. The HELLP syndrome. ActaClin\nBelg. 2010; 65(2): 91-7.\n18. Martin JN Jr, Rinehart BK, May WL, Magann EF,\nTerrone DA, Blake PG. The spectrum of severe\npre-eclampsia: comparative analysis by HELLP\n(hemolysis, elevated liver enzyme levels, and low\nplatelet count) syndrome classification. Am J\nObstet Gynecol. 1999; 180(6 Pt 1): 1373-84.",
  "Am J\nObstet Gynecol. 1999; 180(6 Pt 1): 1373-84.\n\n--- Page 8 ---\n266\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nAppendix\nEtiological workup\nDiagnosis\nProportion\nPathophysiology\nGestational Thrombocytopenia\nAbout 75%\nPhysiological dilution,\naccelerated destruction\nImmune Thrombocytopenic\nAbout 3%\nImmune destruction,\nPurpura (ITP)\nsuppressed production\nThrombotic Thrombocytopenic\nPeripheral consumption,\nPurpura (TTP)\nmicrothrombi\nAtypical Haemolytic Uraemic\nPeripheral consumption,\nSyndrome (aHUS)\nmicrothrombi\nPre-eclampsia, Eclampsia,\nAbout 15-20%\nPeripheral consumption,\nHaemolysis, Elevated liver enzymes\nmicrothrombi\nand low platelet count\nsyndrome (HELLP)\n Hereditary thrombocytopenia\nBone marrow\nunderproduction\nPseudo thrombocytopenia\nLaboratory artefact\nViral infections: HIV, Epstein-Barr virus\nSecondary autoimmune\nthrombocytopenia, Marrow\nsuppression\nMedications: heparin-induced\nImmunological reaction\nLeukaemia/Lymphoma\nFailure of platelet production,\nbone marrow infiltration\nSevere Vitamin B12 or Folate Deficiency\nFailure of platelet production\nSplenomegaly\nSplenic sequestration",
  "Am J\nObstet Gynecol. 1999; 180(6 Pt 1): 1373-84.\n\n--- Page 8 ---\n266\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nAppendix\nEtiological workup\nDiagnosis\nProportion\nPathophysiology\nGestational Thrombocytopenia\nAbout 75%\nPhysiological dilution,\naccelerated destruction\nImmune Thrombocytopenic\nAbout 3%\nImmune destruction,\nPurpura (ITP)\nsuppressed production\nThrombotic Thrombocytopenic\nPeripheral consumption,\nPurpura (TTP)\nmicrothrombi\nAtypical Haemolytic Uraemic\nPeripheral consumption,\nSyndrome (aHUS)\nmicrothrombi\nPre-eclampsia, Eclampsia,\nAbout 15-20%\nPeripheral consumption,\nHaemolysis, Elevated liver enzymes\nmicrothrombi\nand low platelet count\nsyndrome (HELLP)\n Hereditary thrombocytopenia\nBone marrow\nunderproduction\nPseudo thrombocytopenia\nLaboratory artefact\nViral infections: HIV, Epstein-Barr virus\nSecondary autoimmune\nthrombocytopenia, Marrow\nsuppression\nMedications: heparin-induced\nImmunological reaction\nLeukaemia/Lymphoma\nFailure of platelet production,\nbone marrow infiltration\nSevere Vitamin B12 or Folate Deficiency\nFailure of platelet production\nSplenomegaly\nSplenic sequestration\n\n--- Page 9 ---\n267\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nInitial detection of a pregnant woman with thrombocytopenia. Confirm thrombo-\ncytopenia with repeat FBC and manual platelet count\nThrombocytopenia confirmed\nGood clinical assessment\nBlood picture and haematology referral\nMAHA absent in blood picture\nLFT, ANA,TSH, Viralstudies, US scan abdomen,\nDAT, PT/APTT\nIf underlying pathology detected treat the cause\nMAHA present in the blood picture\nLFT, PET screening, LDH, PT/APTT, Creatinine,\nUS scan abdomen, RBS\nMonitor counts, Regular\nhaematological review,\nSteroids, Anticoagulation\nIf the platelet count less than 70×109/L\nwith no identifiable cause, ITP should\nbe considered\nSevere PET, HELLP,\nAFLP\nStabilize the mother\nTTP, aHUS\nPlasmapheresis,\nDeliver the baby\n•\nMonitor counts\n•\nAvoid NSAIDs /Aspirin\n•\nTreatment to elevate count if bleeding or platelet less than 30×109/L\n•\nTake haematology advice regarding IM injections\n•\nElevate platelet count to 50×109/L for antenatal procedures\n•\nAt 35-36wk, treat to keep platelet count above 80×109/L to allow epidural anaesthesia and delivery\n•\nDocument the need to avoid traumatic delivery – avoid ventouse, forceps, scalp sampling, scalp electrodes\n•\nInform neonatologist – paediatric alert to be sent\n•\nCord blood for neonatal platele count, if less than normal-monitor for thrombocytopenia,\nnadir 3-5 days",
  "3, September 2021\nSLCOG Guideline\nInitial detection of a pregnant woman with thrombocytopenia. Confirm thrombo-\ncytopenia with repeat FBC and manual platelet count\nThrombocytopenia confirmed\nGood clinical assessment\nBlood picture and haematology referral\nMAHA absent in blood picture\nLFT, ANA,TSH, Viralstudies, US scan abdomen,\nDAT, PT/APTT\nIf underlying pathology detected treat the cause\nMAHA present in the blood picture\nLFT, PET screening, LDH, PT/APTT, Creatinine,\nUS scan abdomen, RBS\nMonitor counts, Regular\nhaematological review,\nSteroids, Anticoagulation\nIf the platelet count less than 70×109/L\nwith no identifiable cause, ITP should\nbe considered\nSevere PET, HELLP,\nAFLP\nStabilize the mother\nTTP, aHUS\nPlasmapheresis,\nDeliver the baby\n•\nMonitor counts\n•\nAvoid NSAIDs /Aspirin\n•\nTreatment to elevate count if bleeding or platelet less than 30×109/L\n•\nTake haematology advice regarding IM injections\n•\nElevate platelet count to 50×109/L for antenatal procedures\n•\nAt 35-36wk, treat to keep platelet count above 80×109/L to allow epidural anaesthesia and delivery\n•\nDocument the need to avoid traumatic delivery – avoid ventouse, forceps, scalp sampling, scalp electrodes\n•\nInform neonatologist – paediatric alert to be sent\n•\nCord blood for neonatal platele count, if less than normal-monitor for thrombocytopenia,\nnadir 3-5 days\n\n--- Page 10 ---\n268\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n1. New presentation of thrombocytopenia in 1st / 2nd trimester:\nCheck for: drugs: pre-pregnancy FBC: medical disorder; auto-immune phenomena:\nrenal/liver functions\n2. Presentation of patient with known platelet disorder\nPlatelet count >100×109/l\n                                 Platelet count <80 - 100×109/l\nIn all cases exclude presence red cell fragments\nindicating thrombotic microangiopathy\nMonthly checks by midwife / GP\nRefer back if platelet count\n80-100 109/l bleeding\nRefer back if known ITP in 3rd\ntrimester\n– Check maternal platelet count:\nrisk of low neonatal platelet count\n– ensure measures to avoid\ntraumatic delivery and check cord\nplatelet count\nAssess balance of risks.\nDeliver when possible\n2nd/3rd trimesters\nBP, Proteinuria\nLFTs\nPET; HELLP\nIf ≤34 weeks: try\nto stabilize,\nIf ≥34 weeks:\nAnytime:\nFever,\nneurological\nsigns,\ncreatinine\nLikely TTP\nPlasmapheresis\nIn 1st/2nd trimester low\nplatelet counts probabably\nsecondary to immune\nprocess.\nMonitor monthly, treat if\nbleeding or platelet count\n<20-30×109/l\nRaise platelet count to\n>50×109/l for ante-natal\nprocedures.\nAdvise \navoidance \nof\nNSAIDS, aspirin, IM\ninjections.\nFrom 35-36 weeks, aim to raise platelet count >80×109 /l if possible, to allow for epidural. May require\ncombination of treatments\nMonitor more frequently, depending on level, treatment and rate of change of platelet count\nDocument need for atraumatic delivery: advise avoid ventouse, rotational forceps, scalp clips/sampling\nEnsure paediatric alert sent\nTake cord sample to assess neonatal platelet count. If < normal, needs monitoring over next few days –\nnadir is at 2-5 days\nIntervention\nPlatelet count\nAntenatal, no invasive procedures planned\n>20\nVaginal delivery\n>50\nOperative or instrumental delivery\n>50\nEpidural anaesthesia\n>80\nSafe levels of platelets for interventions",
  "--- Page 1 ---\nManagement of Medical Disease Complicating Pregnancies\n 1  Bronchial Asthma \n2  Tuberculosis\n3  Influenza A & B Virus Infection Including H1N1 \n4  Liver Disease\n5  Renal Disease \n6  Tyroid Disease \n7  Rheumatoid Arthritis \n8  Systemic Lupus Erythematosus\n9  Immune Trombocytopaenic Purpura\n10 Antiphospholipid Syndrome\n11 HIV\n12 Syphilis\n13 Malaria\n2015\nFamily Health Bureau",
  "--- Page 2 ---\nNational Guideline for Maternal Care - Volume II\nII\nThese guidelines are published by the Family Health Bureau, Ministry of \nHealth, 231, De Sarem Place, Colombo 10, Sri Lanka\nWeb. www.fhb.health.gov.lk\nPrepared by Ceylon College of Physicians together with the Sri Lanka \nCollege of Obstetricians and Gynaecologists, National STD and AIDS \nControl Progarmme, Anti Malaria Campaign and National Program for \nTuberculosis Control and Chest Diseases\nEdited by Dr. Camaline Motha and Dr. Nilmini Hemachandra\nCopyright @ 2015 Ministry of Health\nPrinted by ……………………………………\nStatement of Intent\nThe main Purpose of these guidelines are to improve the quality of \nclinical care provided by the health care providers at all levels. These \nparameters of practice should be considered as recommendations \nonly. The ultimate judgement regarding a particular clinical procedure \nor a treatment plan must be made by the clinician in light of the clini-\ncal data gathered from the patient and the diagnosis and treatment \noptions available.",
  "These \nparameters of practice should be considered as recommendations \nonly. The ultimate judgement regarding a particular clinical procedure \nor a treatment plan must be made by the clinician in light of the clini-\ncal data gathered from the patient and the diagnosis and treatment \noptions available.\n\n--- Page 3 ---\nNational Guideline for Maternal Care - Volume II\nIII\nPreface\nThis national guideline on maternal care is very well-timed, as a greater \nemphasis is being given for improving the quality of maternal care services \nfor further reduction of maternal and newborn mortality and morbidity \nin Sri Lanka. This set of guidelines has addressed the relatively rare but \nimportant disease entities which is matching with the epidemiological \ntransition of causality of maternal deaths from direct causes to indirect \ncauses. This is an attempt to improve the quality and uniformity of clinical \ncare with efficiency, cost effectiveness and accountability.\nI highly appreciate the contribution made by Ceylon College of Physicians, \nSri Lanka College of Obstetricians and Gynaecologists and relevant public \nhealth programmes in developing these guidelines. Their experience and \nupdated scientific knowledge is reflecting in the guidelines. \nFurther, these guidelines have been developed considering the policies, \nfacilities, and resources available in the country. As such this set of \nguideline will be considered as national guidelines for the conditions \ndescribed.  \nDr. P. G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka",
  "G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka\n\n--- Page 4 ---\nNational Guideline for Maternal Care - Volume II\nIV\nMessage from the President of Ceylon College of \nPhysicians\nThis\n\n--- Page 5 ---\nNational Guideline for Maternal Care - Volume II\nV\nMessage from the President of Sri Lanka College of \nObstetricians and Gynaecologists\nThis",
  "G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka\n\n--- Page 4 ---\nNational Guideline for Maternal Care - Volume II\nIV\nMessage from the President of Ceylon College of \nPhysicians\nThis\n\n--- Page 5 ---\nNational Guideline for Maternal Care - Volume II\nV\nMessage from the President of Sri Lanka College of \nObstetricians and Gynaecologists\nThis\n\n--- Page 6 ---\nNational Guideline for Maternal Care - Volume II\nVI\nContributors for the guideline development\nCeylon College of Physicians\nCoordinated and compiled by  Dr Carmeline Motha\n \n\t\nProf Chandrika Wijeyaratne\n\t\nDr Priyankara Jayawardana\n\t\nDr Ravini Karunatillake \n\t\nDr Geethal Perera\n\t\nProf. Priyadarshani Galappatthy\n\t\nDr Inoshi Atukorala\n\t\nDr. Senani Williams\n\t\nDr Bernadene Fernandopulle\n\t\nDr Durgadevi  Moratuwagama\n\t\nDr Noel Somasundaram\n\t\nDr Charles Antonypillai\n\t\nDr Madunil Niriella\n\t\nDr Hasitha Wijewantha\n\t\nDr Mananjala Senanayake\n\t\nDr Shamila De Silva\n\t\nDr Sandhya Seneviratne\n \nSri Lanka College of Obstetricians and Gynaecologists\n\t\nProf. Hemantha Senanayake\n\t\nDr. U.D.P. Rathnasiri\n\t\nDr. Janaki Kumarasinghe\n\t\nDr. Ajitha Wijesundara\n\t\nDr. Harsha Atapattu\nNational STD and AIDS control Programme\nAnti-Malaria Campaign\nNational Program for Tuberculosis Control and Chest Diseases\nFamily Health Bureau",
  "Ajitha Wijesundara\n\t\nDr. Harsha Atapattu\nNational STD and AIDS control Programme\nAnti-Malaria Campaign\nNational Program for Tuberculosis Control and Chest Diseases\nFamily Health Bureau\n\n--- Page 7 ---\nNational Guideline for Maternal Care - Volume II\nVII\nMessage from the Minister of Health\nMessage from the Secretary of Ministry of Health\nPreface \nMessage from the President Ceylon College of Physicians\nMessage from the President of Sri Lanka College of \nObstetricians and Gynaecologists\nGuideline Development committee\nList of Abbreviations\nList of Tables\nDisclaimer\nIntroduction\n1.  \nBronchial Asthma in Pregnancy\n1.1     \nIntroduction\n1.2     \nWomen with pre-existing bronchial asthma\n1.3     \nWhen to suspect bronchial asthma in a previously \n \nhealthy  woman\n1.4     \nManagement of bronchial asthma in pregnancy\n1.4.1  \nPharmacological management\n1.4.2  \nAdjuvant therapy for bronchial asthma\n1.5  \nIndications for transfer to intensive care unit (ICU)\n1.6  \nAntenatal care\n1.7  \nDelivery\n1.8  \nPostpartum care\n2.  \nManagement of Tuberculosis during Pregnancy\n2.1  \nHow does tuberculosis spread?\n2.2  \nRisk of infection\n2.3.1 \nWho is a TB suspect?\n2.3.2  \nCase of a ‘Bacteriological confirmed TB’\n2.3.3  \nCase of a ‘clinically diagnosed TB’\n2.4  \nCommon symptoms of pulmonary tuberculosis\n2.5  \nInvestigations\n2.6  \nTB treatment regimens\n2.6.1  \nIntensive phase\n2.6.2  \nContinuation phase\n2.6.3  \nStandard code for TB treatment regimens",
  "Bronchial Asthma in Pregnancy\n1.1     \nIntroduction\n1.2     \nWomen with pre-existing bronchial asthma\n1.3     \nWhen to suspect bronchial asthma in a previously \n \nhealthy  woman\n1.4     \nManagement of bronchial asthma in pregnancy\n1.4.1  \nPharmacological management\n1.4.2  \nAdjuvant therapy for bronchial asthma\n1.5  \nIndications for transfer to intensive care unit (ICU)\n1.6  \nAntenatal care\n1.7  \nDelivery\n1.8  \nPostpartum care\n2.  \nManagement of Tuberculosis during Pregnancy\n2.1  \nHow does tuberculosis spread?\n2.2  \nRisk of infection\n2.3.1 \nWho is a TB suspect?\n2.3.2  \nCase of a ‘Bacteriological confirmed TB’\n2.3.3  \nCase of a ‘clinically diagnosed TB’\n2.4  \nCommon symptoms of pulmonary tuberculosis\n2.5  \nInvestigations\n2.6  \nTB treatment regimens\n2.6.1  \nIntensive phase\n2.6.2  \nContinuation phase\n2.6.3  \nStandard code for TB treatment regimens\n\n--- Page 8 ---\nNational Guideline for Maternal Care - Volume II\nVIII\n2.6.4  \nMonitoring of sputum smear- positive pulmonary TB\n2.6.5  \nTreatment during pregnancy\n2.6.6  \nTreatment during breast feeding\n2.6.7  \nManagement of a new born child of a mother with \n \nactive TB\n2.6.8  \nDirectly Observed Treatment\n2.6.9  \nInterruption of treatment (Lost to follow up)\n2.6.9.1.  Measures to minimize treatment interruption\n2.6.9.2  Management of patients who interrupt treatment\n2.7  \nNotification\n2.8  \nContact screening\n2.9  \nPreventive Treatment\n3.  \nManagement of Influenza A & B Virus Infection Including   \n \nH1N1 in pregnancy\n3.1  \nIntroduction\n3.2  \nProtection against infection\n3.3  \nCase identification\n3.4  \nSeeking medical care\n3.5  \nManagement in the hospital\n3.6  \nLaboratory diagnosis\n3.7  \nAntiviral therapy\n3.8  \nManagement of Labour\n3.9  \nNew born care\n3.10  \nDischarged criteria\n3.11  \nNotification\n3.12  \nSafety of HealthCare workers\n4.  \nLiver Disease in pregnancy\n4.1.         Introduction\n4.2         Pre-existing liver disease\n4.1.1. \nChronic viral hepatitis \n4.1.2. \nCirrhosis \n4.1.3. \nAutoimmune hepatitis\n4.1.4. \nWilsons disease \n4.2.3 \nLiver disease specific to pregnancy\n4.1.5. \nWhen to suspect liver disease\n4.1.6. \nHyperemesis gravidarum\n4.1.7. \nIntrahepatic cholestasis of pregnancy",
  "Hyperemesis gravidarum\n4.1.7. \nIntrahepatic cholestasis of pregnancy\n\n--- Page 9 ---\nNational Guideline for Maternal Care - Volume II\nIX\n4.1.8. \nPreeclampsia\n4.1.9. \nHELLP Syndrome\n4.1.10. Acute Fatty Liver of Pregnancy (AFLP)\n4.2. \nLiver disease coincidental to pregnancy\n4.2.1. \nNon alcoholic fatty liver disease (NAFLD)\n4.2.2. \nDengue infection\n4.2.3. \nAcute viral hepatitis \n4.2.4. \nGall stone disease\n4.2.5. \nSepsis\n4.3. \nAcute liver failure\n5. \nRenal disease in pregnancy\n5.1. \nIntroduction\n5.2. \nPre-existing renal  disease\n5.2.1. \nDiabetic nephropathy\n5.2.2. \nAdult onset polycystic kidney disease\n5.2.3. \nLupus nephritis\n5.2.4. \nOther Glomerulonephritides\n5.3. \nRenal disease occurring during pregnancy\n5.3.1. \nUrinary tract infections (UTI)\n5.3.1.1. Lower UTI\n5.3.1.2. Upper UTI\n5.3.1.3. Asymptomatic bacteriuria (AB)\n5.3.2. \nPreeclampsia\n5.3.3. \nAcute fatty liver of pregnancy (AFLP)\n5.3.4. \nHaemolytic Uraemic Syndrome (HUS) / Trombotic Trombo \n \ncytopaenicPurpura (TTP)\n5.4. \nAcute kidney injury (AKI)\n5.5. \nChronic kidney disease\n5.5.1. \nPreconception care\n5.5.2. \nAntenatal care\n5.6. \nRenal transplantation\n5.7. \nWomen on long term renal dialysis\n5.8. \nIndications for renal biopsy during pregnancy\n6. \nTyroid disease in pregnancy\n6.1.  \nIntroduction\n6.1. \nHypothyroidism in pregnancy\n6.1.1. \nDefinitions",
  "Hypothyroidism in pregnancy\n6.1.1. \nDefinitions\n\n--- Page 10 ---\nNational Guideline for Maternal Care - Volume II\nX\n6.2.2.  \nManagement of hypothyroidism in pregnancy\n6.2. \nHyperthyroidism in pregnancy\n6.2.1. \nDefinitions\n6.2.2. \nManagement of overt hyperthyroidism in pregnancy\n6.3. \nPostpartum thyroid dysfunction (PPTD)\n7.  \nRheumatoid arthritis \n7.1.  \nIntroduction\n7.2.  \nPreconception care\n7.3.  \nAntenatal care\n7.4. \nDelivery \n7.5.  \nPostpartum care \n8.  \nSystemic Lupus Erythematosus\n8.1.  \nIntroduction\n8.2  \nPreconception care\n8.3  \nAntenatal care\n8.4  \nDelivery\n8.5  \nPostpartum care\n8.6  \nContraception\n8.7  \nNeonatal lupus syndrome\n8.8 \nTreatment of lupus nephritis (LN) in pregnancy.\n8.9  \nOther autoimmune connective tissue disease\n9. Immune thrombocytopaenic purpura\n9.1. Introduction\n 9.2 Management of ITP in pregnancy\n9.3. Neonate of a mother with ITP\n9.4. Trombotic thrombocytopaenicpurpura (TTP)\n10. Antiphospholipid syndrome\n10.1. Introduction\n10.2. Management of APS during pregnancy\n11. Prevention and management of HIV in pregnancy\n11.1. \nPrimary prevention strategies  \n11.2. \nScreening for HIV during pregnancy\n11.2. \nWhen the confirmatory test results is negative\n11.3. \nWhen the screening test is positive\n11.4. \nSupport to the HIV positive woman\n11.5. \nDelivery care \n11.6. \nPost partum care",
  "Delivery care \n11.6. \nPost partum care\n\n--- Page 11 ---\nNational Guideline for Maternal Care - Volume II\nXI\n11.7. \nCounsel HIV positive woman on family planning\n11.8. \nInfant feeding with HIV\n12. \nPrevention and management of Syphilis during pregnancy\n12.1. Introduction\n12.2. \nScreening for syphilis\n12.3. \nDiagnosis of syphilis\n12.4. \nTreatment of maternal syphilis\n12.4.1. Treatment of primary, secondary and early latent syphilis\n12.4.2. Late latent syphilis:\n12.5. \nFollow up\n12.6. \nAllergy to penicillin\n12.7. \nTreatment of partners\n12.8. \nDiagnosis of congenital syphilis\n12.9. \nTreatment of the baby\n13. \nGuidelines on malaria chemotherapy and management of   \n \npatients with malaria during pregnancy\n13.1  \nIntroduction\n13.2  \nPatients likely to have malaria\n13.3  \nNotification of malaria patients\n13.4. \nDiagnosis of malaria\n13.5.  \nMonitoring during treatment and follow up of patients\n13.6 \nTreatment of patients with malaria \n13.7 \nMono-infection with Plasmodium vivax\n13.8  \nUncomplicated mono-infection with Plasmodium falciparum\n13.9  \nUncomplicated mixed infections with P. falciparum and P.vivax\n13.10  \nSevere P. falciparum malaria\n13.11  \nPatients infected with other malaria parasites\n13.12  \nChemoprophylaxis for malaria",
  "falciparum and P.vivax\n13.10  \nSevere P. falciparum malaria\n13.11  \nPatients infected with other malaria parasites\n13.12  \nChemoprophylaxis for malaria\n\n--- Page 12 ---\nNational Guideline for Maternal Care - Volume II\nXII\nList of Abbreviations\nThis",
  "falciparum and P.vivax\n13.10  \nSevere P. falciparum malaria\n13.11  \nPatients infected with other malaria parasites\n13.12  \nChemoprophylaxis for malaria\n\n--- Page 12 ---\nNational Guideline for Maternal Care - Volume II\nXII\nList of Abbreviations\nThis\n\n--- Page 13 ---\nNational Guideline for Maternal Care - Volume II\nXIII\nDisclaimer\nThis guidance is intended to provide general advice to streamline the \nmanagement and maintain overall quality of patient care. It should \nnever be relied on as a substitute for proper clinical assessment with \nrespect to the particular circumstances and needs of each patient \nunder your care. It is the responsibility of each Practitioner to have \nregard to the particular circumstances of each individual patient, and \nthe application of this guidance.\nThis guidance has been prepared having regard to the information \navailable at the time of its preparation. Medicine is a continually \nevolving science and the users must have regard to relevant information, \nresearch or material, which may have been published or become \navailable subsequently.",
  "It is the responsibility of each Practitioner to have \nregard to the particular circumstances of each individual patient, and \nthe application of this guidance.\nThis guidance has been prepared having regard to the information \navailable at the time of its preparation. Medicine is a continually \nevolving science and the users must have regard to relevant information, \nresearch or material, which may have been published or become \navailable subsequently.\n\n--- Page 14 ---\nNational Guideline for Maternal Care - Volume II\nXIV\nIntroduction\nClinical Guidelines are systematically developed statements which assist \nclinicians and patients in making decisions about appropriate treatment \nfor specific conditions based on the best scientific evidence at the time of \ndevelopment. Guidelines are not intended to limit the clinical freedom; \nhowever, clinicians are expected to follow these recommendations as the \nbasis for their decisions. Availability of resources, the existing situations, \nand the expectations of individual client needs to be considered. \nThe guidelines are intended to guide all health care workers in all \nlevels of institutions where maternity care is provided. Although these \nguidelines are mainly targeted for the government sector institutions, use \nin the private sector institutions where maternity care is provided, is also \nencouraged.\nThese guidelines are developed by expert group from the Ceylon College of \nPhysicians and consensus were obtained from the guideline development \ngroup of the Sri Lanka College of Obstetricians and Gynaecologists in \nconsultation with other relevant specialists such as anaesthesiologists, \nphysicians, endocrinologists, and haematologists etc. The existing national \nand international  guidelines,  and WHO guidelines were perused and \nmixed with the local scenarios and expert opinion. The latest available \nscientific evidences were considered and included where ever necessary. \nThen, the draft guidelines were presented to the wider forum of experts and \nconsensuses were reached. After that   the guidelines were handed over to \nthe Ministry of Health and consensus were built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.",
  "Then, the draft guidelines were presented to the wider forum of experts and \nconsensuses were reached. After that   the guidelines were handed over to \nthe Ministry of Health and consensus were built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume II\n1\nBronchial Asthma\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume II\n2",
  "Then, the draft guidelines were presented to the wider forum of experts and \nconsensuses were reached. After that   the guidelines were handed over to \nthe Ministry of Health and consensus were built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume II\n1\nBronchial Asthma\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume II\n2\n\n--- Page 17 ---\nNational Guideline for Maternal Care - Volume II\n3\n1.Bronchial asthma in pregnancy\n1.1. Introduction\n\t\n➢\t The majority of women with bronchial asthma (BA) have an \t \t\n\t\n\t\nuncomplicated pregnancy.\n\t\n➢\t Poorly controlled BA is associated with maternal and perinatal  \t\n\t\n\t\nmorbidity and mortality, including,\n\t\n\t\no\t  Spontaneous abortion\n\t\n\t\no\t  Fetal growth restriction\n\t\n\t\no\t  Preterm delivery\n\t\n\t\no\t  Low birth weight babies\n1.2. Women with pre-existing bronchial asthma\n\t\n➢\t Optimise control  of bronchial asthma in those with poorly \t \t\n\t\n\t\ncontrolled disease. This should be done in the preconception \t\t\n\t\n\t\nperiod or at least in early pregnancy.\n\t\n➢\t Women who are on prophylactic medication for BA should \t \t\n\t\n\t\ncontinue it during pregnancy. \n\t\n➢\t The course of BA is pregnancy is variable. \n\t\n\t\no\t One third of women experience improvement in symptoms, \t\n\t\n\t\n\t\none third worsening and one third remain unchanged.\n\t\n\t\no\t Women with poorly controlled asthma, are more likely to \t\t\n\t\n\t\n\t\nexperience worsening of symptoms during pregnancy.\n\t\n\t\no\t Worsening of symptoms is most likely in the second and third \t\n\t\n\t\n\t\ntrimesters.\n\t\n\t\no\t In the last month of pregnancy and during the  peripartum \t\n\t\n\t\n\t\nperiod, patients are least likely to have an asthma attack.",
  "➢\t The course of BA is pregnancy is variable. \n\t\n\t\no\t One third of women experience improvement in symptoms, \t\n\t\n\t\n\t\none third worsening and one third remain unchanged.\n\t\n\t\no\t Women with poorly controlled asthma, are more likely to \t\t\n\t\n\t\n\t\nexperience worsening of symptoms during pregnancy.\n\t\n\t\no\t Worsening of symptoms is most likely in the second and third \t\n\t\n\t\n\t\ntrimesters.\n\t\n\t\no\t In the last month of pregnancy and during the  peripartum \t\n\t\n\t\n\t\nperiod, patients are least likely to have an asthma attack.\n\n--- Page 18 ---\nNational Guideline for Maternal Care - Volume II\n4\n1.3. \nWhen to suspect bronchial asthma in a previously \nhealthy woman\n➢ \nBA is a clinical diagnosis based on the recognition of  \n \n \ncharacteristic pattern of symptoms and signs in the absence of  \n \nan alternative explanation.\n➢ \nWhen the diagnosis of BA is doubtful, objective assessment  \n \nshould be carried out.\nDiagnosis of bronchial asthma\nClinical features that increase the \nprobability of asthma\nClinical features that lower the \nprobability of asthma\nIsolated cough in the absence of \nwheezeor difficulty breathing\nRepeatedly normal physical \nexamination of chest when \nsymptomatic\nNormal peak expiratory flow \nrate (PEFR) or spirometry\n when symptomatic\nNo response to a trial of asthma \ntherapy\nClinical features suggestive of \nan alternative diagnosis \nWheeze, cough, difficulty \nbreathing, chest tightness and \naudible wheeze on auscultation, \nparticularly if these symptoms:\n-- are frequent and recurrent \n-- are worse at night and in the \n    early morning\n-- occur in response to, or are \nworse afer, exercise or other \ntriggers such as exposure to pets, \ncold or damp air or with \nemotions or laughter.\nEspecially in the presence of, \na personal history of atopic \ndisorder unexplained \npulmonary eosinophilia\nfamily history of atopic disorder \nand/or asthma\nhistory of improvement in \nsymptoms in response to \nadequate therapy\nlikely\nunlikely",
  "o\t One third of women experience improvement in symptoms, \t\n\t\n\t\n\t\none third worsening and one third remain unchanged.\n\t\n\t\no\t Women with poorly controlled asthma, are more likely to \t\t\n\t\n\t\n\t\nexperience worsening of symptoms during pregnancy.\n\t\n\t\no\t Worsening of symptoms is most likely in the second and third \t\n\t\n\t\n\t\ntrimesters.\n\t\n\t\no\t In the last month of pregnancy and during the  peripartum \t\n\t\n\t\n\t\nperiod, patients are least likely to have an asthma attack.\n\n--- Page 18 ---\nNational Guideline for Maternal Care - Volume II\n4\n1.3. \nWhen to suspect bronchial asthma in a previously \nhealthy woman\n➢ \nBA is a clinical diagnosis based on the recognition of  \n \n \ncharacteristic pattern of symptoms and signs in the absence of  \n \nan alternative explanation.\n➢ \nWhen the diagnosis of BA is doubtful, objective assessment  \n \nshould be carried out.\nDiagnosis of bronchial asthma\nClinical features that increase the \nprobability of asthma\nClinical features that lower the \nprobability of asthma\nIsolated cough in the absence of \nwheezeor difficulty breathing\nRepeatedly normal physical \nexamination of chest when \nsymptomatic\nNormal peak expiratory flow \nrate (PEFR) or spirometry\n when symptomatic\nNo response to a trial of asthma \ntherapy\nClinical features suggestive of \nan alternative diagnosis \nWheeze, cough, difficulty \nbreathing, chest tightness and \naudible wheeze on auscultation, \nparticularly if these symptoms:\n-- are frequent and recurrent \n-- are worse at night and in the \n    early morning\n-- occur in response to, or are \nworse afer, exercise or other \ntriggers such as exposure to pets, \ncold or damp air or with \nemotions or laughter.\nEspecially in the presence of, \na personal history of atopic \ndisorder unexplained \npulmonary eosinophilia\nfamily history of atopic disorder \nand/or asthma\nhistory of improvement in \nsymptoms in response to \nadequate therapy\nlikely\nunlikely\n\n--- Page 19 ---\nNational Guideline for Maternal Care - Volume II\n5\nBox 1.1  Objective assessment of bronchial asthma\n\t\nIt is \n\t\n➢\t When to consider a diagnosis other than bronchial asthma– \t \t\n\t\n\t\nRed flag symptoms/ signs\n\t\n\t\no\t Constitutional symptoms /inadequate weight gain in \t\n\t\n\t\n\t\n\t\npregnancy /loss of appetite \n\t\n\t\no\t Haemoptysis \n\t\n\t\no\t Excessive sputum production \n\t\n\t\no\t Pleuritic chest pain \n\t\n\t\no\t Elevated JVP/significant murmurs \n\t\n\t\no\t Crackles on auscultation of the lungs \nCardiac disease in particular should be excluded, when symptoms are \natypical and not responding to conventional antiasthma medications.\nBronchial asthma is confirmed by demonstrating reversibility of airflow \nobstruction by spirometry or peak expiratory flowmetry during the \nsymptomatic stage.\n• \n •  \n\t\na. \n\t\nb. \n\t\n\t\n\t\n\t\n\t\n-\nIt is important to assess the PEFR and document the highest/best reading \nfor an individual patient for monitoring of disease. \nPEFR should be recorded as the best of three forced expiratory blows \nfrom total lung capacity with a maximum pause of two seconds before \nblowing.\nA FEV1/FVC ratio <0.7 on spirometry, suggests an obstructive \nelement and probable asthma\nReversibility testing - An increase in FEV1 of > 400ml or  peak \nexpiratory flow rate (PEFR) of >15% of baseline PEFR after inhalation \nof \nSalbutamol 400 µg (100 µg *4) via a spacer device \n\t\n\t\n\t\n\t\nOR\nInhaled corticosteroids ( Beclomethasone 200µg BD) for 6-8 \nweeks or oral steroids 30mg OD for 14 days \n\t\nconfirms a diagnosis of bronchial asthma.",
  "-\nIt is important to assess the PEFR and document the highest/best reading \nfor an individual patient for monitoring of disease. \nPEFR should be recorded as the best of three forced expiratory blows \nfrom total lung capacity with a maximum pause of two seconds before \nblowing.\nA FEV1/FVC ratio <0.7 on spirometry, suggests an obstructive \nelement and probable asthma\nReversibility testing - An increase in FEV1 of > 400ml or  peak \nexpiratory flow rate (PEFR) of >15% of baseline PEFR after inhalation \nof \nSalbutamol 400 µg (100 µg *4) via a spacer device \n\t\n\t\n\t\n\t\nOR\nInhaled corticosteroids ( Beclomethasone 200µg BD) for 6-8 \nweeks or oral steroids 30mg OD for 14 days \n\t\nconfirms a diagnosis of bronchial asthma.\n\n--- Page 20 ---\nNational Guideline for Maternal Care - Volume II\n6\nStepwise approach to pharmacological management of pre-existing\nor newly diagnosed bronchial asthma\nDay time symptoms > 3 times/week\nNight time symptoms > 2 times/month\nLimitation of daily activities\nSevere attack/s requiring hospital\nadmission/s\nRescue medication \n(bronchodilators/anticholinergics)>3\ntimes/week \nif yes>1\nif no to all\nMild intermittent BA\nOral/inhaled bronchodilators as\nrequired\nInhaled short-acting ß2 agonists\nInhaled ipratropium bromide\nß2 agonist tablets or syrup\nTeophyllines\n-Short-acting inhaled ß2 agonists \nhavea faster onset of action and \nfewer sideeffects then the \nalternatives.\nPersistent BA\nRequires prevebtive therapy \n(inhaledcorticosteroids) \n- see below*\n1.4. Management of bronchial asthma in pregnancy\n\t\n1.4.1. Pharmacological management\n\t\n➢\t Medications used in the non pregnant population have been \t \t\n\t\n\t\nshown to be safe in pregnancy in treatment doses.\n\t\n➢\t Harm to the fetus from severe or chronically undertreated \t\n\t\n\t\n\t\nasthma outweighs any small risk from the medications used to \t\n\t\n\t\ncontrol asthma.\t\n\t\n➢\t Women should be informed of the importance of continuing \t\t\n\t\n\t\ntheir asthma medications during pregnancy to ensure good \t \t\n\t\n\t\nasthma control.\n\t\n➢\t Management is similar to that outside pregnancy.",
  "Management of bronchial asthma in pregnancy\n\t\n1.4.1. Pharmacological management\n\t\n➢\t Medications used in the non pregnant population have been \t \t\n\t\n\t\nshown to be safe in pregnancy in treatment doses.\n\t\n➢\t Harm to the fetus from severe or chronically undertreated \t\n\t\n\t\n\t\nasthma outweighs any small risk from the medications used to \t\n\t\n\t\ncontrol asthma.\t\n\t\n➢\t Women should be informed of the importance of continuing \t\t\n\t\n\t\ntheir asthma medications during pregnancy to ensure good \t \t\n\t\n\t\nasthma control.\n\t\n➢\t Management is similar to that outside pregnancy.\n\n--- Page 21 ---\nNational Guideline for Maternal Care - Volume II\n7\n• Assess control in 2 weeks\n- If inadequate control, start a preparation of combined\nlong acting ß2 agonist (laba) and steroid\nEg. Salmeterol/Fluticasone or Formeterol/Budesonide\npreparation\nInhaled corticosteroid\nEg. Beclomethasone\nVia HFA inhaler(MDI) 250-500µg/day OR\nDP caps 400-800µg/day\nin twice daily divided doses.\nAssess control in 2 weeks\nStop LABA\nIncrease inhaled steroid\ndose to 800µg/day\nNo response to LABA*\nControl still inadequate\n• High dose inhaled corticosteroid\n  (2000mcg/day)\n• Use oral steroids at lowest dose for\n   adequate control\nContril still inadequate\nTrial of add on therapy\n• Leukotriene receptor antagonists\n• Teophyllines\nResponse to LABA but\ncontrol still inadequate\n• Use  a combination\n   inhaler with higher\n   steroid content\n• Eg: 400/800µg/day\n   via HFA haler\nGood response to LABA\nContinue LABA and\ninhaled corticosteroids\nor\n t Persistent BA\n\t\n➢\t Start patient at a dose of inhaled corticosteroids appropriate to \t\n\t\n\t\nthe severity of disease.\n\t\n➢\t Titrate the dose of inhaled corticosteroid to the lowest dose at \t\n\t\n\t\nwhich effective control of asthma is achieved.\n\t\n➢\t Before initiating a new medication, practitioners should recheck \t\n\t\n\t\nadherence to inhaler technique and help eliminate trigger factors.",
  "Salmeterol/Fluticasone or Formeterol/Budesonide\npreparation\nInhaled corticosteroid\nEg. Beclomethasone\nVia HFA inhaler(MDI) 250-500µg/day OR\nDP caps 400-800µg/day\nin twice daily divided doses.\nAssess control in 2 weeks\nStop LABA\nIncrease inhaled steroid\ndose to 800µg/day\nNo response to LABA*\nControl still inadequate\n• High dose inhaled corticosteroid\n  (2000mcg/day)\n• Use oral steroids at lowest dose for\n   adequate control\nContril still inadequate\nTrial of add on therapy\n• Leukotriene receptor antagonists\n• Teophyllines\nResponse to LABA but\ncontrol still inadequate\n• Use  a combination\n   inhaler with higher\n   steroid content\n• Eg: 400/800µg/day\n   via HFA haler\nGood response to LABA\nContinue LABA and\ninhaled corticosteroids\nor\n t Persistent BA\n\t\n➢\t Start patient at a dose of inhaled corticosteroids appropriate to \t\n\t\n\t\nthe severity of disease.\n\t\n➢\t Titrate the dose of inhaled corticosteroid to the lowest dose at \t\n\t\n\t\nwhich effective control of asthma is achieved.\n\t\n➢\t Before initiating a new medication, practitioners should recheck \t\n\t\n\t\nadherence to inhaler technique and help eliminate trigger factors.\n\n--- Page 22 ---\nNational Guideline for Maternal Care - Volume II\n8\nBox 1.2 Medication summary\nRelievers (For quick relief)\n\t\n➢\t Short acting bronchodilators (SABA)  \n\t\n\t\n•\t Inhaled salbutamol (HFA -100 µg per puff, DP capsules- \t\n\t\n\t\n\t\n200 µg, 400 µg ) or oral salbutamol\n\t\n\t\n•\t Iptratropium inhalers ( DP capsules -20 µg, HFA - 40 µg \t\n\t\n\t\n\t\nper puff)\n\t\n\t\n•\t Oral theophyllines – Theophylline 125 mg bd or modified \t\n\t\n\t\n\t\nrelease formulations for short periods only ( Since serum \t\n\t\n\t\n\t\nlevel monitoring is not available and protein binding \t\n\t\n\t\n\t\ncould change in pregnancy)\n\t\n-\t Metered dose inhalers should preferably be used with a \t\n\t\n\t\nspacer device, especially in the third trimester.  \n\t\n\t\nPreventers (Long term control medications)\n\t\n➢\t Inhaled corticosteroids (ICS)\n\t\n\t\n•\t ICS are more effective when taken twice rather than once \t\n\t\n\t\n\t\ndaily. \n\t\n\t\n•\t There is little evidence of benefit for dosage frequency \t\n\t\n\t\n\t\nmore than twice daily. \n\t\n\t\n•\t Titrate the dose of inhaled corticosteroid to the lowest \t\n\t\n\t\n\t\ndose at which effective control of asthma is maintained.\n\t\n➢\t Long acting beta 2 agonists (LABA)\n\t\n\t\n•\t These should always be given in combination with ICS. \n\t\n\t\n•\t Combined inhaler preparations are available.\n\t\n\t\n\t\nEg:   Salmeterol/Fluticasone \n\t\n\t\n\t\nFormoterol/ Budesonide\n  \n\t\n➢\t Leukotriene receptor antagonists\n\t\n\t\n\t\nEg:  Montelukast 10mg once daily, usually at night",
  "•\t Titrate the dose of inhaled corticosteroid to the lowest \t\n\t\n\t\n\t\ndose at which effective control of asthma is maintained.\n\t\n➢\t Long acting beta 2 agonists (LABA)\n\t\n\t\n•\t These should always be given in combination with ICS. \n\t\n\t\n•\t Combined inhaler preparations are available.\n\t\n\t\n\t\nEg:   Salmeterol/Fluticasone \n\t\n\t\n\t\nFormoterol/ Budesonide\n  \n\t\n➢\t Leukotriene receptor antagonists\n\t\n\t\n\t\nEg:  Montelukast 10mg once daily, usually at night\n\n--- Page 23 ---\nNational Guideline for Maternal Care - Volume II\n9\n1.4.2. Adjuvant therapy for bronchial asthma\n\t\n➢\t Women with recurrent exacerbations related to gastro \t\n\t\n\t\n\t\noesophageal reflux disease or allergic rhinosinusitis, need control \t\n\t\n\t\nof these with appropriate medication and lifestyle measures.\n\t\n\t\no\t Antihistamines - No teratogenicity reported\n\t\n\t\n\t\n-\t\nSedating antihistamines used towards the latter part of \t\n\t\n\t\n\t\n\t\npregnancy may adversely affect the neonate\n\t\n\t\no\t Intranasal steroids- Beclamethasone, Budesonide and \t\n\t\n\t\n\t\n\t\nFluticasone are safe\n\t\n\t\no\t Antacids\n\t\n\t\n-\t   Omeprazole and H2 receptor blockers are safe\n\t\n➢\t Active and passive smoking and indoor air pollution to be \t\n\t\n\t\n\t\navoided\n                \n \t\nPrevention of acute deterioration\n\t\n➢\t A register of patients at risk may help primary care health \t\n\t\n\t\n\t\nprofessionals to identify patients who are at high risk of \t\n\t\n\t\n\t\ndeterioration.",
  "•\t Combined inhaler preparations are available.\n\t\n\t\n\t\nEg:   Salmeterol/Fluticasone \n\t\n\t\n\t\nFormoterol/ Budesonide\n  \n\t\n➢\t Leukotriene receptor antagonists\n\t\n\t\n\t\nEg:  Montelukast 10mg once daily, usually at night\n\n--- Page 23 ---\nNational Guideline for Maternal Care - Volume II\n9\n1.4.2. Adjuvant therapy for bronchial asthma\n\t\n➢\t Women with recurrent exacerbations related to gastro \t\n\t\n\t\n\t\noesophageal reflux disease or allergic rhinosinusitis, need control \t\n\t\n\t\nof these with appropriate medication and lifestyle measures.\n\t\n\t\no\t Antihistamines - No teratogenicity reported\n\t\n\t\n\t\n-\t\nSedating antihistamines used towards the latter part of \t\n\t\n\t\n\t\n\t\npregnancy may adversely affect the neonate\n\t\n\t\no\t Intranasal steroids- Beclamethasone, Budesonide and \t\n\t\n\t\n\t\n\t\nFluticasone are safe\n\t\n\t\no\t Antacids\n\t\n\t\n-\t   Omeprazole and H2 receptor blockers are safe\n\t\n➢\t Active and passive smoking and indoor air pollution to be \t\n\t\n\t\n\t\navoided\n                \n \t\nPrevention of acute deterioration\n\t\n➢\t A register of patients at risk may help primary care health \t\n\t\n\t\n\t\nprofessionals to identify patients who are at high risk of \t\n\t\n\t\n\t\ndeterioration.\n\n--- Page 24 ---\nNational Guideline for Maternal Care - Volume II\n10\n \n1.5.Indications for transfer to the intensive care unit (ICU)\n\t\n➢\t Deteriorating PEFR despite appropriate treatment\n\t\n\t\n➢\t Persisting or worsening hypoxia",
  "•\t Combined inhaler preparations are available.\n\t\n\t\n\t\nEg:   Salmeterol/Fluticasone \n\t\n\t\n\t\nFormoterol/ Budesonide\n  \n\t\n➢\t Leukotriene receptor antagonists\n\t\n\t\n\t\nEg:  Montelukast 10mg once daily, usually at night\n\n--- Page 23 ---\nNational Guideline for Maternal Care - Volume II\n9\n1.4.2. Adjuvant therapy for bronchial asthma\n\t\n➢\t Women with recurrent exacerbations related to gastro \t\n\t\n\t\n\t\noesophageal reflux disease or allergic rhinosinusitis, need control \t\n\t\n\t\nof these with appropriate medication and lifestyle measures.\n\t\n\t\no\t Antihistamines - No teratogenicity reported\n\t\n\t\n\t\n-\t\nSedating antihistamines used towards the latter part of \t\n\t\n\t\n\t\n\t\npregnancy may adversely affect the neonate\n\t\n\t\no\t Intranasal steroids- Beclamethasone, Budesonide and \t\n\t\n\t\n\t\n\t\nFluticasone are safe\n\t\n\t\no\t Antacids\n\t\n\t\n-\t   Omeprazole and H2 receptor blockers are safe\n\t\n➢\t Active and passive smoking and indoor air pollution to be \t\n\t\n\t\n\t\navoided\n                \n \t\nPrevention of acute deterioration\n\t\n➢\t A register of patients at risk may help primary care health \t\n\t\n\t\n\t\nprofessionals to identify patients who are at high risk of \t\n\t\n\t\n\t\ndeterioration.\n\n--- Page 24 ---\nNational Guideline for Maternal Care - Volume II\n10\n \n1.5.Indications for transfer to the intensive care unit (ICU)\n\t\n➢\t Deteriorating PEFR despite appropriate treatment\n\t\n\t\n➢\t Persisting or worsening hypoxia\n\n--- Page 25 ---\nNational Guideline for Maternal Care - Volume II\n11\n\t\n➢\t Hypercapnia or inappropriate eucapnea (see box below)\n\t\n➢\t Arterial blood gas analysis showing a fall in pH or rising H + \t\t\n\t\nconcentration \n\t\n➢\t Exhaustion, feeble respiration\n\t\n➢\t Drowsiness, confusion, altered conscious state\n\t\n➢\t Respiratory arrest\nBox 1.3 Interpretation of arterial blood gas in pregnancy\n1.6.\t Antenatal care\n\t\n➢\t If patient’s disease is under control, the patient does not require \t\n\t\n\t\nany additional monitoring or interventions. \n\t\n➢\t However, if the patient is on preventive therapy and \t \t\n\t\n\t\n\t\ndisease not adequately controlled, refer to a physician for \t\n\t\n\t\n\t\noptimising management and formulating a plan for the rest \t of \t\n\t\n\t\npregnancy.\n\t\n➢\t In the event of uncontrolled/severe BA, regular growth \t\n\t\n\t\n\t\nmonitoring of the fetus should be performed.\n1.7.\t\nDelivery\n\t\n➢\t\nWorsening disease is generally not a problem at this time due to \t\n\t\n\t\nendogenous steroid production at time of labour.\n\t\n➢\t\nWomen should continue their routine asthma medications \t \t\n\t\n\t\nduring labour.\n\t\n➢\t\nIn the absence of acute severe asthma, caesarean section is \t \t\n\t\n\t\nperformed only for obstetric indications.\n\t\n➢\t\nIf anaesthesia is required, regional anaesthesia is preferred \t \t\n\t\n\t\nover general anaesthesia.\n\t\n➢\t\nDue to  progesterone driven increase in minute ventilation the \t\n\t\n\t\nfollowing changes are expected in healthy pregnant women\n\t\no\t\nHigh Pao2\n\t\no\t\nHypocapnia\n\t\no\t\nRespiratory alkalosis\nOxygen saturation remains unaltered",
  "Adjuvant therapy for bronchial asthma\n\t\n➢\t Women with recurrent exacerbations related to gastro \t\n\t\n\t\n\t\noesophageal reflux disease or allergic rhinosinusitis, need control \t\n\t\n\t\nof these with appropriate medication and lifestyle measures.\n\t\n\t\no\t Antihistamines - No teratogenicity reported\n\t\n\t\n\t\n-\t\nSedating antihistamines used towards the latter part of \t\n\t\n\t\n\t\n\t\npregnancy may adversely affect the neonate\n\t\n\t\no\t Intranasal steroids- Beclamethasone, Budesonide and \t\n\t\n\t\n\t\n\t\nFluticasone are safe\n\t\n\t\no\t Antacids\n\t\n\t\n-\t   Omeprazole and H2 receptor blockers are safe\n\t\n➢\t Active and passive smoking and indoor air pollution to be \t\n\t\n\t\n\t\navoided\n                \n \t\nPrevention of acute deterioration\n\t\n➢\t A register of patients at risk may help primary care health \t\n\t\n\t\n\t\nprofessionals to identify patients who are at high risk of \t\n\t\n\t\n\t\ndeterioration.\n\n--- Page 24 ---\nNational Guideline for Maternal Care - Volume II\n10\n \n1.5.Indications for transfer to the intensive care unit (ICU)\n\t\n➢\t Deteriorating PEFR despite appropriate treatment\n\t\n\t\n➢\t Persisting or worsening hypoxia\n\n--- Page 25 ---\nNational Guideline for Maternal Care - Volume II\n11\n\t\n➢\t Hypercapnia or inappropriate eucapnea (see box below)\n\t\n➢\t Arterial blood gas analysis showing a fall in pH or rising H + \t\t\n\t\nconcentration \n\t\n➢\t Exhaustion, feeble respiration\n\t\n➢\t Drowsiness, confusion, altered conscious state\n\t\n➢\t Respiratory arrest\nBox 1.3 Interpretation of arterial blood gas in pregnancy\n1.6.\t Antenatal care\n\t\n➢\t If patient’s disease is under control, the patient does not require \t\n\t\n\t\nany additional monitoring or interventions. \n\t\n➢\t However, if the patient is on preventive therapy and \t \t\n\t\n\t\n\t\ndisease not adequately controlled, refer to a physician for \t\n\t\n\t\n\t\noptimising management and formulating a plan for the rest \t of \t\n\t\n\t\npregnancy.\n\t\n➢\t In the event of uncontrolled/severe BA, regular growth \t\n\t\n\t\n\t\nmonitoring of the fetus should be performed.\n1.7.\t\nDelivery\n\t\n➢\t\nWorsening disease is generally not a problem at this time due to \t\n\t\n\t\nendogenous steroid production at time of labour.\n\t\n➢\t\nWomen should continue their routine asthma medications \t \t\n\t\n\t\nduring labour.\n\t\n➢\t\nIn the absence of acute severe asthma, caesarean section is \t \t\n\t\n\t\nperformed only for obstetric indications.\n\t\n➢\t\nIf anaesthesia is required, regional anaesthesia is preferred \t \t\n\t\n\t\nover general anaesthesia.\n\t\n➢\t\nDue to  progesterone driven increase in minute ventilation the \t\n\t\n\t\nfollowing changes are expected in healthy pregnant women\n\t\no\t\nHigh Pao2\n\t\no\t\nHypocapnia\n\t\no\t\nRespiratory alkalosis\nOxygen saturation remains unaltered\n\n--- Page 26 ---\nNational Guideline for Maternal Care - Volume II\n12\n\t\n➢\t\nWomen who have received a dose of prednisolone > 7.5 \t\n\t\n\t\n\t\nmg/day for more than two weeks prior to delivery, should \t \t\n\t\n\t\nbe commenced on hydrocortisone 100mg 6 hourly during \t \t\n\t\n\t\nlabour.\n\t\n➢\t\nProstaglandin E2 could be safely used for induction of \t\n\t\n\t\n\t\nlabour.\n\t\n➢\t\nProstaglandin F2α (Carboprost/Hemobate) used to treat \t\n\t\n\t\n\t\npostpartum haemorrhage due to uterine atony may cause \t \t\n\t\n\t\nbronchospasm.\n\t\n➢\t\nErgometrine may cause bronchospasm, though Syntometrine \t\n\t\n\t\ndoes not.\n1.8.\t\nPostpartum care\n\t\n➢\t\nAll medications used in control and treatment of asthma is safe \t\n\t\n\t\nto be used during breastfeeding.\n\t\n➢\t\nMaternal dose of up to 20 mg of prednisolone daily is \t\n\t\n\t\n\t\nconsidered  safe.\n\t\n➢\t\nWomen on higher doses of prednisolone should be advised to \t\n\t\n\t\nbreastfeed after a lapse of 3-4 hours of taking the steroid.\nReferences\n1.\t British guideline on the management of asthma; A national \t\n\t\n\t\nclinical guideline. British Thoracic Society, Scottish Intercollegiate \t\n\t\nGuidelines Network 2014.\n2. \t National asthma education and prevention program. Quick \t\n\t\n\t\nReference from the Working Group Report on managing asthma \t\n\t\nduring pregnancy: Recommendations for pharmacological \t\n\t\n\t\ntreatment. Update 2004.\n3. \t Vanessa E. Murphy, Michael Schatz. Asthma in pregnancy: a hit for \t\n\t\ntwo. European respiratory  Review  2014; 23: 64–68.\n4.\t Mina Gaga, Eleftherios Zervas. Breathing for two: pregnancy, asthma \t\n\t\nand respiratory failure. European  Respiratory  Review  2014; 23: 5–7.",
  "Breathing for two: pregnancy, asthma \t\n\t\nand respiratory failure. European  Respiratory  Review  2014; 23: 5–7.\n\n--- Page 27 ---\nNational Guideline for Maternal Care - Volume II\n13\nTuberculosis\n\n--- Page 28 ---\nNational Guideline for Maternal Care - Volume II\n14",
  "Breathing for two: pregnancy, asthma \t\n\t\nand respiratory failure. European  Respiratory  Review  2014; 23: 5–7.\n\n--- Page 27 ---\nNational Guideline for Maternal Care - Volume II\n13\nTuberculosis\n\n--- Page 28 ---\nNational Guideline for Maternal Care - Volume II\n14\n\n--- Page 29 ---\nNational Guideline for Maternal Care - Volume II\n15\n2.\t\nMANAGEMENT OF TUBERCULOSIS DURING PREGNANCY\nTuberculosis is an infectious disease caused by the bacillus \nMycobacterium tuberculosis and occasionally by Mycobacterium bovis \nand Mycobacterium africanum. Tuberculosis commonly affects the lungs, \nbut it can affect any other organ in the body.\n2.1. How does tuberculosis spread? \nThe bacteria that cause tuberculosis usually spread through air. When a \npatient with infectious pulmonary tuberculosis coughs, sneezes or laughs, \nbacilli are expelled into the air in the form of tiny droplets. These droplets \ndry up rapidly to form droplet nuclei and may remain suspended in the \nair for several hours. Adequate through and through ventilation removes \nand dilutes these droplet nuclei, and direct sunlight quickly kills the \nbacilli, but they can survive in the dark for several days. When a healthy \nperson inhales these droplet nuclei containing the tubercle bacilli, he/she \nmay become infected.\n2.2. Risk of infection \nAn individual’s risk of infection depends on the extent of exposure to an \ninfectious source and susceptibility of the individual to infection. The \nrisk of infection is therefore high in a person who has close, prolonged \nexposure to a person with sputum smear positive pulmonary TB. The risk \nof transmission of infection from sputum smear-negative pulmonary TB \nis low and with extrapulmonary TB, still lower.\n2.3.1. Who is a TB suspect? \nA TB suspect is a person who presents with symptoms or signs suggestive \nof TB, particularly cough of two weeks or more. \n2.3.2.\t\nCase of a “Bacteriologically confirmed TB”\nA patient whose biological specimen is positive by smear microscopy, \nculture or WRD (such as Xpert MTB/RIF. \n2.3.3.\t\nA case of a “Clinically diagnosed TB” \nOne who does not fulfil the criteria for bacteriologica confirmation but \nhas been diagnosed with active TB by a clinician who has decided to give \nthe patient a full course of TB treatment. This definition includes cases",
  "2.3.3.\t\nA case of a “Clinically diagnosed TB” \nOne who does not fulfil the criteria for bacteriologica confirmation but \nhas been diagnosed with active TB by a clinician who has decided to give \nthe patient a full course of TB treatment. This definition includes cases\n\n--- Page 30 ---\nNational Guideline for Maternal Care - Volume II\n16\ndiagnosed on the basis of X-ray abnormalities or suggestive histology and \nextra pulmonary cases without laboratory confirmation.\nClinically diagnosed cases subsequently found to be bacteriologically \npositive (before or after starting treatment) should be reclassified as \nbacteriologically confirmed. \n2.4. Common symptoms of pulmonary tuberculosis \nThe clinical presentation of tuberculosis in pregnant women is similar to \nthat in non-pregnant patients.\nRespiratory symptoms: \n\t\nCough – usually more than two weeks \n\t\nShortness of breath \n\t\nChest pain\n\t\nHaemoptysis (blood stained sputum) \nConstitutional Symaptoms:\n\t\nFever and night sweats\n\t\nLoss of appetite\n\t\nLoss of weight\n\t\nTiredness (Fatigue)\nHowever, prevalence surveys worldwide revealed that TB can be presented \nwithout cough also.\nSymptoms of Extrapulmonary TB \nThe symptoms depend on the organ involved. Patients may present with \nconstitutional features of the disease – fever, night sweats, loss of weight, \nand loss of appetite or local symptoms related to the site of the disease.\n2.5. Investigations \nSputum Smear microscopy \nSputum smear microscopy is the most reliable and cost effective method \nof diagnosing infectious cases of pulmonary tuberculosis cases. Whenever \ntuberculosis is suspected in a patient who has had a cough of two weeks \nor more, three sputum samples should be collected and examined by \nmicroscopy for Acid-Fast Bacilli (AFB).",
  "Investigations \nSputum Smear microscopy \nSputum smear microscopy is the most reliable and cost effective method \nof diagnosing infectious cases of pulmonary tuberculosis cases. Whenever \ntuberculosis is suspected in a patient who has had a cough of two weeks \nor more, three sputum samples should be collected and examined by \nmicroscopy for Acid-Fast Bacilli (AFB).\n\n--- Page 31 ---\nNational Guideline for Maternal Care - Volume II\n17\nCollection of sputum samples \nA PTB suspect should submit three sputum samples for microscopy. Three \nearly morning samples are preferable. However due to practical reasons, \nsputum samples are taken in the following manner:\nPatient should be advised to collect sputum after coughing following a \ndeep inspiration and it should not be saliva. \nFirst spot specimen - Supervised spot specimen at the first visit \nEarly morning specimen - Patient is given a sputum container to collect \nearly morning specimen on the following day. \nSecond spot specimen - Second supervised spot specimen is collected \nwhen the patient returns with the early morning specimen, on the \nfollowing day. \nChest X-ray \nThe chest X-ray has a limited role in confirming the diagnosis of pulmonary \ntuberculosis. Diagnosis of tuberculosis by means of X-ray alone is \nunreliable. Abnormalities seen on a chest X-ray may be mimicked by a \nvariety of other conditions. However chest X-ray is helpful particularly \nto diagnose PTB in a suspect whose sputum smears are negative for AFB.\n \nThe decision to start on anti-TB treatment on patients should not be based \nsolely on abnormal chest X-ray findings and all efforts should be made to \nperform sputum microscopy.\n \nIn pregnancy, chest X-rays should be avoided as far as possible, especially \nduring the first trimester, because of the adverse effects of x-rays on the \nfoetus. \nTherefore, diagnosis will depend more on sputum examination when a \npregnant mother presents with symptoms suggestive of tuberculosis. \nHowever, if an X-ray is absolutely necessary, this may be done with the \nabdomen covered with a lead apron. \nSputum Culture for AFB \nCulture examination of sputum for AFB is more sensitive and specific \nthan direct smear microscopy and may be useful in detecting cases where \nthe number of organisms are fewer than can be detected by direct smear",
  "However, if an X-ray is absolutely necessary, this may be done with the \nabdomen covered with a lead apron. \nSputum Culture for AFB \nCulture examination of sputum for AFB is more sensitive and specific \nthan direct smear microscopy and may be useful in detecting cases where \nthe number of organisms are fewer than can be detected by direct smear\n\n--- Page 32 ---\nNational Guideline for Maternal Care - Volume II\n18\nmicroscopy. But this is more expensive and takes at least 6-8 weeks to get \nthe results. \nUnder ideal circumstances pre-treatment sputum cultures for AFB should \nbe performed on all PTB patients.\nWHO recommended Rapid diagnostic tests\nThere are new rapid diagnostic methods available for detection of TB such \nas Xpert MTB/Rif and line probe assay.\nXpert MTB/Rif\nXpert MTB/Rif is an automated nucleic acid amplification test \nrecommended by WHO for early detection of TB and resistance to \nrifampicin which is used as an indicator of multidrug resistance. The test \ntakes around two hours, and requires minimal man power to perform. \nXpert/Rif can detect TB bacteria at much lower concentrations.\nLine probe assay \nLine probe assay is a molecular method of diagnosing TB and the \nmost common genetic mutations causing resistance to rifampicin and \nisoniazid. This technology can diagnose MDR-TB directly from smear \npositive sputum specimens and from culture isolates providing results in \nfive hours. This test does not work well on smear negative specimens.\nAt present, these tests are offered for selected categories of patients \n(MDRTB suspects) due to limited availability.\n2.6.\t\nTB treatment regimens \nTreatment regimens consist of two phases: \n\t\n1. Initial intensive phase \n\t\n2. Continuation phase \n\t\n2.6.1.Intensive phase \nDuring the initial intensive phase, there is rapid killing of TB bacilli. \nInfectious patients quickly become non-infectious (within about two \nweeks) and symptoms improve. Most patients with sputum smear-positive \npulmonary TB becomes smear negative within two months. Directly \nObserved Therapy (DOT) is essential in the initial phase to ensure that \nthe patient takes every single dose. This prevents development of drug",
  "Directly \nObserved Therapy (DOT) is essential in the initial phase to ensure that \nthe patient takes every single dose. This prevents development of drug\n\n--- Page 33 ---\nNational Guideline for Maternal Care - Volume II\n19\nresistance. The risk of development of drug resistance is higher during the \nearly stages of anti-TB treatment, when there are more bacilli. \n\t\n2.6.2.Continuation Phase \nDuring the continuation phase, fewer drugs are necessary, but for a longer \nperiod. The sterilizing effect of the drugs eliminates the remaining bacilli, \nthus preventing subsequent relapses. \nPatients who have taken anti-tuberculosis drugs previously are much \nmore likely to develop drug resistance, which may have been acquired \nthrough inadequate prior chemotherapy. Such patients require a stronger \nregimen consisting of more drugs and for a longer period. \nTherefore, before starting treatment, it is essential to question all \npatients closely and carefully to determine whether or not they have \npreviously taken treatment for tuberculosis, so that they can be given \nthe proper treatment regimen. \n\t\n2.6.3.Standard code for TB treatment regimens \nThere is a standard code for TB treatment regimens and each anti-\ntuberculosis drug has an abbreviation. \n\t\nH – Isoniazid \n\t\nR - Rifampicin \n\t\nZ - Pyrazinamide \n\t\nE - Ethambutol \n\t\nS – Streptomycin \nA TB treatment regimen consists of two phases, the intensive phase and \nthe continuation phase. The number before a phase is the duration of that \nphase in months. A subscript number (e.g. 3) after a letterindicates the \nnumber of doses of that drug per week. No subscript number after a letter \nindicates that the treatment is daily. \nE.g.: 4 HR means 4 months of Isoniazid and Rifampicin daily.\n5 H3 R3 E3 means 5 months of Isoniazid, Rifampicin and Ethambutol \nthree times a week",
  "No subscript number after a letter \nindicates that the treatment is daily. \nE.g.: 4 HR means 4 months of Isoniazid and Rifampicin daily.\n5 H3 R3 E3 means 5 months of Isoniazid, Rifampicin and Ethambutol \nthree times a week\n\n--- Page 34 ---\nNational Guideline for Maternal Care - Volume II\n20\nBox 2.1 Case definitions, Treatment Categories and \nRecommended Regimens\nCase Definition \nNew cases \n- PTB smear-positive \n- PTB smear-negative \n- Extrapulmonary TB \nRe-treatment cases \n- Relapses \n-Treatment after failure \n-Treatment after lost to follow up\n(smear-positive) \nTreatment \nCategory \nCAT 1\n \nCAT II \nTreatment Regimen\nIntensive\nPhase\n2 HRZE\n \n2HRZES \n/ 1 HRZE \nContinuation \nPhase\n4 HR \n5 HRE \n \n\t\n2.6.4.Monitoring of sputum smear-positive pulmonary TB \t\n\t\n\t\npatients\nResponse to treatment should be monitored by sputum smear examination\nFor sputum smear positive PTB patients, sputum smear examinations \nshould be performed at the end of the intensive phase of treatment \n(i.e.,second month), during the fifth month and ai the end of treatment. \nNegative sputum smears indicate good treatment progress.\nFor sputum smear negative patients also  follow up sputum smear \nexaminations should be performed at the end of two months, at the 5th \nmonth and at the end  of the treatment period.\n\t\n2.6.5.Treatment during Pregnancy \nAnti-TB treatment should be started as soon as the diagnosis is made, \nand the full course of treatment given. The basic principles of treatment \nare the same in pregnancy. Most anti-TB drugs are safe for use during \npregnancy except streptomycin. \nStreptomycin should not be given because it can cause oto-toxicity in \nthe foetus. \nPregnant mothers should be given pyridoxine 10mg daily along with \nINAH. \nVitamin K should be administered at birth to the infant of a mother taking \nrifampicin because of the risk of post-natal haemorrhage.",
  "Pregnant mothers should be given pyridoxine 10mg daily along with \nINAH. \nVitamin K should be administered at birth to the infant of a mother taking \nrifampicin because of the risk of post-natal haemorrhage.\n\n--- Page 35 ---\nNational Guideline for Maternal Care - Volume II\n21\n\t\n2.6.6. Treatment during breast-feeding \nA patient who has TB and is breast-feeding should receive the full course of \nanti-TB treatment. Properly taken treatment is the best way of preventing \ntransmission of TB to her baby. All anti-TB drugs are compatible with \nbreast-feeding. A patient taking anti-TB treatment can continue to \nbreastfeed her baby in the normal way. \nBreastfeeding should be avoided only in cases where the mother has dual \nTB/HIV infection. \n\t\n2.6.7. Management of a newborn child of a mother with active TB \n• \t Do not separate the child from the mother unless she is acutely ill.\n \n•\t  If the mother is sputum smear negative, and if the infant has no \t\t\n\t\nevidence of congenital TB, BCG is given to the infant. \nIf the mother is sputum smear-positive at the time of delivery, infant \nshould be carefully examined for evidence of active disease. \n\t\n- If the infant is ill at birth and congenital TB is suspected, a full \t \t\n\t\n   course of anti-TB treatment should be given. \n\t\n- If the child is well, give prophylactic treatment with INAH 5mg/ kg \t\n\t\n   body weight, daily for three months. BCG is withheld. \n• \t The Mantoux skin test is done after three months. \n\t\n- If the Mantoux test is negative and the child is well, prophylactic \t\n\t\n   treatment with INAH is stopped and child is given BCG. \n\t\n- If the Mantoux test is positive, careful examination of the child for \t\n\t\n   active TB is done including a chest X-ray. \n\t\n- If active disease is diagnosed, a full course of anti-TB treatment \t\n\t\n   should be commenced. \n\t\n- If the physical examination and the chest X-ray are normal, INAH \t\n\t\n   chemoprophylaxis is continued up to six months and BCG is given.",
  "- If active disease is diagnosed, a full course of anti-TB treatment \t\n\t\n   should be commenced. \n\t\n- If the physical examination and the chest X-ray are normal, INAH \t\n\t\n   chemoprophylaxis is continued up to six months and BCG is given.\n\n--- Page 36 ---\nNational Guideline for Maternal Care - Volume II\n22\n\t\n2.6.8. Directly Observed Treatment \nDirectly Observed Treatment (DOT) is one of the important elements \nof the internationally recommended strategy for TB control. Directly \nObserved Treatment means that an observer watches the patient swallow \ntheir tablets. This ensures that a TB patient takes the right anti-tuberculosis \ndrugs, in the right doses at the right intervals without interruption and \nensures that the patient completes the full course of treatment. WHO \nrecommendation is to provide DOTs throughout the whole treatment \nperiod.\nDOT Providers – \nThe following categories will provide Direct Observation of Treatment. \n\t\n• Health workers at state health care facilities \n\t\n• Field health care workers \n\t\n• General practitioners \n\t\n• Trained volunteers \n\t\n• Community leaders \nPublic health staff especially Public Health Nursing sisters and Public \nHealth Midwives  can play a significant role as DOT providers for \nantenatal and postnatal mothers in their areas who are on treatment.\nProvision of drugs for the DOT Centres - \nDrugs for each patient will be delivered to the DOT centres from the \nDistrict Chest Clinic by the PHI or any other staff assigned by the DTCO.\n\t\n2.6.9. Interruption of treatment (lost to follow up) \nDirectly Observed Treatment adapted to the needs of the patient is the \nbest method of avoiding treatment interruption. However, even with \ndirectly observed treatment during the intensive period and during the \ncontinuation phase of treatment, which may be self-administered, there \nmay be treatment interruption.",
  "Interruption of treatment (lost to follow up) \nDirectly Observed Treatment adapted to the needs of the patient is the \nbest method of avoiding treatment interruption. However, even with \ndirectly observed treatment during the intensive period and during the \ncontinuation phase of treatment, which may be self-administered, there \nmay be treatment interruption.\n\n--- Page 37 ---\nNational Guideline for Maternal Care - Volume II\n23\n\t\n2.6.9.1.Measures to minimize treatment interruption \nAt the time of registration of a TB patient, the staff must educate the patient \nand the family regarding the duration of treatment and the importance of \nadherence to treatment. \nIt is vital to record the patient’s address and other relevant addresses \ne.g.  parents or work place etc. in order to help locate the patients who \ninterrupt treatment. As far as possible, the address should be verified at \nthe beginning of treatment. \n \nPublic Health Midwives in their field visits and at antenatal clinics should \ninquire about uninterrupted continuation of treatment from patients and \nshould encourage them to continue treatment.\n\t\n\t\n2.6.9.2.\t Management of patients who interrupt treatment \nIt is important to take action on defaulters immediately. Patients should \nbe contacted the day after missing a dose during the intensive phase and \nas soon as possible during the continuation phase. It is important to find \nout the reason for the patient’s absence in order to take appropriate action \nand continue treatment.\n2.7. Notification\nAt the point of diagnosis, all tuberculosis patients should be notified using \nTB notification Form (H 816).\n2.8. Contact screening \nHousehold contacts of all TB patients (adults and children >5 years) \nshould be screened for symptoms of TB. Those who have symptoms \nsuggestive of TB should be investigated with sputum smears irrespective \nof the duration of the symptoms. \nChildren under the age of 5 years should be screened with chest X-ray and \nMantoux test.",
  "Those who have symptoms \nsuggestive of TB should be investigated with sputum smears irrespective \nof the duration of the symptoms. \nChildren under the age of 5 years should be screened with chest X-ray and \nMantoux test.\n\n--- Page 38 ---\nNational Guideline for Maternal Care - Volume II\n24\n2.9. Preventive treatment \nThe aim of preventive treatment is to prevent progression of M. \ntuberculosis infection to disease. \nPrimary chemoprophylaxis \nWhen a person is exposed to TB bacilli, but not yet infected eg. newborn \nbreastfed baby of a sputum smear-positive mother \nSecondary chemoprophylaxis \nA person who is infected, but not yet developed clinical disease \ne.g. tuberculin positive close contacts of sputum smear-positive patients. \nIn Sri Lanka, chemoprophylaxis is given for the following groups: \n\t\n• Breast fed infants of sputum smear-positive mothers. \n\t\n• Household contacts below 5 years of age of sputum smear-positive \t\n\t\npatients, who do not have evidence of active disease. \n\t\nProphylactic treatment in Sri Lanka is – INAH 5mg/ kg body weight \t\n\t\nfor 6 months. \nFor further details refer ‘General Manual for Tuberculosis Control’ \npublished by National Program for Tuberculosis Control and Chest \nDiseases.",
  "Prophylactic treatment in Sri Lanka is – INAH 5mg/ kg body weight \t\n\t\nfor 6 months. \nFor further details refer ‘General Manual for Tuberculosis Control’ \npublished by National Program for Tuberculosis Control and Chest \nDiseases.\n\n--- Page 39 ---\nNational Guideline for Maternal Care - Volume II\n25\nInfluenza A & B Virus Infection \nIncluding H1N1\n\n--- Page 40 ---\nNational Guideline for Maternal Care - Volume II\n26",
  "Prophylactic treatment in Sri Lanka is – INAH 5mg/ kg body weight \t\n\t\nfor 6 months. \nFor further details refer ‘General Manual for Tuberculosis Control’ \npublished by National Program for Tuberculosis Control and Chest \nDiseases.\n\n--- Page 39 ---\nNational Guideline for Maternal Care - Volume II\n25\nInfluenza A & B Virus Infection \nIncluding H1N1\n\n--- Page 40 ---\nNational Guideline for Maternal Care - Volume II\n26\n\n--- Page 41 ---\nNational Guideline for Maternal Care - Volume II\n27\n3. Management of Influenza A & B Virus Infection \nIncluding H1N1 in Pregnancy \n3.1. Introduction\nWith the presence of community transmission of influenza A/B (including \nH1N1) virus infection, it is important to note that pregnancy is considered \nas a high risk condition.\nThe disease may become more severe during pregnancy and there is a \nhigh risk of mortality due to complications especially in pregnant women \nwith co morbidities such as diabetes, heart disease, bronchial asthma, \ncancer and anaemia. H1N1 infection is also associated with increased risk \nof adverse pregnancy outcomes such as spontaneous abortion, preterm \nbirth and foetal distress.\nThe objective of this document is to provide all healthcare providers, \nboth in preventive and curative sectors with specific guidelines to follow \naiming to mitigate untoward consequences following H1N1 infection.\n3.2. Protection against infection\n\t\nA.\t\nPregnant women and women in reproductive age \t \t\n\t\n\t\n\t\ngroup should be educated on early clinical \t\n\t\n\t\n\t\n\t\nmanifestations of influenza virus infection.\n\t\nB.\t\nThey should avoid unnecessary travel, crowded public \t\n\t\n\t\n\t\nplaces and public transport as much as possible.\n\t\nC.\t\nThey should be advised to stay at home and encourage to \t\n\t\n\t\n\t\npractice cough and sneeze etiquette (covering mouth and nose \t\n\t\n\t\nwhen coughing or sneezing) or wear a face mask (at least a \t \t\n\t\n\t\nhome-\t made mask) if they have fever and flu-like symptoms.\nClinical Manifestations\n•\t\nFever along with cough\n•\t\nSore throat\n•\t\nRhinorrhoea\n•\t\nHeadache\n•\t\nMuscle pain\n•\t\nMalaise",
  "H1N1 infection is also associated with increased risk \nof adverse pregnancy outcomes such as spontaneous abortion, preterm \nbirth and foetal distress.\nThe objective of this document is to provide all healthcare providers, \nboth in preventive and curative sectors with specific guidelines to follow \naiming to mitigate untoward consequences following H1N1 infection.\n3.2. Protection against infection\n\t\nA.\t\nPregnant women and women in reproductive age \t \t\n\t\n\t\n\t\ngroup should be educated on early clinical \t\n\t\n\t\n\t\n\t\nmanifestations of influenza virus infection.\n\t\nB.\t\nThey should avoid unnecessary travel, crowded public \t\n\t\n\t\n\t\nplaces and public transport as much as possible.\n\t\nC.\t\nThey should be advised to stay at home and encourage to \t\n\t\n\t\n\t\npractice cough and sneeze etiquette (covering mouth and nose \t\n\t\n\t\nwhen coughing or sneezing) or wear a face mask (at least a \t \t\n\t\n\t\nhome-\t made mask) if they have fever and flu-like symptoms.\nClinical Manifestations\n•\t\nFever along with cough\n•\t\nSore throat\n•\t\nRhinorrhoea\n•\t\nHeadache\n•\t\nMuscle pain\n•\t\nMalaise\n\n--- Page 42 ---\nNational Guideline for Maternal Care - Volume II\n28\n\t\nD.\t\nPregnant women and new mothers should avoid providing \t\t\n\t\n\t\ncare of persons with influenza like illnesses, except for their own \t\n\t\n\t\nnewborns.\n\t\nE.\t\nAll preventive measures to avoid transmission of infection \t \t\n\t\n\t\nshould be taken by health care workers when attending to \t \t\n\t\n\t\npregnant women.\n\t\nF.\t\nAnyone with respiratory symptoms should not provide care for \t\n\t\n\t\nthe pregnant women, the mother and newborn baby.\n\t\nG.\t\nCare for symptomatic pregnant women (with fever and flu-like \t\n\t\n\t\nsymptoms), should be organized in a separate area in the clinic \t\n\t\n\t\nor OPD whenever possible.\n\t\n3.3. Case identification\nSuspected Case:\nAn individual presenting with acute febrile respiratory illness (fever > 38 \noC) with the spectrum of disease from influenza-like illness (cough, sore \nthroat, shortness of breath) to pneumonia.\n \nProbable case:\nAn individual tested positive for influenza A, but hasn’t subtyped by \nreagents used to differentiate influenza virus strains.\n \nConfirmed Case of H1N1 infection:\nAn individual tested positive for influenza A (H1N1) 2009 by real time \nRT-PCR\nNote: A negative PCR result does not rule out that a person may be in-\nfected with influenza A (H1N1) 2009 virus. Results should be interpreted \nin conjunction with the available clinical and epidemiological information.\n \n 3.4.  Seeking medical care \n\t\nA)\t\nPregnant mothers should consult a qualified physicians (either \t\n\t\n\t\nin government or private sector) immediately if they have above \t\n\t\n\t\nsymptoms (fever with cough, sore throat, rhinorrhea, headache, \t\n\t\n\t\nmuscle pain, malaise).\n\t\nB)\t\nSuspected cases should be admitted to a hospital for specialized \t\n\t\n\t\ncare, for management.",
  "Results should be interpreted \nin conjunction with the available clinical and epidemiological information.\n \n 3.4.  Seeking medical care \n\t\nA)\t\nPregnant mothers should consult a qualified physicians (either \t\n\t\n\t\nin government or private sector) immediately if they have above \t\n\t\n\t\nsymptoms (fever with cough, sore throat, rhinorrhea, headache, \t\n\t\n\t\nmuscle pain, malaise).\n\t\nB)\t\nSuspected cases should be admitted to a hospital for specialized \t\n\t\n\t\ncare, for management.\n\n--- Page 43 ---\nNational Guideline for Maternal Care - Volume II\n29\n\t\nC)\t\nIf they present with features of complicated influenza or pro\t\t\n\t\n\t\ngressive disease such women may need ICU care.\n\t\n\t\n•\t\nManifestations of cardio-respiratory distress (e.g. short\t\n\t\n\t\n\t\nness of breath either during physical activity or while \t\n\t\n\t\n\t\nresting / dyspnoea tachypnea, hypoxia, low blood pres\t\n\t\n\t\n\t\nsure).\n\t\n\t\n•\t\nRadiological signs of lower respiratory tract disease \t\n\t\n\t\n\t\n(e.g. pneumonia)\n\t\n\t\n•\t\nCentral nervous system (CNS) involvement (e.g. al\t\t\n\t\n\t\n\t\ntered mental status, unconsciousness, drowsiness, re\t\n\t\n\t\n\t\ncurring or persistent convulsions (seizures), confusion, \t\n\t\n\t\n\t\nsevere weakness or paralysis)\n\t\n\t\n•\t\nSevere dehydration\n\t\nD)\t Medical Officers of Health and other healthcare workers in\t \t\n\t\n\t\nvolved in provision of care to pregnant mothers should \t\n\t\n\t\n\t\nhighlight signs and symptoms of influenza illness in all health \t\n\t\n\t\neducation activities, especially in routine antenatal clinics.\n\t\nE)\t\nPublic Health Midwives and other field officials should refer any \t\n\t\n\t\npregnant mother with fever and flu-like symptoms for proper \t\n\t\n\t\nmedical care without delay.\n\t\nF)\t\nIt is important note that pregnant mothers and postpartum \t\t\n\t\n\t\nmothers can rapidly progress to severe form of the infection \t\n\t\n\t\nwithin a short period of time. Hence high degree of suspicion \t\n\t\n\t\nand vigilance is needed in treating influenza infection.\nAll pregnant mothers with influenza like illness should be admitted \nto a hospitals with specialist care. \n3.5. Management in the hospital \n\t\nA)\t\nProvide a disposable/surgical facemask to the patient.\n\t\nB)\t\nAsk to practice good hand hygiene and washing hands often \t\n\t\n\t\nusing simple disinfectants such as soap. Discourage nose \t\n\t\n\t\n\t\npicking and limit touching the eyes, nose and mouth.\n\t\nC)\t\nAttending health care providers should wear face masks \t\n\t\n\t\n\t\nproperly whenever in contact with infected/suspected mother.",
  "Management in the hospital \n\t\nA)\t\nProvide a disposable/surgical facemask to the patient.\n\t\nB)\t\nAsk to practice good hand hygiene and washing hands often \t\n\t\n\t\nusing simple disinfectants such as soap. Discourage nose \t\n\t\n\t\n\t\npicking and limit touching the eyes, nose and mouth.\n\t\nC)\t\nAttending health care providers should wear face masks \t\n\t\n\t\n\t\nproperly whenever in contact with infected/suspected mother.\n\n--- Page 44 ---\nNational Guideline for Maternal Care - Volume II\n30\n\t\nD)\t Isolation – care for symptomatic patients should be organized in \t\n\t\n\t\na separate area in the antenatal ward (cohort isolation).\n\t\nE)\t\nConsultant or the clinician of the highest rank (Senior \t\n\t\n\t\n\t\nRegistrar/ Registrar/ SHO) should be informed immediately on \t\n\t\n\t\nadmission.\n\t\nF)\t\nInstitutions managing pregnant women should request \t\n\t\n\t\n\t\nadequate stocks of oseltamivir\n\t\nG)\t Consider transferring patients only if required specialized care.\n \n\t\nH)\t Most of the infected pregnant women can be managed \t\n\t\n\t\n\t\neffectively if oseltamivir is started early. It is a must to start \t \t\n\t\n\t\noseltamivir when influenza is suspected without waiting for \t\n\t\n\t\nlaboratory confirmation.\n \n3.6.\t\nLaboratory Diagnosis\n\t\nA)\t\nUpper respiratory samples are the most appropriate laboratory \t\n\t\n\t\nspecimens. Samples should be taken from the deep nostrils \t\t\n\t\n\t\n(nasal swab), throat swab and nasopharynx (nasopharyngeal \t\n\t\n\t\nswab). Nasopharyngeal aspirate and bronchial aspirate gives the \t\n\t\n\t\nbest diagnostic yield.\n\t\nB)\t\nUpper respiratory samples should be collected in to a special \t\n\t\n\t\nViral Transport Medium (VTM) obtained from the Medical \t\n\t\n\t\nResearch Institute (MRI).\n\t\nC)\t\nHealth care workers should adhere to appropriate standard \t\t\n\t\n\t\nprecautions when collecting specimens since this may expose \t\n\t\n\t\nto respiratory secretions from patients. Surgical mask and \t \t\n\t\n\t\ngloves are appropriate for obtaining upper respiratory tract  \t\n\t\n\t\nsamples and N95 mask, gown and gloves are recommended \t\n\t\n\t\nin aerosol generating procedures like aspirating respiratory \t\t\n\t\n\t\nsecretions.\n\t\nD)\t Avoid collecting samples in open areas in the ward/clinic.\n\t\nE)\t\nThese specimens should be sent to the MRI in ice packs without \t\n\t\n\t\ndelay, using special request form developed by the MRI for this \t\n\t\n\t\npurpose.",
  "Nasopharyngeal aspirate and bronchial aspirate gives the \t\n\t\n\t\nbest diagnostic yield.\n\t\nB)\t\nUpper respiratory samples should be collected in to a special \t\n\t\n\t\nViral Transport Medium (VTM) obtained from the Medical \t\n\t\n\t\nResearch Institute (MRI).\n\t\nC)\t\nHealth care workers should adhere to appropriate standard \t\t\n\t\n\t\nprecautions when collecting specimens since this may expose \t\n\t\n\t\nto respiratory secretions from patients. Surgical mask and \t \t\n\t\n\t\ngloves are appropriate for obtaining upper respiratory tract  \t\n\t\n\t\nsamples and N95 mask, gown and gloves are recommended \t\n\t\n\t\nin aerosol generating procedures like aspirating respiratory \t\t\n\t\n\t\nsecretions.\n\t\nD)\t Avoid collecting samples in open areas in the ward/clinic.\n\t\nE)\t\nThese specimens should be sent to the MRI in ice packs without \t\n\t\n\t\ndelay, using special request form developed by the MRI for this \t\n\t\n\t\npurpose.\n\n--- Page 45 ---\nNational Guideline for Maternal Care - Volume II\n31\n\t\nF)\t\nA detailed clinical history indicating the justification for the \t\n\t\n\t\ninvestigation should be included in the request.\n\t\nG)\t If there is a delay in transportation, place the sample temporally \t\n\t\n\t\nin the freezer compartment (4-8 Co) in the fridge for 24-48 hr. \t\n\t\n\t\nNEVER store the sample in deep freezer section in the fridge.\n3.7. Antiviral therapy\nConsultant or his delegate caring for the pregnant mother should start \nantiviral therapy immediately in suspected cases. \nDose: Oseltamivir 75 mg twice a day for 5 days.\nIn severe cases higher doses (150 mg) and longer duration of treatment \nmay be considered.\nDrug supply: Arrangements should be made to make 24hr availability of \nantiviral drugs in the hospital and /or obstetric and gynaecological wards.\nThe antiviral drug is safe for use even in the first trimester.\nAll pregnant mothers with severe/complicated disease or signs of \nprogression of the disease (or even suspected cases) should be treated \nwith oseltamivir.\nTreatment should be initiated as soon as possible, without delay\nTreatment with antiviral medications should begin without waiting \nfor collecting specimen or results of diagnostic testing.\n Chemoprophylaxis is NOT recommended in pregnancy\nThe patient should be provided with necessary supportive therapy \n(adequate nutrition and oral fluids) and medication (eg antipyretics, \nantibiotics where indicated, rehydration etc.).\nOxygen saturation should be monitored by pulse oximetry, whenever \npossible. Supplement oxygen should be provided to correct hypoxaemia.\nSevere cases may need care at an Intensive Care Unit. Therefore ensure \nthe availability of such facilities beforehand.\n Non-steroidal Anti Inflammatory Drugs. (NSAIDs) should be avoided.",
  "Therefore ensure \nthe availability of such facilities beforehand.\n Non-steroidal Anti Inflammatory Drugs. (NSAIDs) should be avoided.\n\n--- Page 46 ---\nNational Guideline for Maternal Care - Volume II\n32\n Since there is high risk of foetal distress and preterm labour, consider \nadministration of corticosteroids for promotion of fetal lung maturation \nwhere applicable.\n \n3.8. Management of Labour\n\t\nA)\t\nOrganize separate areas for labour and delivery for infected or \t\n\t\n\t\nsuspected pregnant mothers\n\t\nB)\t\nProvided routine intrapartum and postpartum care.\n\t\nC)\t\nProvide appropriate interventions where indicated for specific \t\n\t\n\t\ncomplications related to childbirth, the postpartum/postnatal \t\n\t\n\t\nperiod or the newborn.\n\t\nD)\t Tocolytics can be used as for any other obstetric case.\n\t\nE)\t\nSince there is a higher risk of fetal distress, discuss with \t\n\t\n\t\n\t\nanaesthesiologist the risks and benefits of vaginal \t \t\n\t\n\t\n\t\ndelivery and caesarean delivery. Consider the risks of \t\n\t\n\t\n\t\nanaesthesia in a severely ill woman.\n\t\nF)\t\nReduce the length of stay in the postnatal ward to the minimum \t\n\t\n\t\nrequired by maternal and newborn condition.\n\t\nG)\t Anyone (including health care workers) with respiratory \t\n\t\n\t\n\t\nsymptoms should not provide care for the pregnant woman or \t\n\t\n\t\nthe mother and newborn baby.\n \n3.9.\t\nNewborn Care\n\t\nA)\t\nDo not separate the baby from the mother even if the mother \t\n\t\n\t\nhas influenza A pandemic (H1N1). Institute rooming –in.\n\t\nB)\t\nMothers should wear a disposable/surgical facemask and \t\n\t\n\t\n\t\npractice good hand hygiene and hand washing with soap and \t\n\t\n\t\nwater regularly before feeding or handing the baby.\n\t\nC)\t\nSupport mothers to initiate breastfeeding within one hour of \t\n\t\n\t\ngiving birth and to breastfeed frequently and exclusively on \t\t\n\t\n\t\ndemand. If mother is ill, she should be helped to express her \t\n\t\n\t\nbreast milk and feed it to the infant.",
  "Institute rooming –in.\n\t\nB)\t\nMothers should wear a disposable/surgical facemask and \t\n\t\n\t\n\t\npractice good hand hygiene and hand washing with soap and \t\n\t\n\t\nwater regularly before feeding or handing the baby.\n\t\nC)\t\nSupport mothers to initiate breastfeeding within one hour of \t\n\t\n\t\ngiving birth and to breastfeed frequently and exclusively on \t\t\n\t\n\t\ndemand. If mother is ill, she should be helped to express her \t\n\t\n\t\nbreast milk and feed it to the infant.\n\n--- Page 47 ---\nNational Guideline for Maternal Care - Volume II\n33\n\t\nD)\t Antivirals not a contraindication for breastfeeding.\n\t\nE)\t\nNewborns of infected mothers should be closely observed for \t\n\t\n\t\npossible development of infection.\n\t\nF)\t\nNewborn infants are unlikely to have typical influenza signs. \t\n\t\n\t\nInfluenza or its complications in newborn infants may begin \t\n\t\n\t\nwith less typical signs such as apnoea, fever, fast breathing, \t \t\n\t\n\t\ncyanosis, excessive sleeping, lethargy, feeding poorly and \t\n\t\n\t\n\t\ndehydration.\n\t\nG)\t Newborn infants with severe or deteriorating illness and those \t\n\t\n\t\nat risk of more severe or complicated illness should promptly be \t\n\t\n\t\ntreated with antiviral drugs.\n\t\nOseltamivir dose for babies: 3mg/kg twice daily for 5 days\n\t\nH)\t Mothers who are breast feeding may continue breastfeeding \t\n\t\nwhile ill and receiving oseltamivir.\n \n3.10. Discharged Criteria\n Pregnant mothers could be discharged after completion of 4 days of \ntreatment if she has clinically recovered. Decision on discharging those \nwith severe disease should be taken by the treating clinicians based on \ntheir clinical judgment. \n3.11.\t Notification:\nAll admitted cases should be notified using routine procedure to the \nrelevant Medical Officer of Health by the treating clinicians.\nMedical Officer – Maternal and Child Health (MO – MCH) should notify \nall suspected cases of H1N1 in pregnancy to Epidemiology Unit.\n In the event of a maternal death, notification should be sent without delay \nto the Family Health Bureau. It should be emphasized that a post mortem \nis mandatory in all maternal deaths.\n In addition to routine notification, all suspected or confirmed pregnant \nwomen/ newborns/children with H1N1 should be notified to family \nHealth Bureau.",
  "3.11.\t Notification:\nAll admitted cases should be notified using routine procedure to the \nrelevant Medical Officer of Health by the treating clinicians.\nMedical Officer – Maternal and Child Health (MO – MCH) should notify \nall suspected cases of H1N1 in pregnancy to Epidemiology Unit.\n In the event of a maternal death, notification should be sent without delay \nto the Family Health Bureau. It should be emphasized that a post mortem \nis mandatory in all maternal deaths.\n In addition to routine notification, all suspected or confirmed pregnant \nwomen/ newborns/children with H1N1 should be notified to family \nHealth Bureau.\n\n--- Page 48 ---\nNational Guideline for Maternal Care - Volume II\n34\n3.12.\t  Safety of Health Care Workers\nPlease refer to the General Circular No: 01-37/2009 Interim Guidelines \nfor Clinical Management and Laboratory Investigation of Patients with \nPandemic Influenza A (H1N1) 2009. Virus Infection in a Setting with \nSustained Transmission issued by Director General Services, Ministry of \nHealth and Website of Epidemiology Unit www.epid.gov.lk\nCare of pregnant HCW\nPregnant health care workers should be reassigned to non-contaminated \nor low risk areas eg. Orthopaedic units, dermatology Units.\nThey should be given high priority to receive Personal Protection \nEquipments.",
  "Virus Infection in a Setting with \nSustained Transmission issued by Director General Services, Ministry of \nHealth and Website of Epidemiology Unit www.epid.gov.lk\nCare of pregnant HCW\nPregnant health care workers should be reassigned to non-contaminated \nor low risk areas eg. Orthopaedic units, dermatology Units.\nThey should be given high priority to receive Personal Protection \nEquipments.\n\n--- Page 49 ---\nNational Guideline for Maternal Care - Volume II\n35\nLiver Disease\n\n--- Page 50 ---\nNational Guideline for Maternal Care - Volume II\n36",
  "Virus Infection in a Setting with \nSustained Transmission issued by Director General Services, Ministry of \nHealth and Website of Epidemiology Unit www.epid.gov.lk\nCare of pregnant HCW\nPregnant health care workers should be reassigned to non-contaminated \nor low risk areas eg. Orthopaedic units, dermatology Units.\nThey should be given high priority to receive Personal Protection \nEquipments.\n\n--- Page 49 ---\nNational Guideline for Maternal Care - Volume II\n35\nLiver Disease\n\n--- Page 50 ---\nNational Guideline for Maternal Care - Volume II\n36\n\n--- Page 51 ---\nNational Guideline for Maternal Care - Volume II\n37\nBox 4.1: Normal biochemical changes during pregnancy\nTotal bilirubin\nAST/ALT\nAlkaline phosphatase\nGamma  glutamyltransferase\nAlbumin\nProthrombin time/INR\nPlatelets\nTotal cholesterol and triglyceride\nNo change or slight decrease\nNo change\nIncreased by 200-400% (placenta \nand bone)\nNo change or slight decrease\nDecreased \nNo change\nNo change/mild decrease\nincreased\n4. Liver disease in pregnancy\n4.1. Introduction\n\t\n➢\t\nLiver dysfunction is known to affect up to 3% percent of \t\n\t\n\t\n\t\npregnancies and is a leading cause of maternal mortality and \t\n\t\n\t\nmorbidity in Sri Lanka.",
  "Liver disease in pregnancy\n4.1. Introduction\n\t\n➢\t\nLiver dysfunction is known to affect up to 3% percent of \t\n\t\n\t\n\t\npregnancies and is a leading cause of maternal mortality and \t\n\t\n\t\nmorbidity in Sri Lanka.\n\n--- Page 52 ---\nNational Guideline for Maternal Care - Volume II\n38\n\t\n➢\t\nTherefore, any increase in alanine aminotransferase (ALT), as\t\n\t\n\t\npartate aminotransferase (AST),serum bilirubin and INR  in \t\n\t\n\t\npregnancy warrants further evaluation. \n4.2.\t\nPre-existing liver disease\n\t\nPre conception care\n\t\n➢\t\nRisks of complications in the mother and fetus depends on the \t\n\t\n\t\nunderlying condition and severity.\n\t\n➢\t\nThe woman should be assessed by a specialist physician prior \t\n\t\n\t\nto pregnancy for advice on suitability for pregnancy, review and \t\n\t\n\t\noptimizing medication and target organ screening.\n\t\n4.2.1. Chronic viral hepatitis \n\t\n➢\t\nWomen should be reviewed by a hepatologist early in \t\n\t\n\t\n\t\npregnancy for plan of management during pregnancy; Refer \t\n\t\n\t\nfor hepatology opinion if the maternal viral load is high in the \t\n\t\n\t\nthird trimester. \n\t\n➢\t\nVertical transmission of hepatitis B during pregnancy is \t\n\t\n\t\n\t\nthought \tto be mainly transplacental even though transmission \t\n\t\n\t\nthrough secretions are also documented. However, studies \t \t\n\t\n\t\nto date have not shown any conclusive evidence of benefit of \t\n\t\n\t\ncaesarean section over vaginal delivery. Mode of delivery should \t\n\t\n\t\nbe based on obstetric indications. \n\t\n➢\t\nMother to baby transmission is proportional to the maternal \t\n\t\n\t\nviral DNA and e antigen level.\n\t\n➢\t\nAll babies born to hepatitis B surface antigen positive mothers \t\n\t\n\t\nshould receive hepatitis B immunoglobulin and the first dose of \t\n\t\n\t\nthe hepatitis B vaccine within 12 hours of birth. \n\t\n➢\t\nPatients with chronic viral hepatitis C are monitored closely, \t\n\t\n\t\nbut there is no place for treatment during pregnancy. Mother \t\n\t\n\t\nto baby transmission rate of Hepatitis C has been shown to be \t\n\t\n\t\nhigher with prolonged rupture of membranes.",
  "➢\t\nPatients with chronic viral hepatitis C are monitored closely, \t\n\t\n\t\nbut there is no place for treatment during pregnancy. Mother \t\n\t\n\t\nto baby transmission rate of Hepatitis C has been shown to be \t\n\t\n\t\nhigher with prolonged rupture of membranes.\n\n--- Page 53 ---\nNational Guideline for Maternal Care - Volume II\n39\n\t\n4.2.2.Cirrhosis \n\t\n➢\t\nAll patients with cirrhosis should be managed in a tertiary care \t\n\t\n\t\ncenter with facilities for endoscopy and variceal ligation.\n\t\n➢\t\nWomen with suspected portal hypertension should have an \t\t\n\t\n\t\nupper endoscopy ideally in the preconception stage or at least in \t\n\t\n\t\nthe second trimester to look for esophageal varices. \n\t\n\t\no\t\nManagement of esophageal varices:\n\t\n\t\n\t\n-Prophylactic banding especially if the risk \t\n\t\n\t\n\t\n\t\n  of bleeding is high, such as ‘red signs’ on varices or in \t\n\t\n\t\n\t\n  patents with decompensated cirrhosis\n\t\n\t\n\t\n-Avoidance of vaginal delivery due to risk of rupture of \t\n\t\n\t\n\t\n  varices during the second stage of labour. \n\t\n\t\n\t\n-Continuations of beta blockers( Eg: Propranolol ) \t\t\n\t\n\t\n\t\n  throughout pregnancy with close maternal and fetal \t\n\t\n\t\n\t\n  monitoring\n\t\n\t\no\t\nManagement of upper  GI bleeding:\n\t\n\t\n\t\n-Endoscopic banding is the treatment of choice\n\t\n\t\n\t\n-Broad spectrum antibiotics (preferably a 3rd \t\n\t\n\t\n\t\n\t\n  generation cephalosporin such as IV Ceftriaxone) is \t\n\t\n\t\n\t\n  recommended\n\t\n\t\n\t\n-Vassopressin is contraindicated; Terlipressin has not \t\n\t\n\t\n\t\n  been studied in pregnancy\n\t\n\t\n\t\n-There is inadequate evidence for Octreotide, though \t\n\t\n\t\n\t\n  if endoscopy and banding are delayed due to \t\n\t\n\t\n\t\n\t\n  unavoidable circumstances, this may be \t \t\n\t\n\t\n\t\n\t\n  considered. However this should not be considered an \t\n\t\n\t\n\t\n  alternative to timely endoscopy.\n\t\n\t\n➢\t\nPatients with cirrhosis should be screened with ultrasound \t \t\n\t\n\t\nspecifically looking for the presence of a splenicartery \t\n\t\n\t\n\t\naneurysm and if present referred to a tertiary care center for \t\n\t\n\t\nmanagement\n\t\n4.2.3. Autoimmune hepatitis\n\t\n➢\t\nSteroids and Azathioprine could be continued during \t\n\t\n\t\n\t\npregnancy.",
  "However this should not be considered an \t\n\t\n\t\n\t\n  alternative to timely endoscopy.\n\t\n\t\n➢\t\nPatients with cirrhosis should be screened with ultrasound \t \t\n\t\n\t\nspecifically looking for the presence of a splenicartery \t\n\t\n\t\n\t\naneurysm and if present referred to a tertiary care center for \t\n\t\n\t\nmanagement\n\t\n4.2.3. Autoimmune hepatitis\n\t\n➢\t\nSteroids and Azathioprine could be continued during \t\n\t\n\t\n\t\npregnancy.\n\n--- Page 54 ---\nNational Guideline for Maternal Care - Volume II\n40\n\t\n➢\t\nFlares are infrequent during pregnancy though postpartum \t\t\n\t\n\t\nflares are expected. \n\t\n\t\no \t\nClose surveillance postpartum with review at 6 weeks is \t\n\t\n\t\n\t\nrecommended. \n\t\n4.2.4. Wilsons disease \n\t\n➢\t\nLowering the dose of D-penicillamine during the first trimester \t\n\t\n\t\nis recommended with maintenance on the lowest dosage during \t\n\t\n\t\nall trimesters.\n\t\n➢\t\nReduce   D-penicillamine to a minimal dose of 300–600 mg/\t\n\t\n\t\nday in the last trimester in order to avoid copper deficiency \t\t\n\t\n\t\nin the fetus and insufficient wound healing after caesarean \t \t\n\t\n\t\nsection or episiotomy.\n\t\n\t\no\t\nIf caesarean section is planned, the dose of \t\n\t\n\t\n\t\n\t\nPenicillamine should be limited to 250 mg/day \t\n\t\n\t\n\t\n\t\nfor 6 weeks before delivery and postoperatively until \t\n\t\n\t\n\t\nwound healing is complete\n\t\n➢\t\nBreast feeding under chelation therapy is not recommended.\n4.3.\t\nLiver disease specific to pregnancy \n\t\n4.3.1. When to suspect liver disease\nSymptoms:\n\t\nPruritus, right hypochondrial pain, dark coloured urine or \nyellow discoloration of eyes, vomiting and swelling of feet (sudden onset \nin latter part of pregnancy), drowsiness and flu like symptoms.\nSigns:\n\t\nIcterus, peripheral oedema out of proportion to the gestational \nperiod/rapid onset or associated with hypertension, right hypochondrial \ntenderness, splenomegaly, reduced level of consciousness and liver flaps.",
  "Wilsons disease \n\t\n➢\t\nLowering the dose of D-penicillamine during the first trimester \t\n\t\n\t\nis recommended with maintenance on the lowest dosage during \t\n\t\n\t\nall trimesters.\n\t\n➢\t\nReduce   D-penicillamine to a minimal dose of 300–600 mg/\t\n\t\n\t\nday in the last trimester in order to avoid copper deficiency \t\t\n\t\n\t\nin the fetus and insufficient wound healing after caesarean \t \t\n\t\n\t\nsection or episiotomy.\n\t\n\t\no\t\nIf caesarean section is planned, the dose of \t\n\t\n\t\n\t\n\t\nPenicillamine should be limited to 250 mg/day \t\n\t\n\t\n\t\n\t\nfor 6 weeks before delivery and postoperatively until \t\n\t\n\t\n\t\nwound healing is complete\n\t\n➢\t\nBreast feeding under chelation therapy is not recommended.\n4.3.\t\nLiver disease specific to pregnancy \n\t\n4.3.1. When to suspect liver disease\nSymptoms:\n\t\nPruritus, right hypochondrial pain, dark coloured urine or \nyellow discoloration of eyes, vomiting and swelling of feet (sudden onset \nin latter part of pregnancy), drowsiness and flu like symptoms.\nSigns:\n\t\nIcterus, peripheral oedema out of proportion to the gestational \nperiod/rapid onset or associated with hypertension, right hypochondrial \ntenderness, splenomegaly, reduced level of consciousness and liver flaps.\n\n--- Page 55 ---\nNational Guideline for Maternal Care - Volume II\n41\nBox 4.2: First line Investigations in a pregnant woman suspected with \nliver disease\nInvestigation\nSGOT (AST)\nSGPT(ALT)\nSerum \nbilirubin\nFBC\nPT/INR\nGamma GT\nAlkaline \nphosphatase\nFinding\nAny rise warrants \nevaluation \nAny rise warrants \nevaluation\nThrombocytopaenia\nAny rise needs further \nevaluation\nAny rise needs further \nevaluation\nIsolated elevation is \nnormal in pregnancy\nComments\nMild elevation\nDengue infection (SGOT>SGPT)\nPreeclampsia/HELLP syndrome(SGOT>SGPT)\nIntrahepatic cholestasis of pregnancy (ICP)\nHyperemesis gravidarum\nAcute fatty liver of pregnancy (AFLP )\nMarked elevation (Serum level >1000 U/L)\nAcute viral hepatitis\nDrug induced liver disease including \nParacetamol overdose\nHypoxic hepatic injury\nMild elevation in otherwise asymptomatic \nindividual \nPreexisting fatty liver disease\nCirrhosis\nMild elevation\nHyperemesis gravidarum (HG)\nAcute fatty liver of pregnancy (AFLP) –early \nstage\nHaemolysis, elevated liver enzymes and low \nplatelets (HELLP)\nSepsis\nMarked elevation\nCholestatic viral hepatitis\nLate stage of  AFLP\nAny cause of obstructive jaundice\nCirrhosis with portal hypertension \nSevere pre eclampsia\nHELLP syndrome\nLiver failure\nProlongation suggests liver failure\nProlonged in cholestatic and drug induced liver \ndisease \nFurther evaluation of a woman with suspected liver disease\n Details are specified under individual liver disease below.",
  "Wilsons disease \n\t\n➢\t\nLowering the dose of D-penicillamine during the first trimester \t\n\t\n\t\nis recommended with maintenance on the lowest dosage during \t\n\t\n\t\nall trimesters.\n\t\n➢\t\nReduce   D-penicillamine to a minimal dose of 300–600 mg/\t\n\t\n\t\nday in the last trimester in order to avoid copper deficiency \t\t\n\t\n\t\nin the fetus and insufficient wound healing after caesarean \t \t\n\t\n\t\nsection or episiotomy.\n\t\n\t\no\t\nIf caesarean section is planned, the dose of \t\n\t\n\t\n\t\n\t\nPenicillamine should be limited to 250 mg/day \t\n\t\n\t\n\t\n\t\nfor 6 weeks before delivery and postoperatively until \t\n\t\n\t\n\t\nwound healing is complete\n\t\n➢\t\nBreast feeding under chelation therapy is not recommended.\n4.3.\t\nLiver disease specific to pregnancy \n\t\n4.3.1. When to suspect liver disease\nSymptoms:\n\t\nPruritus, right hypochondrial pain, dark coloured urine or \nyellow discoloration of eyes, vomiting and swelling of feet (sudden onset \nin latter part of pregnancy), drowsiness and flu like symptoms.\nSigns:\n\t\nIcterus, peripheral oedema out of proportion to the gestational \nperiod/rapid onset or associated with hypertension, right hypochondrial \ntenderness, splenomegaly, reduced level of consciousness and liver flaps.\n\n--- Page 55 ---\nNational Guideline for Maternal Care - Volume II\n41\nBox 4.2: First line Investigations in a pregnant woman suspected with \nliver disease\nInvestigation\nSGOT (AST)\nSGPT(ALT)\nSerum \nbilirubin\nFBC\nPT/INR\nGamma GT\nAlkaline \nphosphatase\nFinding\nAny rise warrants \nevaluation \nAny rise warrants \nevaluation\nThrombocytopaenia\nAny rise needs further \nevaluation\nAny rise needs further \nevaluation\nIsolated elevation is \nnormal in pregnancy\nComments\nMild elevation\nDengue infection (SGOT>SGPT)\nPreeclampsia/HELLP syndrome(SGOT>SGPT)\nIntrahepatic cholestasis of pregnancy (ICP)\nHyperemesis gravidarum\nAcute fatty liver of pregnancy (AFLP )\nMarked elevation (Serum level >1000 U/L)\nAcute viral hepatitis\nDrug induced liver disease including \nParacetamol overdose\nHypoxic hepatic injury\nMild elevation in otherwise asymptomatic \nindividual \nPreexisting fatty liver disease\nCirrhosis\nMild elevation\nHyperemesis gravidarum (HG)\nAcute fatty liver of pregnancy (AFLP) –early \nstage\nHaemolysis, elevated liver enzymes and low \nplatelets (HELLP)\nSepsis\nMarked elevation\nCholestatic viral hepatitis\nLate stage of  AFLP\nAny cause of obstructive jaundice\nCirrhosis with portal hypertension \nSevere pre eclampsia\nHELLP syndrome\nLiver failure\nProlongation suggests liver failure\nProlonged in cholestatic and drug induced liver \ndisease \nFurther evaluation of a woman with suspected liver disease\n Details are specified under individual liver disease below.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume II\n42\n\t\n4.3.2. Hyperemesis gravidarum\n\t\n➢\t\nPatients present with persistent vomiting, weight loss, \t\n\t\n\t\n\t\ndehydration +/- ketosis usually from  4th to 20 th week \t\n\t\n\t\n\t\nof pregnancy.\n\t\n➢\t\nAffects 1-1.5% of pregnancies.\n\t\n➢\t\nIs more common with molar pregnancy, preexisting diabetes, \t\n\t\n\t\nand multiple  pregnancies.\n\t\n➢\t\nUsually has no effect on fetal outcome, unless prolonged and \t\n\t\n\t\nassociated with nutritional deficiencies.\n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\n\t o\t\nIncreased transaminases in 50% (in the lower \t\n\t\n\t\n\t\n\t \t\t\nhundreds)\n\t\n\t\n\t o\t\nAn  increase in bilirubin being less common with \t \t\n\t\n\t\n\t \t\t\njaundice found only occasionally\n\t\n\t\n\t o\t\nSeverity of liver disease correlates with vomiting\n\t\n➢\t Management includes:\n\t\n\t\n\t \to\t\nHydration, with monitoring of fluid balance and \t\n\t\n\t\n\t\n\t \t\t\nelectrolytes.\n\t\n\t\n\t \to\t\nEndoscopic insertion of a NJ tube should be considered \t\n\t\n\t\n\t \t\t\nin very severe cases when adequate nutrition and \t \t\n\t\n\t\n\t \t\t\nhydration cannot be maintained by other means.\n\t\n\t\no\t\nAntiemetics\n\t\n4.3.3.Intrahepatic cholestasis of pregnancy\n\t\n➢\t\nPrevalence is around 2/1000 of pregnancies.\n\t\n➢\t\nTypically presents with pruritus at around 25 to 32 weeks of \t\n\t\n\t\ngestation.\n\t\n\t\no\t\nPruritus  is severe at night and  affects palms and soles\n\t\n➢\t\nNo maternal complications except for pruritus, which could be \t\n\t\n\t\ndistressing.\n\t\n➢\t\nFetal complications include premature labor and sudden fetal \t\n\t\n\t\ndeath.\n\t\n➢\t\nPruritus and liver dysfunction resolve after delivery.\n\t\n➢\t\nHigh risk of recurrence in a subsequent pregnancy.\n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nElevated aminotransferase  levels (10 to 20 fold)\n\t\n\t\no\t\nJaundice in 10%-25% of patients, 2-4 weeks after  \t \t\n\t\n\t\n\t\npruritus; Bilirubin is usually less than 5mg/d\n\t\n\t\no\t\nRise in alkaline  phosphatase levels upto fourfold with a \t\n\t\n\t\n\t\nnormal or mildly elevated  GGT\n\t\n\t\no\t\nElevated fasting serum bile acid levels (>10 µmol/L)",
  "When to suspect liver disease\nSymptoms:\n\t\nPruritus, right hypochondrial pain, dark coloured urine or \nyellow discoloration of eyes, vomiting and swelling of feet (sudden onset \nin latter part of pregnancy), drowsiness and flu like symptoms.\nSigns:\n\t\nIcterus, peripheral oedema out of proportion to the gestational \nperiod/rapid onset or associated with hypertension, right hypochondrial \ntenderness, splenomegaly, reduced level of consciousness and liver flaps.\n\n--- Page 55 ---\nNational Guideline for Maternal Care - Volume II\n41\nBox 4.2: First line Investigations in a pregnant woman suspected with \nliver disease\nInvestigation\nSGOT (AST)\nSGPT(ALT)\nSerum \nbilirubin\nFBC\nPT/INR\nGamma GT\nAlkaline \nphosphatase\nFinding\nAny rise warrants \nevaluation \nAny rise warrants \nevaluation\nThrombocytopaenia\nAny rise needs further \nevaluation\nAny rise needs further \nevaluation\nIsolated elevation is \nnormal in pregnancy\nComments\nMild elevation\nDengue infection (SGOT>SGPT)\nPreeclampsia/HELLP syndrome(SGOT>SGPT)\nIntrahepatic cholestasis of pregnancy (ICP)\nHyperemesis gravidarum\nAcute fatty liver of pregnancy (AFLP )\nMarked elevation (Serum level >1000 U/L)\nAcute viral hepatitis\nDrug induced liver disease including \nParacetamol overdose\nHypoxic hepatic injury\nMild elevation in otherwise asymptomatic \nindividual \nPreexisting fatty liver disease\nCirrhosis\nMild elevation\nHyperemesis gravidarum (HG)\nAcute fatty liver of pregnancy (AFLP) –early \nstage\nHaemolysis, elevated liver enzymes and low \nplatelets (HELLP)\nSepsis\nMarked elevation\nCholestatic viral hepatitis\nLate stage of  AFLP\nAny cause of obstructive jaundice\nCirrhosis with portal hypertension \nSevere pre eclampsia\nHELLP syndrome\nLiver failure\nProlongation suggests liver failure\nProlonged in cholestatic and drug induced liver \ndisease \nFurther evaluation of a woman with suspected liver disease\n Details are specified under individual liver disease below.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume II\n42\n\t\n4.3.2. Hyperemesis gravidarum\n\t\n➢\t\nPatients present with persistent vomiting, weight loss, \t\n\t\n\t\n\t\ndehydration +/- ketosis usually from  4th to 20 th week \t\n\t\n\t\n\t\nof pregnancy.\n\t\n➢\t\nAffects 1-1.5% of pregnancies.\n\t\n➢\t\nIs more common with molar pregnancy, preexisting diabetes, \t\n\t\n\t\nand multiple  pregnancies.\n\t\n➢\t\nUsually has no effect on fetal outcome, unless prolonged and \t\n\t\n\t\nassociated with nutritional deficiencies.\n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\n\t o\t\nIncreased transaminases in 50% (in the lower \t\n\t\n\t\n\t\n\t \t\t\nhundreds)\n\t\n\t\n\t o\t\nAn  increase in bilirubin being less common with \t \t\n\t\n\t\n\t \t\t\njaundice found only occasionally\n\t\n\t\n\t o\t\nSeverity of liver disease correlates with vomiting\n\t\n➢\t Management includes:\n\t\n\t\n\t \to\t\nHydration, with monitoring of fluid balance and \t\n\t\n\t\n\t\n\t \t\t\nelectrolytes.\n\t\n\t\n\t \to\t\nEndoscopic insertion of a NJ tube should be considered \t\n\t\n\t\n\t \t\t\nin very severe cases when adequate nutrition and \t \t\n\t\n\t\n\t \t\t\nhydration cannot be maintained by other means.\n\t\n\t\no\t\nAntiemetics\n\t\n4.3.3.Intrahepatic cholestasis of pregnancy\n\t\n➢\t\nPrevalence is around 2/1000 of pregnancies.\n\t\n➢\t\nTypically presents with pruritus at around 25 to 32 weeks of \t\n\t\n\t\ngestation.\n\t\n\t\no\t\nPruritus  is severe at night and  affects palms and soles\n\t\n➢\t\nNo maternal complications except for pruritus, which could be \t\n\t\n\t\ndistressing.\n\t\n➢\t\nFetal complications include premature labor and sudden fetal \t\n\t\n\t\ndeath.\n\t\n➢\t\nPruritus and liver dysfunction resolve after delivery.\n\t\n➢\t\nHigh risk of recurrence in a subsequent pregnancy.\n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nElevated aminotransferase  levels (10 to 20 fold)\n\t\n\t\no\t\nJaundice in 10%-25% of patients, 2-4 weeks after  \t \t\n\t\n\t\n\t\npruritus; Bilirubin is usually less than 5mg/d\n\t\n\t\no\t\nRise in alkaline  phosphatase levels upto fourfold with a \t\n\t\n\t\n\t\nnormal or mildly elevated  GGT\n\t\n\t\no\t\nElevated fasting serum bile acid levels (>10 µmol/L)\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume II\n43\n\t\n\t\n\t\nwhich is the most specific and sensitive marker of ICP; \t\n\t\n\t\n\t\nThis could rise  upto 100 fold\n\t\n\t\no\t\nDeficiency of Vit K if liver functions are severely \t\n\t\n\t\n\t\n\t\nderanged\n\t\n➢\t\nManagement includes:\n\t\n\t\no\t\nSymptomatic therapy \n\t\n\t\n-\t\nUrsodeoxycholic acid (UDCA)  10 to 15 mg/kg body \t\n\t\n\t\n\t\nweight per day\n\t\n\t\n-\t\nFat soluble vitamin supplementation in severe \t\n\t\n\t\n\t\n\t\nsteatorrhoea\n\t\n\t\no\t\nClose monitoring and early delivery of the fetus.\n\t\n4.3.4. Pre eclampsia\n\t\n➢\t\nPreeclampsia is the occurrence of hypertension, proteinuria +/- \t\n\t\n\t\noedema after 20 weeks of pregnancy. \n\t\n➢\t\nIt affects around 3% of pregnancies; Is the commonest cause of \t\n\t\n\t\nhepatic tenderness in pregnancy\n\t\n➢\t\nLiver involvement, indicates severe preeclampsia.\n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nIncrease in serum aminotransferase levels which is \t\t\n\t\n\t\n\t\nusually mild. SGOT is usually more than SGPT.\n\t\n\t\no\t\nJaundice which is not common and usually associated \t\n\t\n\t\n\t\nwith serum bilirubin level less than 5 mg/dL\n\t\n\t\no\t\nSubcapsular haematoma which could occur with severe  \t\n\t\n\t\n\t\nliver derangement\n\t\n➢\t\nManagement includes:\n\t\n\t\no\t\nClose monitoring of maternal and fetal well being\n\t\n\t\no\t\nDelivery is the definitive therapy\n\t\n\t\n-\t\nNo specific therapy is needed for hepatic involvement \t\n\t\n\t\n\t\nof preeclampsia; It’s significance is as an indicator of \t\n\t\n\t\n\t\nsevere disease.\n\t\n4.3.5. HELLP Syndrome\n\t\n➢\t\nSevere preeclampsia is complicated in 2%-12% of cases by \t \t\n\t\n\t\nhemolysis (H), elevated liver enzymes (EL), and low platelet \t\n\t\n\t\ncount (LP).\n\t\n➢\t\nDiagnosis requires the presence of all 3 laboratory criteria.\n\t\n➢\t\nMost patients present in the 3rd trimester, but 25% present in \t\n\t\n\t\nthe postpartum period.",
  "SGOT is usually more than SGPT.\n\t\n\t\no\t\nJaundice which is not common and usually associated \t\n\t\n\t\n\t\nwith serum bilirubin level less than 5 mg/dL\n\t\n\t\no\t\nSubcapsular haematoma which could occur with severe  \t\n\t\n\t\n\t\nliver derangement\n\t\n➢\t\nManagement includes:\n\t\n\t\no\t\nClose monitoring of maternal and fetal well being\n\t\n\t\no\t\nDelivery is the definitive therapy\n\t\n\t\n-\t\nNo specific therapy is needed for hepatic involvement \t\n\t\n\t\n\t\nof preeclampsia; It’s significance is as an indicator of \t\n\t\n\t\n\t\nsevere disease.\n\t\n4.3.5. HELLP Syndrome\n\t\n➢\t\nSevere preeclampsia is complicated in 2%-12% of cases by \t \t\n\t\n\t\nhemolysis (H), elevated liver enzymes (EL), and low platelet \t\n\t\n\t\ncount (LP).\n\t\n➢\t\nDiagnosis requires the presence of all 3 laboratory criteria.\n\t\n➢\t\nMost patients present in the 3rd trimester, but 25% present in \t\n\t\n\t\nthe postpartum period.\n\n--- Page 58 ---\nNational Guideline for Maternal Care - Volume II\n44\nBox 4.3- Diagnostic Criteria for HELLP Syndrome\nHaemolysis \n\t\n-Fragmented red blood cells /LDH >600 U/L/ \t\n\t\n Elevated  indirect bilirubin\nElevated liver enzymes\n\t\n- AST>70U/L\nLow platelets \n\t\n- Plt ct< 150×109\n\t\n➢\t\nMost patients present with upper abdominal pain and \t\n\t\n\t\n\t\ntenderness, nausea, vomiting, malaise, headache, oedema, \t \t\n\t\n\t\nhypertension and   proteinuria.\n\t\n➢\t\nThe diagnosis of HELLP syndrome must be quickly established \t\n\t\n\t\nbecause of the necessity for immediate delivery considering the \t\n\t\n\t\nmaternal and fetal risk. \n\t\n➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nRaised aminotransferase levels  from mild to 10-20 fold\n\t\n\t\no\t\nMildly elevated serum bilirubin; Jaundice is \t\n\t\n\t\n\t\n\t\nuncommon\n\t\n➢\t\nManagement includes\n:\n\t\n\t\no\t\nDelivery as the definitive therapy \n\t\n4.3.6. Acute Fatty Liver of Pregnancy (AFLP)\n\t\n➢\t\nThis almost exclusively occurs in the third trimester; rarely in \t\n\t\n\t\nlate second trimester.\n\t\n➢\t\nCommon presentations are anorexia, nausea, vomiting and \t\t\n\t\n\t\nright upper quadrant pain.\n\t\n➢\t\nPatient may have jaundice, hypertension, peripheral oedema, \t\n\t\n\t\nascites and hepatic encephalopathy.\n\t\n➢\t\nPatient may present with hepatic failure; therefore is associated \t\n\t\n\t\nwith significant maternal and perinatal morbidity and mortality.",
  "➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nRaised aminotransferase levels  from mild to 10-20 fold\n\t\n\t\no\t\nMildly elevated serum bilirubin; Jaundice is \t\n\t\n\t\n\t\n\t\nuncommon\n\t\n➢\t\nManagement includes\n:\n\t\n\t\no\t\nDelivery as the definitive therapy \n\t\n4.3.6. Acute Fatty Liver of Pregnancy (AFLP)\n\t\n➢\t\nThis almost exclusively occurs in the third trimester; rarely in \t\n\t\n\t\nlate second trimester.\n\t\n➢\t\nCommon presentations are anorexia, nausea, vomiting and \t\t\n\t\n\t\nright upper quadrant pain.\n\t\n➢\t\nPatient may have jaundice, hypertension, peripheral oedema, \t\n\t\n\t\nascites and hepatic encephalopathy.\n\t\n➢\t\nPatient may present with hepatic failure; therefore is associated \t\n\t\n\t\nwith significant maternal and perinatal morbidity and mortality.\n\n--- Page 59 ---\nNational Guideline for Maternal Care - Volume II\n45\n\t\n➢\t\nAbout 50% of patients with AFLP have preeclampsia, and there \t\n\t\n\t\nis overlap with HELLP syndrome.\n\t\n➢\t\nWomen with AFLP have an increased risk of recurrence in a \t\n\t\n\t\nfuture pregnancy.\n\t\n➢\t\nThe main differential diagnoses for acute liver failure in the \t\t\n\t\n\t\nthird trimester are AFLP, HELLP, and fulminant viral hepatitis.\n\t\n\t\n–\t\nIn comparison with HELLP syndrome, patients \t\n\t\n\t\n\t\n\t\nwith AFLP are more likely to develop  coagulopathy, \t\n\t\n\t\n\t\nhypoglycemia, encephalopathy,DIC, and renal failure\n\t\n➢\t\nLiver dysfunction include:\n\t\n\t\no\t\nMild to severe elevation of aminotransferases (usually \t\n\t\n\t\n\t\nupto 300 to 500U/L)\n\t\n\t\no\t\nMild elevation of serum bilirubin which is usuallyless \t\n\t\n\t\n\t\nthan 5mg/dL but higher in severe or complicated \t \t\n\t\n\t\n\t\ndisease\nBox 4.4- Swansea diagnostic criteria for diagnosis of acute fatty liver \nof pregnancy\nSix or more of the following features in the absence of another \nexplanation suggests a diagnosis of AFLP\n\t\n• Vomiting\n\t\n• Abdominal pain\n\t\n• Polydipsia/polyuria\n\t\n• Encephalopathy\n\t\n• High bilirubin (>14 μmol/L)\n\t\n• Hypoglycaemia (<4 mmol/L)\n\t\n• High uric acid (>340 μmol/L)\n\t\n• Leucocytosis (>11×106/L)",
  "➢\t\nLiver dysfunction includes:\n\t\n\t\no\t\nRaised aminotransferase levels  from mild to 10-20 fold\n\t\n\t\no\t\nMildly elevated serum bilirubin; Jaundice is \t\n\t\n\t\n\t\n\t\nuncommon\n\t\n➢\t\nManagement includes\n:\n\t\n\t\no\t\nDelivery as the definitive therapy \n\t\n4.3.6. Acute Fatty Liver of Pregnancy (AFLP)\n\t\n➢\t\nThis almost exclusively occurs in the third trimester; rarely in \t\n\t\n\t\nlate second trimester.\n\t\n➢\t\nCommon presentations are anorexia, nausea, vomiting and \t\t\n\t\n\t\nright upper quadrant pain.\n\t\n➢\t\nPatient may have jaundice, hypertension, peripheral oedema, \t\n\t\n\t\nascites and hepatic encephalopathy.\n\t\n➢\t\nPatient may present with hepatic failure; therefore is associated \t\n\t\n\t\nwith significant maternal and perinatal morbidity and mortality.\n\n--- Page 59 ---\nNational Guideline for Maternal Care - Volume II\n45\n\t\n➢\t\nAbout 50% of patients with AFLP have preeclampsia, and there \t\n\t\n\t\nis overlap with HELLP syndrome.\n\t\n➢\t\nWomen with AFLP have an increased risk of recurrence in a \t\n\t\n\t\nfuture pregnancy.\n\t\n➢\t\nThe main differential diagnoses for acute liver failure in the \t\t\n\t\n\t\nthird trimester are AFLP, HELLP, and fulminant viral hepatitis.\n\t\n\t\n–\t\nIn comparison with HELLP syndrome, patients \t\n\t\n\t\n\t\n\t\nwith AFLP are more likely to develop  coagulopathy, \t\n\t\n\t\n\t\nhypoglycemia, encephalopathy,DIC, and renal failure\n\t\n➢\t\nLiver dysfunction include:\n\t\n\t\no\t\nMild to severe elevation of aminotransferases (usually \t\n\t\n\t\n\t\nupto 300 to 500U/L)\n\t\n\t\no\t\nMild elevation of serum bilirubin which is usuallyless \t\n\t\n\t\n\t\nthan 5mg/dL but higher in severe or complicated \t \t\n\t\n\t\n\t\ndisease\nBox 4.4- Swansea diagnostic criteria for diagnosis of acute fatty liver \nof pregnancy\nSix or more of the following features in the absence of another \nexplanation suggests a diagnosis of AFLP\n\t\n• Vomiting\n\t\n• Abdominal pain\n\t\n• Polydipsia/polyuria\n\t\n• Encephalopathy\n\t\n• High bilirubin (>14 μmol/L)\n\t\n• Hypoglycaemia (<4 mmol/L)\n\t\n• High uric acid (>340 μmol/L)\n\t\n• Leucocytosis (>11×106/L)\n\n--- Page 60 ---\nNational Guideline for Maternal Care - Volume II\n46\n\t\n➢\t\nOther typical abnormalities are:\n\t\n\t\no\t\nNormochromic, normocytic anaemia\n\t\n\t\no\t\nThrombocytopaenia\n\t\n➢\t\nManagement \n\t\n\t\no\t\nEarly referral to a specialist care center on suspicion of \t\n\t\n\t\n\t\nAFLP\n\t\n\t\no\t\nConsider immediate delivery to avoid adverse maternal \t\n\t\n\t\n\t\nand fetal outcome\n\t\n\t\no\t\nIntensive care to manage complications of liver failure\n \n\t\n➢\t\nMost patients improve in 1 to 4 weeks postpartum, although a \t\n\t\n\t\ncholestatic phase with rising bilirubin and alkaline phosphatase \t\n\t\n\t\nmay persist.\n\t\n➢\t\nRecovery can occur in days or be delayed for months but is \t\t\n\t\n\t\ncomplete with no signs of chronic liver disease.\n\t\n➢\t\nLiver transplantation has a very limited role because of the \t \t\n\t\n\t\ngreat potential for recovery with delivery, but ideally may have \t\n\t\n\t\na place in patients whose clinical course continues to deteriorate \t\n\t\n\t\nwith advancing fulminant hepatic failure.\n4.4. Liver disease coincidental to pregnancy\n\t\n4.4.1. Non alcoholic fatty liver disease (NAFLD)\n\t\n➢\t\nIncidental detection of fatty liver on USS with isolated, mild \t\n\t\n\t\nelevation in liver transaminases suggest NAFLD. \n\t\n➢\t\nFirst diagnosis of NAFLD during pregnancy should be made \t\n\t\n\t\nonly after excluding other causes of liver dysfunction. \n\t\n➢\t\nPatient should have a plan for follow up after delivery. \n\t\n4.4.2. Dengue infection\n\t\n➢\t\nIt is associated with fever, myalgia, arthralgia, headache and \t\n\t\n\t\nvomiting.",
  "4.4.2. Dengue infection\n\t\n➢\t\nIt is associated with fever, myalgia, arthralgia, headache and \t\n\t\n\t\nvomiting.\n\n--- Page 61 ---\nNational Guideline for Maternal Care - Volume II\n47\n\t\n➢\t\nHigh transaminases (SGOT>SGPT) and thrombocytopenia is \t\n\t\n\t\nseen.\n\t\n➢\t\nDengue antigen (Ag) is positive on day 1-2 of fever while \t\n\t\n\t\n\t\nDengue IgM/IgG is positive on day 5-7 of illness. \n\t\n4.4.3. Acute viral hepatitis \n\t\n➢\t\nIt usually follows the same disease course as the non pregnant \t\n\t\n\t\npopulation. \n\t\n\t\no\t\nExceptions are hepatitis E and herpes simplex \t\n\t\n\t\n\t\n\t\ninfection, which have significant mortality and \t\n\t\n\t\n\t\n\t\nmorbidity in pregnancy \n\t\n➢\t\nHigh transaminase levels typically over 1000 U/L, +/- recent \t\n\t\n\t\nhistory of fever, vomiting and right hypochondrial pain suggest \t\n\t\n\t\nviral hepatits though AFLP could present in a similar way. \t \t\n\t\n\t\n(Elevation of transaminases is usually <1000U/L, in AFLP).\n\t\n➢\t\nHep A IgM/Hep B s Ag/HCV antibodies/Hep E Ab should be \t\n\t\n\t\nrequested for confirmation of viral hepatitis.\n\t\n➢\t\nBreast feeding in patients with Viral Hepatitis \n\t\n\t\no\t\nHepatitis A and E –Breast feeding can be continued\n\t\n\t\no\t\nHepatitis B –Once the baby is immunized, the benefits \t\n\t\n\t\n\t\noutweighs risk of transmission Therefore breast feeding \t\n\t\n\t\n\t\nshould not be delayed. However it should be avoided if \t\n\t\n\t\n\t\nthe nipples are cracked\n\t\n\t\no\t\nHepatitis C - Benefits outweighs risk of transmission; \t\n\t\n\t\n\t\nTherefore breast feeding should not be delayed. If \t \t\n\t\n\t\n\t\nnipples are cracked, expressed breast milk can be used \n\t\nHepatitis E infection\n\t\n➢\t\nAcute infection with Hep E virus may result in fulminant \t \t\n\t\n\t\nhepatitis with risk of liver failure.\n\t\nHerpes simplex virus (HSV) hepatitis\n\t\n➢\t\nHigh transaminase levels may occur.",
  "However it should be avoided if \t\n\t\n\t\n\t\nthe nipples are cracked\n\t\n\t\no\t\nHepatitis C - Benefits outweighs risk of transmission; \t\n\t\n\t\n\t\nTherefore breast feeding should not be delayed. If \t \t\n\t\n\t\n\t\nnipples are cracked, expressed breast milk can be used \n\t\nHepatitis E infection\n\t\n➢\t\nAcute infection with Hep E virus may result in fulminant \t \t\n\t\n\t\nhepatitis with risk of liver failure.\n\t\nHerpes simplex virus (HSV) hepatitis\n\t\n➢\t\nHigh transaminase levels may occur.\n\n--- Page 62 ---\nNational Guideline for Maternal Care - Volume II\n48\n\t\n➢\t\nHSV DNA is positive. \n\t\n➢\t\nConsider Acyclovir. \n\t\n4.4.4. Gall stone disease\n\t\n➢\t\nGallstones are more common in pregnancy, especially during \t\n\t\n\t\nthe second and third trimester and should be considered, \t \t\n\t\n\t\nespecially in the presence of characteristic abdominal pain. \n\t\n➢\t\nPatients with symptomatic gall stones should be managed \t \t\n\t\n\t\nin a tertiary care centre where facilities for ERCP and \t\n\t\n\t\n\t\nlaparoscopic cholecystectomy are available. \n\t\n➢\t\nERCP can be performed if it is absolutely necessary with \t\n\t\n\t\n\t\nadequate radiation protection. \n\t\n➢\t\nPregnancy itself does not increase frequency or severity of \t \t\n\t\n\t\nERCP related complications. \n\t\n➢\t\nCholecystectomy is best performed in the second trimester. \n\t\n\t\no\t\nLaparoscopic cholecystectomy is preferred over open \t\n\t\n\t\n\t\nsurgery. \n\t\n4.4.5. Sepsis\n\t\n➢\t\nThis mimics liver disease in pregnancy. \n\t\n➢\t\nBiochemical abnormalities include:\n\t\n\t\no\t\nHigh WBC\n\t\n\t\no\t\nElevated serum bilirubin\n\t\n\t\no\t\nMild –moderate elevation in liver transaminases \n\t\n\t\no\t\nCoagulopathy and DIC- high INR and \t\n\t\n\t\n\t\n\t\n\t\nthrombocytopaenia.\n\t\n➢\t\nBlood culture should be obtained   and IV antibiotics \t\n\t\n\t\n\t\ncommenced early.\n4.5.Acute liver failure\nDefinition:\nThe presence of coagulopathy (international normalized ratio [INR] >1.5) \nand any degree of encephalopathy occurring within 24 weeks of the first",
  "Sepsis\n\t\n➢\t\nThis mimics liver disease in pregnancy. \n\t\n➢\t\nBiochemical abnormalities include:\n\t\n\t\no\t\nHigh WBC\n\t\n\t\no\t\nElevated serum bilirubin\n\t\n\t\no\t\nMild –moderate elevation in liver transaminases \n\t\n\t\no\t\nCoagulopathy and DIC- high INR and \t\n\t\n\t\n\t\n\t\n\t\nthrombocytopaenia.\n\t\n➢\t\nBlood culture should be obtained   and IV antibiotics \t\n\t\n\t\n\t\ncommenced early.\n4.5.Acute liver failure\nDefinition:\nThe presence of coagulopathy (international normalized ratio [INR] >1.5) \nand any degree of encephalopathy occurring within 24 weeks of the first\n\n--- Page 63 ---\nNational Guideline for Maternal Care - Volume II\n49\nonset of symptoms of liver disease in patients without previous history of \nliver impairment.\nCauses of acute liver failure include,\nAcute viral hepatitis, AFLP, Paracetamol poisoning, autoimmune \nhepatitis, Budd-Chiari syndrome.\nManagement of acute liver failure\nGeneral measures:\n➢\t The patient should be managed in an intensive care unit under the \t\n\t\ncare \tof the obstetrician and hepatologist/gastrointestinal physician.\n\t\n1.\t\nClose monitoring of mean arterial pressure, serum electrolytes, \t\n\t\n\t\nfluid balance, renal functions and blood sugar values.\n\t\n2.\t\nElevate the head of the bed 30° and maintain the head in a \t \t\n\t\n\t\nneutral position.\n\t\n3.\t\nLactulose may be used to ensure regular bowel opening.\n\t\n4.\t\nAlthough oral Metronidazole is beneficial in patients with \t \t\n\t\n\t\nchronic hepatic encephalopathy, the benefit of these \t\n\t\n\t\n\t\ndrugs in acute liver failure is controversial as the pathogenesis \t\n\t\n\t\nof acute liver failure is related to cerebral edema as opposed to \t\n\t\n\t\nammonia excess.\n\t\n5.\t\n3rd generation cephalosporin is the choice of prophylactic \t \t\n\t\n\t\nantibiotic.\n\t\n6.\t\nConsider IV  N- Acetyl cysteine (NAC)  - 150mg/Kg over 1 \t\t\n\t\n\t\nhour, 50mg/Kg over 4 hours,  150mg/Kg over 24 hours. \t\n\t\n\t\n\t\nLast dose should be repeated for 3 days.\n\t\n7.\t\nMonitor with daily liver function tests including INR and \t \t\n\t\n\t\nclinical assessment of level of consciousness including \t\n\t\n\t\n\t\nliver flaps.\n\t\n8.\t\nIf sepsis is suspected, treat with IV antibiotics.\nSpecific measures:\nThe patient should be referred to the hepatologist for investigation and \ntreatment of the underlying cause for acute liver failure.",
  "➢\t\nBiochemical abnormalities include:\n\t\n\t\no\t\nHigh WBC\n\t\n\t\no\t\nElevated serum bilirubin\n\t\n\t\no\t\nMild –moderate elevation in liver transaminases \n\t\n\t\no\t\nCoagulopathy and DIC- high INR and \t\n\t\n\t\n\t\n\t\n\t\nthrombocytopaenia.\n\t\n➢\t\nBlood culture should be obtained   and IV antibiotics \t\n\t\n\t\n\t\ncommenced early.\n4.5.Acute liver failure\nDefinition:\nThe presence of coagulopathy (international normalized ratio [INR] >1.5) \nand any degree of encephalopathy occurring within 24 weeks of the first\n\n--- Page 63 ---\nNational Guideline for Maternal Care - Volume II\n49\nonset of symptoms of liver disease in patients without previous history of \nliver impairment.\nCauses of acute liver failure include,\nAcute viral hepatitis, AFLP, Paracetamol poisoning, autoimmune \nhepatitis, Budd-Chiari syndrome.\nManagement of acute liver failure\nGeneral measures:\n➢\t The patient should be managed in an intensive care unit under the \t\n\t\ncare \tof the obstetrician and hepatologist/gastrointestinal physician.\n\t\n1.\t\nClose monitoring of mean arterial pressure, serum electrolytes, \t\n\t\n\t\nfluid balance, renal functions and blood sugar values.\n\t\n2.\t\nElevate the head of the bed 30° and maintain the head in a \t \t\n\t\n\t\nneutral position.\n\t\n3.\t\nLactulose may be used to ensure regular bowel opening.\n\t\n4.\t\nAlthough oral Metronidazole is beneficial in patients with \t \t\n\t\n\t\nchronic hepatic encephalopathy, the benefit of these \t\n\t\n\t\n\t\ndrugs in acute liver failure is controversial as the pathogenesis \t\n\t\n\t\nof acute liver failure is related to cerebral edema as opposed to \t\n\t\n\t\nammonia excess.\n\t\n5.\t\n3rd generation cephalosporin is the choice of prophylactic \t \t\n\t\n\t\nantibiotic.\n\t\n6.\t\nConsider IV  N- Acetyl cysteine (NAC)  - 150mg/Kg over 1 \t\t\n\t\n\t\nhour, 50mg/Kg over 4 hours,  150mg/Kg over 24 hours. \t\n\t\n\t\n\t\nLast dose should be repeated for 3 days.\n\t\n7.\t\nMonitor with daily liver function tests including INR and \t \t\n\t\n\t\nclinical assessment of level of consciousness including \t\n\t\n\t\n\t\nliver flaps.\n\t\n8.\t\nIf sepsis is suspected, treat with IV antibiotics.\nSpecific measures:\nThe patient should be referred to the hepatologist for investigation and \ntreatment of the underlying cause for acute liver failure.\n\n--- Page 64 ---\nNational Guideline for Maternal Care - Volume II\n50\nReferences\n\t\n1.\t\nJoshi D, James A, Quaglia A, Westbrook RH, Heneghan MA \t\n\t\n\t\nLiver disease in pregnancy.  Lancet 2010; 375: 594–605.\n\t\n2.\t\nPatton H,   Misel M, Gish RG et al Acute Liver Failure in \t\n\t\n\t\n\t\nAdults: An Evidence-Based Management Protocol for \t\n\t\n\t\n\t\nClinicians Gastroenterology & Hepatology2012 Volume 8, Issue \t\n\t\n\t\n3 March 2012 161-173.\n\t\n3.\t\nGami N et al.An approach to diagnosis and management of \t\t\n\t\n\t\nacute fatty liver of pregnancy International Journal \t\t\n\t\n\t\n\t\nof Reproduction, Contraception, Obstetrics and Gynecology \t\n\t\n\t\n2013 March;2(1):104-108.\n\t\n4.\t\nIbdah JA Acute fatty liver of pregnancy: An update \ton    \t\n\t\n\t\n\t\npathogenesis and clinical implications World Journal of \t\n\t\n\t\n\t\nGastroenterology 2006 December 14; 12(46): 7397-7404.\n\t\n5.\t\nLee WM, HynanLS, Rossaro L, Fontana RJ, Stravitz RT, et al \t\n\t\n\t\nIntravenous n-acetylcysteine improves transplantfree survival \t\n\t\n\t\nin early stage non-acetaminophen acute liver failure \t\n\t\n\t\n\t\nGastroenterology. 2009 September ; 137(3): 856–864.\n\t\n6.\t\n  Allen AM , Hay JE Review article: the management of cirrhosis \t\n\t\n\t\nin women Alimentary Pharmacology and Therapeutics 2014; \t\n\t\n\t\n40: 1146–1154.",
  "Lancet 2010; 375: 594–605.\n\t\n2.\t\nPatton H,   Misel M, Gish RG et al Acute Liver Failure in \t\n\t\n\t\n\t\nAdults: An Evidence-Based Management Protocol for \t\n\t\n\t\n\t\nClinicians Gastroenterology & Hepatology2012 Volume 8, Issue \t\n\t\n\t\n3 March 2012 161-173.\n\t\n3.\t\nGami N et al.An approach to diagnosis and management of \t\t\n\t\n\t\nacute fatty liver of pregnancy International Journal \t\t\n\t\n\t\n\t\nof Reproduction, Contraception, Obstetrics and Gynecology \t\n\t\n\t\n2013 March;2(1):104-108.\n\t\n4.\t\nIbdah JA Acute fatty liver of pregnancy: An update \ton    \t\n\t\n\t\n\t\npathogenesis and clinical implications World Journal of \t\n\t\n\t\n\t\nGastroenterology 2006 December 14; 12(46): 7397-7404.\n\t\n5.\t\nLee WM, HynanLS, Rossaro L, Fontana RJ, Stravitz RT, et al \t\n\t\n\t\nIntravenous n-acetylcysteine improves transplantfree survival \t\n\t\n\t\nin early stage non-acetaminophen acute liver failure \t\n\t\n\t\n\t\nGastroenterology. 2009 September ; 137(3): 856–864.\n\t\n6.\t\n  Allen AM , Hay JE Review article: the management of cirrhosis \t\n\t\n\t\nin women Alimentary Pharmacology and Therapeutics 2014; \t\n\t\n\t\n40: 1146–1154.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume II\n51\nRenal Disease",
  "Lancet 2010; 375: 594–605.\n\t\n2.\t\nPatton H,   Misel M, Gish RG et al Acute Liver Failure in \t\n\t\n\t\n\t\nAdults: An Evidence-Based Management Protocol for \t\n\t\n\t\n\t\nClinicians Gastroenterology & Hepatology2012 Volume 8, Issue \t\n\t\n\t\n3 March 2012 161-173.\n\t\n3.\t\nGami N et al.An approach to diagnosis and management of \t\t\n\t\n\t\nacute fatty liver of pregnancy International Journal \t\t\n\t\n\t\n\t\nof Reproduction, Contraception, Obstetrics and Gynecology \t\n\t\n\t\n2013 March;2(1):104-108.\n\t\n4.\t\nIbdah JA Acute fatty liver of pregnancy: An update \ton    \t\n\t\n\t\n\t\npathogenesis and clinical implications World Journal of \t\n\t\n\t\n\t\nGastroenterology 2006 December 14; 12(46): 7397-7404.\n\t\n5.\t\nLee WM, HynanLS, Rossaro L, Fontana RJ, Stravitz RT, et al \t\n\t\n\t\nIntravenous n-acetylcysteine improves transplantfree survival \t\n\t\n\t\nin early stage non-acetaminophen acute liver failure \t\n\t\n\t\n\t\nGastroenterology. 2009 September ; 137(3): 856–864.\n\t\n6.\t\n  Allen AM , Hay JE Review article: the management of cirrhosis \t\n\t\n\t\nin women Alimentary Pharmacology and Therapeutics 2014; \t\n\t\n\t\n40: 1146–1154.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume II\n51\nRenal Disease\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume II\n52",
  "Lancet 2010; 375: 594–605.\n\t\n2.\t\nPatton H,   Misel M, Gish RG et al Acute Liver Failure in \t\n\t\n\t\n\t\nAdults: An Evidence-Based Management Protocol for \t\n\t\n\t\n\t\nClinicians Gastroenterology & Hepatology2012 Volume 8, Issue \t\n\t\n\t\n3 March 2012 161-173.\n\t\n3.\t\nGami N et al.An approach to diagnosis and management of \t\t\n\t\n\t\nacute fatty liver of pregnancy International Journal \t\t\n\t\n\t\n\t\nof Reproduction, Contraception, Obstetrics and Gynecology \t\n\t\n\t\n2013 March;2(1):104-108.\n\t\n4.\t\nIbdah JA Acute fatty liver of pregnancy: An update \ton    \t\n\t\n\t\n\t\npathogenesis and clinical implications World Journal of \t\n\t\n\t\n\t\nGastroenterology 2006 December 14; 12(46): 7397-7404.\n\t\n5.\t\nLee WM, HynanLS, Rossaro L, Fontana RJ, Stravitz RT, et al \t\n\t\n\t\nIntravenous n-acetylcysteine improves transplantfree survival \t\n\t\n\t\nin early stage non-acetaminophen acute liver failure \t\n\t\n\t\n\t\nGastroenterology. 2009 September ; 137(3): 856–864.\n\t\n6.\t\n  Allen AM , Hay JE Review article: the management of cirrhosis \t\n\t\n\t\nin women Alimentary Pharmacology and Therapeutics 2014; \t\n\t\n\t\n40: 1146–1154.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume II\n51\nRenal Disease\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume II\n52\n\n--- Page 67 ---\nNational Guideline for Maternal Care - Volume II\n53\n5. Renal disease in pregnancy\n5.1. Introduction\nRenal disease could be either pre-existing or diagnosed for the first time \nin pregnancy. Renal impairment is associated with significant maternal \nand feotal morbidity and mortality.\nPhysiological changes in renal system in pregnancy\n\t\n1.\t\nIncrease in proteinuria\n\t\n\t\no\t\nProteinuria increases upto 300mg/d by the third \t\n\t\n\t\n\t\n\t\ntrimester of pregnancy\n\t\n\t\n-\t\n24 h urine collection for urinary protein excretion \t \t\n\t\n\t\n\t\nand measurement of creatinine clearance remains the \t\n\t\n\t\n\t\ngold standard for measurement of renal function in \t\n\t\n\t\n\t\npregnancy\n\t\n2.\t\nDecrease in serum creatinine levels\n\t\n\t\no\t\nSerum creatinine falls by an average of 0.4 mg/dL to a \t\n\t\n\t\n\t\npregnancy range of 0.4 to 0.8 mg/dL.\n\t\n\t\n-\t\nHence, a serum creatinine of 1.0 mg/dL, although \t \t\n\t\n\t\n\t\nnormal in a non-pregnant individual, reflects \t\n\t\n\t\n\t\n\t\nrenal impairment in a pregnant woman\n\t\n3.\t\nDilatation of the renal tract with increased incidence of reflux \t\n\t\n\t\nnephropathy\n\t\n\t\no\t\nThe urinary collecting system (renal calyces, pelvis, and \t\n\t\n\t\n\t\nureters) \tdilate. The dilated collecting systems can hold \t\n\t\n\t\n\t\nup to 300 mL of urine and hence serves as a reservoir \t\n\t\n\t\n\t\nfor bacteria.\n\t\n\t\no\t\nIn the later stages of pregnancy, mechanical \t\n\t\n\t\n\t\n\t\ncompression of the ureter against the pelvic \t\n\t\n\t\n\t\n\t\nbrim may lead to hydroureter and hydronephrosis. \n\t\n\t\no\t\nHydronephrosis occurs on the right in 90% of cases \t\n\t\n\t\n\t\ndue to dextrorotation of the uterus by the sigmoid \t \t\n\t\n\t\n\t\ncolon. \nPregnancy and kidney disease\nThe main determinant of pregnancy outcome is the degree of renal \nimpairment.",
  "o\t\nHydronephrosis occurs on the right in 90% of cases \t\n\t\n\t\n\t\ndue to dextrorotation of the uterus by the sigmoid \t \t\n\t\n\t\n\t\ncolon. \nPregnancy and kidney disease\nThe main determinant of pregnancy outcome is the degree of renal \nimpairment.\n\n--- Page 68 ---\nNational Guideline for Maternal Care - Volume II\n54\nEffect of pregnancy on kidney disease:\nWorsening proteinuria \nLoss of kidney function- may be irreversible\nEffect of kidney disease on pregnancy:\nPreterm delivery\nFetal growth restriction (FGR)\nIntrauterine death\nPreeclampsia\n5.2. Pre-existing renal  disease\nPreconception care\n\t\n➢\t\nAll women with renal disease should be seen by a nephrologist \t\n\t\n\t\nprior to becoming pregnant. \n\t\n➢\t\nWomen should be counselled on the risk of pregnancy, \t\n\t\n\t\n\t\ndepending on the underlying renal disease and baseline renal \t\n\t\n\t\nfunctions. \n\t\n➢\t\nAn individualized care plan including cardiac assessment \t \t\n\t\n\t\nshould be performed, in view of increased risk of coronary \t \t\n\t\n\t\nartery disease.\n\t\nFertility\n\t\n➢\t\nFertility rates are thought to decline proportionately with \t\n\t\n\t\n\t\ndeclining renal function. Women with CKD stage ≥ 3 (GFR < \t\n\t\n\t\n30ml/min/1.73m2) are generally less fertile.\nContraception\n\t\n➢\t\nUse of contraceptives should be advocated until it is safe for the \t\n\t\n\t\nwoman to become pregnant. \n\t\n➢\t\nMost contraceptives could be used in women with renal \t\n\t\n\t\n\t\nimpairment. \n\t\n\t\no\t\nOestrogen containing contraceptives should be avoided \t\n\t\n\t\n\t\nin women with hypertension and those at increased \t\n\t\n\t\n\t\nrisk of thrombosis (eg: nephrotic syndrome).\n\t\n➢\t\nIntra uterine device (IUD) could be used.",
  "➢\t\nMost contraceptives could be used in women with renal \t\n\t\n\t\n\t\nimpairment. \n\t\n\t\no\t\nOestrogen containing contraceptives should be avoided \t\n\t\n\t\n\t\nin women with hypertension and those at increased \t\n\t\n\t\n\t\nrisk of thrombosis (eg: nephrotic syndrome).\n\t\n➢\t\nIntra uterine device (IUD) could be used.\n\n--- Page 69 ---\nNational Guideline for Maternal Care - Volume II\n55\n\t\n5.2.1. Diabetic nephropathy\n\t\n➢\t\nThe presence of diabetic nephropathy is a risk factor for \t\n\t\n\t\n\t\nincreased perinatal morbidity and mortality. \n\t\n\t\no\t\nA favourable outcome is to be expected with\n\t\n\t\n-\t\nSerum creatinine <1.4 mg/dl (124 mmol/L)\n\t\n\t\n-\t\nProteinuria  <1 g/24 h\n\t\n\t\n-\t\nNormal blood pressure\n\t\n\t\no\t\nSerum creatinine >2 mg/dL (176 mmol/L) is the best \t\n\t\n\t\n\t\npredictor of the risk of pregnancy induced decline in \t\n\t\n\t\n\t\nmaternal kidney function leading to end stage renal \t\n\t\n\t\n\t\ndisease (ESRD) during pregnancy or shortly \t\n\t\n\t\n\t\n\t\nafterwards.\n\t\n\t\nManagement \n\t\n➢\t\nMultidisciplinary care with involvement of the obstetrician and \t\n\t\n\t\nnephrologist.\n\t\n➢\t\nAttain normotension and euglycaemia in the preconception \t\n\t\n\t\nstage, with counselling on the risk of worsening proteinuria and \t\n\t\n\t\nits implications on pregnancy.\n\t\n➢\t\nAngiotensin receptor inhibitors (ACEI) and angiotensin \t\n\t\n\t\n\t\nreceptor blockers (ARB) must be withheld in pregnancy.\n\t\n➢\t\nDuring pregnancy, 75mg of Aspirin should be commenced at 12 \t\n\t\n\t\nweeks of gestation and continued until delivery.\n\t\n➢\t\nAim to maintain blood pressure < 135/85mHg throughout \t \t\n\t\n\t\npregnancy with monthly assessment of renal functions (serum \t\n\t\n\t\ncreatinine, electrolytes and proteinuria). \n\t\n➢\t\nFetal growth monitoring after 28 weeks.\n\t\n5.2.2. Adult onset polycystic kidney disease\n\t\n➢\t\nNormotensive women with normal renal function generally \t\n\t\n\t\nhave uncomplicated pregnancies, though there is an increased \t\n\t\n\t\nrisk of maternal complications such as hypertension and \t\n\t\n\t\n\t\npreeclampsia.\n\t\n➢\t\nCerebral imaging for aneurysm should be performed before \t\n\t\n\t\npregnancy, and if present, consider elective caesarean as mode \t\n\t\n\t\nof delivery.\n\t\n➢\t\nThe patient and the spouse should be counselled regarding the \t\n\t\n\t\nrisks of giving birth to an offspring who has a 50% \tchance of \t\n\t\n\t\ndeveloping this condition later in life",
  "➢\t\nFetal growth monitoring after 28 weeks.\n\t\n5.2.2. Adult onset polycystic kidney disease\n\t\n➢\t\nNormotensive women with normal renal function generally \t\n\t\n\t\nhave uncomplicated pregnancies, though there is an increased \t\n\t\n\t\nrisk of maternal complications such as hypertension and \t\n\t\n\t\n\t\npreeclampsia.\n\t\n➢\t\nCerebral imaging for aneurysm should be performed before \t\n\t\n\t\npregnancy, and if present, consider elective caesarean as mode \t\n\t\n\t\nof delivery.\n\t\n➢\t\nThe patient and the spouse should be counselled regarding the \t\n\t\n\t\nrisks of giving birth to an offspring who has a 50% \tchance of \t\n\t\n\t\ndeveloping this condition later in life\n\n--- Page 70 ---\nNational Guideline for Maternal Care - Volume II\n56\n\t\n5.2.3. Lupus nephritis\n\t\n➢\t\nPregnancy is safe if,\n\t\n\t\no\t\nin remission with ≤10 mg daily of prednisone for 6 \t\t\n\t\n\t\n\t\nmonths\n\t\n\t\no\t\nSerum creatinine is < 1.4 mg/dL\n\t\n\t\no\t\nBlood pressure is well controlled\n\t\n➢\t\nWomen with class III or IV lupus nephritis are at increased risk \t\n\t\n\t\nof hypertension and renal flares.\n\t\n➢\t\n Complications of poorly controlled disease include,\n\t\n\t\no\t\nspontaneous abortions\n\t\n\t\no\t\nfetal growth restriction \n\t\n\t\no\t\npremature delivery\n\t\n\t\n-\t\nEspecially in the presence of antiphospholipid \t\n\t\n\t\n\t\n\t\nantibodies\n\t\n➢\t\nAzathioprine and Prednisolone are safe in pregnancy. \n\t\n5.2.4. Other Glomerulonephritides\n\t\n➢\t\nAssessment for suitability of pregnancy and optimization of \t\n\t\n\t\ndisease should be undertaken in the preconception stage.\n\t\n\t\no\t\nAim for disease remission for at least six months before \t\n\t\n\t\n\t\nplanning pregnancy\n\t\n➢\t\nFocal segmental glomerulosclerosis (FSGS) and \t\n\t\n\t\n\t\n\t\nmembranocapillary glomerulonephritis (MCGN) are generally \t\n\t\n\t\nassociated with poor prognosis with risk of worsening renal \t\n\t\n\t\n\t\nimpairment in pregnancy.\n\t\n➢\t\nMinimal change and membranous glomerulonephritis usually \t\n\t\n\t\nhave a good outcome.\n\t\n➢\t\nWomen with significant proteinuria are at high risk of deep vein \t\n\t\n\t\nthrombosis; Need for thromboprophylaxis during pregnancy \t\n\t\n\t\nand the postpartum period should be discussed.\n5.3. Renal disease occurring during pregnancy\n\t\n5.3.1. Urinary tract infections (UTI)\n\t\n\t\n5.3.1.1.\t Lower UTI\n\t\n\t\n➢\t\nTake a single urine sample for culture before empiric \t\n\t\n\t\n\t\nantibiotic is started.  \n\t\n\t\n➢\t\nA seven day course of treatment is normally sufficient. \n\t\n\t\n➢\t\nA urine culture should be performed two weeks after \t\n\t\n\t\n\t\ncompletion of antibiotic treatment as a test of cure. \t\t\n\t\n\t\n\t\nMonthly urine cultures should be checked thereafter \t\n\t\n\t\n\t\nuntil delivery.",
  "➢\t\nA urine culture should be performed two weeks after \t\n\t\n\t\n\t\ncompletion of antibiotic treatment as a test of cure. \t\t\n\t\n\t\n\t\nMonthly urine cultures should be checked thereafter \t\n\t\n\t\n\t\nuntil delivery.\n\n--- Page 71 ---\nNational Guideline for Maternal Care - Volume II\n57\n\t\n\t\n5.3.1.2.\t Upper UTI\n\t\n\t\n➢\t\nThe incidence of pyelonephritis is higher in pregnancy \t\n\t\n\t\n\t\ndue to the physiological changes of the urinary tract.\n\t\n\t\n➢\t\nThe risk of renal impairment secondary to \t\t\n\t\n\t\n\t\n\t\npyelonephritis is also higher in pregnancy compared to \t\n\t\n\t\n\t\nthe non-pregnant population\nBox 5.1: Empiric antibiotic therapy for lower UTI\n•  \t Nitrofurantoin 100 mg  6 hourly\n\t\n-  Avoid in G6PD deficiency\n\t\n-  Do not prescribe in the last 2 to 4 weeks of pregnancy\n•\t Amoxicillin 500 mg 8 hourly \n•\t Coamoxiclav 625 mg 12 hourly \n•\t Cephalexin 500 mg 8 hourly \nBox 5.2:  Empiric antibiotic therapy for upper UTI\n•\t Ceftriaxone 1-2 g IV or IM daily\n•\t Aztreonam 1 g IV 8-12 hourly\n•\t Piperacillin-tazobactam 3.375-4.5 g IV 6 hourly\n•\t Cefepime 1 g IV 12 hourly\n•\t Imipenem-cilastatin 500 mg IV 6 hourly\n•\t Ampicillin  2 g IV 6 hourly\n•\t Gentamicin 3-5 mg/kg/day IV in 3 divided doses\n\t\n\t\n➢\t\nAfter clinical improvement parenteral therapy can be \t\n\t\n\t\n\t\nswitched to oral therapy for a total treatment duration \t\n\t\n\t\n\t\nof 7-10 days. \n\t\n\t\n➢\t\nThose with complicated disease may require a longer \t\n\t\n\t\n\t\ncourse of antibiotic. \n\t\n\t\n➢\t\nMonthly urine cultures must be checked till delivery.\n\t\n\t\n➢\t\nUltrasound scan of KUB should be done to look for \t\n\t\n\t\n\t\nobstruction, calculi or anatomical abnormalities.\n\t\n\t\n5.3.1.3.\t Asymptomatic bacteriuria (AB)\n\t\n\t\n➢\t\nAsymptomatic bacteriuria is diagnosed when two \t \t\n\t\n\t\n\t\nconsecutive voided urine specimens grow >105cfu/\t\t\n\t\n\t\n\t\nmL of the same bacterial species or a single \t\n\t\n\t\n\t\n\t\ncatheterised specimen grows >105cfu/mL of an \t\n\t\n\t\n\t\n\t\nuropathogen, in the absence of symptoms of \t\n\t\n\t\n\t\n\t\nurine infection.",
  "➢\t\nThose with complicated disease may require a longer \t\n\t\n\t\n\t\ncourse of antibiotic. \n\t\n\t\n➢\t\nMonthly urine cultures must be checked till delivery.\n\t\n\t\n➢\t\nUltrasound scan of KUB should be done to look for \t\n\t\n\t\n\t\nobstruction, calculi or anatomical abnormalities.\n\t\n\t\n5.3.1.3.\t Asymptomatic bacteriuria (AB)\n\t\n\t\n➢\t\nAsymptomatic bacteriuria is diagnosed when two \t \t\n\t\n\t\n\t\nconsecutive voided urine specimens grow >105cfu/\t\t\n\t\n\t\n\t\nmL of the same bacterial species or a single \t\n\t\n\t\n\t\n\t\ncatheterised specimen grows >105cfu/mL of an \t\n\t\n\t\n\t\n\t\nuropathogen, in the absence of symptoms of \t\n\t\n\t\n\t\n\t\nurine infection.\n\n--- Page 72 ---\nNational Guideline for Maternal Care - Volume II\n58\n\t\n\t\n➢\t\nTreatment of asymptomatic bacteriuria in pregnancy \t\n\t\n\t\n\t\nreduces the risk of pyelonephritis, preterm delivery and \t\n\t\n\t\n\t\nlow birth weight babies.  \n\t\n\t\n➢\t\nAsymptomatic bacteriuria in pregnancy is usually \t \t\n\t\n\t\n\t\ntreated with a short course (3-7 days) of antibiotics, \t\n\t\n\t\n\t\nsimilar to that used in treatment of low UTI. \n\t\n\t\n➢\t\nAll pregnant women should be screened for bacteriuria \t\n\t\n\t\n\t\nduring the first trimester.\n\t\n5.3.2. Preeclampsia\n\t\n➢\t\nPre eclampsia (BP ≥ 140/90 mmHg, proteinuria ≥ 300mg/day \t\n\t\n\t\n+/- peripheral oedema, occurring after 20 weeks of gestation) \t\n\t\n\t\nis the commonest medical complication in pregnancy and is \t\n\t\n\t\nmore common in women with preexisting hypertension and \t\n\t\n\t\nchronic renal disease of any cause or severity.\n\t\n➢\t\nRenal impairment could accompany severe preeclampsia, which \t\n\t\n\t\nis usually reversible following delivery.\n\t\n➢\t\nWomen with the following risk factors should be commenced \t\n\t\n\t\non 75mg of Aspirin at 12 weeks of pregnancy and continued \t\n\t\n\t\nuntil delivery, in order to reduce the risk of preeclampsia.\n\t\n\t\no\t\nPre-existing types 1 or 2 diabetes mellitus\n\t\n\t\no\t\nHistory of hypertensive disease in pregnancy\n\t\n\t\no\t\nWomen with systemic lupus erythematosus (SLE) or \t\n\t\n\t\n\t\nantiphospholipid syndrome\n\t\n\t\no\t\nWomen with preexisting hypertension, irrespective of \t\n\t\n\t\n\t\nthe aetiology\n\t\n\t\no\t\nWomen with chronic renal impairment, irrespective of \t\n\t\n\t\n\t\nthe aetiology\n\t\n5.3.3. Acute fatty liver of pregnancy (AFLP)\n\t\n➢\t\nThis condition, which usually occurs in the third trimester, is \t\n\t\n\t\nprimarily a disease of the liver which causes acute kidney injury \t\n\t\n\t\n(AKI) in severe cases. \n\t\n➢\t\nManagement of renal impairment is similar to that described \t\n\t\n\t\nunder AKI below. (AFLP is dealt with in detail  in the section \t\n\t\n\t\non ‘liver disease in pregnancy’)\n\t\n5.3.4. Haemolytic Uraemic Syndrome (HUS) / Thrombotic \t\n\t\n\t\nThrombocytopaenic Purpura (TTP)\n\t\n➢\t\nThese thrombotic microangiopathies belong to a spectrum of \t\n\t\n\t\ndisease, though they are two different entities.",
  "(AFLP is dealt with in detail  in the section \t\n\t\n\t\non ‘liver disease in pregnancy’)\n\t\n5.3.4. Haemolytic Uraemic Syndrome (HUS) / Thrombotic \t\n\t\n\t\nThrombocytopaenic Purpura (TTP)\n\t\n➢\t\nThese thrombotic microangiopathies belong to a spectrum of \t\n\t\n\t\ndisease, though they are two different entities.\n\n--- Page 73 ---\nNational Guideline for Maternal Care - Volume II\n59\n\t\n➢\t\nIt typically occurs within in the last trimester and up to 8-10 \t\n\t\n\t\nweeks postpartum. \n\t\n➢\t\nAcute kidney injury is a feature.\n\t\n➢\t\nPlasma exchange is the treatment of choice.\n5.4.\t\nAcute kidney injury (AKI)\nAKI is defined as any one of the following (Acute Kidney Injury \nNetwork criteria) : \n\t\n• \t\nIncrease in serum creatinine by ≥ 0.3 mg/dL (≥26.5 μmol/l) \t\n\t\n\t\nwithin 48 hours or,\n   \t •\t\nIncrease in serum creatinine to ≥1.5 times baseline, which is \t\n\t\n\t\nknown or presumed to have occurred within the prior 7 days or\n   \t • \t\nUrine volume <0.5 ml/kg/hour for 6 hours,\nin an individual without  pre-existing renal impairment\nBox 5.3: Causes of AKI in pregnancy\n1.\t Massive PPH\n2.\t Acute pyelonephritis\n3.\t Preeclampsia\n4.\t Diabetic nephropathy\n5.\t Glomerulonephritides\n6.\t Acute fatty liver of pregnancy\n7.\t Thrombotic thrombocytopaenic purpura/Haemolytic \t\n\t\nuraemic syndrome\n\t\nManagement\n\t\n➢\t\nManagement is similar to that outside pregnancy.\n\t\n➢\t\nStabilise the patient and arrange transfer to a tertiary care center \t\n\t\n\t\nwith facilities for dialysis/CVVH and for multidisciplinary care.\n\t\n\t\nManagement of hyperkalaemia associated with AKI\n\t\n➢\t\nHyperkalaemia is defined as serum K concentration > 5.5 \t \t\n\t\n\t\nmmol/L.\n\t\n➢\t\nIn an emergency, K+ measured from an arterial or venous \t \t\n\t\n\t\nblood sample using a blood gas analyser is acceptable whilst \t\n\t\n\t\nawaiting the results from a formal laboratory measurement.\n\t\n➢\t\nECG monitoring is recommended for all patients with serum \t\n\t\n\t\nK+ value ≥ 6.5 mmol/L.",
  "Haemolytic Uraemic Syndrome (HUS) / Thrombotic \t\n\t\n\t\nThrombocytopaenic Purpura (TTP)\n\t\n➢\t\nThese thrombotic microangiopathies belong to a spectrum of \t\n\t\n\t\ndisease, though they are two different entities.\n\n--- Page 73 ---\nNational Guideline for Maternal Care - Volume II\n59\n\t\n➢\t\nIt typically occurs within in the last trimester and up to 8-10 \t\n\t\n\t\nweeks postpartum. \n\t\n➢\t\nAcute kidney injury is a feature.\n\t\n➢\t\nPlasma exchange is the treatment of choice.\n5.4.\t\nAcute kidney injury (AKI)\nAKI is defined as any one of the following (Acute Kidney Injury \nNetwork criteria) : \n\t\n• \t\nIncrease in serum creatinine by ≥ 0.3 mg/dL (≥26.5 μmol/l) \t\n\t\n\t\nwithin 48 hours or,\n   \t •\t\nIncrease in serum creatinine to ≥1.5 times baseline, which is \t\n\t\n\t\nknown or presumed to have occurred within the prior 7 days or\n   \t • \t\nUrine volume <0.5 ml/kg/hour for 6 hours,\nin an individual without  pre-existing renal impairment\nBox 5.3: Causes of AKI in pregnancy\n1.\t Massive PPH\n2.\t Acute pyelonephritis\n3.\t Preeclampsia\n4.\t Diabetic nephropathy\n5.\t Glomerulonephritides\n6.\t Acute fatty liver of pregnancy\n7.\t Thrombotic thrombocytopaenic purpura/Haemolytic \t\n\t\nuraemic syndrome\n\t\nManagement\n\t\n➢\t\nManagement is similar to that outside pregnancy.\n\t\n➢\t\nStabilise the patient and arrange transfer to a tertiary care center \t\n\t\n\t\nwith facilities for dialysis/CVVH and for multidisciplinary care.\n\t\n\t\nManagement of hyperkalaemia associated with AKI\n\t\n➢\t\nHyperkalaemia is defined as serum K concentration > 5.5 \t \t\n\t\n\t\nmmol/L.\n\t\n➢\t\nIn an emergency, K+ measured from an arterial or venous \t \t\n\t\n\t\nblood sample using a blood gas analyser is acceptable whilst \t\n\t\n\t\nawaiting the results from a formal laboratory measurement.\n\t\n➢\t\nECG monitoring is recommended for all patients with serum \t\n\t\n\t\nK+ value ≥ 6.5 mmol/L.\n\n--- Page 74 ---\nNational Guideline for Maternal Care - Volume II\n60\nBox 5.4: Pharmacological management of hyperkalaemia\n•\t 10ml of 10% Calcium gluconate over 10 minutes into a peripheral \t\n\t\nvein if ECG shows features suggestive of hyperkalaemia. (Tall \t\n\t\n\t\npeaked T waves, small/absent P waves, wide QRS complex)\n\t\n-\t\nRepeat ECG in 10 minutes- If no improvement repeat same \t\t\n\t\n\t\ndosage; Could give 3 doses in total\n•\t Insulin Actrapid (short acting insulin) 10 units in 50 mL of 50% \t \t\n\t\nglucose over 30 minutes (via intravenous  infusion).\n•\t Monitor blood glucose after 15mins, 30mins and then hourly for \t\t\n\t\nup to 6 hours as there is a risk of late hypoglycaemia.\n•\t Nebulised salbutamol 10-20mg.\n•\t Serum potassium should be assessed at least 1, 2, 4, 6 and 24 \t\n\t\n\t\nhours after identification and treatment of hyperkalaemia.\n•\t Arrange transfer to a nephrology center in whom hyperkalaemia \t\n\t\ncannot be controlled \n5.5. Chronic kidney disease\n\t\n5.5.1. Preconception care\n\t\n➢\t\nThe degree of renal insufficiency, rather than the underlying \t\n\t\n\t\nrenal diagnosis, is the primary determinant of outcome, with \t\n\t\n\t\nthe exception of scleroderma and polyarteritis nodosa, which \t\n\t\n\t\ngenerally have a poor prognosis.\n\t\n➢\t\nFactors generally associated with unfavourable pregnancy \t \t\n\t\n\t\noutcome include:\n\t\n\t\no\t\nEstimated GFR of ≤40 ml/min/1.73m2\n\t\n\t\no\t\nProteinuria ≥1 g/d \n\t\n\t\no\t\nSerum creatinine ≥ 1.4g/dL\t\n\t\n-\t\nComplications in the presence of any of the above include, \t \t\n\t\n\t\naccelerated progression towards end stage renal disease (ESRD) \t\n\t\n\t\nand preterm delivery.\n\t\n➢\t\nReview by a nephrologist for advise on suitability for pregnancy \t\n\t\n\t\nand review and optimizations of medications is mandatory. \n\t\nAnaemia\n\t\n➢\t\nConsider erythropoietin when the Hb < 9g/dL and the iron \t\t\n\t\n\t\nstores are replete.\n\t\nBone disease\n\t\n➢\t\nPhosphate binders and vitamin D analogues are currently used",
  "Preconception care\n\t\n➢\t\nThe degree of renal insufficiency, rather than the underlying \t\n\t\n\t\nrenal diagnosis, is the primary determinant of outcome, with \t\n\t\n\t\nthe exception of scleroderma and polyarteritis nodosa, which \t\n\t\n\t\ngenerally have a poor prognosis.\n\t\n➢\t\nFactors generally associated with unfavourable pregnancy \t \t\n\t\n\t\noutcome include:\n\t\n\t\no\t\nEstimated GFR of ≤40 ml/min/1.73m2\n\t\n\t\no\t\nProteinuria ≥1 g/d \n\t\n\t\no\t\nSerum creatinine ≥ 1.4g/dL\t\n\t\n-\t\nComplications in the presence of any of the above include, \t \t\n\t\n\t\naccelerated progression towards end stage renal disease (ESRD) \t\n\t\n\t\nand preterm delivery.\n\t\n➢\t\nReview by a nephrologist for advise on suitability for pregnancy \t\n\t\n\t\nand review and optimizations of medications is mandatory. \n\t\nAnaemia\n\t\n➢\t\nConsider erythropoietin when the Hb < 9g/dL and the iron \t\t\n\t\n\t\nstores are replete.\n\t\nBone disease\n\t\n➢\t\nPhosphate binders and vitamin D analogues are currently used\n\n--- Page 75 ---\nNational Guideline for Maternal Care - Volume II\n61\n\t\n\t\nwith no adverse effects. There is limited experience with \t\n\t\n\t\n\t\nCinacalcet and Lanthanum carbonate.\n\t\n\t\n5.5.2. Antenatal care\n\t\n➢\t\nArrange for regular review by the nephrologist.\n\t\n➢\t\nPatient should be assessed in the antenatal clinic every 2 weeks \t\n\t\n\t\nuntil 32 weeks and weekly thereafter.\n\t\n\t\no\t\nBP should be carefully monitored\n\t\n\t\nAim to:\n\t\n\t\n-\t\nMaintain blood pressure below 150/100 mmHg and \t\n\t\n\t\n\t\ndiastolic BP above 80 mmHg in women with \t\n\t\n\t\n\t\n\t\nuncomplicated chronic hypertension\n\t\n\t\n-\t\nMaintain blood pressure below 140/90 mmHg in those \t\n\t\n\t\n\t\nwith target organ damage secondary to chronic \t\n\t\n\t\n\t\n\t\nhypertension (eg: renal impairment)\n\t\n\t\no\t\nSerum creatinine and 24 hour protein excretion should \t\n\t\n\t\n\t\nbe monitored monthly\n\t\n\t\no\t\nFetal growth should be closely monitored\n\t\n➢\t\nIf renal impairment is progressive, with no evidence of a \t\n\t\n\t\n\t\nreversible cause, termination of pregnancy should be considered \t\n\t\n\t\nat the earliest.\n\t\n\t\no\t\nIf only proteinuria is increasing, with no evidence of \t\n\t\n\t\n\t\nfetal growth restriction, pregnancy can be continued \t\n\t\n\t\n\t\nunder close monitoring by the nephrologist and \t\n\t\n\t\n\t\n\t\nobstetrician\n\t\n➢\t\nDialysis is required when the GFR falls to less than 20ml/\t\n\t\n\t\n\t\nmin/1.73m2. \n\t\n\t\no\t\nAt least 20 hours of dialysis per week is required with \t\n\t\n\t\n\t\nthe aim  of maintaining  blood urea below 60mg/dL\n5.6. Renal transplantation\n\t\n➢\t\nFertility rates increase dramatically after transplantation.\n\t\n➢\t\nWomen with a renal transplant should be referred to a \t\n\t\n\t\n\t\nnephrologist for advise on suitability of pregnancy and \t\n\t\n\t\n\t\noptimisation of the underlying renal condition.\n\t\n➢\t\nGraft rejection rates are similar to the general population.\n\t\n➢\t\nIn general, fetal outcome is good.\n\t\n\t\no\t\nRisk of preterm birth and small for gestational age \t\t\n\t\n\t\n\t\nbabies increase in the presence of maternal \t\n\t\n\t\n\t\n\t\nhypertension and impaired baseline renal graft \t\n\t\n\t\n\t\n\t\nfunction",
  "o\t\nAt least 20 hours of dialysis per week is required with \t\n\t\n\t\n\t\nthe aim  of maintaining  blood urea below 60mg/dL\n5.6. Renal transplantation\n\t\n➢\t\nFertility rates increase dramatically after transplantation.\n\t\n➢\t\nWomen with a renal transplant should be referred to a \t\n\t\n\t\n\t\nnephrologist for advise on suitability of pregnancy and \t\n\t\n\t\n\t\noptimisation of the underlying renal condition.\n\t\n➢\t\nGraft rejection rates are similar to the general population.\n\t\n➢\t\nIn general, fetal outcome is good.\n\t\n\t\no\t\nRisk of preterm birth and small for gestational age \t\t\n\t\n\t\n\t\nbabies increase in the presence of maternal \t\n\t\n\t\n\t\n\t\nhypertension and impaired baseline renal graft \t\n\t\n\t\n\t\n\t\nfunction\n\n--- Page 76 ---\nNational Guideline for Maternal Care - Volume II\n62\n\t\n➢\t\nCalcineurin inhibitors, steroids, and Azathioprine are safe for \t\n\t\n\t\nuse in pregnant transplant recipients.\n\t\n\t\no\t\nScreening for gestational diabetes is important, with \t\n\t\n\t\n\t\nprolonged use of steroids.\n5.7. Women on long term renal dialysis\n\t\n➢\t\nIt is not advisable to become pregnant because pregnancy \t \t\n\t\n\t\nusually leads to volume overload, exacerbation of hypertension \t\n\t\n\t\nand preeclampsia. \n\t\n➢\t\nIf patient wishes to continue pregnancy, then frequency and \t\n\t\n\t\nduration of dialysis should be increased to 20 hours per week \t\n\t\n\t\nand blood urea maintained below 60 mg/dL.\n5.8. Indications for renal biopsy during pregnancy\n\t\n➢\t\nRapidly progressive renal failure (RPRF) with no obvious cause \n\t\n➢\t\nSymptomatic nephrotic syndrome– not a universal indication\nRenal biopsy is best avoided after 32 weeks of gestation, at which time the \nrisks and benefits of biopsy versus delivery should be considered.\nReferences\n\t\n1.\t\nMathiesen ER, Ringholm L, Feldt-Rasmussen B, et al Obstetric \t\n\t\n\t\nNephrology: Pregnancy in Women with Diabetic \t \t\n\t\n\t\n\t\nNephropathy—The Role of Antihypertensive Treatment Clin J \t\n\t\n\t\nAm Soc Nephrol 2012; 7: 2081–2088.\n\t\n2.\t\nVellanki K. Pregnancy in Chronic Kidney Disease Advances in \t\n\t\n\t\nChronic Kidney Disease 2013;20 (30): 223-228.\n\t\n3.\t\nCarmona F, Font J, Moga I, et al. Class III-IV proliferative lupus \t\n\t\n\t\nnephritis and pregnancy: a study of 42 cases. Am J Reprod \t \t\n\t\n\t\nImmunol. 2005;53(4):182-188.\n\t\n4.\t\nSusana M,  Nuno F, Andreia B, et al  Acute kidney injury in \t\t\n\t\n\t\npregnancy: a clinical challenge J nephrol 2012; 25(01): 19- 30.",
  "Am J Reprod \t \t\n\t\n\t\nImmunol. 2005;53(4):182-188.\n\t\n4.\t\nSusana M,  Nuno F, Andreia B, et al  Acute kidney injury in \t\t\n\t\n\t\npregnancy: a clinical challenge J nephrol 2012; 25(01): 19- 30.\n\n--- Page 77 ---\nNational Guideline for Maternal Care - Volume II\n63\nThyroid Disease\n\n--- Page 78 ---\nNational Guideline for Maternal Care - Volume II\n64",
  "Am J Reprod \t \t\n\t\n\t\nImmunol. 2005;53(4):182-188.\n\t\n4.\t\nSusana M,  Nuno F, Andreia B, et al  Acute kidney injury in \t\t\n\t\n\t\npregnancy: a clinical challenge J nephrol 2012; 25(01): 19- 30.\n\n--- Page 77 ---\nNational Guideline for Maternal Care - Volume II\n63\nThyroid Disease\n\n--- Page 78 ---\nNational Guideline for Maternal Care - Volume II\n64\n\n--- Page 79 ---\nNational Guideline for Maternal Care - Volume II\n65\n6. Thyroid disease in pregnancy\n6.1. Introduction\n\t\n➢\t\nThyroid dysfunction in pregnancy includes hyperthyroidism \t\n\t\n\t\nand hypothyroidism. \n\t\n➢\t\nHypothyroidism is commoner than hyperthyroidism and is \t\t\n\t\n\t\nknown to affect around 2.5-3% of pregnancies.\n\t\n➢\t\nPrevalence of hyperthyroidism in pregnancy is around 0.1-1%. \n\t\n➢\t\nImportant changes in thyroid physiology during pregnancy \t\t\n\t\n\t\ninclude: \n\t\n\t\no\t\n10% increase in size of the thyroid gland in iodine \t \t\n\t\n\t\n\t\nreplete women\n\t\n\t\no\t\nLowering of thyroid stimulating hormone (TSH) in \t\n\t\n\t\n\t\nthe first trimester due to effect of  serum  hCG, with \t\n\t\n\t\n\t\ngradual increase thereafter with advancing pregnancy, \t\n\t\n\t\n\t\nbut still below the non pregnant reference range\n\t\n\t\no\t\nSerum TSH > 4 µIU/mL by the third trimester in \t \t\n\t\n\t\n\t\nnearly one fifth of women with autoimmune thyroid \t\n\t\n\t\n\t\ndysfunction\n\t\n\t\no\t\nDevelopment of postpartum thyroid dysfunction in 33-\t\n\t\n\t\n\t\n50% of women with thyroid autoimmunity\n\t\n➢\t\nTesting for thyroid functions\n\t\n\t\no\t\nTotal binding globulin (TBG) increases by around 50 \t\n\t\n\t\n\t\n% by 6-8 weeks of pregnancy and remains high until \t\n\t\n\t\n\t\ndelivery. Therefore, the free fraction of thyroxine (FT4) \t\n\t\n\t\n\t\nshould be assessed, in addition to serum TSH level. \n\t\n\t\no\t\nFree T3 assay is not reliable and therefore should not be \t\n\t\n\t\n\t\nroutinely performed unless the patient is clinically \t\t\n\t\n\t\n\t\nthyrotoxic with a low TSH and normal FT4.\n\t\n\t\no\t\nThe optimal method to assess serum FT4 during \t\n\t\n\t\n\t\n\t\npregnancy is measurement of T4 in the dialysate or \t\n\t\n\t\n\t\nultrafiltrate of serum samples employing on-line \t\n\t\n\t\n\t\n\t\nextraction/liquid chromatography/tandem mass \t\n\t\n\t\n\t\n\t\nspectrometry (LC/MS/MS). This method \t \t\n\t\n\t\n\t\n\t\nis not routinely available and immunoassay methods \t\n\t\n\t\n\t\nare employed for assessment of thyroid function in Sri \t\n\t\n\t\n\t\nLanka.",
  "o\t\nFree T3 assay is not reliable and therefore should not be \t\n\t\n\t\n\t\nroutinely performed unless the patient is clinically \t\t\n\t\n\t\n\t\nthyrotoxic with a low TSH and normal FT4.\n\t\n\t\no\t\nThe optimal method to assess serum FT4 during \t\n\t\n\t\n\t\n\t\npregnancy is measurement of T4 in the dialysate or \t\n\t\n\t\n\t\nultrafiltrate of serum samples employing on-line \t\n\t\n\t\n\t\n\t\nextraction/liquid chromatography/tandem mass \t\n\t\n\t\n\t\n\t\nspectrometry (LC/MS/MS). This method \t \t\n\t\n\t\n\t\n\t\nis not routinely available and immunoassay methods \t\n\t\n\t\n\t\nare employed for assessment of thyroid function in Sri \t\n\t\n\t\n\t\nLanka.\n\n--- Page 80 ---\nNational Guideline for Maternal Care - Volume II\n66\nBox 6.1: Normal reference range for thyroid hormones in pregnancy\nTrimester\nFirst\nSecond \nThird\nSerumTSH\n(µIU/mL)\n0.1-2.5 \n0.2-3.0 \n0.3-3.0 \n FT4 (pg/ml)\n0.83-1.27 \n0.71-1.05 \n0.72-1.06 \n6.2. Hypothyroidism in pregnancy\n\t\n6.2.1. Definitions\nOvert hypothyroidism \n\t\nDefinition:\n\t\n➢\t\nTSH above 2.5 µIU/mL with  free T4 below the trimester \t\n\t\n\t\n\t\nspecific reference range or\n\t\n➢\t\nTSH >10 µIU/mL, irrespective of the free T4 level\n\t\nAdverse effects of overt hypothyroidism include:\n\t\nMaternal complications \n\t\n•\t\nGestational hypertension\n\t\n•\t\nPlacental abruption\n\t\n•\t\nPostpartum haemorrhage\n\t\nFetal complications \n\t\n•\t\nFetal  loss \n\t\n•\t\nPremature birth\n\t\n•\t\nLow birth weight\n\t\n•\t\nNeonatal respiratory distress\n\t\n•\t\nImpaired neurocognitive development in the offspring\n\t\nSubclinial hypothyroidism (SCH) \n\t\nDefinition:\n\t\n➢\t\nTSH between 2.5-10 µIU/mL with normal FT4 level SCH is \t\n\t\n\t\nknown to be associated with infertility, fetal loss, preterm \t \t\n\t\n\t\ndelivery and neonatal respiratory distress. SCH  needs \t\n\t\n\t\n\t\nto be treated in pregnancy.",
  "Definitions\nOvert hypothyroidism \n\t\nDefinition:\n\t\n➢\t\nTSH above 2.5 µIU/mL with  free T4 below the trimester \t\n\t\n\t\n\t\nspecific reference range or\n\t\n➢\t\nTSH >10 µIU/mL, irrespective of the free T4 level\n\t\nAdverse effects of overt hypothyroidism include:\n\t\nMaternal complications \n\t\n•\t\nGestational hypertension\n\t\n•\t\nPlacental abruption\n\t\n•\t\nPostpartum haemorrhage\n\t\nFetal complications \n\t\n•\t\nFetal  loss \n\t\n•\t\nPremature birth\n\t\n•\t\nLow birth weight\n\t\n•\t\nNeonatal respiratory distress\n\t\n•\t\nImpaired neurocognitive development in the offspring\n\t\nSubclinial hypothyroidism (SCH) \n\t\nDefinition:\n\t\n➢\t\nTSH between 2.5-10 µIU/mL with normal FT4 level SCH is \t\n\t\n\t\nknown to be associated with infertility, fetal loss, preterm \t \t\n\t\n\t\ndelivery and neonatal respiratory distress. SCH  needs \t\n\t\n\t\n\t\nto be treated in pregnancy.\n\n--- Page 81 ---\nNational Guideline for Maternal Care - Volume II\n67\n\t\nIsolated hypothyroxinaemia\n\t\nDefinition:\n\t\n➢\t\nNormal TSH with FT4 below the trimester specific reference \t\n\t\n\t\nrange. \n     There is no conclusive evidence of benefit of treating with levothyroxine \nduring pregnancy.\n\t\n\t\n6.2.2. Management of hypothyroidism in pregnancy\n\t\n\t\nPreconception care\n\t\n➢\t\nPregnancy should be planned, with TSH levels maintained \t \t\n\t\n\t\nbelow 2.5 µIU/mL. \n\t\n➢\t\nIf pregnancy is unplanned, the dose of thyroxine should be \t\t\n\t\n\t\nincreased by 25-50% of the preconception dose as early as possi\t\n\t\n\t\nble in pregnancy, while awaiting the TSH result.\n\t\n\t\nAntenatal management\n\t\n➢\t\nThe aim of treatment should be maintenance of TSH within the \t\n\t\n\t\ntrimester specific reference range.\n\t\n➢\t\nTSH should be assessed every 4-6 weeks to ensure that the \t \t\n\t\n\t\nwoman is euthyroid. \n\t\n➢\t\nIf the TSH fails to normalise while the patient is compliant with \t\n\t\n\t\nmedication, refer her to the endocrinologist/physician for fur\t\n\t\n\t\nther management.\n\t\n➢\t\nLevothyroxine is the treatment of choice for overt and subclini\t\n\t\n\t\ncal hypothyroidism. \n\t\n➢\t\nAdvise on general measures that enhance the absorption of \t\t\n\t\n\t\nthyroxine.\n\t\n\t\no\t\nTo take thyroxine on an empty stomach upon waking \t\n\t\n\t\n\t\nin the morning with a lapse of at least half an hour until \t\n\t\n\t\n\t\nthe first drink or meal\n\t\n\t\no\t\n To take iron and calcium supplements at separate \t \t\n\t\n\t\n\t\ntimes of day\n\t\nHypothyroidism diagnosed for the first time in pregnancy\n\t\n➢\t\nTSH should be normalised as rapidly as possible with the aim of \t\n\t\n\t\nachieving the trimester specific reference range. \n\t\n➢\t\nThe usual starting dose of thyroxine is 2µg/Kg/d (maximum of \t\n\t\n\t\n2.5 µg /Kg/d).",
  "➢\t\nAdvise on general measures that enhance the absorption of \t\t\n\t\n\t\nthyroxine.\n\t\n\t\no\t\nTo take thyroxine on an empty stomach upon waking \t\n\t\n\t\n\t\nin the morning with a lapse of at least half an hour until \t\n\t\n\t\n\t\nthe first drink or meal\n\t\n\t\no\t\n To take iron and calcium supplements at separate \t \t\n\t\n\t\n\t\ntimes of day\n\t\nHypothyroidism diagnosed for the first time in pregnancy\n\t\n➢\t\nTSH should be normalised as rapidly as possible with the aim of \t\n\t\n\t\nachieving the trimester specific reference range. \n\t\n➢\t\nThe usual starting dose of thyroxine is 2µg/Kg/d (maximum of \t\n\t\n\t\n2.5 µg /Kg/d).\n\n--- Page 82 ---\nNational Guideline for Maternal Care - Volume II\n68\n\t\n➢\t\nThe dose should be titrated according to the thyroid status of \t\n\t\n\t\nthe woman assessed by serum TSH.\n\t\n\t\n\t\nWomen with pre-existing hypothyroidism\n\t\n➢\t\nA TSH should be performed as soon as possible. \n\t\n\t\no\t\nIf the TSH is within the trimester specific reference \t\n\t\n\t\n\t\nrange,\n\t\n\t\n-\t\nContinue the same dose of thyroxine and ar\t\n\t\n\t\n\t\nrange for review at 4-6 weeks with a TSH \t \t\n\t\n\t\n\t\nvalue.\n\t\no\t\nIf the TSH is above the trimester specific reference \t\t\n\t\n\t\nrange, \n\t\n\t\n-\t\nModify  the thyroxine dose as follows\nBox 6.2: Dose increment based on serum TSH level\nTSH level\n(µIU/mL)\n2.5-10\n10-20\n>20\nDose increment\n(as a percentage of thyroxine dose)\n25-50%\n50-75%\n75-100%\n\t\nPostpartum management\n\t\n➢\t\nThyroxine is safe during breast feeding. \n\t\n➢\t\nMost women could be changed over to the prepregnancy dose \t\n\t\n\t\nof thyroxine. \n\t\n➢\t\nA follow up TSH at 6 weeks postpartum is recommended.\n\t\n➢\t\nNeonatal TSH should be tested by one week. \n\t\n\t\nScreening for hypothyroidism in pregnancy\n\t\n➢\t\nThere is no evidence on benefit of routine screening for thyroid \t\n\t\n\t\ndysfunction in pregnancy. \n\t\n➢\t\n All pregnant women should be clinically evaluated  at the \t \t\n\t\n\t\nbooking visit for any of the features listed below.\n\t\n\t\no\t\nA family history of autoimmune thyroid disease or \t\t\n\t\n\t\n\t\nhypothyroidism\n\t\n\t\no\t\nPresence of a goitre\n\t\n\t\no\t\nPresence of thyroid antibodies, primarily thyroid per\t\n\t\n\t\n\t\noxidase antibodies\n\t\n\t\no\t\nSymptoms or clinical signs suggestive of \t \t\n\t\n\t\n\t\n\t\nhypothyroidism\n\t\n\t\no\t\nWomen with type 1 diabetes mellitus, or other",
  "Screening for hypothyroidism in pregnancy\n\t\n➢\t\nThere is no evidence on benefit of routine screening for thyroid \t\n\t\n\t\ndysfunction in pregnancy. \n\t\n➢\t\n All pregnant women should be clinically evaluated  at the \t \t\n\t\n\t\nbooking visit for any of the features listed below.\n\t\n\t\no\t\nA family history of autoimmune thyroid disease or \t\t\n\t\n\t\n\t\nhypothyroidism\n\t\n\t\no\t\nPresence of a goitre\n\t\n\t\no\t\nPresence of thyroid antibodies, primarily thyroid per\t\n\t\n\t\n\t\noxidase antibodies\n\t\n\t\no\t\nSymptoms or clinical signs suggestive of \t \t\n\t\n\t\n\t\n\t\nhypothyroidism\n\t\n\t\no\t\nWomen with type 1 diabetes mellitus, or other\n\n--- Page 83 ---\nNational Guideline for Maternal Care - Volume II\n69\n\t\n\t\n   autoimmune disorders\n\t\n\t\no\t Women with infertility\n\t\n\t\no\t Women with a prior history of miscarriage or preterm \t\n\t\n\t\n\t\n\t\ndelivery\n\t\n\t\no\t Women with prior therapeutic head or neck irradiation \t\n\t\n\t\n\t\n\t\nor prior thyroid surgery\n\t\n\t\no\t Women currently receiving levothyroxine replacement\n\t\n\t\no\t Women living in a region presumed to be  iodine defi\t\n\t\n\t\n\t\n\t\ncient\n\t\n➢\t A  serum TSH level should be performed in women with any of \t\n\t\n\t\nthe risk factors mentioned  above and managed accordingly. \n6.3. Hyperthyroidism in pregnancy\n\t\n6.3.1. Definitions\n\t\nOvert hyperthyroidism\n\t\nDefinition:\n\t\n➢\t Low serum TSH with an elevated free FT4 level (according to \t\n\t\n\t\nthe trimester specific reference range). \n\t\nAdverse effects of maternal hyperthyroidism include:\n\t\nMaternal complications  \n\t\n\t\n•\t Miscarriage\n\t\n\t\n•\t gestational hypertension\n\t\n\t\n•\t thyroid storm\n\t\n\t\n•\t maternal congestive heart failure\n\t\nFetal complications\n\t\n\t\n•\t Prematurity\n\t\n\t\n•\t low birth weight\n\t\n\t\n•\t fetal growth restriction\n\t\n\t\n•\t stillbirth\n\t\n\t\n•\t neonatal  goitre\n\t\n\t\n\t\n-\t Subclinical hyperthyroidism (Low TSH with normal FT4) \t\n\t\n\t\n\t\n\t\nand isolated hyperthyroxinaemia does not require treat\t\n\t\n\t\n\t\n\t\nment in pregnancy.\n\t\n➢\t Causes of hyperthyroidism in pregnancy include:\n\t\n\t\no\t  Gestational thyrotoxicosis",
  "Definitions\n\t\nOvert hyperthyroidism\n\t\nDefinition:\n\t\n➢\t Low serum TSH with an elevated free FT4 level (according to \t\n\t\n\t\nthe trimester specific reference range). \n\t\nAdverse effects of maternal hyperthyroidism include:\n\t\nMaternal complications  \n\t\n\t\n•\t Miscarriage\n\t\n\t\n•\t gestational hypertension\n\t\n\t\n•\t thyroid storm\n\t\n\t\n•\t maternal congestive heart failure\n\t\nFetal complications\n\t\n\t\n•\t Prematurity\n\t\n\t\n•\t low birth weight\n\t\n\t\n•\t fetal growth restriction\n\t\n\t\n•\t stillbirth\n\t\n\t\n•\t neonatal  goitre\n\t\n\t\n\t\n-\t Subclinical hyperthyroidism (Low TSH with normal FT4) \t\n\t\n\t\n\t\n\t\nand isolated hyperthyroxinaemia does not require treat\t\n\t\n\t\n\t\n\t\nment in pregnancy.\n\t\n➢\t Causes of hyperthyroidism in pregnancy include:\n\t\n\t\no\t  Gestational thyrotoxicosis\n\n--- Page 84 ---\nNational Guideline for Maternal Care - Volume II\n70\n\t\n\t\n\t\n-\t Commonest cause of hyperthyroidism; Affects 1-3% of \t\n\t\n\t\n\t\n\t\npregnancies\n\t\n\t\n\t\n-\t Transient hyperthyroidism due to marked elevation in \t\t\n\t\n\t\n\t\n\t\nserum hCG; Seen in the first/early second trimester\n\t\n\t\n\t\n-\t This should be suspected when symptomatic. Eg: tremu\t\n\t\n\t\n\t\n\t\nlousness, heat intolerance, palpitations\n\t\n\t\n\t\n-\t Associated with hyperemesis gravidarum. More common \t\n\t\n\t\n\t\n\t\nwith  multiple pregnancies and hydatidiform mole\n\t\n\t\n\t\n-\t Treatment – Supportive therapy; Hydration and \t\n\t\n\t\n\t\n\t\n\t\nantiemetics. Beta blockers may provide symptomatic \t \t\n\t\n\t\n\t\n\t\nbenefit. Antithyroid medication is not needed\n\t\n\t\no\t Graves disease\n\t\n\t\n\t\n-\t Usually pre existing but may present for the first time in \t\n\t\n\t\n\t\n\t\npregnancy\n\t\n\t\n\t\n-\t Is associated with thyroid eye signs\n\t\n\t\n\t\n-\t Characterised by presence of thyroid receptor antibody \t\n\t\n\t\n\t\n\t\n(TRAb ) \n\t\n\t\no\t Toxic multinodular goitre\n\t\n\t\no\t Toxic adenoma\n\t\n6.3.2. Management of overt hyperthyroidism in pregnancy\n\t\nPreconception care\n\t\n➢\t Pregnancy should be planned with women rendered euthyroid \t\n\t\n\t\n(TSH between 0.3-2.5 µIU/mL) before attempting pregnancy.\n\t\n➢\t If 131 I is used to achieve euthyroidism, conception should be \t\n\t\n\t\ndelayed for a minimum of 6 months (ideally 12 months). \n\t\n\t\no\t These women require a reliable method of contraception \t \t\n\t\n\t\n\t\npreferably IUD.\n\t\nAntenatal management\n\t\n➢\t First line therapy for hyperthyroidism is antithyroid drugs (ATD).\n\t\n\t\no\t Propylthoiuracil (PTU) should be used in the first trimester of \t\n\t\n\t\n\t\npregnancy\n\t\n\t\no\t Carbimazole should be started from the second trimester \t \t\n\t\n\t\n\t\nonwards\n\t\n\t\no\t The initial dose of ATDs depends on the severity of the \t\n\t\n\t\n\t\n\t\nsymptoms and the degree of hyperthyroxinemia\n\t\n\t\no\t In general, initial doses of ATDs are as follows:\n\t\n\t\n\t\n-\t Carbimazole, 10–15 mg daily in divided doses",
  "Management of overt hyperthyroidism in pregnancy\n\t\nPreconception care\n\t\n➢\t Pregnancy should be planned with women rendered euthyroid \t\n\t\n\t\n(TSH between 0.3-2.5 µIU/mL) before attempting pregnancy.\n\t\n➢\t If 131 I is used to achieve euthyroidism, conception should be \t\n\t\n\t\ndelayed for a minimum of 6 months (ideally 12 months). \n\t\n\t\no\t These women require a reliable method of contraception \t \t\n\t\n\t\n\t\npreferably IUD.\n\t\nAntenatal management\n\t\n➢\t First line therapy for hyperthyroidism is antithyroid drugs (ATD).\n\t\n\t\no\t Propylthoiuracil (PTU) should be used in the first trimester of \t\n\t\n\t\n\t\npregnancy\n\t\n\t\no\t Carbimazole should be started from the second trimester \t \t\n\t\n\t\n\t\nonwards\n\t\n\t\no\t The initial dose of ATDs depends on the severity of the \t\n\t\n\t\n\t\n\t\nsymptoms and the degree of hyperthyroxinemia\n\t\n\t\no\t In general, initial doses of ATDs are as follows:\n\t\n\t\n\t\n-\t Carbimazole, 10–15 mg daily in divided doses\n\n--- Page 85 ---\nNational Guideline for Maternal Care - Volume II\n71\n\t\n\t\n\t\n-\t PTU, 50–300 mg daily in divided doses\n\t\n\t\no\t Use the smallest possible dose of ATD to maintain \t\n\t\n\t\n\t\n\t\neuthyroidism and keep FT4 in the upper normal range\n\t\n➢\t For symptomatic relief, beta blockers could be used.\n\t\n\t\no\t Eg. Propranolol 20–40 mg every 6–8 hours\n\t\n\t\n\t\n-\t The dose should be reduced as early as possible in view \t\n\t\n\t\n\t\n\t\nof risk of fetal growth restriction, fetal bradycardia and \t\n\t\n\t\n\t\n\t\nneonatal hypoglycaemia\n\t\n\t\n\t\n-\t In the vast majority of cases, beta blockers can be \t\n\t\n\t\n\t\n\t\n\t\ndiscontinued in 2–6 weeks\n\t\n➢\t Thyroidectomy in pregnancy is rarely indicated to control \t\n\t\n\t\n\t\nhyperthyroidism. \n\t\n\t\no\t If required, the optimal time for thyroidectomy is the second \t\n\t\n\t\n\t\ntrimester\n\t\n➢\t Radioactive iodine treatment is contraindicated during \t\n\t\n\t\n\t\npregnancy.\n\t\nMonitoring \n\t\n➢\t Treatment is monitored with FT4 and TSH every 4–6 weeks.\n\t\n\t\no\t  Aim to maintain serum FT4 at the upper reference range.\n\t\n➢\t Fetal monitoring is performed for early detection of \t \t\n\t\n\t\n\t\ncomplications and management. \n\t\nGraves disease\n\t\n➢\t  During the first trimester of pregnancy exacerbation of \t\n\t\n\t\n\t\nsymptoms may occur. \n\t\n➢\t  As pregnancy advances, a gradual improvement in disease \t\n\t\n\t\n\t\nactivity is seen.\n\t\n\t\no\t This will result in a need to decrease the dose of ATDs \n\t\n\t\no\t Discontinuation of all ATD therapy is feasible in 20%–30% of \t\n\t\n\t\n\t\npatients in the last trimester of gestation\n\t\n\t\no\t The exception are women with high levels of  thyroid receptor \t\n\t\n\t\n\t\nstimulating antibodies (TRAb ), in which case ATD therapy \t\n\t\n\t\n\t\nshould generally be continued until delivery\n\t\n➢\t Indications for ordering a TRAb test in a woman with  Graves \t\n\t\n\t\ndisease include,",
  "Graves disease\n\t\n➢\t  During the first trimester of pregnancy exacerbation of \t\n\t\n\t\n\t\nsymptoms may occur. \n\t\n➢\t  As pregnancy advances, a gradual improvement in disease \t\n\t\n\t\n\t\nactivity is seen.\n\t\n\t\no\t This will result in a need to decrease the dose of ATDs \n\t\n\t\no\t Discontinuation of all ATD therapy is feasible in 20%–30% of \t\n\t\n\t\n\t\npatients in the last trimester of gestation\n\t\n\t\no\t The exception are women with high levels of  thyroid receptor \t\n\t\n\t\n\t\nstimulating antibodies (TRAb ), in which case ATD therapy \t\n\t\n\t\n\t\nshould generally be continued until delivery\n\t\n➢\t Indications for ordering a TRAb test in a woman with  Graves \t\n\t\n\t\ndisease include,\n\n--- Page 86 ---\nNational Guideline for Maternal Care - Volume II\n72\n\t\n\t\no\t Active maternal hyperthyroidism\n\t\n\t\no\t History of treatment with radioiodine\n\t\n\t\no\t History of delivering an infant with hyperthyroidism\n\t\n\t\no\t History of thyroidectomy for treatment of Graves disease\n\t\n\t\n\t\n-\t Serum TRAb levels should be determined at 24–28 weeks \t\n\t\n\t\n\t\n\t\ngestation in these women\n\t\n\t\n\t\n-\t A value over three times the upper limit of normal is an \t\n\t\n\t\n\t\n\t\nindication for close follow up of the fetus\n\t\n\t\n-\t Fetal monitoring includes serial ultrasound scan for \t\n\t\n\t\n\t\n\t\nassessment of fetal growth, fetal heart rate, amniotic fluid \t \t\n\t\n\t\n\t\nvolume and goitre \n\t\n\t\n-\t The neonate should be reviewed by a paediatrician at birth.\n\t\n\t\n\t\n (TRAb assay is not available in the state sector. Patients \t \t\n\t\n\t\n\t\nsuspected with Graves disease maybe managed without this \t\n\t\n\t\n\t\ntest considering its cost.)\n\t\nDelivery\n\t\n➢\t No special precautions are needed during delivery.\n\t\n➢\t Women with poorly controlled hyperthyroidism should be closely \t\n\t\n\t\nmonitored due to risk of exacerbation of thyrotoxic symptoms \t\n\t\n\t\nand risk of thyroid storm.\nBox 6.3:  Management of thyroid storm\n1.Propylthiouracil 500-1000mg followed by 250mg 4 hourly\n                  or\n   Carbimazole 60-80 mg 4 hourly\n2.  Oral  Propranolol 60-80mg 4-6 hourly\n3. Lugols iodine  5 drops oral 6 hourly\n        –Start 1 hour after commencement of antithyroid drugs\n4. Hydrocortisone 200 mg bolus; 100mg 6 hourly\n5. Intravenous hydration\n6. Antipyretics\n\t\nPostpartum care\n\t\n➢\t Breast feeding\n\t\n\t\no\t Breastfeeding is safe in mothers on ATDs at moderate doses\n\t\n\t\no\t Mothers should be advised to take their ATDs in divided \t \t\n\t\n\t\n\t\ndoses immediately following the feed\n\t\n➢\t Due to risk of flares postpartum in women with Graves disease, \t\n\t\n\t\na review should be arranged at 6 weeks or before in women with \t\n\t\n\t\npoorly controlled disease.",
  "Intravenous hydration\n6. Antipyretics\n\t\nPostpartum care\n\t\n➢\t Breast feeding\n\t\n\t\no\t Breastfeeding is safe in mothers on ATDs at moderate doses\n\t\n\t\no\t Mothers should be advised to take their ATDs in divided \t \t\n\t\n\t\n\t\ndoses immediately following the feed\n\t\n➢\t Due to risk of flares postpartum in women with Graves disease, \t\n\t\n\t\na review should be arranged at 6 weeks or before in women with \t\n\t\n\t\npoorly controlled disease.\n\n--- Page 87 ---\nNational Guideline for Maternal Care - Volume II\n73\n\t\n➢\t Any form of contraceptive is acceptable.\n6.4.\t\nPostpartum thyroid dysfunction (PPTD)\n\t\nDefinition:\n\t\n➢\t Occurrence of thyrotoxicosis or hypothyroidism within the first \t\n\t\n\t\npostpartum year, in a woman without clinically evident thyroid \t\n\t\n\t\ndisease before pregnancy\n\t\n\t\no\t This usually occurs in thyroid antibody (TPO Ab and antithy\t\n\t\n\t\n\t\nroglobulin Ab) positive women\n\t\n\t\no\t The prevalence is around 7% and is seen more often in women \t\n\t\n\t\n\t\nwith other autoimmune conditions. Eg. Type 1 diabetes mel\t\n\t\n\t\n\t\nlitus.\n\t\n\t\no\t The classical course is hyperthyroidism followed by hypothy\t\n\t\n\t\n\t\nroidism and finally euthyroidism. \n\t\n\t\n\t\n-\t However, the majority will not show this pattern and may \t\n\t\n\t\n\t\n\t\npresent with hyperthyroidism or hypothyroidism alone.\n\t\nHyperthyroid phase\n\t\n➢\t Thyrotoxic symptoms occur around 3 months postpartum.\n\t\n➢\t Graves disease is the main differential diagnosis. \n\t\n\t\no\t Physical stigmata of Graves’ disease, TRAb levels and USS of \t\n\t\n\t\n\t\nthe thyroid will help differentiate between hyperthyroidism \t\n\t\n\t\n\t\nassociated with Graves disease and PPTD.\n\t\n\t\n\t\n-\t TRAb positivity and high radio iodine uptake by the thy\t\n\t\n\t\n\t\n\t\nroid gland suggest Graves disease\n\t\nHypothyroid phase\n\t\n➢\t This occurs around 6 months postpartum and lasts for 4-6 \t\n\t\n\t\n\t\nmonths.\n\t\n➢\t  More than 50% will be asymptomatic. \n\t\n➢\t This stage may be preceded by a thyrotoxic phase.\n \n\t\nEuthyroid phase\n\t\n➢\t The majority of women with PPTD become euthyroid by 1 year \t\n\t\n\t\npostpartum.  \n\t\n\t\n-\t However 30% of women who develop PPTD will remain hy\t\n\t\n\t\n\t\npothyroid at 1 year with risk of permanent hypothyroidism",
  "➢\t This stage may be preceded by a thyrotoxic phase.\n \n\t\nEuthyroid phase\n\t\n➢\t The majority of women with PPTD become euthyroid by 1 year \t\n\t\n\t\npostpartum.  \n\t\n\t\n-\t However 30% of women who develop PPTD will remain hy\t\n\t\n\t\n\t\npothyroid at 1 year with risk of permanent hypothyroidism\n\n--- Page 88 ---\nNational Guideline for Maternal Care - Volume II\n74\nFigure 6.1 Management of postpartum thyrold dysfunction\n\n--- Page 89 ---\nNational Guideline for Maternal Care - Volume II\n75\n \n \n \nA2(3*(-/\"G-&&*\"&2\"(5\"^2,1$/,&$-'()'\"7$'F%$0,.#&'W790(,1'F--(.,#\",(&')(0'\"7$'+,#B&(-,-'#&1'8#&#B$%$&\"'()'\nW790(,1'+,-$#-$'+20,&B'@0$B&#&.9'#&1'@(-\"P#0\"2%\"Q+2%')&\"#^!!\"\n \nFigure 6.2 Management of thyroid nodule in oregnancy",
  "➢\t This stage may be preceded by a thyrotoxic phase.\n \n\t\nEuthyroid phase\n\t\n➢\t The majority of women with PPTD become euthyroid by 1 year \t\n\t\n\t\npostpartum.  \n\t\n\t\n-\t However 30% of women who develop PPTD will remain hy\t\n\t\n\t\n\t\npothyroid at 1 year with risk of permanent hypothyroidism\n\n--- Page 88 ---\nNational Guideline for Maternal Care - Volume II\n74\nFigure 6.1 Management of postpartum thyrold dysfunction\n\n--- Page 89 ---\nNational Guideline for Maternal Care - Volume II\n75\n \n \n \nA2(3*(-/\"G-&&*\"&2\"(5\"^2,1$/,&$-'()'\"7$'F%$0,.#&'W790(,1'F--(.,#\",(&')(0'\"7$'+,#B&(-,-'#&1'8#&#B$%$&\"'()'\nW790(,1'+,-$#-$'+20,&B'@0$B&#&.9'#&1'@(-\"P#0\"2%\"Q+2%')&\"#^!!\"\n \nFigure 6.2 Management of thyroid nodule in oregnancy\n\n--- Page 90 ---\nNational Guideline for Maternal Care - Volume II\n76\nReferences \n1.\t Satgnaro Green et al. Guidelines of the American Thyroid \t\n\t\n\t\nAssociation for the Diagnosis and Management of Thyroid Disease \t\n\t\nDuring Pregnancy and Postpartum. Thyroid 2011; 21(10): 1081-1125.\n2.\t Management of thyroid dysfunction during  pregnancy and \t\n\t\n\t\npostpartum:An endocrine society clinical practice guideline Journal \t\n\t\nof Clinical Endocrinology & Metabolism 2012;97: 2543–2565.\n3\t The Endocrine Society of Sri Lanka’s clinical guidelines on thyroid \t\n\t\ndiseases (2013).\n4.\t Wright H V, Williams D J.  Thyrotoxicosis in pregnancy  Fetal and \t\n\t\nMaternal Medicine Review 2013; 24(2):  108 – 128.",
  "Thyroid 2011; 21(10): 1081-1125.\n2.\t Management of thyroid dysfunction during  pregnancy and \t\n\t\n\t\npostpartum:An endocrine society clinical practice guideline Journal \t\n\t\nof Clinical Endocrinology & Metabolism 2012;97: 2543–2565.\n3\t The Endocrine Society of Sri Lanka’s clinical guidelines on thyroid \t\n\t\ndiseases (2013).\n4.\t Wright H V, Williams D J.  Thyrotoxicosis in pregnancy  Fetal and \t\n\t\nMaternal Medicine Review 2013; 24(2):  108 – 128.\n\n--- Page 91 ---\nNational Guideline for Maternal Care - Volume II\n77\nRheumatoid arthritis\n\n--- Page 92 ---\nNational Guideline for Maternal Care - Volume II\n78",
  "Thyroid 2011; 21(10): 1081-1125.\n2.\t Management of thyroid dysfunction during  pregnancy and \t\n\t\n\t\npostpartum:An endocrine society clinical practice guideline Journal \t\n\t\nof Clinical Endocrinology & Metabolism 2012;97: 2543–2565.\n3\t The Endocrine Society of Sri Lanka’s clinical guidelines on thyroid \t\n\t\ndiseases (2013).\n4.\t Wright H V, Williams D J.  Thyrotoxicosis in pregnancy  Fetal and \t\n\t\nMaternal Medicine Review 2013; 24(2):  108 – 128.\n\n--- Page 91 ---\nNational Guideline for Maternal Care - Volume II\n77\nRheumatoid arthritis\n\n--- Page 92 ---\nNational Guideline for Maternal Care - Volume II\n78\n\n--- Page 93 ---\nNational Guideline for Maternal Care - Volume II\n79\n7. Rheumatoid arthritis \n7.1. Introduction\n\t\n➢\t Disease activity in women with rheumatoid arthritis (RA) usually \t\n\t\n\t\nimproves or remains the same during pregnancy although flares \t\n\t\n\t\ncould occur postpartum.\n\t\n➢\t Women with poorly controlled disease have a greater risk of flares \t\n\t\n\t\nin the postpartum period.\n7.2. Preconception care\nAims of preconception care:\n\t\n➢\t To assess suitability for  pregnancy\n\t\n\t\no\t Contraindications to pregnancy include moderate /severe \t\t\n\t\n\t\n\t\npulmonary hypertension, advanced rheumatoid lung disease \t\n\t\n\t\n\t\nand advanced renal impairment (serum creatinine > 2.8 mg/\t\n\t\n\t\n\t\ndL)\n\t\n\t\no\t Specialist assessment is needed for all women with active \t \t\n\t\n\t\n\t\ndisease \n\t\n\t\no\t Disease remission should be maintained for at least one year \t\n\t\n\t\n\t\nprior to conception.\n\t\n\t\n\t\n-\t Disease activity should be assessed by using one of the \t\t\n\t\n\t\n\t\n\t\naccepted composite disease activity scores. e.g. Disease \t\n\t\n\t\n\t\n\t\nActivity Score (DAS) - DAS 28 or clinical disease activity \t\n\t\n\t\n\t\n\t\nindex- CDAI \n\t\n➢\t To screen for target organ damage \n\t\n\t\no\t Cardiac, pulmonary and renal assessment (blood pressure, \t\n\t\n\t\n\t\nserum creatinine, echocardiography and lung function tests) \t\n\t\n\t\n\t\nshould be performed depending on organ involvement\n\t\n➢\t To screen for concomitant autoimmune conditions, especially \t\n\t\n\t\nautoimmune thyroid dysfunction.\n\t\n➢\t To advice contraception until disease activity is controlled \n\t\n\t\no\t  Intrauterine Device (IUD) /Oral contraceptive Pill (OCP)/\t\n\t\n\t\n\t\nDepot Medroxy Progesterone Acetate (DMPA)/Implants are \t\n\t\n\t\n\t\nacceptable\n\t\n\t\no\t  Emergency contraception in the event of unprotected sexual \t\n\t\n\t\n\t\nintercourse.\n\t\n➢\t Periconceptional folate supplementation- Folic acid at a dose of 5 \t\n\t\n\t\nmg daily should be commenced.\n\t\n➢\t For review  of medication and appropriate adjustment prior to  \t\n\t\n\t\npregnancy (Box 2.1).",
  "e.g. Disease \t\n\t\n\t\n\t\n\t\nActivity Score (DAS) - DAS 28 or clinical disease activity \t\n\t\n\t\n\t\n\t\nindex- CDAI \n\t\n➢\t To screen for target organ damage \n\t\n\t\no\t Cardiac, pulmonary and renal assessment (blood pressure, \t\n\t\n\t\n\t\nserum creatinine, echocardiography and lung function tests) \t\n\t\n\t\n\t\nshould be performed depending on organ involvement\n\t\n➢\t To screen for concomitant autoimmune conditions, especially \t\n\t\n\t\nautoimmune thyroid dysfunction.\n\t\n➢\t To advice contraception until disease activity is controlled \n\t\n\t\no\t  Intrauterine Device (IUD) /Oral contraceptive Pill (OCP)/\t\n\t\n\t\n\t\nDepot Medroxy Progesterone Acetate (DMPA)/Implants are \t\n\t\n\t\n\t\nacceptable\n\t\n\t\no\t  Emergency contraception in the event of unprotected sexual \t\n\t\n\t\n\t\nintercourse.\n\t\n➢\t Periconceptional folate supplementation- Folic acid at a dose of 5 \t\n\t\n\t\nmg daily should be commenced.\n\t\n➢\t For review  of medication and appropriate adjustment prior to  \t\n\t\n\t\npregnancy (Box 2.1).\n\n--- Page 94 ---\nNational Guideline for Maternal Care - Volume II\n80\nBox 7.1  Safety of medications used for rheumatoid arthritis \nin pregnancy\nPregnancy category X\n\t\nMethotrexate \n\t\nStop for at least 3 months prior to attempting conception.\n\t\nLeflunomide\n\t\nConception should be avoided for minimum of 2 years since \t\n\t\n\t\ndiscontinuing Leflunomide.  If cholestyramine washout is \t\n\t\n\t\ncarried out for an special indication, pregnancy must be deferred \t\n\t\nfor 3 menstrual cycles after  the wash out period. \nPregnancy category D \n\t\nNon steroidal anti inflammatory drugs (NSAIDS )\n\t\nNSAIDs, including COX-2 inhibitors, are contraindicated in \t\n\t\n\t\nthe third trimester. Could be used with caution prior to 24 weeks \t\n\t\nof gestation, with intermittent use of those with a short half life. \t \t\n\t\nRisk of miscarriage in the first trimester.\nPregnancy category C \n\t\nHydroxychloroquine \n\t\nLowest possible dose (200mg ) should be used.\n\t\nSteroids\n\t\nPrednisolone and hydrocortisone are preferred. Lowest possible \t \t\n\t\ndose should be used.\nPregnancy category B\n\t\nSulphasalazine (Category D if used for prolonged periods or \t \t\n\t\nnear term)\n\t\nLowest possible dose (500mg -1g/day ) if absolutely indicated.\n\t\nFolate supplementation is encouraged during its use during \t\n\t\n\t\npreconception and pregnancy.",
  "Risk of miscarriage in the first trimester.\nPregnancy category C \n\t\nHydroxychloroquine \n\t\nLowest possible dose (200mg ) should be used.\n\t\nSteroids\n\t\nPrednisolone and hydrocortisone are preferred. Lowest possible \t \t\n\t\ndose should be used.\nPregnancy category B\n\t\nSulphasalazine (Category D if used for prolonged periods or \t \t\n\t\nnear term)\n\t\nLowest possible dose (500mg -1g/day ) if absolutely indicated.\n\t\nFolate supplementation is encouraged during its use during \t\n\t\n\t\npreconception and pregnancy.\n\n--- Page 95 ---\nNational Guideline for Maternal Care - Volume II\n81\n7.3. Antenatal care\n\t\n➢\t Frequency of monitoring should vary depending on the patient’s \t\n\t\n\t\ndisease activity and systemic involvement.\n\t\n\t\no\t All patients should be reviewed by the rheumatologist/\t\n\t\n\t\n\t\n\t\nphysician at least every trimester.\n\t\n\t\no\t Women with unstable disease needs more frequent \t\n\t\n\t\n\t\n\t\nmonitoring.  \n\t\n➢\t Review of medications (Refer details in Box 3.1 above ).\n7.4. Delivery \n\t\n➢\t No special measures are needed during delivery. Women with \t\n\t\n\t\nhip deformities or valgus knee deformities should be considered \t\n\t\n\t\nfor caesarean section. \n7.5. Postpartum care\n\t\n➢\t Review drugs for suitability for breast feeding.\nBox 7.2:  Safety of medications during breast feeding\nSafe to continue during lactation\n\t\nNSAIDs\n\t\nCorticosteroids\n\t\nHydroxychloroquine\n\t\nSulfasalazine1\nInadequate data regarding lactation –Avoid \n\t\nTNFα inhibitors\n\t\nAnakinra\n\t\nAbatacept\n\t\nRituximab\n\t\nTocilizumab\n\t\nTofacitinib\nContraindicated during lactation\n\t\nMethotrexate\n\t\nLeflunomide\n\t\nAzathioprine 2\n\t\n1 \t Use with caution in settings of prematurity, hyperbilirubinemia \t\n\t\n\t\nand  glucose-6-phosphate dehydrogenase deficiency.\n\t\n2\t Avoidance is recommended by the manufacturer, primarily \t \t\n\t\n\t\nbased on theoretical risk.",
  "7.5. Postpartum care\n\t\n➢\t Review drugs for suitability for breast feeding.\nBox 7.2:  Safety of medications during breast feeding\nSafe to continue during lactation\n\t\nNSAIDs\n\t\nCorticosteroids\n\t\nHydroxychloroquine\n\t\nSulfasalazine1\nInadequate data regarding lactation –Avoid \n\t\nTNFα inhibitors\n\t\nAnakinra\n\t\nAbatacept\n\t\nRituximab\n\t\nTocilizumab\n\t\nTofacitinib\nContraindicated during lactation\n\t\nMethotrexate\n\t\nLeflunomide\n\t\nAzathioprine 2\n\t\n1 \t Use with caution in settings of prematurity, hyperbilirubinemia \t\n\t\n\t\nand  glucose-6-phosphate dehydrogenase deficiency.\n\t\n2\t Avoidance is recommended by the manufacturer, primarily \t \t\n\t\n\t\nbased on theoretical risk.\n\n--- Page 96 ---\nNational Guideline for Maternal Care - Volume II\n82\n\t\n➢\t Advice to take medication immediately after breast feeding \t\n\t\n\t\n\t\nand preferably postpone the next feed for four hours after taking \t\n\t\n\t\nthe medication. \n\t\n➢\t Women should be monitored more frequently, due to risk of \t \t\n\t\n\t\ndisease flares. \n\t\n\t\no\t Review at six weeks postpartum, with those with active disease \t\n\t\n\t\n\t\nreviewed earlier and more frequently.\n\t\nReferences \n\t\n1.\t Megan L. Krause, Shreyasee Amin and Ashima Makol. \t\n\t\n\t\n\t\nUse of DMARDs and biologics during pregnancy and lactation \t\n\t\n\t\nin rheumatoid  arthritis: what the rheumatologist needs to know. \t\n\t\n\t\nTherapeutic Advances in  Musculoskeetal Diease 2014, Vol. 6(5) \t\n\t\n\t\n169–184.\n\t\n2.\t Varsha Jain  and Caroline Gordon. Managing pregnancy in \t\n\t\n\t\n\t\ninflammatory rheumatological diseases. 2011 Arthritis Research \t\n\t\n\t\n& Therapy 2011, 13: 206",
  "Managing pregnancy in \t\n\t\n\t\n\t\ninflammatory rheumatological diseases. 2011 Arthritis Research \t\n\t\n\t\n& Therapy 2011, 13: 206\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume II\n83\nSystemic Lupus Erythematosus\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume II\n84",
  "Managing pregnancy in \t\n\t\n\t\n\t\ninflammatory rheumatological diseases. 2011 Arthritis Research \t\n\t\n\t\n& Therapy 2011, 13: 206\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume II\n83\nSystemic Lupus Erythematosus\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume II\n84\n\n--- Page 99 ---\nNational Guideline for Maternal Care - Volume II\n85\n8. Systemic Lupus Erythematosus\n8.1. Introduction\n\t\n➢\t Disease activity of systemic lupus erythematosus (SLE) varies in \t\n\t\n\t\npregnancy. \n\t\n\t\no\t Disease activity in the preconception stage is the most \t\n\t\n\t\n\t\n\t\nimportant predictor of flares during     pregnancy\n\t\n\t\no\t Disease flares commonly involve the skin and musculoskeletal \t\n\t\n\t\n\t\nsystem\n\t\n\t\no\t Identifying a disease flare is challenging as physiological \t \t\n\t\n\t\n\t\nchanges of pregnancy mimic  a disease flare \n\t\n➢\t Factors associated with an adverse pregnancy outcome include,\n\t\n\t\no\t Active disease in the preconception stage\n\t\n\t\no\t Lupus nephritis with increased baseline serum creatinine (S \t\n\t\n\t\n\t\ncreatinine >1.4mg/dL). \n\t\n\t\no\t Presence of antiphospholipid syndrome (APS)\n\t\n➢\t SLE could present for the first time in pregnancy. \n\t\n➢\t Maternal and fetal complications of active disease include,  \nMaternal complications\n\t\n•\t Hypertensive disorders including preeclampsia, HELLP syndrome \n\t\n•\t Gestational diabetes mellitus (GDM)\n\t\n•\t Premature rupture of Membranes (PROM)\n\t\n•\t Arterial and venous thrombosis especially in the presence of APS\n\t\n•\t Catastrophic APS \n\t\n•\t Immune thrombocytopaenia\n\t\n•\t Infections\n\t\n•\t Autoimmue hepatitis\nFetal complications  \n\t\n•\t Miscarriage (more common in the presence of APS)\n\t\n•\t Fetal growth restriction\n\t\n•\t Stillbirth\n\t\n•\t Prematurity\n\t\n•\t Neonatal lupus.\n(Presence of active disease and lupus nephritis substantially increase the \nrisk of fetal loss and prematurity)\n8.2.\t\nPreconception care\nAims of preconception care:",
  "o\t Presence of antiphospholipid syndrome (APS)\n\t\n➢\t SLE could present for the first time in pregnancy. \n\t\n➢\t Maternal and fetal complications of active disease include,  \nMaternal complications\n\t\n•\t Hypertensive disorders including preeclampsia, HELLP syndrome \n\t\n•\t Gestational diabetes mellitus (GDM)\n\t\n•\t Premature rupture of Membranes (PROM)\n\t\n•\t Arterial and venous thrombosis especially in the presence of APS\n\t\n•\t Catastrophic APS \n\t\n•\t Immune thrombocytopaenia\n\t\n•\t Infections\n\t\n•\t Autoimmue hepatitis\nFetal complications  \n\t\n•\t Miscarriage (more common in the presence of APS)\n\t\n•\t Fetal growth restriction\n\t\n•\t Stillbirth\n\t\n•\t Prematurity\n\t\n•\t Neonatal lupus.\n(Presence of active disease and lupus nephritis substantially increase the \nrisk of fetal loss and prematurity)\n8.2.\t\nPreconception care\nAims of preconception care:\n\n--- Page 100 ---\nNational Guideline for Maternal Care - Volume II\n86\n\t\n➢\t Assess suitability for pregnancy\n\t\n\t\no\t Pregnancy should be avoided in the presence of moderate/ \t\n\t\n\t\n\t\nsevere pulmonary hypertension, severe restrictive lung disease \t\n\t\n\t\n\t\n(forced vital capacity <1L) or advanced renal disease  (serum \t\n\t\n\t\n\t\ncreatinine level >2.8 mg/dl).\n\t\n\t\no\t Pregnancy should be deferred if disease remission has not \t\t\n\t\n\t\n\t\nbeen achieved for at least six months.\n\t\n\t\n\t\n-\t Disease activity score could be assessed using the \t\n\t\n\t\n\t\n\t\n\t\nEuropean Consensus Lupus Activity Measurement \t\n\t\n\t\n\t\n\t\n\t\n(ECLAM) modified version validated for use in pregnancy\n\t\n\t\n\t\n-\t Levels of serum complements (C3 and C4) and  dsDNA  \t\n\t\n\t\n\t\n\t\nmay  be used for monitoring of disease activity\n\t\n➢\t Assessment for other autoantibodies\n\t\n\t\no\t Anti - Ro and anti - La antibodies should preferably be \t\n\t\n\t\n\t\n\t\nassessed to identify risk of complete heart block (CHB) in the \t\n\t\n\t\n\t\nfetus \n\t\n\t\no\t Anticardiolipin antibodies, lupus antico¬agulant and \t\n\t\n\t\n\t\n\t\nanti β2 glycoprotein should be assessed to detect the presence \t\n\t\n\t\n\t\nof antiphospholipid syndrome \n\t\n➢\t Review of medications\n\t\n\t\no\t Antihypertensives \n\t\n\t\n\t\n-\t Withhold  Angiotensin converting enzyme inhibitors \t \t\n\t\n\t\n\t\n\t\n(ACEI) and Angiotensin receptor blockers (ARB)  in \t \t\n\t\n\t\n\t\n\t\npregnancy \n\t\n\t\n\t\n-\t Give alternative antihypertensives (eg. Calcium channel \t\n\t\n\t\n\t\n\t\nblockers, Methyldopa)\n\t\n\t\no\t Most immunosuppressive drugs (Cyclophosphamide, \t\n\t\n\t\n\t\n\t\nMethotrexate, Mycophenolic acid, Leflunomide) are \t\n\t\n\t\n\t\n\t\ncontraindicated during pregnancy. (Refer Box 3.1 –\t\n\t\n\t\n\t\n\t\nRheumatoid arthritis)\n\t\n\t\n\t\n-\t They should be discontinued at least 3 months before \t \t\n\t\n\t\n\t\n\t\nconception\n\t\n\t\n\t\n-\t Leflunomide has a long half life; Pregnancy should either \t\n\t\n\t\n\t\n\t\nbe deferred for 2 years after discontinuation of the drug or \t\n\t\n\t\n\t\n\t\na washout procedure should be employed\n\t\n➢\t Contraception\n\t\n\t\no\t A contraceptive method should be used until it is safe to \t \t\n\t\n\t\n\t\nconceive.",
  "Calcium channel \t\n\t\n\t\n\t\n\t\nblockers, Methyldopa)\n\t\n\t\no\t Most immunosuppressive drugs (Cyclophosphamide, \t\n\t\n\t\n\t\n\t\nMethotrexate, Mycophenolic acid, Leflunomide) are \t\n\t\n\t\n\t\n\t\ncontraindicated during pregnancy. (Refer Box 3.1 –\t\n\t\n\t\n\t\n\t\nRheumatoid arthritis)\n\t\n\t\n\t\n-\t They should be discontinued at least 3 months before \t \t\n\t\n\t\n\t\n\t\nconception\n\t\n\t\n\t\n-\t Leflunomide has a long half life; Pregnancy should either \t\n\t\n\t\n\t\n\t\nbe deferred for 2 years after discontinuation of the drug or \t\n\t\n\t\n\t\n\t\na washout procedure should be employed\n\t\n➢\t Contraception\n\t\n\t\no\t A contraceptive method should be used until it is safe to \t \t\n\t\n\t\n\t\nconceive.\n\n--- Page 101 ---\nNational Guideline for Maternal Care - Volume II\n87\n Hormonal contraception\n-\t Low dose combined hormonal contraceptive may be used in patients \t\n\t\nwith inactive or mild disease activity. In moderate to severe disease \t\n\t\nand with prolonged use, they may be associated with lupus flares and  \t\n\t\nthromboembolic risk especially in the presence of APS\n-\t Progesterone containing oral, injectable or implantable \t \t\n\t\n\t\ncontraceptives may be  recommended as contraceptives in SLE \t \t\n\t\nfor shorter periods, but use over 2 years could increase the risk of \t\n\t\nosteoporosis \nIntrauterine contraceptive device\n-\t May be suitable for patients on minimal immunosuppressives for \t\n\t\nlong term use.\n8.3. Antenatal care\n\t\n➢\t Women with major organ involvement or poorly controlled \t \t\n\t\n\t\ndisease are best managed in a tertiary care center with \t\n\t\n\t\n\t\ninvolvement of a multidisciplinary team. \n\t\n➢\t Folic acid 5 mg daily should be continued throughout the first \t\n\t\n\t\ntrimester.\n\t\n➢\t Aspirin 75mg daily should be commenced at 10- 12 weeks and \t\n\t\n\t\ncontinued until 36 weeks of pregnancy.\n\t\n➢\t Women on steroids or heparin should receive supplemental \t \t\n\t\n\t\ncalcium and vitamin D \n\t\n\t\no\t Elemental calcium 1200 U (minimum  800 U ) daily.\n\t\n\t\no\t Vitamin D 800-1000 U daily.\n\t\n(Vitamin A and  D preparations should be avoided as a method of \t\n\t\nsupplementing vitamin D due to teratogenic potential of vitamin A).\n \t\n➢\t Regular review by the rheumatologist/specialist physician should \t\n\t\n\t\nbe undertaken for assessment of disease activity and control.\n\t\n\t\no\t Those with active disease   - at least fortnightly\n\t\n\t\no\t Those in disease remission - monthly\n\t\n➢\t Close monitoring of blood pressure, blood sugar levels and \t\n\t\n\t\n\t\nmaternal weight gain in women on steroids.",
  "Antenatal care\n\t\n➢\t Women with major organ involvement or poorly controlled \t \t\n\t\n\t\ndisease are best managed in a tertiary care center with \t\n\t\n\t\n\t\ninvolvement of a multidisciplinary team. \n\t\n➢\t Folic acid 5 mg daily should be continued throughout the first \t\n\t\n\t\ntrimester.\n\t\n➢\t Aspirin 75mg daily should be commenced at 10- 12 weeks and \t\n\t\n\t\ncontinued until 36 weeks of pregnancy.\n\t\n➢\t Women on steroids or heparin should receive supplemental \t \t\n\t\n\t\ncalcium and vitamin D \n\t\n\t\no\t Elemental calcium 1200 U (minimum  800 U ) daily.\n\t\n\t\no\t Vitamin D 800-1000 U daily.\n\t\n(Vitamin A and  D preparations should be avoided as a method of \t\n\t\nsupplementing vitamin D due to teratogenic potential of vitamin A).\n \t\n➢\t Regular review by the rheumatologist/specialist physician should \t\n\t\n\t\nbe undertaken for assessment of disease activity and control.\n\t\n\t\no\t Those with active disease   - at least fortnightly\n\t\n\t\no\t Those in disease remission - monthly\n\t\n➢\t Close monitoring of blood pressure, blood sugar levels and \t\n\t\n\t\n\t\nmaternal weight gain in women on steroids.\n\n--- Page 102 ---\nNational Guideline for Maternal Care - Volume II\n88\n\t\n➢\t Review of medications\n\t\n\t\no\t Hydroxychloroquine could be continued during pregnancy\n\t\n\t\no\t Azathioprine is safe, provided the dose does not exceed 2 mg/ \t\n\t\n\t\n\t\nkg day\n\t\n\t\no\t Calcineurin inhibi¬tors, Tacrolimus and Cyclosporine could \t\n\t\n\t\n\t\nbe considered in persistent disease activity\n\t\n\t\no\t Most immunosuppressive drugs (Cyclophosphamide, \t\n\t\n\t\n\t\n\t\nMethotrexate, Mycophenolic acid, Leflunomide) are \t\n\t\n\t\n\t\n\t\ncontraindicated during pregnancy\n\t\n➢\t Fetal monitoring\n\t\n\t\no\t Monitoring of growth and doppler uterine artery blood flow \t\n\t\n\t\n\t\nfor detection of fetal growth restriction.\n\t\n\t\no\t Fetal echocardiography if indicated.\n8.4.\t\nDelivery\n\t\n➢\t Women who have been on steroids  >7.5mg/day  for ≥ 2 weeks \t\n\t\n\t\npreceding delivery, should be given IV Hydrocortisone 100mg \t\n\t\n\t\nfollowed by  50 mg 6 hourly  for 24 hours from the time of active \t\n\t\n\t\nlabour.\n8.5.\t\nPostpartum care\n\t\n➢\t The risk of disease flare is high.  \n\t\n\t\no\t Review all women at 6 weeks and those with active disease at 2 \t\n\t\n\t\n\t\nweeks postpartum.\n\t\n➢\t  In women with APS, heparin should be continued postpartum. \t\n\t\n\t\n(Refer section on APS for duration of anticoagulation).\n\t\n➢\t Women on lifelong anticoagulation should be converted to \t\n\t\n\t\n\t\nwarfarin prior to discharge.\n\t\n➢\t Breast feeding- Refer the section on  Safety of medications \t\n\t\n\t\n\t\nduring breast feeding Box 3.2 Rheumatoid arthritis for advice on  \t\n\t\n\t\nmedication during breast feeding. \n8.6.\t\nContraception\n➢\t Refer section on contraception - preconception care in SLE.",
  "(Refer section on APS for duration of anticoagulation).\n\t\n➢\t Women on lifelong anticoagulation should be converted to \t\n\t\n\t\n\t\nwarfarin prior to discharge.\n\t\n➢\t Breast feeding- Refer the section on  Safety of medications \t\n\t\n\t\n\t\nduring breast feeding Box 3.2 Rheumatoid arthritis for advice on  \t\n\t\n\t\nmedication during breast feeding. \n8.6.\t\nContraception\n➢\t Refer section on contraception - preconception care in SLE.\n\n--- Page 103 ---\nNational Guideline for Maternal Care - Volume II\n89\n8.7. Neonatal lupus syndrome\n\t\n➢\t Neonatal lupus syndrome represent fetal mani¬festations of \t \t\n\t\n\t\npassively acquired autoimmunity. \n\t\n➢\t NLS may manifest as rash, haematologic/hepatic abnormalities or \t\n\t\n\t\ncardiac complications. \n\t\n➢\t These manifestations generally resolve by 6 to 8 months after \t\t\n\t\n\t\nbirth.   \n\t\n➢\t All babies born to mothers with SLE need to be reviewed by a \t\n\t\n\t\npaediatrician.\n8.8.\t\nTreatment of lupus nephritis (LN) in pregnancy\n\t\n➢\t Risk of renal flare is high in pregnancy and requires \t \t\n\t\n\t\n\t\ndifferentiation from pre eclampsia.  \nBox 8.1: Differentiating features of pre eclampsia and lupus nephritis\nClinical and laboratory \nfeatures\nHypertension\nUrinary sediment\nDNA antibody levels\nComplement levels- C3,C4 \nPre eclampsia \nOnset usually after 20 weeks\nInactive\nNormal\nNormal\nLupus nephritis\nOnset could be any time\nActive \nRising\nMore than 25% decline \n\t\n➢\t  If active nephritis is present, glucocorticoids could be prescribed \t\n\t\n\t\nto control disease activity, and if necessary Azathioprine can \t \t\n\t\n\t\nbe added. (The dose of Azathioprine should not exceed 2 mg/kg \t\n\t\n\t\nin a pregnant woman).\n\t\n➢\t For patients with persistently active nephritis with documented \t\n\t\n\t\nor suspected class III or IV lupus nephritis with crescents, \t\n\t\n\t\n\t\nconsider early delivery.\n8.9. Other autoimmune connective tissue disease\n\t\nSystemic Sclerosis\n\t\n➢\t Contraindications to pregnancy include moderate/ severe \t\n\t\n\t\n\t\npulmonary hypertension, severe pulmonary fibrosis and \t\n\t\n\t\n\t\nadvanced renal disease (S,creatinine > 2.8mg/dL).",
  "(The dose of Azathioprine should not exceed 2 mg/kg \t\n\t\n\t\nin a pregnant woman).\n\t\n➢\t For patients with persistently active nephritis with documented \t\n\t\n\t\nor suspected class III or IV lupus nephritis with crescents, \t\n\t\n\t\n\t\nconsider early delivery.\n8.9. Other autoimmune connective tissue disease\n\t\nSystemic Sclerosis\n\t\n➢\t Contraindications to pregnancy include moderate/ severe \t\n\t\n\t\n\t\npulmonary hypertension, severe pulmonary fibrosis and \t\n\t\n\t\n\t\nadvanced renal disease (S,creatinine > 2.8mg/dL).\n\n--- Page 104 ---\nNational Guideline for Maternal Care - Volume II\n90\n\t\n➢\t Risk of premature rupture of membranes (PROM) is high.\n\t\n➢\t Nifedipine given for Raynauds disease may interfere with uterine \t\n\t\n\t\ncontractions in the latter part of pregnancy. \n\t\n➢\t In women with gastrointestinal involvement, \n\t\n\t\no\t nutritional problems and constipations  requires specialist \t\n\t\n\t\n\t\nattention and care\n\t\n\t\no\t anaesthetic review is required due to anticipated problems \t\n\t\n\t\n\t\nduring intubation\nWomen with undifferentiated autoimmune connective tissue disease \n(CTD), dermatomyositis, mixed CTD and overlap syndrome should \nbe referred for specialist assessment for gauging of  disease activity and \norgan involvement prior to pregnancy. \nReferences\n1.\t Aisha Lateef and Michelle Petri. Management of pregnancy in \t\n\t\n\t\nsystemic lupus erythematosus . Nature Reviews; Rheumatology.  \t\t\n\t\n2012.\t\n2.\t American College of Rheumatology Guidelines for Screening, \t\n\t\n\t\nTreatment, and Management of Lupus Nephritis  Arthritis Care & \t\n\t\nResearch 2012;  64(6): 797–808.\n3.\t Petri M, Kim MY, Kalunian KC, Grossman J, Hahn BH, \t\t\n\t\n\t\nSammaritano LR, et al. Combined oral contraceptives in women with \t\n\t\nsystemic lupus erythematosus. New England Journal of \t Medicine \t\n\t\n2005;353:2550–8.\n4.\t Culwell KR, Curtis KM, del Carmen Cravioto M. Safety of \t\n\t\n\t\ncontraceptive method use among women with systemic lupus \t\n\t\n\t\nerythematosus: a systematic review. Obstetrics and Gynecology \t \t\n\t\n2009;114:341–53.\n5.\t Truitt ST, Fraser AB, Grimes DA et al. Combined hormonal versus \t\n\t\nprogestin-only contraception in lactation. Cochrane Database Syst \t\n\t\nRev. 2003;2:CD003988 (updated 6 May 2008).\n6.\t Queenan JT. Contraception and breastfeeding. Clin Obstet Gynecol. \t\n\t\n2004;47:734-9. \n7.\t Anon. FFPRHC Guidance (July 2004): Contraceptive choices for \t\t\n\t\nbreastfeeding women. J Fam Plann Reprod Health Care. 2004; \t\n\t\n\t\n30:181-9.",
  "J Fam Plann Reprod Health Care. 2004; \t\n\t\n\t\n30:181-9.\n\n--- Page 105 ---\nNational Guideline for Maternal Care - Volume II\n91\nImmune Thrombocytopaenic \nPurpura\n\n--- Page 106 ---\nNational Guideline for Maternal Care - Volume II\n92\n\n--- Page 107 ---\nNational Guideline for Maternal Care - Volume II\n93\n9. Immune thrombocytopaenic purpura\n9.1. Introduction\n\t\n➢\t Thrombocytopaenia in pregnancy is defined as a platetet count \t\n\t\n\t\n<150x 109/L.\n\t\n➢\t It is the second commonest haematological disorder in pregnancy \t\n\t\n\t\nafter anaemia, and affects around 7–10% of pregnancies.\n\t\n➢\t Immune thrombocytopaenic purpura (ITP) is just one of several \t\n\t\n\t\ncauses in pregnancy and is a diagnosis following exclusion of \t\t\n\t\n\t\nmore sinister causes of thrombocytopaenia. \n\t\n➢\t In the absence of an initiating/ underlying cause for \t \t\n\t\n\t\n\t\nisolated thrombocytopaenia AND absent lymphadenopathy and  \t\n\t\n\t\nhepatosplenomegaly, a diagnosis of ITP can be made.",
  "Introduction\n\t\n➢\t Thrombocytopaenia in pregnancy is defined as a platetet count \t\n\t\n\t\n<150x 109/L.\n\t\n➢\t It is the second commonest haematological disorder in pregnancy \t\n\t\n\t\nafter anaemia, and affects around 7–10% of pregnancies.\n\t\n➢\t Immune thrombocytopaenic purpura (ITP) is just one of several \t\n\t\n\t\ncauses in pregnancy and is a diagnosis following exclusion of \t\t\n\t\n\t\nmore sinister causes of thrombocytopaenia. \n\t\n➢\t In the absence of an initiating/ underlying cause for \t \t\n\t\n\t\n\t\nisolated thrombocytopaenia AND absent lymphadenopathy and  \t\n\t\n\t\nhepatosplenomegaly, a diagnosis of ITP can be made.\n\n--- Page 108 ---\nNational Guideline for Maternal Care - Volume II\n94\nCondition\nGestational\nthrombocytopenia\nPre eclampsia\nViral infections\nITP\nHELLP syndrome\nIncidence  \n(%)\n5-9%\n5-8%\n<1%\n<1%\nDiagnostic features\n•Commonest cause of thrombocytopaenia in \npregnancy (70-80%) \n•Is a diagnosis of exclusion \n•Onset in  late second or third trimester\n•Platelet count normal outside  pregnancy\n•No neonatal thrombocytopenia\n•Thrombocytopenia resolves postpartum\n•Onset in late second or third trimester\n•Seen in any trimester\n•Seen in any trimester\n•Thrombocytopenia outside of pregnancy is seen\n•May be asssociated with fetal thrombocytopaenia\n•Variant of pre eclampsia\n•70% onset in late second or third trimester\n•In 30% onset postpartum\nClinical presentation \n•Asymptomatic\n•Headache, blurred vision, \nepigastric pain, oedema \n•Systolic BP≥ 140mmHg and/\nor diastolic BP ≥ 90mmHg\n•Fever, associated with \nheadache, myalgia and \narthralgia \n•May have signs of bleeding \n-bruising, petechiae\n•Majority will have \npreeclampsia \nLaboratory findings\n•Platelets usually >70 x 109/L\n•> 0.3g urine protein / 24hrs\n•Elevated liver transaminases, \nrenal impairment and  \ncoagulopathy in severe cases\n•White blood cell count is low \nor in the  lower normal range \n•Elevated transaminases may \noccur\n•Platelet  <100 x 109/L  +/- \nlarge platelets on peripheral \nblood smear\n•Microangiopathic \nhaemolytic anaemia; Elevated \nLDH\n•Elevated liver transaminases\nBox 9.1: Causes of thrombocytopaenia in pregnancy in order of frequency",
  "Introduction\n\t\n➢\t Thrombocytopaenia in pregnancy is defined as a platetet count \t\n\t\n\t\n<150x 109/L.\n\t\n➢\t It is the second commonest haematological disorder in pregnancy \t\n\t\n\t\nafter anaemia, and affects around 7–10% of pregnancies.\n\t\n➢\t Immune thrombocytopaenic purpura (ITP) is just one of several \t\n\t\n\t\ncauses in pregnancy and is a diagnosis following exclusion of \t\t\n\t\n\t\nmore sinister causes of thrombocytopaenia. \n\t\n➢\t In the absence of an initiating/ underlying cause for \t \t\n\t\n\t\n\t\nisolated thrombocytopaenia AND absent lymphadenopathy and  \t\n\t\n\t\nhepatosplenomegaly, a diagnosis of ITP can be made.\n\n--- Page 108 ---\nNational Guideline for Maternal Care - Volume II\n94\nCondition\nGestational\nthrombocytopenia\nPre eclampsia\nViral infections\nITP\nHELLP syndrome\nIncidence  \n(%)\n5-9%\n5-8%\n<1%\n<1%\nDiagnostic features\n•Commonest cause of thrombocytopaenia in \npregnancy (70-80%) \n•Is a diagnosis of exclusion \n•Onset in  late second or third trimester\n•Platelet count normal outside  pregnancy\n•No neonatal thrombocytopenia\n•Thrombocytopenia resolves postpartum\n•Onset in late second or third trimester\n•Seen in any trimester\n•Seen in any trimester\n•Thrombocytopenia outside of pregnancy is seen\n•May be asssociated with fetal thrombocytopaenia\n•Variant of pre eclampsia\n•70% onset in late second or third trimester\n•In 30% onset postpartum\nClinical presentation \n•Asymptomatic\n•Headache, blurred vision, \nepigastric pain, oedema \n•Systolic BP≥ 140mmHg and/\nor diastolic BP ≥ 90mmHg\n•Fever, associated with \nheadache, myalgia and \narthralgia \n•May have signs of bleeding \n-bruising, petechiae\n•Majority will have \npreeclampsia \nLaboratory findings\n•Platelets usually >70 x 109/L\n•> 0.3g urine protein / 24hrs\n•Elevated liver transaminases, \nrenal impairment and  \ncoagulopathy in severe cases\n•White blood cell count is low \nor in the  lower normal range \n•Elevated transaminases may \noccur\n•Platelet  <100 x 109/L  +/- \nlarge platelets on peripheral \nblood smear\n•Microangiopathic \nhaemolytic anaemia; Elevated \nLDH\n•Elevated liver transaminases\nBox 9.1: Causes of thrombocytopaenia in pregnancy in order of frequency\n\n--- Page 109 ---\nNational Guideline for Maternal Care - Volume II\n95\nAcute fatty liver of \npregnancy (AFLP)\nThrombotic \nthrombocytopaenic \npurpura (TTP)/ \nHaemolytic \nuraemic syndrome \n(HUS)\nDisseminated \nintravascular \ncoagulation (DIC)\n<0.01%\n<0.01%\n•Onset in third trimester\n•Onset in any trimester, but common during third \ntrimester or postpartum\n•Secondary to pregnancy related complications \nsuch as severe pre eclampsia, amniotic fluid \nembolism, IUD, placental abruption\n•Right hypochondrial pain\n•Jaundice\n•Nausea/vomiting\n•Hepatic encephalopathy\n•Fever\n•Visual changes\n•Altered mental status\n•Thrombotic episodes\n•Renal impairment\n•Clinical features of the \nunderlying condition with \t\nevidence of coagulopathy\n•Moderate or severe \nthrombocytopaenia\n•Elevated LFTs, creatinine, \nWBC,  uric acid, ammonia\n•Prolonged PT/APTT\n•Hypoglycaemia\n(Liver dysfunction more \nsignificant than in HELLP/pre \neclampsia)\n•Microangiopathic \nhaemolytic anaemia\n•Elevated creatinine\n•Normal coagulation screen\n•Elevated LDH\n•Prolonged INR and APTT\n•Haemolysis \n•Muliorgan failure may occur",
  "Introduction\n\t\n➢\t Thrombocytopaenia in pregnancy is defined as a platetet count \t\n\t\n\t\n<150x 109/L.\n\t\n➢\t It is the second commonest haematological disorder in pregnancy \t\n\t\n\t\nafter anaemia, and affects around 7–10% of pregnancies.\n\t\n➢\t Immune thrombocytopaenic purpura (ITP) is just one of several \t\n\t\n\t\ncauses in pregnancy and is a diagnosis following exclusion of \t\t\n\t\n\t\nmore sinister causes of thrombocytopaenia. \n\t\n➢\t In the absence of an initiating/ underlying cause for \t \t\n\t\n\t\n\t\nisolated thrombocytopaenia AND absent lymphadenopathy and  \t\n\t\n\t\nhepatosplenomegaly, a diagnosis of ITP can be made.\n\n--- Page 108 ---\nNational Guideline for Maternal Care - Volume II\n94\nCondition\nGestational\nthrombocytopenia\nPre eclampsia\nViral infections\nITP\nHELLP syndrome\nIncidence  \n(%)\n5-9%\n5-8%\n<1%\n<1%\nDiagnostic features\n•Commonest cause of thrombocytopaenia in \npregnancy (70-80%) \n•Is a diagnosis of exclusion \n•Onset in  late second or third trimester\n•Platelet count normal outside  pregnancy\n•No neonatal thrombocytopenia\n•Thrombocytopenia resolves postpartum\n•Onset in late second or third trimester\n•Seen in any trimester\n•Seen in any trimester\n•Thrombocytopenia outside of pregnancy is seen\n•May be asssociated with fetal thrombocytopaenia\n•Variant of pre eclampsia\n•70% onset in late second or third trimester\n•In 30% onset postpartum\nClinical presentation \n•Asymptomatic\n•Headache, blurred vision, \nepigastric pain, oedema \n•Systolic BP≥ 140mmHg and/\nor diastolic BP ≥ 90mmHg\n•Fever, associated with \nheadache, myalgia and \narthralgia \n•May have signs of bleeding \n-bruising, petechiae\n•Majority will have \npreeclampsia \nLaboratory findings\n•Platelets usually >70 x 109/L\n•> 0.3g urine protein / 24hrs\n•Elevated liver transaminases, \nrenal impairment and  \ncoagulopathy in severe cases\n•White blood cell count is low \nor in the  lower normal range \n•Elevated transaminases may \noccur\n•Platelet  <100 x 109/L  +/- \nlarge platelets on peripheral \nblood smear\n•Microangiopathic \nhaemolytic anaemia; Elevated \nLDH\n•Elevated liver transaminases\nBox 9.1: Causes of thrombocytopaenia in pregnancy in order of frequency\n\n--- Page 109 ---\nNational Guideline for Maternal Care - Volume II\n95\nAcute fatty liver of \npregnancy (AFLP)\nThrombotic \nthrombocytopaenic \npurpura (TTP)/ \nHaemolytic \nuraemic syndrome \n(HUS)\nDisseminated \nintravascular \ncoagulation (DIC)\n<0.01%\n<0.01%\n•Onset in third trimester\n•Onset in any trimester, but common during third \ntrimester or postpartum\n•Secondary to pregnancy related complications \nsuch as severe pre eclampsia, amniotic fluid \nembolism, IUD, placental abruption\n•Right hypochondrial pain\n•Jaundice\n•Nausea/vomiting\n•Hepatic encephalopathy\n•Fever\n•Visual changes\n•Altered mental status\n•Thrombotic episodes\n•Renal impairment\n•Clinical features of the \nunderlying condition with \t\nevidence of coagulopathy\n•Moderate or severe \nthrombocytopaenia\n•Elevated LFTs, creatinine, \nWBC,  uric acid, ammonia\n•Prolonged PT/APTT\n•Hypoglycaemia\n(Liver dysfunction more \nsignificant than in HELLP/pre \neclampsia)\n•Microangiopathic \nhaemolytic anaemia\n•Elevated creatinine\n•Normal coagulation screen\n•Elevated LDH\n•Prolonged INR and APTT\n•Haemolysis \n•Muliorgan failure may occur\n\n--- Page 110 ---\nNational Guideline for Maternal Care - Volume II\n96\nBox 9.2: First line treatment for ITP in pregnancy\n9.2. Managementof ITP in pregnancy\n\t\nPreconception care\n\t\n➢\t Disease remission for at least 6 months prior to conception \t\n\t\n\t\n\t\nshould have been achieved. \n\t\nAntenatal care \n\t\n➢\t The mother needs to be followed up in collaboration with a \t \t\n\t\n\t\nhaematologist for specialised care.  \n\t\n➢\t Aim to keep the platelet count > 30 x 109/L throughout \t\n\t\n\t\n\t\npregnancy.\nSteroids\nOral prednisolone 0.25-0.5 mg/Kg (15-30mg/day) taken as a single \ndose in the morning +/- proton pump inhibitors.\n\t\n➢\t In pregnancy, prednisolone is preferred to dexamethasone, as the \t\n\t\n\t\nlatter crosses the placenta more readily. \n\t\n➢\t The patient should be reviewed in one week to assess the platelet \t\n\t\n\t\ncount.\n\t\n\t\no\t70-80% responds initially\n\t\n\t\no\tApproximate time to response vary from several days to \t\n\t\n\t\n\t\n\t several weeks\n\t\n\t\no\tThe steroid dose should be tapered to maintain a safe platelet \t\n\t\n\t\n\t count\n\t\n-\t Regular monitoring for steroid induced diabetes should be \t\n\t\n\t\n\t\nperformed",
  "➢\t Aim to keep the platelet count > 30 x 109/L throughout \t\n\t\n\t\n\t\npregnancy.\nSteroids\nOral prednisolone 0.25-0.5 mg/Kg (15-30mg/day) taken as a single \ndose in the morning +/- proton pump inhibitors.\n\t\n➢\t In pregnancy, prednisolone is preferred to dexamethasone, as the \t\n\t\n\t\nlatter crosses the placenta more readily. \n\t\n➢\t The patient should be reviewed in one week to assess the platelet \t\n\t\n\t\ncount.\n\t\n\t\no\t70-80% responds initially\n\t\n\t\no\tApproximate time to response vary from several days to \t\n\t\n\t\n\t\n\t several weeks\n\t\n\t\no\tThe steroid dose should be tapered to maintain a safe platelet \t\n\t\n\t\n\t count\n\t\n-\t Regular monitoring for steroid induced diabetes should be \t\n\t\n\t\n\t\nperformed\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume II\n97\nBox 9.3:  Second line treatment (In order of priority)\n1.\t IV immunoglobulins\n\t\n➢\t This is considered in the absence/inadequate response to \t\n\t\n\t\n\t\nprednisolone\n\t\n➢\t Dose: 1g/kg/day for 1-2 days\n\t\n➢\t Up to 80% responds initially; Usually a rapid response, typically \t\n\t\n\t\nin 2-4 days \n2.\t Splenectomy\n\t\n➢\t Is safe to perform in the second trimester\n\t\n➢\t Response rate is 80%\n3.\t Azathioprine\n\t\n➢\t Dose is 1-2mg/kg/day; Maximum dose is 150mg/day\n\t\n➢\t Response rate is 40%; Usually a slow response; May need to \t \t\n\t\n\t\ncontinue for several months\n\t\n➢\t Can be used as a steroid sparing agent\nContraindicated in pregnancy\n\t\n➢\t Cyclophosphamide, Mycophenolate, Vincristine, Danazol\nTransfusion of platelets has no place in the management of ITP, except \nin the following circumstances:\n\t\n-\t Platelet  count <10 x 109 /L with bleeding\n\t\n-\t Need for emergency  delivery, surgery or invasive procedures \t\t\n\t\n\t\nwith suboptimal platelet count \n\t\n-\t Life threatening bleed  \nBox 9.4:  Management of a life threatening bleed\n•\t In the event of a life threatening bleed (Eg. intracranial \t \t\n\t\n\t\nhaemorrhage) associated with a low platelet count the following \t \t\n\t\nshould be administered.\n\t\n-\t Platelet transfusion, IV immunoglobulin (1g/kg/day for 1-2 \t \t\n\t\n\t\ndays)  and IV Methyl prednisolone (0.5-1.0 g/d for 3 days)",
  "➢\t The patient should be reviewed in one week to assess the platelet \t\n\t\n\t\ncount.\n\t\n\t\no\t70-80% responds initially\n\t\n\t\no\tApproximate time to response vary from several days to \t\n\t\n\t\n\t\n\t several weeks\n\t\n\t\no\tThe steroid dose should be tapered to maintain a safe platelet \t\n\t\n\t\n\t count\n\t\n-\t Regular monitoring for steroid induced diabetes should be \t\n\t\n\t\n\t\nperformed\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume II\n97\nBox 9.3:  Second line treatment (In order of priority)\n1.\t IV immunoglobulins\n\t\n➢\t This is considered in the absence/inadequate response to \t\n\t\n\t\n\t\nprednisolone\n\t\n➢\t Dose: 1g/kg/day for 1-2 days\n\t\n➢\t Up to 80% responds initially; Usually a rapid response, typically \t\n\t\n\t\nin 2-4 days \n2.\t Splenectomy\n\t\n➢\t Is safe to perform in the second trimester\n\t\n➢\t Response rate is 80%\n3.\t Azathioprine\n\t\n➢\t Dose is 1-2mg/kg/day; Maximum dose is 150mg/day\n\t\n➢\t Response rate is 40%; Usually a slow response; May need to \t \t\n\t\n\t\ncontinue for several months\n\t\n➢\t Can be used as a steroid sparing agent\nContraindicated in pregnancy\n\t\n➢\t Cyclophosphamide, Mycophenolate, Vincristine, Danazol\nTransfusion of platelets has no place in the management of ITP, except \nin the following circumstances:\n\t\n-\t Platelet  count <10 x 109 /L with bleeding\n\t\n-\t Need for emergency  delivery, surgery or invasive procedures \t\t\n\t\n\t\nwith suboptimal platelet count \n\t\n-\t Life threatening bleed  \nBox 9.4:  Management of a life threatening bleed\n•\t In the event of a life threatening bleed (Eg. intracranial \t \t\n\t\n\t\nhaemorrhage) associated with a low platelet count the following \t \t\n\t\nshould be administered.\n\t\n-\t Platelet transfusion, IV immunoglobulin (1g/kg/day for 1-2 \t \t\n\t\n\t\ndays)  and IV Methyl prednisolone (0.5-1.0 g/d for 3 days)\n\n--- Page 112 ---\nNational Guideline for Maternal Care - Volume II\n98\n\t\n➢\t Monitoring during pregnancy should be individualised according \t\n\t\n\t\nto the platelet count, the trimester and the trend of platelet rise.\n\t\n\t\no\t Monthly monitoring of platelet count is recommended in 1st \t\n\t\n\t\n\t\nand 2nd trimesters\n\t\n\t\no\t In the third trimester more frequent monitoring is \t\n\t\n\t\n\t\n\t\nrecommended\n\t\n➢\t Avoid IM injections and NSAID use when the platelet count is < \t\n\t\n\t\n50 x 109/L. \n\t\n➢\t Weigh the risk and  benefits in women with a platelet count < 50x \t\n\t\n\t\n109/Lwho require aspirin for obstetric indications.\n\t\n\t\nIndications for admission\n\t\n➢\t If the platelet count is less than < 10 x 109 /L (repeated and \t\n\t\n\t\n\t\nconfirmed)\n\t\n➢\t When spontaneous bleeding occurs (irrespective of the platelet \t\n\t\n\t\ncount)\n\t\nDelivery\n\t\n➢\t The platelet count should be monitored every week from 36 \t \t\n\t\n\t\nweeks \tonwards. If delivery is planned earlier, weekly monitoring \t\n\t\n\t\nfrom 34 weeks onwards is advised.\n\t\n➢\t ITP is not an indication for caesarean section. Mode of delivery \t\n\t\n\t\nshould be based on obstetric indications.\nBox 9.5:  Safe platelet count for delivery\n•\t Vaginal delivery >50 x 109/L\n•\t Caesarean section >50 x 109/L\n•\t Epidural anaesthesia> 80 x 109/L\n\t\n➢\t If a safe platelet count is not achieved with steroid treatment and  \t\n\t\n\t\nthe patient is close to delivery (>37 weeks of gestation) consider,\n\t\n\t\no\t IV immunoglobulin 1g/Kg /day-for 2 consecutive days. The \t\n\t\n\t\n\t\nresponse lasts for 2-3 weeks.\n\t\n\t\no\t If IV immunoglobulin is not available, a course of \t\n\t\n\t\n\t\n\t\ni.v.methylprednisolone (1g daily for 3 days) can be given.\n\t\n\t\no\t If maternal platelet count remains low (<50x 109/L) around \t\n\t\n\t\n\t\nthe time of delivery inspite of all above measures, platelets \t\n\t\n\t\n\t\nshould be available on standby.\n\t\n\t\no\t If the  platelet count is < 10x 109/L or if haemorrhage occurs \t\n\t\n\t\n\t\nwith a platelet count <  50 x 109/L at delivery, 6-10 units of \t\n\t\n\t\n\t\nplatelet packs should be given",
  "Mode of delivery \t\n\t\n\t\nshould be based on obstetric indications.\nBox 9.5:  Safe platelet count for delivery\n•\t Vaginal delivery >50 x 109/L\n•\t Caesarean section >50 x 109/L\n•\t Epidural anaesthesia> 80 x 109/L\n\t\n➢\t If a safe platelet count is not achieved with steroid treatment and  \t\n\t\n\t\nthe patient is close to delivery (>37 weeks of gestation) consider,\n\t\n\t\no\t IV immunoglobulin 1g/Kg /day-for 2 consecutive days. The \t\n\t\n\t\n\t\nresponse lasts for 2-3 weeks.\n\t\n\t\no\t If IV immunoglobulin is not available, a course of \t\n\t\n\t\n\t\n\t\ni.v.methylprednisolone (1g daily for 3 days) can be given.\n\t\n\t\no\t If maternal platelet count remains low (<50x 109/L) around \t\n\t\n\t\n\t\nthe time of delivery inspite of all above measures, platelets \t\n\t\n\t\n\t\nshould be available on standby.\n\t\n\t\no\t If the  platelet count is < 10x 109/L or if haemorrhage occurs \t\n\t\n\t\n\t\nwith a platelet count <  50 x 109/L at delivery, 6-10 units of \t\n\t\n\t\n\t\nplatelet packs should be given\n\n--- Page 113 ---\nNational Guideline for Maternal Care - Volume II\n99\n\t\n➢\t Paediatric team to be informed at time of delivery.\n\t\n\t\nPostpartum care\n\t\n➢\t Risk of disease flare is increased.\n\t\n➢\t Plan to review with a platelet count at one month postpartum and \t\n\t\n\t\nif normal at six weeks postpartum.\n\t\n➢\t Arrange for long term care after the 6 week review.\n9.3. Neonate of a mother with ITP\n\t\n➢\t Check the full blood count on a cord blood sample; Maternal \t\t\n\t\n\t\nplatelet count is a poor predictor of the neonatal platelet count.\n\t\n\t\no\t The platelet count should be reassessed the following day, if \t\n\t\n\t\n\t\nthe initial count is low. \n\t\n\t\no\t Neonates with low platelet count should be monitored as the \t\n\t\n\t\n\t\nplatelet count falls to a nadir between 2-5 days.\n\t\n➢\t If the neonatal platelet count is < 50 x 109/L at any time, perform \t\n\t\n\t\na cranial US scan.\n\t\n➢\t If the platelet count is < 20 x 109/Lwith evidence of haemorrhage, \t\n\t\n\t\na single dose of IV immunoglobulin (1g/Kg) could be \t\n\t\n\t\n\t\nadministered and  repeated as necessary.\n\t\n➢\t Platelets should be transfused for life threatening bleeds.\n\t\n➢\t Intramuscular  vitamin K should be avoided until  the  platelet  \t\n\t\n\t\ncount is known; Consider giving it orally if the platelet count is \t\n\t\n\t\n<50 x 109 /L.\n9.4. Thrombotic thrombocytopaenic purpura (TTP)\n\t\n➢\t This is a prothrombotic state caused by ultra large Von Willibrand \t\n\t\n\t\nfactor (Vwf)  molecules leading to aggregation and adhesion of \t\n\t\n\t\nplatelets within the microvasculature.\n\t\n➢\t Pregnancy is known to precipitate TTP. It is also associated with \t\n\t\n\t\nautoimmune conditions.\n\t\n➢\t Without appropriate treatment the mortality is high as 90%.\n\t\n➢\t This can recur in future pregnancies. \n\t\nDiagnostic criteria\n\t\n\t\no\t Fever \n\t\n\t\no\t Acute Renal impairment\n\t\n\t\no\t Central nervous system  involvement\n\t\n\t\no\t Thrombocytopaenia\n\t\n\t\no\t Microangiopathic haemolytic anaemia \n\t\n➢\t Blood picture is helpful in suspected TTP and with very high \t\t\n\t\n\t\nLDH levels helps confirm.",
  "It is also associated with \t\n\t\n\t\nautoimmune conditions.\n\t\n➢\t Without appropriate treatment the mortality is high as 90%.\n\t\n➢\t This can recur in future pregnancies. \n\t\nDiagnostic criteria\n\t\n\t\no\t Fever \n\t\n\t\no\t Acute Renal impairment\n\t\n\t\no\t Central nervous system  involvement\n\t\n\t\no\t Thrombocytopaenia\n\t\n\t\no\t Microangiopathic haemolytic anaemia \n\t\n➢\t Blood picture is helpful in suspected TTP and with very high \t\t\n\t\n\t\nLDH levels helps confirm.\n\n--- Page 114 ---\nNational Guideline for Maternal Care - Volume II\n100\n\t\n➢\t The pentad need not be fulfilled for diagnosis.\n\t\n➢\t A normal coagulation profile is seen.\n\t\n\t\nManagement \n\t\n➢\t If TTP is suspected, plasma exchange should be instituted as \t \t\n\t\n\t\nearly as possible. These patients should be transferred to a \t\n\t\n\t\n\t\ntertiary care unit urgently where facilities for plasma exchange \t\n\t\n\t\nand specialist care is available.\n\t\n\t\no\t If facilities for plasma exchange are not available, cryo poor \n\t\n\t\n\t\nplasma should be infused without delay.\n\t\n\t\no\t If cryo poor plasma is not available FFP can be given. \n\t\n➢\t Platelet transfusion is contraindicated in this situation\n\t\n➢\t Once platelet count rises to >50,000 consider LMWH for \t\n\t\n\t\n\t\nthromboprophylaxis as DVT risk is very high.\nReferences\n\t\n1.\t Scully M, Hunt BJ, Benjamin S, Liesner R, et al.Guideline on the \t\n\t\n\t\ndiagnosis and management of thrombotic \t \t\n\t\n\t\n\t\n\t\nthrombocytopaenicpurpura and other thrombotic \t\n\t\n\t\n\t\n\t\nmicroangiopathies. British journal of haematology 2012.\n\t\n2.\t Gernsheimer T,  James AH,  Stasi R How I treat \t\n\t\n\t\n\t\n\t\nthrombocytopenia in pregnancy.  Blood  2013;121(1) : 38-47.\n\t\n3.\t Clinical Practice Guide on Thrombocytopenia in Pregnancy.  \t\t\n\t\n\t\nAmerican society of haematology 2013.",
  "Blood  2013;121(1) : 38-47.\n\t\n3.\t Clinical Practice Guide on Thrombocytopenia in Pregnancy.  \t\t\n\t\n\t\nAmerican society of haematology 2013.\n\n--- Page 115 ---\nNational Guideline for Maternal Care - Volume II\n101\nAntiphospholipid Syndrome\n\n--- Page 116 ---\nNational Guideline for Maternal Care - Volume II\n102",
  "Blood  2013;121(1) : 38-47.\n\t\n3.\t Clinical Practice Guide on Thrombocytopenia in Pregnancy.  \t\t\n\t\n\t\nAmerican society of haematology 2013.\n\n--- Page 115 ---\nNational Guideline for Maternal Care - Volume II\n101\nAntiphospholipid Syndrome\n\n--- Page 116 ---\nNational Guideline for Maternal Care - Volume II\n102\n\n--- Page 117 ---\nNational Guideline for Maternal Care - Volume II\n103\n10. Antiphospholipid syndrome\n10.1. Introduction\n\t\n➢\t Antiphospholipid syndrome(APS)  is an acquired thrombophilic \t\n\t\n\t\nstate caused by autoantibodies. \n\t\n➢\t APS is diagnosed when 1 clinical and 1 laboratory criteria \t\n\t\n\t\n\t\n(confirmed on two occasions 12 weeks apart) is positive.\nBox 10.1:  Revised diagnostic criteria for APS\nClinical criteria\n1.\t Vascular thrombosis\n\t\n•\t One or more clinical episodes of arterial, venous or small \t\n\t\n\t\n\t\nvessel thrombosis in any tissue or organ\n2.\t Pregnancy related morbidity\n\t\n•\t One or more unexplained deaths of a morphologically \t\n\t\n\t\n\t\nnormal fetus at or beyond the 10th week of gestation OR\n\t\n•\t One or more premature births of a morphologically normal \t \t\n\t\n\t\nneonate before 34 weeks of gestation, due to eclampsia, severe \t\n\t\n\t\npreeclampsia or recognised features of placental insufficiency \t\t\n\t\n\t\nOR\n\t\n•\t Three or more unexplained consecutive spontaneous \t\n\t\n\t\n\t\nmiscarriages before 10th week gestation with maternal, \t\n\t\n\t\n\t\nanatomical, hormonal abnormalities and parental \t\n\t\n\t\n\t\n\t\nchromosomal causes excluded\nLaboratory criteria (A positive test should be repeated after a \nminimum interval of 12 weeks\n1.\t Positive lupus anticoagulant in plasma\n2.\t Anticardiolipin antibody of IgG/IgM present in medium/high \t\n\t\n\t\ntitres measured by a standardized ELISA test\n3.\t Anti β2 glycoprotein 1 of IgG and/or IgM in titre > 99th \t\t\n\t\n\t\npercentile measured by a standardized ELISA test",
  "Introduction\n\t\n➢\t Antiphospholipid syndrome(APS)  is an acquired thrombophilic \t\n\t\n\t\nstate caused by autoantibodies. \n\t\n➢\t APS is diagnosed when 1 clinical and 1 laboratory criteria \t\n\t\n\t\n\t\n(confirmed on two occasions 12 weeks apart) is positive.\nBox 10.1:  Revised diagnostic criteria for APS\nClinical criteria\n1.\t Vascular thrombosis\n\t\n•\t One or more clinical episodes of arterial, venous or small \t\n\t\n\t\n\t\nvessel thrombosis in any tissue or organ\n2.\t Pregnancy related morbidity\n\t\n•\t One or more unexplained deaths of a morphologically \t\n\t\n\t\n\t\nnormal fetus at or beyond the 10th week of gestation OR\n\t\n•\t One or more premature births of a morphologically normal \t \t\n\t\n\t\nneonate before 34 weeks of gestation, due to eclampsia, severe \t\n\t\n\t\npreeclampsia or recognised features of placental insufficiency \t\t\n\t\n\t\nOR\n\t\n•\t Three or more unexplained consecutive spontaneous \t\n\t\n\t\n\t\nmiscarriages before 10th week gestation with maternal, \t\n\t\n\t\n\t\nanatomical, hormonal abnormalities and parental \t\n\t\n\t\n\t\n\t\nchromosomal causes excluded\nLaboratory criteria (A positive test should be repeated after a \nminimum interval of 12 weeks\n1.\t Positive lupus anticoagulant in plasma\n2.\t Anticardiolipin antibody of IgG/IgM present in medium/high \t\n\t\n\t\ntitres measured by a standardized ELISA test\n3.\t Anti β2 glycoprotein 1 of IgG and/or IgM in titre > 99th \t\t\n\t\n\t\npercentile measured by a standardized ELISA test\n\n--- Page 118 ---\nNational Guideline for Maternal Care - Volume II\n104\n\t\n➢\t Time lapse between the clinical event and laboratory testing \t \t\n\t\n\t\nshould not be less than 12 weeks or more than 5 years.  \n\t\n➢\t Lupus anticoagulant (LA),\n\t\n\t\no\t  is a coagulation based test \n\t\n\t\no\t  should not be tested during pregnancy and until 6 weeks \t \t\n\t\n\t\n\t\npostpartum \n\t\n\t\no\t  testing should not be performed while on anticoagulants \n\t\n➢\t Anticardiolipin (aCL) antibody and anti-β2 glycoprotein 1 \n\t\n\t\ninhibitor (Anti- β2  GP1 ), \n\t\n\t\no\t  are immune mediated tests.\n\t\n\t\no\t  could be evaluated during pregnancy and while on \t\n\t\n\t\n\t\n\t\nanticoagulation. \n10.2. Management of APS during pregnancy\nPreconception \n\t\n➢\t A history of pulmonary embolism needs assessment for \t\n\t\n\t\n\t\npulmonary hypertension, which is a contraindication for \t\n\t\n\t\n\t\npregnancy. \n\t\n➢\t Secondary APS (APS associated with autoimmune connective \t\n\t\n\t\ntissue disease, commonly  SLE) should be excluded in view of \t\n\t\n\t\nadverse implications in pregnancy.\nAntenatal care\n\t\n➢\t Women already on anticoagulation should withhold warfarin \t\n\t\n\t\non \tconfirmation of pregnancy and be reviewed by a \t \t\n\t\n\t\n\t\nhaematologist/specialist physician for advise on suitable \t\n\t\n\t\n\t\nanticoagulation  during pregnancy. (The different  anticoagulation \t\n\t\n\t\nregimens are given in Table 6.2 below)\n\t\n\t\no\t Baseline full blood count and coagulation assays should be \t\n\t\n\t\n\t\nperformed prior to commencement of heparin.\n\t\n\t\no\t Low molecular weight heparin (LMWH), throughout \t\n\t\n\t\n\t\n\t\npregnancy is the preferred. Use of heparin in the first trimester \t\n\t\n\t\n\t\nwith warfarin substituted in the second trimester until \t\n\t\n\t\n\t\n\t\n36 weeks of gestation, is an alternative when there is \t\n\t\n\t\n\t\n\t\nconstraints in accessing LMWH.\n\t\n\t\no\t LMWH and Aspirin should be commenced in early pregnancy \t\n\t\n\t\n\t\nonce an intrauterine viable fetus is confirmed by ultrasound \t\n\t\n\t\n\t\nscan.",
  "(The different  anticoagulation \t\n\t\n\t\nregimens are given in Table 6.2 below)\n\t\n\t\no\t Baseline full blood count and coagulation assays should be \t\n\t\n\t\n\t\nperformed prior to commencement of heparin.\n\t\n\t\no\t Low molecular weight heparin (LMWH), throughout \t\n\t\n\t\n\t\n\t\npregnancy is the preferred. Use of heparin in the first trimester \t\n\t\n\t\n\t\nwith warfarin substituted in the second trimester until \t\n\t\n\t\n\t\n\t\n36 weeks of gestation, is an alternative when there is \t\n\t\n\t\n\t\n\t\nconstraints in accessing LMWH.\n\t\n\t\no\t LMWH and Aspirin should be commenced in early pregnancy \t\n\t\n\t\n\t\nonce an intrauterine viable fetus is confirmed by ultrasound \t\n\t\n\t\n\t\nscan.\n\n--- Page 119 ---\nNational Guideline for Maternal Care - Volume II\n105\n\t\n➢\t Graduated compression leg stockings are recommended for \t \t\n\t\n\t\nthose at risk of deep vein thrombosis in pregnancy and upto 2 \t\n\t\n\t\nweeks postpartum\t\nBox 10.2:   Preferred treatment in pregnancy in women with \nantiphosholipid syndrome \nClinical situations\naPL positive women with \nno history of thrombosis or \npregnancy loss\nAPS and previous recurrent \nfirst trimester miscarriage, \nsecond/third trimester \nloss, severe pre eclampsia, \nfetal growth restriction or \nplacental abruption\nAPS and previous venous \nthrombosis\nSuggested treatment\nAlthough there is no evidence of benefit, \nlow dose Aspirin is recommended during \nthe antenatal period; Consider 7 days \nof thromboprophylaxis with Heparin \npostpartum.\nStart low dose Aspirin and fixed dose \nof Heparin (Eg. Enoxaparin 40 mg \ndaily) early in pregnancy once a viable \nfetus is seen and continue until 7 days \npostpartum.\nAspirin and fixed dose heparin, which is \ndoubled at 16 – 20 weeks and continued \nuntil 6 weeks postpartum.\n\t\n➢\t Assessment of Anti X a levels is not routinely recommended in \t\n\t\n\t\npregnancy. It is indicated only in the following situations.\n\t\n\t\no\t In women at extremes of body weight (less than 50 Kg or more \t\n\t\n\t\n\t\nthan 90 Kg) on therapeutic dose of LMWH\n\t\n\t\no\t Renal impairment\n\t\n\t\no\t History of recurrent VTE while on anticoagulation\n\t\n\t\n\t\n-\t Assessment of anti X a levels is currently not available in \t\n\t\n\t\n\t\n\t\nSri Lanka. \nDelivery\n\t\n➢\t Women on warfarin should be changed over to LMWH at 36 \t\t\n\t\n\t\nweeks.\n \n\t\n➢\t Vaginal delivery is the preferred mode; Caesarean section should \t\n\t\n\t\nbe performed only for obstetric indications.\n\t\n➢\t Delivery should be planned.",
  "It is indicated only in the following situations.\n\t\n\t\no\t In women at extremes of body weight (less than 50 Kg or more \t\n\t\n\t\n\t\nthan 90 Kg) on therapeutic dose of LMWH\n\t\n\t\no\t Renal impairment\n\t\n\t\no\t History of recurrent VTE while on anticoagulation\n\t\n\t\n\t\n-\t Assessment of anti X a levels is currently not available in \t\n\t\n\t\n\t\n\t\nSri Lanka. \nDelivery\n\t\n➢\t Women on warfarin should be changed over to LMWH at 36 \t\t\n\t\n\t\nweeks.\n \n\t\n➢\t Vaginal delivery is the preferred mode; Caesarean section should \t\n\t\n\t\nbe performed only for obstetric indications.\n\t\n➢\t Delivery should be planned.\n\n--- Page 120 ---\nNational Guideline for Maternal Care - Volume II\n106\n\t\n\t\no\t  Prophylactic LMWH should be withheld 12 hours prior to  \t\n\t\n\t\n\t\ndelivery \n\t\n\t\no\t Therapeutic LMWH  should be withheld  24 hrs prior to \t \t\n\t\n\t\n\t\ndelivery\nPostpartum\n\t\n➢\t Therapeutic dose of LMWH should be continued for 6 weeks \t\t\n\t\n\t\npostpartum in the event of an acute thrombosis in pregnancy and \t\n\t\n\t\nin women who have a history of arterial or venous thrombosis \t\n\t\n\t\noutside pregnancy.\n\t\n➢\t  In women with obstetric manifestatations of APS, 7 days of \t \t\n\t\n\t\nprophylactic LMWH is adequate.\n\t\n➢\t Early mobilisation, adequate hydration and wearing of \t\n\t\n\t\n\t\ncompression stockings until 2 weeks postpartum should be \t \t\n\t\n\t\nadvised. \nContraception\n\t\n➢\t Oestrogen containing contraceptives and Depot rpovera are \t \t\n\t\n\t\ncontraindicated.\n\t\n\t\no\t  Copper IUD is acceptable.\nReferences\n1.\t  Keeling D,  Mackie I, Moore GW, Greer IA. Guidelines on the \t\n\t\n\t\ninvestigation and management of antiphospholipid syndrome.  \t \t\n\t\nBritish Journal of Haematology 2012; 157: 47–58.\n2.\t Jain V, Gordon C. Managing pregnancy in inflammatory \t\n\t\n\t\nrheumatological diseases. Arthritis Research & Therapy 2011; 13:206.\n3.\t Giannakopoulos B, Krilis SA. How I treat the antiphospholipid \t \t\n\t\nsyndrome. Blood  2009;114: 2020-30.\n4.\t Galapatthhy P. Management of obstetric antiphospholipid syndrome. \t\n\t\nSri Lanka prescriber 2013;21(3) 1-4.",
  "Management of obstetric antiphospholipid syndrome. \t\n\t\nSri Lanka prescriber 2013;21(3) 1-4.\n\n--- Page 121 ---\nNational Guideline for Maternal Care - Volume II\n107\nHIV\n\n--- Page 122 ---\nNational Guideline for Maternal Care - Volume II\n108",
  "Management of obstetric antiphospholipid syndrome. \t\n\t\nSri Lanka prescriber 2013;21(3) 1-4.\n\n--- Page 121 ---\nNational Guideline for Maternal Care - Volume II\n107\nHIV\n\n--- Page 122 ---\nNational Guideline for Maternal Care - Volume II\n108\n\n--- Page 123 ---\nNational Guideline for Maternal Care - Volume II\n109\n11. Prevention And Management Of HIV In \nPregnancy\n11.1. Primary prevention strategies  \nRaising awareness of antenatal mothers and their partners on HIV, \nAIDS and PMTCT\nInformation on sexually transmitted infections including HIV and \nsyphilis should be included in the general information given to pregnant \nwomen along with information about other infections and antenatal tests. \nThey should be informed:\n\t\n➢\t Perinatal transmission of HIV and adverse pregnancy outcomes.\n \n\t\n➢\t The potential benefits of knowing their HIV infection status \t \t\n\t\n\t\nby getting tested, both for their own health and to reduce the risk \t\n\t\n\t\nof perinatal transmission\n\t\n➢\t Mother to child transmission of HIV can be greatly reduced \t \t\n\t\n\t\nthrough antenatal and perinatal treatment with anti-retroviral \t\n\t\n\t\ndrugs, safer delivery and safer infant feeding practices.\n\t\n➢\t Information on facilities for screening \n\t\n➢\t Information on safe and responsible sexual behaviour and \t\n\t\n\t\n\t\npractices \n11.2. Screening for HIV during pregnancy\n•\t HIV screening is included in the basic investigation services  package \t\n\t\nduring pregnancy. Blood samples are collected at the first antenatal \t\n\t\nclinic visit and send to the allocated STD clinic for testing. All \t\n\t\n\t\nmothers are to be screened before 12 weeks of gestation for syphilis \t\n\t\nand HIV (preferably at the first visit).\n•\t Antenatal clinic services (MOH clinics and Hospital ANC clinics) \t\n\t\nhave to arrange collection of 5cc of blood in a vacutainer tube and \t\n\t\ntransport to the STD clinic for Syphilis and HIV testing. The mode \t\n\t\nof sample transport needs to be locally adopted, after discussions \t\n\t\nwith RDHS, MOMCH, MO/STD and MOHs.",
  "All \t\n\t\n\t\nmothers are to be screened before 12 weeks of gestation for syphilis \t\n\t\nand HIV (preferably at the first visit).\n•\t Antenatal clinic services (MOH clinics and Hospital ANC clinics) \t\n\t\nhave to arrange collection of 5cc of blood in a vacutainer tube and \t\n\t\ntransport to the STD clinic for Syphilis and HIV testing. The mode \t\n\t\nof sample transport needs to be locally adopted, after discussions \t\n\t\nwith RDHS, MOMCH, MO/STD and MOHs.\n\n--- Page 124 ---\nNational Guideline for Maternal Care - Volume II\n110\n•\t The first blood test is called a screening test. All positive \t\t\n\t\n\t\nscreening tests in Sri Lanka are tested with a confirmatory \t\n\t\n\t\ntest. If the confirmatory test is positive,  the woman is considered \t\n\t\nas infected with HIV.  \n•\t Assure the woman that her test result is confidential and will be \t \t\n\t\nshared only with her.\n•\t STD clinics will carry out HIV screening tests on the blood \t\n\t\n\t\nsamples received from ANC clinics and send reports to the \t\n\t\n\t\nrelevant officers. \n•\t The information on HIV positive reports will be informed to \t\n\t\n\t\nthe MO, MOH or VOG and measures should be taken to strictly \t\t\n\t\nmaintain the confidentiality of the information.\n•\t The screening test positive pregnant women need to be referred \t \t\n\t\nto the STD clinic for further management.\nTest result should be given only to the relevant person. Do not \nconvey any HIV test result (positive or negative) to any other person \nor over the phone.\n11.2. When the confirmatory test results is negative:\n\t\n•\t Counsel on the importance of staying negative by safer sex \t\n\t\n\t\n\t\nincluding use of condoms.\n11.3.\t When the screening test is positive:\n•\t All pregnant women with HIV should be provided appropriate \t \t\n\t\nservices including institutional care, without stigma and \t\t\n\t\n\t\ndiscrimination\n•\t Refer them to the STD clinic and further management will  be done \t\n\t\nby the STD clinic.\n•\t MOH/MO has to briefly counsel her before sending to STD clinic.\n•\t At the STD clinic she will be subjected to a detail one- to- one pre-\t\n\t\ntest counselling session prior to the confirmatory test.\n•\t Select a suitable place where the counselling session could be carried \t\n\t\nout maintaining privacy. \n•\t Discuss the HIV screening test results when the woman is alone or \t\n\t\nwith the person of her choice.\n•\t State test results in a neutral tone and explain that this is only a \t \t\n\t\nscreening test and now the confirmatory test has to be done.",
  "When the confirmatory test results is negative:\n\t\n•\t Counsel on the importance of staying negative by safer sex \t\n\t\n\t\n\t\nincluding use of condoms.\n11.3.\t When the screening test is positive:\n•\t All pregnant women with HIV should be provided appropriate \t \t\n\t\nservices including institutional care, without stigma and \t\t\n\t\n\t\ndiscrimination\n•\t Refer them to the STD clinic and further management will  be done \t\n\t\nby the STD clinic.\n•\t MOH/MO has to briefly counsel her before sending to STD clinic.\n•\t At the STD clinic she will be subjected to a detail one- to- one pre-\t\n\t\ntest counselling session prior to the confirmatory test.\n•\t Select a suitable place where the counselling session could be carried \t\n\t\nout maintaining privacy. \n•\t Discuss the HIV screening test results when the woman is alone or \t\n\t\nwith the person of her choice.\n•\t State test results in a neutral tone and explain that this is only a \t \t\n\t\nscreening test and now the confirmatory test has to be done.\n\n--- Page 125 ---\nNational Guideline for Maternal Care - Volume II\n111\n•\t Explain to the woman that screening test can be positive due to \t \t\n\t\nreasons other than HIV (false positive results)\n•\t Give the patient adequate time to express her emotions.\n•\t Explain to her that only if the confirmatory test is positive, there is \t\n\t\nevidence that she is infected with HIV.\n•\t For the confirmatory test, a second sample has to be taken and \t \t\n\t\nexplain this to her. Then refer her to the closest STD clinic. Inform \t\n\t\nher that if she is positive, there are several interventions including \t\n\t\nmedications, safe delivery and feeding practices which are able to \t\n\t\nminimize the risk of transmission of HIV to the baby. \n•\t Inform her that support and counselling is available if needed. \t\n\t\n\t\nIdentify what difficulties or problems the woman foresees and how to \t\n\t\ndeal with them \n•\t Encourage her to ask questions \n•\t Ask if she has any concerns.\nWhen the confirmatory test result is positive the woman will be \ncounselled and managed at the STD clinic. \nMaintain the confidentiality of HIV status\n•\t Assure the woman that the test result is confidential and will be \t\n\t\nshared only with her.\n•\t Ensure all records are confidential and kept locked away and \t\n\t\nonly health care workers taking care of her have access to the \t\n\t\nrecords.\n•\t Do not enter in the ANC record as HIV positive. Only the date, \t\n\t\nsample for HIV is taken and the date results informed are \t\n\t\nentered in the ANC record. \t\n11.4. Support to the HIV positive woman\nPregnant women with HIV infection will receive HIV care services  at the \nSTD clinic. As the pregnant woman with HIV has to be managed at a ter-\ntiary care centre  she will be referred to consultant obstetricians and other \nnecessary specialists. You may get involved in the management when you \nare requested to do so by the MOH.\n\t\n•\t Advise her to get admitted to the hospital as instructed.\n\t\n•\t Tell her to take ART medicine as instructed.\n\t\n•\t Discuss the infant feeding options\n\t\n•\t Counsel her on post partum family planning.",
  "As the pregnant woman with HIV has to be managed at a ter-\ntiary care centre  she will be referred to consultant obstetricians and other \nnecessary specialists. You may get involved in the management when you \nare requested to do so by the MOH.\n\t\n•\t Advise her to get admitted to the hospital as instructed.\n\t\n•\t Tell her to take ART medicine as instructed.\n\t\n•\t Discuss the infant feeding options\n\t\n•\t Counsel her on post partum family planning.\n\n--- Page 126 ---\nNational Guideline for Maternal Care - Volume II\n112\n11.5.\t Delivery care -\nAvoid suctioning the infants mouth and pharynx, which may cause trau-\nma to the mucus membranes thus promoting MTCT.\nClean the eyes of the baby with saline at delivery of the head.\nClamp the cord as soon as possible to minimise the maternal fetal micro-\ntransfusions.\nCover the umbilical cord with a swab when cutting to prevent blood \nspurting.\nTowel dry the baby.\nClean the baby’s skin thoroughly before any infusions or injections.\n11.6.\t Post partum care \n•\t Be aware of signs of infection following delivery. Like uninfected \t\t\n\t\nwomen, HIV positive women are also vulnerable to infection \t\n\t\n\t\nfollowing delivery and retained blood and placental tissues. \t\n\t\n\t\nPost partum uterine infection is a common and potentially life-\t \t\n\t\nthreatening condition, and early detection and effective treatment are \t\n\t\nimportant measures to prevent complications. \n•\t Monitor for secondary postpartum haemorrhage\n•\t Manage infected tears or episiotomy\n•\t Advise women to come back to the same institution if LSCS \t\n\t\n\t\nwound infection is observed \n•\t When they are discharged from the healthcare facility women \t\n\t\n\t\nshould be advised to return to the clinic or inform the PHM if they \t\n\t\nnotice symptoms such as fever, lower abdominal pain, burning with \t\n\t\nurination, foul smelling discharge, abnormal bleeding, \t \t\n\t\n\t\ncough, shortness of breath, calf pain (increasing on walking), \t\n\t\n\t\ndiarrhoea, unusual / abnormal behaviour\n•\t Give information on care of the perineum and breasts. \n•\t Instruct her about the safe disposal of lochia and blood-stained \t \t\n\t\nsanitary wear or other potential infectious materials. \n•\t If contraception has not been discussed before delivery it should be \t\n\t\ndone during the early postpartum period (see below). \n11.7.\t Counsel HIV positive woman on family planning\nAdvice and counsel on family planning during antenatal period and post \npartum visits.\nHIV positive women and men should be empowered to take informed \nchoices relating to their reproductive lives, free of coercion.",
  "•\t If contraception has not been discussed before delivery it should be \t\n\t\ndone during the early postpartum period (see below). \n11.7.\t Counsel HIV positive woman on family planning\nAdvice and counsel on family planning during antenatal period and post \npartum visits.\nHIV positive women and men should be empowered to take informed \nchoices relating to their reproductive lives, free of coercion.\n\n--- Page 127 ---\nNational Guideline for Maternal Care - Volume II\n113\nThe same contraceptive options which are available to uninfected \ncouples are available to HIV infected couples. Most methods are \nconsidered to be safe and effective for HIV infected women. However, \nas these women are on ART for lifetime, the decision on the suitable \nfamily planning method should be taken in consultation with the \nVenereologist.  \nProtection against both unintended pregnancy and STI is referred to \nas “dual protection”. Condoms are the mainstay of dual protection; \nCondoms should be used in combination with another family planning \nmethod. \nContraceptive counselling may be done by the MOH in consultation \nwith the STD clinic.\nDuring counselling for a contraceptive plan;\n•\t Encourage the woman to bring her husband for contraception coun\t\n\t\nselling as it is best that they both decide on a suitable method.\n•\t Discuss their thoughts about having more children.\n•\t Listen carefully to the couples’ views.  Correct any factual misunder\t\n\t\nstandings.\n•\t If the husband is HIV negative emphasize the importance of using \t\n\t\ncondoms to protect him from HIV infection.\n•\t If the husband is HIV positive, explain that although they both have \t\n\t\nHIV they could become infected with another strain of HIV and so it \t\n\t\nis sensible to use condoms to prevent pregnancy and infection.\n•\t Discuss where they could obtain condoms.  Demonstrate how to use \t\n\t\ncondoms correctly.  Provide them with condoms and an information \t\n\t\nleaflet.\n•\t If they have decided that they want no more children, discuss vasec\t\n\t\ntomy and female sterilization.\n•\t If they are uncertain about having more children in future, explain \t\n\t\nthat waiting at least 2 years after the last birth to become pregnant \t\n\t\nagain is healthiest for mother and child. Discuss the need of a \t\n\t\n\t\nplanned pregnancy. \n•\t Discuss other temporary methods of contraception.\n11.8.\t Infant feeding with HIV\nCounselling and support for safer infant feeding \nThe most appropriate infant feeding option for an HIV positive mother \ndepends on her individual circumstances, including her health status and",
  "Discuss the need of a \t\n\t\n\t\nplanned pregnancy. \n•\t Discuss other temporary methods of contraception.\n11.8.\t Infant feeding with HIV\nCounselling and support for safer infant feeding \nThe most appropriate infant feeding option for an HIV positive mother \ndepends on her individual circumstances, including her health status and\n\n--- Page 128 ---\nNational Guideline for Maternal Care - Volume II\n114\nthe local situation, the health services availability and the counselling and \nsupport she is likely to receive. \nThe expectant mother should be counselled by a counsellor who has \nadequate knowledge on the safer feeding options that are currently rec-\nommended. The counsellor considers the risk of infants acquiring HIV \nthrough breast milk with the higher risk of death from causes other \nthan HIV, in particular malnutrition and serious illness such as diarrhea \namong non-breastfed infants in identifying suitable options. Counselling \nis done by the Venereologist and Paediatrician to assist the mother in ar-\nriving at a decision.\nCurrently in Sri Lanka HIV positive pregnant mothers who decide on \nformula feeding are offered formula milk for the baby up to one year of \nage by an NGO.",
  "The counsellor considers the risk of infants acquiring HIV \nthrough breast milk with the higher risk of death from causes other \nthan HIV, in particular malnutrition and serious illness such as diarrhea \namong non-breastfed infants in identifying suitable options. Counselling \nis done by the Venereologist and Paediatrician to assist the mother in ar-\nriving at a decision.\nCurrently in Sri Lanka HIV positive pregnant mothers who decide on \nformula feeding are offered formula milk for the baby up to one year of \nage by an NGO.\n\n--- Page 129 ---\nNational Guideline for Maternal Care - Volume II\n115\nSyphilis\n\n--- Page 130 ---\nNational Guideline for Maternal Care - Volume II\n116",
  "The counsellor considers the risk of infants acquiring HIV \nthrough breast milk with the higher risk of death from causes other \nthan HIV, in particular malnutrition and serious illness such as diarrhea \namong non-breastfed infants in identifying suitable options. Counselling \nis done by the Venereologist and Paediatrician to assist the mother in ar-\nriving at a decision.\nCurrently in Sri Lanka HIV positive pregnant mothers who decide on \nformula feeding are offered formula milk for the baby up to one year of \nage by an NGO.\n\n--- Page 129 ---\nNational Guideline for Maternal Care - Volume II\n115\nSyphilis\n\n--- Page 130 ---\nNational Guideline for Maternal Care - Volume II\n116\n\n--- Page 131 ---\nNational Guideline for Maternal Care - Volume II\n117\n12. Prevention And Management Of Syphilis \nDuring Pregnancy\n12.1. Introduction\nIf a woman with untreated syphilis becomes pregnant, or a woman ac-\nquires syphilis during pregnancy, depending on the stage of syphilis, the \ninfection can be transmitted to the foetus causing adverse pregnancy out-\ncomes including congenital syphilis. Unlike many neonatal infections, \ncongenital syphilis (CS) can be effectively prevented, either through pre-\nvention of maternal infection or by detecting the infection early in preg-\nnancy and providing adequate treatment. \n12.2.\t Screening for syphilis\n•\t All mothers are to be screened before 12 weeks of gestation for Syphi\t\n\t\nlis (preferably at the first visit).\n•\t Antenatal clinic services (MOH clinics and Hospital ANC clinics) \t\n\t\nhave \t to arrange collection of 5cc of blood in a vacutainer tube and \t\n\t\ntransport to the STD clinic for Syphilis and HIV testing. The mode \t\n\t\nof sample transport needs to be locally adopted, after discussions \t\n\t\nwith \t RDHS, MOMCH, MO/STD and MOHs.\n•\t STD clinics have to carry out Syphilis screening tests on the blood \t\n\t\nsamples received from ANC clinics and send reports to the relevant \t\n\t\nofficers. \n12.3.\t Diagnosis of syphilis\n•\t All screening positive samples will be tested further using \t\n\t\n\t\ntreponemal tests as confirmatory tests.",
  "The mode \t\n\t\nof sample transport needs to be locally adopted, after discussions \t\n\t\nwith \t RDHS, MOMCH, MO/STD and MOHs.\n•\t STD clinics have to carry out Syphilis screening tests on the blood \t\n\t\nsamples received from ANC clinics and send reports to the relevant \t\n\t\nofficers. \n12.3.\t Diagnosis of syphilis\n•\t All screening positive samples will be tested further using \t\n\t\n\t\ntreponemal tests as confirmatory tests.\n\n--- Page 132 ---\nNational Guideline for Maternal Care - Volume II\n118\n•\t The information of reactive treponemal reports need to be informed \t\n\t\nto the MO, MOH or VOG and measures should be taken to strictly \t\n\t\nmaintain the confidentiality of the information.\n•\t The screening test positive pregnant women need to be referred to \t\n\t\nthe STD clinic for further management.\n•\t All pregnant women with Syphilis should be provided appropriate \t\n\t\nservices according to the national guidelines including institutional \t\n\t\ncare, without stigma or discrimination.\n12.4. Treatment of maternal syphilis\nTreatment for syphilis should be provided early in gestation before \nsignificant fetal damage take place. Treating the mother with penicillin \nduring the first and second trimester will prevent faetal wastage due to \nsyphilis such as still birth, intrauterine death, abortion   or birth of an \ninfected child.\n12.4.1. Treatment of primary, secondary and early latent syphilis\n\t\nOne or two doses of Benzathine benzyl penicillin 2.4 million units \t\n\t\nIM given depending on the stage after excluding allergy.\n12.4.2. Late latent syphilis:\n\t\nBenzathine benzyl penicillin 2.4 million units IM once a week for \t\n\t\nconsecutive 3 weeks. \n\t\nAdequate penicillin treatment will end infectivity within 24-48 hrs. \t\n\t\nPregnant women who miss any dose must repeat the full course of \t\n\t\ntherapy.",
  "Adequate penicillin treatment will end infectivity within 24-48 hrs. \t\n\t\nPregnant women who miss any dose must repeat the full course of \t\n\t\ntherapy.\n\n--- Page 133 ---\nNational Guideline for Maternal Care - Volume II\n119\n12.5. Follow up\nSerological (VDRL) follow-up should be at months 1, 2, 3, 6 and 12, then \n6 monthly until VDRL negative or for 2 years.\nA sustained fourfold or greater increase in the VDRL titre suggests re-\ninfection or treatment failure and needs to be retreated.  \nIt is not necessary to retreat pregnant mothers who have positive \ntreponemal test results and have documented evidence of adequate \ntherapy for diagnosis of syphilis previously, so long as there is no evidence \nof serologic or clinical evidence of re-infection or relapse. Babies born to \nsuch mothers do not require prophylactic penicillin therapy.\nIf doubts exist about the adequacy of previous therapy, re-treatment \nshould be commenced promptly.\n12.6. Allergy to penicillin\nErythromycin 500mg four times per day for 14 days in early syphilis and \nfor 28 days in late syphilis.(In pregnancy Doxycycline is contraindicated).\nWhen mother is treated with erythromycin baby should be considered as \na presumptive case of congenital syphilis treat adequately for congenital \nsyphilis.\n12.7. Treatment of partners\nSexual partners should be referred to the STD clinic for assessment. They \nwill be treated according to the stage of syphilis, if clinical evidence of \nsyphilis is present or if serology is positive.\n12.8.Diagnosis of congenital syphilis\nAll babies born to mothers with syphilis, should have\n\t\n•\t Clinical evaluation: if lesions (bulbous skin rash, nasal discharge,) \t\n\t\n\t\npresent carry out dark ground microscopy.",
  "Treatment of partners\nSexual partners should be referred to the STD clinic for assessment. They \nwill be treated according to the stage of syphilis, if clinical evidence of \nsyphilis is present or if serology is positive.\n12.8.Diagnosis of congenital syphilis\nAll babies born to mothers with syphilis, should have\n\t\n•\t Clinical evaluation: if lesions (bulbous skin rash, nasal discharge,) \t\n\t\n\t\npresent carry out dark ground microscopy.\n\n--- Page 134 ---\nNational Guideline for Maternal Care - Volume II\n120\n\t\n•\t Carry out serological tests\nVDRL and TPPA in both mother and baby. Syphilis specific EIA IgM an-\ntibody test of baby (If available)\nVDRL titre of the baby is more than fourfold that of the mother or positive \nsyphilis specific IgM need to be managed as congenital syphilis .Until 18 \nmonths it’s difficult to differentiate whether mother’s antibodies or babies \nantibodies would give positive VDRL and TPPA results. Placental transfer \nof maternal IgG can give positive results in baby even in the absence of \ncongenital syphilis.  If clinical signs are present with positive serological \ntests a bone survey should be considered and baby should be treated for \ncongenital syphilis \n12.9. Treatment of the baby\nIf the mother had been adequately treated before 36 weeks of POA the risk \nof mother to child transmission (MTCT) is low. However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)",
  "However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)\n\n--- Page 135 ---\nNational Guideline for Maternal Care - Volume II\n121\n\t\niii.\tWith a reactive syphilis specific IgM antibody test (If available)\n\t\niv.\t Born to mothers who were treated with penicillin <4 weeks before \t\n\t\n\t\ndelivery\n\t\nv.\t Born to mothers who did not complete the recommended course \t\n\t\n\t\nof penicillin during pregnancy\n\t\nvi.\t Born to mothers whose non treponemal high titre had not \t\n\t\n\t\n\t\ndropped four fold at the time of delivery\n\t\nvii.\tBorn to mothers who were treated with non penicillin regimens \t\n\t\n\t\n(Erythromycin) during pregnancy\n\t\nviii.Born to mothers whose treatment status is unknown or undocu\t\n\t\n\t\nmented",
  "However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)\n\n--- Page 135 ---\nNational Guideline for Maternal Care - Volume II\n121\n\t\niii.\tWith a reactive syphilis specific IgM antibody test (If available)\n\t\niv.\t Born to mothers who were treated with penicillin <4 weeks before \t\n\t\n\t\ndelivery\n\t\nv.\t Born to mothers who did not complete the recommended course \t\n\t\n\t\nof penicillin during pregnancy\n\t\nvi.\t Born to mothers whose non treponemal high titre had not \t\n\t\n\t\n\t\ndropped four fold at the time of delivery\n\t\nvii.\tBorn to mothers who were treated with non penicillin regimens \t\n\t\n\t\n(Erythromycin) during pregnancy\n\t\nviii.Born to mothers whose treatment status is unknown or undocu\t\n\t\n\t\nmented\n\n--- Page 136 ---\nNational Guideline for Maternal Care - Volume II\n122\n!\n&\n45*%*)*-&+*5&\"$%($\"%\"-&%(2%#$6&+*5&2.7'#-#2!\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n•\nX&,,$C#!A,&&(!E%&4!#>$!4&#>$%!!\n•\n\"$.(!#&!`\"MXZ6.$+%$)#!\"GQ!X,'.'C6#$)#'.5!'.)#'#@#'&.!\nZ&)'#'H$!OQN\\!\n•\nX&.E'%4!A;!GZZM!!\n•\nB.E&%4!#>$!!%$)@,#)!#&!%$,$H+.#!W*a!A;!#>$!W*6BX!\n•\na+%(!C&-;!&E!#>$!#$)#!%$)@,#)!)>&@,(!A$!)$.#!#&!#>$!\nW*a!\n•\nb>$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!\n#>$!%$,$H+.#!W*a!#>+#!'#!')!.&#!\";->',')!!\n•\nW*a!)>&@,(!'.E&%4!#>$!%$,$H+.#!ZaW!#&!#%+C$!#>$!\n4&#>$%!\n•\nW&#>$%!)>&@,(!A$!5'H$.!+!%$E$%%+,!.&#$!#&!H')'#!#>$!\n\"GQ!C,'.'C!!!!!!!8X&.E'($.#'+,'#;!)>&@,(!A$!4+'.#+'.$(<!!!\n189:;<44=&%(2%&5(23-%2&2'*3-,&\n>(&)*--()%(,&>.&%'(&5(-(?\"$%&\n*++#)(52&\n•\n=--&$(6\"%#?(&%(2%&5(23-%2&2'*3-,&>(&\n($%(5(,&#$&45(6$\"$).&5()*5,&@/ABC&\n=&D&E&F&G#%'&%'(&4H=&>.&4/!I&&\n•\nJ(5*K&$(6\"%#?(&L*%'(52&2'*3-,&>(&\n#$+*5L(,&%'\"%&%'(.&\"5(&+5((&*+&\n2.7'#-#2I&\n•\nEM4&5(23-%2&2'*3-,&>(&($%(5(,&>.&\n!H/&\"2&189:&5(\")%#?(&\"$,&<44=&\n$(6\"%#?(&@$*%&\"2&2.7'#-#2&7*2#%#?(F&\n!\n90\nQ$#+',$(!a')#&%;?!$F+4'.+#'&.!?)#+5'.5!&E!);->',')!\n10\n\"C%$$.'.5!E&%!&#>$%!\"GB)!\n:0\nG%$+#!+CC&%('.5!#&!#>$!)#+5$!&E!);->',')!8-%$E$%+A,;!I'#>!-$.'C',,'.<!\nU0\n\"C%$$.'.5!-+%#.$%)!+.(!$-'($4'&,&5'C+,!#%$+#4$.#!\n20\nX&@.)$,!&.!)+E$%!)$F!\ne0\nZ%&4&#$!aBO!#$)#'.5!\nJ0\nd&,,&I!@-!&E!#>$!4&#>$%!\nK0\nW+=$!+%%+.5$4$.#!E&%!4+.+5$4$.#!&E!A+A;!8Z%&->;,+F')!-$.'C',,'.!&%!BO!-$.'C',,'.!%$5'4$.<!\n_0\nc+A;!)>&@,(!A$!E&,,&I$(!@-!'.!#>$!\"GQ!C,'.'C!+#!:DeD!+.(!91!4&.#>)!\nN'($&%'(&L*%'(5&\"%%($,&%'(&J<8&)-#$#)&\n•\nC$,&2\"L7-(&2'*3-,&>(&%\"O($&&+*5&5()*$+#5L\"%#*$&\n•\nN'($&C$,&2\"L7-(&@%5(7*$(L\"-&%(2%F&7*2#%#?(&2%\"5%&\n%'(&L\"$\"6(L($%&",
  "However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)\n\n--- Page 135 ---\nNational Guideline for Maternal Care - Volume II\n121\n\t\niii.\tWith a reactive syphilis specific IgM antibody test (If available)\n\t\niv.\t Born to mothers who were treated with penicillin <4 weeks before \t\n\t\n\t\ndelivery\n\t\nv.\t Born to mothers who did not complete the recommended course \t\n\t\n\t\nof penicillin during pregnancy\n\t\nvi.\t Born to mothers whose non treponemal high titre had not \t\n\t\n\t\n\t\ndropped four fold at the time of delivery\n\t\nvii.\tBorn to mothers who were treated with non penicillin regimens \t\n\t\n\t\n(Erythromycin) during pregnancy\n\t\nviii.Born to mothers whose treatment status is unknown or undocu\t\n\t\n\t\nmented\n\n--- Page 136 ---\nNational Guideline for Maternal Care - Volume II\n122\n!\n&\n45*%*)*-&+*5&\"$%($\"%\"-&%(2%#$6&+*5&2.7'#-#2!\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n•\nX&,,$C#!A,&&(!E%&4!#>$!4&#>$%!!\n•\n\"$.(!#&!`\"MXZ6.$+%$)#!\"GQ!X,'.'C6#$)#'.5!'.)#'#@#'&.!\nZ&)'#'H$!OQN\\!\n•\nX&.E'%4!A;!GZZM!!\n•\nB.E&%4!#>$!!%$)@,#)!#&!%$,$H+.#!W*a!A;!#>$!W*6BX!\n•\na+%(!C&-;!&E!#>$!#$)#!%$)@,#)!)>&@,(!A$!)$.#!#&!#>$!\nW*a!\n•\nb>$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!\n#>$!%$,$H+.#!W*a!#>+#!'#!')!.&#!\";->',')!!\n•\nW*a!)>&@,(!'.E&%4!#>$!%$,$H+.#!ZaW!#&!#%+C$!#>$!\n4&#>$%!\n•\nW&#>$%!)>&@,(!A$!5'H$.!+!%$E$%%+,!.&#$!#&!H')'#!#>$!\n\"GQ!C,'.'C!!!!!!!8X&.E'($.#'+,'#;!)>&@,(!A$!4+'.#+'.$(<!!!\n189:;<44=&%(2%&5(23-%2&2'*3-,&\n>(&)*--()%(,&>.&%'(&5(-(?\"$%&\n*++#)(52&\n•\n=--&$(6\"%#?(&%(2%&5(23-%2&2'*3-,&>(&\n($%(5(,&#$&45(6$\"$).&5()*5,&@/ABC&\n=&D&E&F&G#%'&%'(&4H=&>.&4/!I&&\n•\nJ(5*K&$(6\"%#?(&L*%'(52&2'*3-,&>(&\n#$+*5L(,&%'\"%&%'(.&\"5(&+5((&*+&\n2.7'#-#2I&\n•\nEM4&5(23-%2&2'*3-,&>(&($%(5(,&>.&\n!H/&\"2&189:&5(\")%#?(&\"$,&<44=&\n$(6\"%#?(&@$*%&\"2&2.7'#-#2&7*2#%#?(F&\n!\n90\nQ$#+',$(!a')#&%;?!$F+4'.+#'&.!?)#+5'.5!&E!);->',')!\n10\n\"C%$$.'.5!E&%!&#>$%!\"GB)!\n:0\nG%$+#!+CC&%('.5!#&!#>$!)#+5$!&E!);->',')!8-%$E$%+A,;!I'#>!-$.'C',,'.<!\nU0\n\"C%$$.'.5!-+%#.$%)!+.(!$-'($4'&,&5'C+,!#%$+#4$.#!\n20\nX&@.)$,!&.!)+E$%!)$F!\ne0\nZ%&4&#$!aBO!#$)#'.5!\nJ0\nd&,,&I!@-!&E!#>$!4&#>$%!\nK0\nW+=$!+%%+.5$4$.#!E&%!4+.+5$4$.#!&E!A+A;!8Z%&->;,+F')!-$.'C',,'.!&%!BO!-$.'C',,'.!%$5'4$.<!\n_0\nc+A;!)>&@,(!A$!E&,,&I$(!@-!'.!#>$!\"GQ!C,'.'C!+#!:DeD!+.(!91!4&.#>)!\nN'($&%'(&L*%'(5&\"%%($,&%'(&J<8&)-#$#)&\n•\nC$,&2\"L7-(&2'*3-,&>(&%\"O($&&+*5&5()*$+#5L\"%#*$&\n•\nN'($&C$,&2\"L7-(&@%5(7*$(L\"-&%(2%F&7*2#%#?(&2%\"5%&\n%'(&L\"$\"6(L($%&\n\n--- Page 137 ---\nNational Guideline for Maternal Care - Volume II\n123\nMalaria",
  "However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)\n\n--- Page 135 ---\nNational Guideline for Maternal Care - Volume II\n121\n\t\niii.\tWith a reactive syphilis specific IgM antibody test (If available)\n\t\niv.\t Born to mothers who were treated with penicillin <4 weeks before \t\n\t\n\t\ndelivery\n\t\nv.\t Born to mothers who did not complete the recommended course \t\n\t\n\t\nof penicillin during pregnancy\n\t\nvi.\t Born to mothers whose non treponemal high titre had not \t\n\t\n\t\n\t\ndropped four fold at the time of delivery\n\t\nvii.\tBorn to mothers who were treated with non penicillin regimens \t\n\t\n\t\n(Erythromycin) during pregnancy\n\t\nviii.Born to mothers whose treatment status is unknown or undocu\t\n\t\n\t\nmented\n\n--- Page 136 ---\nNational Guideline for Maternal Care - Volume II\n122\n!\n&\n45*%*)*-&+*5&\"$%($\"%\"-&%(2%#$6&+*5&2.7'#-#2!\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n•\nX&,,$C#!A,&&(!E%&4!#>$!4&#>$%!!\n•\n\"$.(!#&!`\"MXZ6.$+%$)#!\"GQ!X,'.'C6#$)#'.5!'.)#'#@#'&.!\nZ&)'#'H$!OQN\\!\n•\nX&.E'%4!A;!GZZM!!\n•\nB.E&%4!#>$!!%$)@,#)!#&!%$,$H+.#!W*a!A;!#>$!W*6BX!\n•\na+%(!C&-;!&E!#>$!#$)#!%$)@,#)!)>&@,(!A$!)$.#!#&!#>$!\nW*a!\n•\nb>$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!\n#>$!%$,$H+.#!W*a!#>+#!'#!')!.&#!\";->',')!!\n•\nW*a!)>&@,(!'.E&%4!#>$!%$,$H+.#!ZaW!#&!#%+C$!#>$!\n4&#>$%!\n•\nW&#>$%!)>&@,(!A$!5'H$.!+!%$E$%%+,!.&#$!#&!H')'#!#>$!\n\"GQ!C,'.'C!!!!!!!8X&.E'($.#'+,'#;!)>&@,(!A$!4+'.#+'.$(<!!!\n189:;<44=&%(2%&5(23-%2&2'*3-,&\n>(&)*--()%(,&>.&%'(&5(-(?\"$%&\n*++#)(52&\n•\n=--&$(6\"%#?(&%(2%&5(23-%2&2'*3-,&>(&\n($%(5(,&#$&45(6$\"$).&5()*5,&@/ABC&\n=&D&E&F&G#%'&%'(&4H=&>.&4/!I&&\n•\nJ(5*K&$(6\"%#?(&L*%'(52&2'*3-,&>(&\n#$+*5L(,&%'\"%&%'(.&\"5(&+5((&*+&\n2.7'#-#2I&\n•\nEM4&5(23-%2&2'*3-,&>(&($%(5(,&>.&\n!H/&\"2&189:&5(\")%#?(&\"$,&<44=&\n$(6\"%#?(&@$*%&\"2&2.7'#-#2&7*2#%#?(F&\n!\n90\nQ$#+',$(!a')#&%;?!$F+4'.+#'&.!?)#+5'.5!&E!);->',')!\n10\n\"C%$$.'.5!E&%!&#>$%!\"GB)!\n:0\nG%$+#!+CC&%('.5!#&!#>$!)#+5$!&E!);->',')!8-%$E$%+A,;!I'#>!-$.'C',,'.<!\nU0\n\"C%$$.'.5!-+%#.$%)!+.(!$-'($4'&,&5'C+,!#%$+#4$.#!\n20\nX&@.)$,!&.!)+E$%!)$F!\ne0\nZ%&4&#$!aBO!#$)#'.5!\nJ0\nd&,,&I!@-!&E!#>$!4&#>$%!\nK0\nW+=$!+%%+.5$4$.#!E&%!4+.+5$4$.#!&E!A+A;!8Z%&->;,+F')!-$.'C',,'.!&%!BO!-$.'C',,'.!%$5'4$.<!\n_0\nc+A;!)>&@,(!A$!E&,,&I$(!@-!'.!#>$!\"GQ!C,'.'C!+#!:DeD!+.(!91!4&.#>)!\nN'($&%'(&L*%'(5&\"%%($,&%'(&J<8&)-#$#)&\n•\nC$,&2\"L7-(&2'*3-,&>(&%\"O($&&+*5&5()*$+#5L\"%#*$&\n•\nN'($&C$,&2\"L7-(&@%5(7*$(L\"-&%(2%F&7*2#%#?(&2%\"5%&\n%'(&L\"$\"6(L($%&\n\n--- Page 137 ---\nNational Guideline for Maternal Care - Volume II\n123\nMalaria\n\n--- Page 138 ---\nNational Guideline for Maternal Care - Volume II\n124",
  "However, irrespective of \nmother’s treatment all babies born to mothers with positive treponemal \ntests are given prophylactic penicillin. \nBaby is given one dose of Benzathine penicillin 50,000IU/Kg of Body \nWeight, as prophylactic treatment.\nIf congenital syphilis could not be excluded, baby need to be treated \nwith crystalline penicillin 50,000IU/Kg/day twice day for 7 days and \nthree times per day for further 3 days to complete the total of 10 days \ntreatment\nThis should be given to:\n1.\t All symptomatic babies\n2.\t All asymptomatic babies\n\t\ni.\t Whose VDRL titre is a 4 fold higher than that of the mother at \t\n\t\n\t\ndelivery\n\t\nii.\t Rising non-treponemal titre (VDRL)\n\n--- Page 135 ---\nNational Guideline for Maternal Care - Volume II\n121\n\t\niii.\tWith a reactive syphilis specific IgM antibody test (If available)\n\t\niv.\t Born to mothers who were treated with penicillin <4 weeks before \t\n\t\n\t\ndelivery\n\t\nv.\t Born to mothers who did not complete the recommended course \t\n\t\n\t\nof penicillin during pregnancy\n\t\nvi.\t Born to mothers whose non treponemal high titre had not \t\n\t\n\t\n\t\ndropped four fold at the time of delivery\n\t\nvii.\tBorn to mothers who were treated with non penicillin regimens \t\n\t\n\t\n(Erythromycin) during pregnancy\n\t\nviii.Born to mothers whose treatment status is unknown or undocu\t\n\t\n\t\nmented\n\n--- Page 136 ---\nNational Guideline for Maternal Care - Volume II\n122\n!\n&\n45*%*)*-&+*5&\"$%($\"%\"-&%(2%#$6&+*5&2.7'#-#2!\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n•\nX&,,$C#!A,&&(!E%&4!#>$!4&#>$%!!\n•\n\"$.(!#&!`\"MXZ6.$+%$)#!\"GQ!X,'.'C6#$)#'.5!'.)#'#@#'&.!\nZ&)'#'H$!OQN\\!\n•\nX&.E'%4!A;!GZZM!!\n•\nB.E&%4!#>$!!%$)@,#)!#&!%$,$H+.#!W*a!A;!#>$!W*6BX!\n•\na+%(!C&-;!&E!#>$!#$)#!%$)@,#)!)>&@,(!A$!)$.#!#&!#>$!\nW*a!\n•\nb>$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!\n#>$!%$,$H+.#!W*a!#>+#!'#!')!.&#!\";->',')!!\n•\nW*a!)>&@,(!'.E&%4!#>$!%$,$H+.#!ZaW!#&!#%+C$!#>$!\n4&#>$%!\n•\nW&#>$%!)>&@,(!A$!5'H$.!+!%$E$%%+,!.&#$!#&!H')'#!#>$!\n\"GQ!C,'.'C!!!!!!!8X&.E'($.#'+,'#;!)>&@,(!A$!4+'.#+'.$(<!!!\n189:;<44=&%(2%&5(23-%2&2'*3-,&\n>(&)*--()%(,&>.&%'(&5(-(?\"$%&\n*++#)(52&\n•\n=--&$(6\"%#?(&%(2%&5(23-%2&2'*3-,&>(&\n($%(5(,&#$&45(6$\"$).&5()*5,&@/ABC&\n=&D&E&F&G#%'&%'(&4H=&>.&4/!I&&\n•\nJ(5*K&$(6\"%#?(&L*%'(52&2'*3-,&>(&\n#$+*5L(,&%'\"%&%'(.&\"5(&+5((&*+&\n2.7'#-#2I&\n•\nEM4&5(23-%2&2'*3-,&>(&($%(5(,&>.&\n!H/&\"2&189:&5(\")%#?(&\"$,&<44=&\n$(6\"%#?(&@$*%&\"2&2.7'#-#2&7*2#%#?(F&\n!\n90\nQ$#+',$(!a')#&%;?!$F+4'.+#'&.!?)#+5'.5!&E!);->',')!\n10\n\"C%$$.'.5!E&%!&#>$%!\"GB)!\n:0\nG%$+#!+CC&%('.5!#&!#>$!)#+5$!&E!);->',')!8-%$E$%+A,;!I'#>!-$.'C',,'.<!\nU0\n\"C%$$.'.5!-+%#.$%)!+.(!$-'($4'&,&5'C+,!#%$+#4$.#!\n20\nX&@.)$,!&.!)+E$%!)$F!\ne0\nZ%&4&#$!aBO!#$)#'.5!\nJ0\nd&,,&I!@-!&E!#>$!4&#>$%!\nK0\nW+=$!+%%+.5$4$.#!E&%!4+.+5$4$.#!&E!A+A;!8Z%&->;,+F')!-$.'C',,'.!&%!BO!-$.'C',,'.!%$5'4$.<!\n_0\nc+A;!)>&@,(!A$!E&,,&I$(!@-!'.!#>$!\"GQ!C,'.'C!+#!:DeD!+.(!91!4&.#>)!\nN'($&%'(&L*%'(5&\"%%($,&%'(&J<8&)-#$#)&\n•\nC$,&2\"L7-(&2'*3-,&>(&%\"O($&&+*5&5()*$+#5L\"%#*$&\n•\nN'($&C$,&2\"L7-(&@%5(7*$(L\"-&%(2%F&7*2#%#?(&2%\"5%&\n%'(&L\"$\"6(L($%&\n\n--- Page 137 ---\nNational Guideline for Maternal Care - Volume II\n123\nMalaria\n\n--- Page 138 ---\nNational Guideline for Maternal Care - Volume II\n124\n\n--- Page 139 ---\nNational Guideline for Maternal Care - Volume II\n125\n13. Guidelines on malaria chemotherapy and \nmanagement of patients with malaria during \npregnancy\n13.1. Introduction\nWith no indigenous malaria cases being reported since October 2012, \nSri Lanka is currently in the malaria elimination and prevention of re-\nintroduction phase. With progressively increasing incidence of imported \nmalaria cases in recent years, early diagnosis and treatment of such cases \nhave become the highest priority for prevention of re-introduction. Most \nof these infections have been acquired in India, Pakistan, South East \nAsian and African countries.\nCurrently, a low level of clinical suspicion in the backdrop of a very low \ndisease burden has led to a significant delay in diagnosis of malaria cases. \nAs a result, there were several patients who presented to the health care \ninstitutions with uncomplicated fever progressing to develop severe \nmalaria while being at the hospital.\n13.2. Patients likely to have malaria\nMalaria should be suspected in:\n1.\t any febrile individual (including foreign nationals):\n\t\n−\t with unexplained fever and a history of recent travel (within1 \t\n\t\n\t\nyear) to a malaria endemic country (esp. India, Pakistan, Haiti \t\n\t\n\t\nand African countries). Refer Annex II for a list of countries \t \t\n\t\n\t\nwhere malaria transmission occurs).\n\t\n−\t belonging to high risk groups e.g. businessmen, pilgrims \t\n\t\n\t\n\t\nand seamen returning from malaria endemic countries, re-settled \t\n\t\n\t\ncommunities, skilled and unskilled foreign workers, illegal/\t\n\t\n\t\n\t\nirregular migrants, refugees, asylum seekers, security forces \t \t\n\t\n\t\nreturning from peace keeping missions etc.\n\t\n−\t with a history of malaria infection within the past 3 years\n\t\n−\t with fever of unknown origin\n2.\t any individual presenting with clinical features of severe malaria \t\t\n\t\n(refer Annex I for clinical features of severe malaria)\n3.\t Patients with anaemia of unknown cause \n4.\t Patients with hepatomegaly and/or splenomegaly",
  "Refer Annex II for a list of countries \t \t\n\t\n\t\nwhere malaria transmission occurs).\n\t\n−\t belonging to high risk groups e.g. businessmen, pilgrims \t\n\t\n\t\n\t\nand seamen returning from malaria endemic countries, re-settled \t\n\t\n\t\ncommunities, skilled and unskilled foreign workers, illegal/\t\n\t\n\t\n\t\nirregular migrants, refugees, asylum seekers, security forces \t \t\n\t\n\t\nreturning from peace keeping missions etc.\n\t\n−\t with a history of malaria infection within the past 3 years\n\t\n−\t with fever of unknown origin\n2.\t any individual presenting with clinical features of severe malaria \t\t\n\t\n(refer Annex I for clinical features of severe malaria)\n3.\t Patients with anaemia of unknown cause \n4.\t Patients with hepatomegaly and/or splenomegaly\n\n--- Page 140 ---\nNational Guideline for Maternal Care - Volume II\n126\n5.\t Recipients of blood or blood products who develop fever within 3 \t\n\t\nmonths of transfusion \nPlease note: \n\t\n−\t Malaria can present with non-specific symptoms even if there is \t\n\t\n\t\nno fever.\n\t\n−\t Thrombocytopaenia has been a frequent finding among patients \t\n\t\n\t\nwith malaria reported in the recent years, yet a diagnosis of ma\t\n\t\n\t\nlaria has not been considered as a result of them being misdi\t \t\n\t\n\t\nagnosed as having dengue. This had led to a delayed malaria diag\t\n\t\n\t\nnosis resulting in adverse sequelae. \n13.3. Notification of malaria patients\nAny patient strongly suspected of having malaria should immediately be \nnotified via telephone to the Regional Malaria Officer (RMO) and Anti \nMalaria Campaign Headquarters. In addition, it should be notified to the \nMedical Officer of Health (MOH) of the area where the patient resides \nfollowing the standard notification procedure (Form H544).\nThe AMC will ensure:\n\t\n−\t confirmation of diagnosis by species\n\t\n−\t provision of appropriate anti-malarial drugs\n\t\n−\t guidance on treatment\n\t\n−\t initiation of rapid response to search for additional cases and \t\t\n\t\n\t\nprevent onward transmission of the disease\n\t\n−\t follow up of the patient in the field in order to achieve radical cure.\nThe contact numbers of the AMC Headquarters and the RMOs are given \nin Annex III.\n13.4.Diagnosis of malaria\n•\t In every suspected case of malaria, laboratory confirmation by \t\n\t\n\t\nmicroscopic examination of blood smears and/or Rapid \t\t\n\t\n\t\nDiagnostic Test (RDT) is mandatory prior to initiation of anti-\t\n\t\n\t\nmalarial treatment. Treating malaria based on clinical suspicion \t \t\n\t\nwithout laboratory confirmation should be avoided. \n•\t If there is a strong clinical suspicion of malaria, and the blood \t\n\t\n\t\nsmears/RDT are negative at the time of initial testing, a minimum \t\n\t\nof three consecutive blood smears/RDT should be done prior to \t \t\n\t\nconcluding that the patient is negative for malaria.",
  "Treating malaria based on clinical suspicion \t \t\n\t\nwithout laboratory confirmation should be avoided. \n•\t If there is a strong clinical suspicion of malaria, and the blood \t\n\t\n\t\nsmears/RDT are negative at the time of initial testing, a minimum \t\n\t\nof three consecutive blood smears/RDT should be done prior to \t \t\n\t\nconcluding that the patient is negative for malaria.\n\n--- Page 141 ---\nNational Guideline for Maternal Care - Volume II\n127\n•\t Blood should be collected for investigations prior to the administration \nof anti-malarials:\n−\t In all confirmed malaria patients\n−\t If anti-malarial treatment is required as a life saving measure based on \nclinical suspicion without laboratory confirmation of malaria \n•\t Blood should be collected in the following manner:\n−\t 2ml of venous blood collected to an EDTA bottle and refrigerated \nuntil transported to the AMC headquarters.\n−\t Dried blood spots on filter paper: drop the blood (approx. 1.5 ml) \nin the syringe on the filter paper labelled with the patient’s name; four \nblood spots with 3 drops per each spot. Air dry for one hour at room \ntemperature. Place each filter paper in an individual envelope. Store at \nroom temperature until transported to the AMC Headquarters.\n−\t (please contact AMC Headquarters for details).\n13.5. Monitoring during treatment and follow up of patients\n•\t To ensure an effective parasitological response to the anti-malarial \ndrugs, a blood smear should be obtained daily and examined over the \nthree day that the patient is admitted. If parasitaemia persists beyond \n3 days blood smears should be taken daily until parasitaemia clears. In \nsevere malaria cases, blood smears have to be taken at a higher frequency. \n•\t Thereafter the patient will be followed up to one year (frequency and \nduration will depend on the species) by the AMC field staff. \n13.6. Treatment of patients with malaria \nSpecific treatment and management of malaria will depend on the para-\nsite species causing infection, severity of disease and the biological factors \nof the patient.\n•\t Objectives of treatment:  \n−\t Primary objective of treatment: to ensure rapid and complete elimi-\nnation of the Plasmodium parasite from the patient’s blood in order to \nprevent progression of uncomplicated malaria to severe disease or death.\n−\t From a public health perspective: to reduce transmission of the in-\nfection to others by reducing the infectious reservoir and to prevent the \nemergence and spread of resistance to anti-malarial medicines. \n•\t All confirmed malaria patients should be admitted to a medical insti-\ntution for a minimum of 3 days to be managed under supervision. \n•\t If facilities are available, a test for G6PD deficiency should be carried \nout prior to administration of primaquine.",
  "•\t All confirmed malaria patients should be admitted to a medical insti-\ntution for a minimum of 3 days to be managed under supervision. \n•\t If facilities are available, a test for G6PD deficiency should be carried \nout prior to administration of primaquine.\n\n--- Page 142 ---\nNational Guideline for Maternal Care - Volume II\n128\n13.6.1.\t Mono-infection with Plasmodium vivax\n•\t For radical cure of P. vivax malaria, the patient should be treated with \t\n\t\nchloroquine and primaquine.\n•\t Chloroquine: base at a total dose of 25 mg/kg body weight (bw) over \t\n\t\nthree days. This dose should be divided as 10mg/kg on the first and \t\n\t\nsecond day followed by 5 mg/kg bw on the third day.\n•\t Primaquine: the adult dose is 15mg base (0.25mg/kg per day) \t\n\t\n\t\nfor fourteen days unless it is contraindicated. The administration of \t\n\t\nprimaquine is not recommended during pregnancy and \t\t\n\t\n\t\nlactation, infancy and in severe G6PD deficiency (<10% of residual \t\n\t\nenzyme activity). \n•\t In patient with mild to moderate G6PD deficiency (10-60% of \t\n\t\n\t\nresidual enzyme activity) primaquine can be administered in a \t \t\n\t\ndosage of 0.75 mg/kg weekly for 8 weeks under specialized \t\n\t\n\t\nsupervision.\n13.6.2.\t Uncomplicated mono-infection with Plasmodium falciparum\n•\t For radical cure of falciparum malaria, the patient should be treated \nwith ACT and primaquine.\n•\t Artemisinin based combination Therapy (ACT): Weight appropriate \ndose. Coartem® (containing 20mg of artemether and 120mg of \nlumefantrine) is the ACT used in Sri Lanka.\n•\t Artemisinin and its derivatives should never be used as monotherapy. \n•\t Coartem® tablets are packed in four colour coded blister packs. The \nrecommended treatment is 6-dose regimen over a three day period \naccording to the weight of the patient as indicated in table 1.\nTable 13.1. Number of ACT (Coartem®) tablets administered based on \nweight of patient\nInterval \nbetween doses\n0 Hours\n8 Hours\n24 Hours\n36 Hours\n48 Hours\n60 Hours\nTotal\n5 -14 kg\n(Yellow \nPack)\n1\n1\n1\n1\n1\n1\n6\n15 -to 24 kg\n(Blue Pack)\n2\n2\n2\n2\n2\n2\n12\n25- 34 kg\n(Orange pack)\n3\n3\n3\n3\n3\n3\n18\n>35 kg\n(Green pack)\n4\n4\n4\n4\n4\n4\n24",
  "The \nrecommended treatment is 6-dose regimen over a three day period \naccording to the weight of the patient as indicated in table 1.\nTable 13.1. Number of ACT (Coartem®) tablets administered based on \nweight of patient\nInterval \nbetween doses\n0 Hours\n8 Hours\n24 Hours\n36 Hours\n48 Hours\n60 Hours\nTotal\n5 -14 kg\n(Yellow \nPack)\n1\n1\n1\n1\n1\n1\n6\n15 -to 24 kg\n(Blue Pack)\n2\n2\n2\n2\n2\n2\n12\n25- 34 kg\n(Orange pack)\n3\n3\n3\n3\n3\n3\n18\n>35 kg\n(Green pack)\n4\n4\n4\n4\n4\n4\n24\n\n--- Page 143 ---\nNational Guideline for Maternal Care - Volume II\n129\nACT should be taken immediately after a meal or drink containing at \nleast 1.2g of fat (e.g. a glass of milk) since its absorption is enhanced by \nco-administration with fat. As low blood levels of ACT with treatment \nfailure could potentially result from inadequate fat intake, it is essential \nthat patients or carers are informed of the need to take Coartem® with \nmilk or fat containing food, particularly on the second or third day of \ntreatment.\n \n•\t Primaquine: A weight appropriate single dose of primaquine (0.75mg/\nkg bw) should be administered unless contraindicated, on day 3 of \ntreatment or prior to discharge from hospital to destroy gametocytes. \nUncomplicated P. falciparum malaria in infants and young children\n•\t ACT (Coartem®) is the first line treatment in infants and young \t \t\n\t\nchildren. \n•\t Primaquine should be avoided in children less than 1 year of age.\n•\t An acutely ill child requires careful clinical monitoring as she/he may \t\n\t\ndeteriorate rapidly.\n•\t Please contact Anti Malaria Campaign Headquarters for further \t\t\n\t\nguidance.\nUncomplicated P. falciparum malaria in Pregnancy\n•\t 1st Trimester: Uncomplicated falciparum malaria is treated with oral \t\n\t\nquinine sulfate 10mg/kg body weight at 8 hourly intervals plus clinda\t\n\t\nmycin 10 mg/kg bw twice a day for 7 days. If clindamycin in unavail\t\n\t\nable, \tquinine monotherapy may be given.\n•\t 2nd and 3rd Trimester: Uncomplicated falciparum malaria is treated \t\n\t\nwith Coartem®. \n•\t Primaquine should not be administered during pregnancy.\nUncomplicated P. falciparum malaria during Lactation\n•\t Lactating women can receive the recommended dose of Coartem®.\n•\t Primaquine should not be given during lactation.\n13.6.3.\t Uncomplicated mixed infections with P. falciparum and \nP.vivax\n•\t Artemisinin based combination therapy: Coartem® is given at a \t \t\n\t\nweight appropriate dose.\n•\t Primaquine base: at a dose of 0.25mg/kg bw per day for fourteen \t\t\n\t\ndays \tunless it is contraindicated.",
  "falciparum malaria during Lactation\n•\t Lactating women can receive the recommended dose of Coartem®.\n•\t Primaquine should not be given during lactation.\n13.6.3.\t Uncomplicated mixed infections with P. falciparum and \nP.vivax\n•\t Artemisinin based combination therapy: Coartem® is given at a \t \t\n\t\nweight appropriate dose.\n•\t Primaquine base: at a dose of 0.25mg/kg bw per day for fourteen \t\t\n\t\ndays \tunless it is contraindicated.\n\n--- Page 144 ---\nNational Guideline for Maternal Care - Volume II\n130\n13.6.4.\t Severe P. falciparum malaria\nSevere malaria is a medical emergency. After rapid clinical assessment \nand confirmation of the diagnosis, full doses of parenteral antimalarial \ntreatment should be started without delay. Patients with severe malaria \nrequire intensive nursing care, preferably in an intensive care unit where \npossible. Clinical observations should be made as frequently as possible. \nThese should include monitoring of vital signs, coma score, and urine \noutput. Blood glucose should also be monitored every four hours, if pos-\nsible, particularly in unconscious patients.\n•\t Intravenous artesunate, 2.4mg/kg bw given on admission (time = 0), \nthen at 12 hour and 24 hour, then once a day until the patient is able to \ntake oral medication. If intra venous administration is not possible, it can \nalso be given as an intramuscular injection. \nIf parenteral artesunate is NOT available:\n•\t Quinine dihydrochloride, 20mg salt/kg bw (loading dose) on admis-\nsion, then 10mg/kg every 8 hours. Each dose is given as a rate controlled \nintra venous infusion diluted in 10ml/kg bw of isotonic fluid over 2-4 \nhours at an infusion rate that should not exceed 5mg salt/kg body weight \nper hour. \nThe most important adverse effect is hyperinsulinaemic hypoglycaemia. \nHypotension and cardiac arrest may result from rapid intravenous injec-\ntion. Quinine causes prolongation of the electrocardiograph QT interval. \nTherefore; this administration should be accompanied by frequent blood \nglucose monitoring to prevent hypoglycaemia and cardiac monitoring. \nDuration of parenteral treatment\nGive parenteral antimalarials in the treatment of severe malaria for a \nminimum of 24 hours, even if the patient can tolerate oral medication. \nFollow up on oral treatment\nComplete the treatment by giving a full course of Coartem® as soon as the \npatient is able to take oral medication, but not before a minimum of 24 \nhours of parenteral treatment. This should be followed by a single dose of \nprimaquine.\nArtesunate is dispensed as a powder of artesunic acid. This powder is dis-\nsolved in 1ml of 5% sodium bicarbonate to form sodium artesunate. The \nsolution is then diluted with 5 ml of 5% dextrose and given immediately",
  "This powder is dis-\nsolved in 1ml of 5% sodium bicarbonate to form sodium artesunate. The \nsolution is then diluted with 5 ml of 5% dextrose and given immediately\n\n--- Page 145 ---\nNational Guideline for Maternal Care - Volume II\n131\nby intravenous bolus (‘push’) injection or by intramuscular injection (to \nthe anterior thigh). The solution should be prepared freshly for each ad-\nministration and should not be stored.\nSevere P. falciparum malaria in pregnancy\n•\t 1st Trimester: should be treated with parenteral quinine until clinical \t\n\t\nimprovement, followed by oral quinine therapy for a total of 7 days. \n•\t 2nd and 3rd Trimester of pregnancy: parenteral artesunate/quinine \t\n\t\ncan be administered as above. After clinical improvement, Coartem® \t\n\t\nshould be administered in the weight appropriate dose. \nPlease note: Primaquine should not be administered during pregnancy.\nSevere P. falciparum and P.vivax mixed infections\n•\t Parenteral administration of artesunate or quinine dihydrochloride \t\n\t\nfollowed by a full course of oral Coartem® (as described in manage\t\n\t\nment of severe falciparum malaria). \n•\t These patients should be given a course of primaquine base at a dose \t\n\t\nof 0.25mg/kg per day for fourteen days unless it is contraindicated.\n13.6.5.\t Patients infected with other malaria parasites\nThe recommended treatment for malaria caused by P.ovale is the same as \nthat given to achieve radical cure in P. vivax malaria, i.e. with chloroquine \nand primaquine. \nP. malariae should be treated with the standard regimen of chloroquine as \nfor P. vivax malaria, but it does not require radical cure with primaquine.\n13.7.\t Chemoprophylaxis for malaria\nChemoprophylaxis is not needed for visitors to Sri Lanka and anyone \nliving within the country including pregnant women. \nChemoprophylaxis is recommended for travellers to malaria endemic \ncountries (the list of countries where malaria transmission occurs is given \nin Annex II). Contact Anti Malaria Campaign to obtain chemoprophylactic \ndrugs and for further details.",
  "Chemoprophylaxis is recommended for travellers to malaria endemic \ncountries (the list of countries where malaria transmission occurs is given \nin Annex II). Contact Anti Malaria Campaign to obtain chemoprophylactic \ndrugs and for further details.\n\n--- Page 146 ---\nNational Guideline for Maternal Care - Volume II\n132\nAnnex I. Severe malaria\nDefinition of Severe malaria\nSevere malaria is defined by clinical or laboratory evidence of vital \norgan dysfunction (WHO, 2012). In a patient with P. falciparum asexual \nparasitaemia and no other obvious cause of symptoms, the presence of one \nor more clinical or laboratory features classifies the patient as suffering \nfrom severe malaria.\nClinical features of severe malaria\n•\t\nimpaired consciousness (including unarousable coma);\n•\t\nprostration, i.e. generalized weakness so that the patient is \t \t\n\t\nunable to walk sit up without assistance;\n•\t\nmultiple convulsions-more than two episodes in 24h;\n•\t\ndeep breathing, respiratory distress (acidotic breathing);\n•\t\nacute pulmonary oedema and acute respiratory distress \t\n\t\n\t\nsyndrome;\n•\t\ncirculatory collapse or shock, systolic blood pressure <80 mm \t\n\t\nHg in adults and < 50 mm Hg in children;\n•\t\nacute kidney injury;\n•\t\nclinical jaundice plus evidence of vital organ dysfunction; and\n•\t\nabnormal bleeding\nLaboratory findings\n•\t\nhyperparasitaemia \n•\t\nhypoglycaemia (blood glucose <2.2 mmol/l or <40mg/dl);\n•\t\nmetabolic acidosis (plasma bicarbonate < 15 mmol/l);\n•\t\nsevere normocytic anaemia (In children: Hb <5g/dl, packed cell \t\n\t\nvolume <15%. In adults: Hb<7g/dl, packed cell volume, PCV< \t\n\t\n20%)\n•\t\nhaemoglobinuria;\n•\t\nhyperlactataemia (lactate > 5 mmol/l);\n•\t\nrenal impairment (serum creatinine> 265 µmol/l);\n•\t\npulmonary oedema (radiological)\nReference: \nWHO, 2012, Management of severe malaria, A practical handbook, 3rd \nEd., World Health Organization",
  "generalized weakness so that the patient is \t \t\n\t\nunable to walk sit up without assistance;\n•\t\nmultiple convulsions-more than two episodes in 24h;\n•\t\ndeep breathing, respiratory distress (acidotic breathing);\n•\t\nacute pulmonary oedema and acute respiratory distress \t\n\t\n\t\nsyndrome;\n•\t\ncirculatory collapse or shock, systolic blood pressure <80 mm \t\n\t\nHg in adults and < 50 mm Hg in children;\n•\t\nacute kidney injury;\n•\t\nclinical jaundice plus evidence of vital organ dysfunction; and\n•\t\nabnormal bleeding\nLaboratory findings\n•\t\nhyperparasitaemia \n•\t\nhypoglycaemia (blood glucose <2.2 mmol/l or <40mg/dl);\n•\t\nmetabolic acidosis (plasma bicarbonate < 15 mmol/l);\n•\t\nsevere normocytic anaemia (In children: Hb <5g/dl, packed cell \t\n\t\nvolume <15%. In adults: Hb<7g/dl, packed cell volume, PCV< \t\n\t\n20%)\n•\t\nhaemoglobinuria;\n•\t\nhyperlactataemia (lactate > 5 mmol/l);\n•\t\nrenal impairment (serum creatinine> 265 µmol/l);\n•\t\npulmonary oedema (radiological)\nReference: \nWHO, 2012, Management of severe malaria, A practical handbook, 3rd \nEd., World Health Organization\n\n--- Page 147 ---\nNational Guideline for Maternal Care - Volume II\n133\nAnnex II.  \nCountries where malaria transmission occurs\nAfghanistan\t\nDominican Republic\t\nMadagascar\t\nSaudiArabia\nAngola\t\nEcuador\t\nMalawi\t\nSenegal\nBangladesh\t\nEquatorial Guinea\t\nMalaysia\t\nSierra Leone\nBelize\t\nEritrea\t\nMali\t\nSolomonIslands\nBenin\t\nEthiopia\t\nMauritania \t\nSomalia\nBhutan\t\nFrench  Guiana\t\nMayotte\t\nSouth Africa\nBolivia\t\nGabon\t\nMozambique\t\nSudan\nBotswana\t\nGambia\t\nMyanmar\t\nSwaziland\nBrazil\t\nGhana\t\nMexico\t\nSuriname\nBurkina Faso\t\nGuatemala\t\nNamibia\t\nThailand \nBurundi\t\nGuinea\t\nNiger\t\nTimor Leste\nCambodia\t\nGuinea- Bissau\t\nNigeria\t\nTogo\nCameroon\t\nGuyana\t\nNepal\t\nTajikistan\nCentral African Rep.\t Haiti\t\nNicaragua\t\nTurkey\nChad\t\nHonduras\t\nPakistan\t\nUganda\nChina\t\nIndia\t\nPanama\t\nTanzania\nColombia\t\nIndonesia\t\nPapua New Guinea\t\nVanuatu\nComoros\t\nIran \t\nPeru\t\nVietnam\nCongo\t\nIraq\t\nPhilippines\t\nVenezuela\nCosta Rica\t\nKenya\t\nParaguay\t\nYemen Socotra Island\nCote d’Ivoire\t\nLao PDR\t\nRwanda\t\nZambia\nDjibouti\t\nLiberia\t\nSao Tome & Principe \t Zimbabwe\nNote: \t\nThere are some other countries with very limited malaria risk. For \nmore details please refer International Travel and Health-2012 at \nhttp://www.who.int/ith/chapters/ith2012en_countrylist.pdf",
  "Countries where malaria transmission occurs\nAfghanistan\t\nDominican Republic\t\nMadagascar\t\nSaudiArabia\nAngola\t\nEcuador\t\nMalawi\t\nSenegal\nBangladesh\t\nEquatorial Guinea\t\nMalaysia\t\nSierra Leone\nBelize\t\nEritrea\t\nMali\t\nSolomonIslands\nBenin\t\nEthiopia\t\nMauritania \t\nSomalia\nBhutan\t\nFrench  Guiana\t\nMayotte\t\nSouth Africa\nBolivia\t\nGabon\t\nMozambique\t\nSudan\nBotswana\t\nGambia\t\nMyanmar\t\nSwaziland\nBrazil\t\nGhana\t\nMexico\t\nSuriname\nBurkina Faso\t\nGuatemala\t\nNamibia\t\nThailand \nBurundi\t\nGuinea\t\nNiger\t\nTimor Leste\nCambodia\t\nGuinea- Bissau\t\nNigeria\t\nTogo\nCameroon\t\nGuyana\t\nNepal\t\nTajikistan\nCentral African Rep.\t Haiti\t\nNicaragua\t\nTurkey\nChad\t\nHonduras\t\nPakistan\t\nUganda\nChina\t\nIndia\t\nPanama\t\nTanzania\nColombia\t\nIndonesia\t\nPapua New Guinea\t\nVanuatu\nComoros\t\nIran \t\nPeru\t\nVietnam\nCongo\t\nIraq\t\nPhilippines\t\nVenezuela\nCosta Rica\t\nKenya\t\nParaguay\t\nYemen Socotra Island\nCote d’Ivoire\t\nLao PDR\t\nRwanda\t\nZambia\nDjibouti\t\nLiberia\t\nSao Tome & Principe \t Zimbabwe\nNote: \t\nThere are some other countries with very limited malaria risk. For \nmore details please refer International Travel and Health-2012 at \nhttp://www.who.int/ith/chapters/ith2012en_countrylist.pdf\n\n--- Page 148 ---\nNational Guideline for Maternal Care - Volume II\n134\nAnnex III. \nTelephone numbers related to Anti Malaria \t\n\t\n\t\n\t\nCampaign\nAnti Malaria Campaign Headquarters:\t\n\t\nTele: (011) 2588408, (011) 2368173\n\t\n(011) 2368174\n\t\n(011) 7626626 (hotline)\n\t\n\te-mail\t : antimalariacampaignsl@gmail.com\n\t\n\t\n\t\nWebsite\t: www.malariacampaign.gov.lk\n\t\n\t\nRegional Malaria Offices\n\t\n\t\nAmpara\t\n(063) 2223464\t Kandy \t\n(081) 2210687\t Monaragala\t\n(055) 2276698\nAnuradhapura\t (025) 2221844\t Kegalle\t\n(035) 2222549\t Mullaitivu\t\n(024) 3248341\nBadulla\t\n(055) 2226018\t Kilinochchi\t (024) 3247236\t Polonnaruwa\t (027) 2226018\nBatticaloa\t\n(065) 2222931\t Kurunegala\t (037) 2222193\t Puttalam\t\n(032) 2265319\nHambanthota\t\n(047) 2220135\t Maho\t\n(037) 2275254\t Ratnapura\t\n(047) 2230301\nJaffna\t\n(021) 2227924\t Mannar\t\n(023) 2222326\t Trincomalee\t\n(026) 2222584\nKalmunai\t\n(067) 2220206\t Matale\t\n(066) 2222295\t Vavuniya\t\n(024) 2222954",
  "--- Page 1 ---\nSLCOG \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nPlease cite this paper as:  Abeywardane A, Rajapakse L, Marleen S,  Kadotgajan T, Lanerolle S, \nDodampahala S H, on behalf of the Sri Lanka College of Obstetricians and Gynaecologists. Blood \nTransfusion in Pregnancy. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nSri Lanka College of Obstetricians and Gynaecologists\nBlood Transfusion in Pregnancy \nGuideline No: 01 \nSeptember 2023 \nSri Lanka Journal of Obstetrics and Gynaecology",
  "Blood \nTransfusion in Pregnancy. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nSri Lanka College of Obstetricians and Gynaecologists\nBlood Transfusion in Pregnancy \nGuideline No: 01 \nSeptember 2023 \nSri Lanka Journal of Obstetrics and Gynaecology\n\n--- Page 2 ---\n143\nVol. 45, No. 3, September 2023\nSLCOG Guideline\nBlood transfusion in pregnancy\nA Abeywardanea, L Rajapakseb, S Marleenc, T Kadotgajand, S Lanerolled, S H Dodampahalae on behalf\nof the Sri Lanka College of Obstetricians and Gynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2023; 45: 143-150\na Consultant Transfusion Physician, Sri Jayewardenepura General Hospital, Sri Lanka.\nb Consultant Obstetrician and Gynaecologist, District General Hospital, Matale, Sri Lanka.\nc Consultant Obstetrician and Gynaecologist, Sri Jayewardenepura General Hospital, Sri Lanka.\nd Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Sri Lanka.\ne Professor in Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo, Sri Lanka.\nSLCOG Guideline\n1.  Purpose and scope\nBlood transfusion is an essential component of\nemergency obstetric care and, at times, lifesaving, but\nit is not without risks. This guideline aims to provide\nguidance on the appropriate use of blood products,\nwhich would neither compromise nor expose the\npatient to unnecessary risks associated with trans-\nfusion. Strategies to optimise the haemoglobin (Hb)\nlevel at delivery and minimise blood loss at delivery\nare also discussed.\n2.  Introduction\nObstetric haemorrhage remains a leading cause of direct\nmaternal deaths in Sri Lanka, accounting for 15.4%\nof total maternal deaths in 20201. Eventhough a large\nmajority of patients with obstetric haemorrhage survive\nuneventfully with timely interventions, it re-mains an\nimportant cause of severe maternal morbidity.\nIn 2022, the prevalence of anaemia among pregnant\nwomen in Sri Lanka was 29.1%2. A significant pro-\nportion of pregnant women with anaemia may require\nblood transfusion if it is not addressed in a timely\nmanner. Transfusion services in Sri Lanka are rapidly\nimproving, with all blood components prepared with\n100% volunteer donations, which are mandatorily\ntested for HIV 1 and 2, Hepatitis B, Hepatitis C, Syphilis\nand Malaria.\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/\n3. Strategies to minimise the requirement\nfor transfusion\n3.1. Optimisation of haemoglobin during the\nantenatal period\n3.1.1. Diagnosis\nAll pregnant women should be screened for anaemia\nat the booking visit and 28 weeks. Anaemia in\npregnancy is defined as first-trimester Hb less than\n11g/dL, second and third-trimester Hb less than 10.5g/dL,\nand postpartum Hb less than 10g/dL according to the\nBritish Committee for Standards in Haematology3. If\nthe Hb level is less than the relevant thresholds, consider\nhaematinic deficiency once haemoglobin-opathies have\nbeen excluded.\n3.1.2. Treatment and management\nOral iron should be the preferred first-line treatment\nfor iron deficiency anaemia. Parenteral iron is indicated\nwhen oral iron is not tolerated or absorbed, patient\ncompliance is in doubt or if the woman is approaching\nterm when there is insufficient time for oral supple-\nmentation to be effective. Women should receive\ninformation on improving dietary iron intake and the\nfactors affecting the absorption of dietary iron.\nMeta-analysis of randomised trials on the antenatal use\nof iron, with or without folic acid, showed a 50%",
  "Parenteral iron is indicated\nwhen oral iron is not tolerated or absorbed, patient\ncompliance is in doubt or if the woman is approaching\nterm when there is insufficient time for oral supple-\nmentation to be effective. Women should receive\ninformation on improving dietary iron intake and the\nfactors affecting the absorption of dietary iron.\nMeta-analysis of randomised trials on the antenatal use\nof iron, with or without folic acid, showed a 50%\n\n--- Page 3 ---\n144\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nreduction in the risk of anaemia in the third trimester\nor at delivery4,5. Parenteral iron therapy offers a shorter\nduration of treatment and a quicker response but is\nmore invasive. Intravenous iron preparation should be\nadministered with all resuscitation facilities available\nimmediately, as severe allergic reactions are possible.\nAnaemia not due to haematinic deficiency should be\nmanaged in close conjunction with a haematologist and\ntransfusion physician.\n3.2. Strategies to minimise blood loss at delivery\nWomen at high risk of haemorrhage should be delivered\nin a hospital with facilities to manage massive bleeding.\nActive management of the third stage of labour is\nrecommended to reduce postpartum blood loss.\n4. General principles of blood transfusion\n4.1. Consent\nValid informed consent should be obtained where\npossible before blood transfusion. In case of an\nemergency, where it is not feasible to get consent prior\nto transfusion, transfusions should not be delayed, but\ninformation on blood transfusion should be provided\nretrospectively.\nWhere transfusion of all or a specific blood component\nis refused, or an advanced directive exists, detailed\ncounselling should be arranged with a transfusion\nphysician where available. This should be documented\nin the patient’s clinical records and communicated to\nall relevant healthcare professionals. Following detailed\ncounselling, should the patient not consent for\ntransfusion of blood and blood products, legal guidance\nshould be sought.\n4.2. Requirements for group and screen samples\nand cross-matching\nAll women should have their blood group and red cell\nantibody status checked at booking and 28 weeks\ngestation. If red cell antibodies are detected in the\nbooking sample, further testing of maternal blood\nshould be done to determine the specificity and the\ntitre of antibody/antibodies detected and to assess the\nlikelihood of haemolytic disease of the foetus and\nnewborn.\nGroup and screen samples used for the provision of\nblood in pregnancy should be less than 3 days old.\nThis should accompany a separate sample for blood\ngroup confirmation if the blood group has not been\ndone before. In a woman at high risk of emergency\ntransfusion, e.g., placenta previa, with no clinically\nsignificant alloantibodies, group and screen samples\nshould be sent once a week to exclude or to identify\nany new antibody formation and to keep blood available\nif necessary. Close liaison with the transfusion\nphysician/team is essential.\n4.3. Blood product specifications in pregnancy and\npuerperium\nABO and RhD identical or compatible red cell units\nshould be transfused. If clinically significant red cell\nantibodies are present, blood negative for the relevant\nred cell antigen should be cross-matched for\ntransfusion. Where complex antibodies or rare red cell\nphenotypes are identified, provision of compatible blood\nmay take time, and when transfusions are needed in\nsuch instances, inform the transfusion laboratory in\nadvance to avoid potential delays in the provision of\nblood. All patients receiving transfusions should be\nclosely monitored throughout the transfusion to\nidentify signs of transfusion reactions and adverse\nevents early and act promptly.\n4.4. Intraoperative cell salvage\nIntraoperative cell salvage could be considered in\npatients who are expected to have a blood loss of more\nthan 500ml or more than 10% of the patient’s estimated\nblood volume if facilities are available6.  However, such\nfacilities are currently unavailable in Sri Lanka.\n5.  Management of obstetric haemorrhage\nwith blood components\nClinicians should familiarise themselves with the\nexisting guidelines on the management of PPH and\nprotocols for managing major obstetric haemorrhage,\nincluding the mechanical strategies employed to reduce\npostpartum blood loss7.\n5.1. When should red cells be used?\nThe decision to transfuse should be made on clinical\nand haematological grounds. Although the aim of blood\ntransfusion in a bleeding patient is to maintain Hb more\nthan 8g/dL, patients with acute haemorrhage can have\nnormal Hb and clinical evaluation in this situation is\nextremely important.",
  "When should red cells be used?\nThe decision to transfuse should be made on clinical\nand haematological grounds. Although the aim of blood\ntransfusion in a bleeding patient is to maintain Hb more\nthan 8g/dL, patients with acute haemorrhage can have\nnormal Hb and clinical evaluation in this situation is\nextremely important.\n\n--- Page 4 ---\n145\nVol. 45, No. 3, September 2023\nSLCOG Guideline\nIn an emergency where the patient’s blood group is\nunknown, group O RhD-negative red cells should be\ngiven until the blood group is established and then\nswitch to group-specific red cells. In case of a severe\nhaemorrhage, if there is a history of clinically significant\nred cell antibodies being present, close liaison with the\ntransfusion physician is essential to avoid delay in\ntransfusion. Once bleeding is controlled, restoring Hb\nto physiological levels with red cell transfusions is not\nindicated8.\n5.2. In what circumstances should fresh frozen\nplasma (FFP) and cryoprecipitate be used?\nWhen available, point-of-care testing-guided FFP and\ncryoprecipitate transfusions are preferable to optimise\nhaemostatic management9. If results of point-of-care\nor haemostatic testing are unavailable and haemorrhage\ncontinues, FFP at a dose of 12-15 ml/kg should be\nadministered for every six units of red cell concentrates\n(RCC)5. Early use of FFP should be considered for\nconditions with a suspected coagulopathy, such as\nplacental abruption or amniotic fluid embolism, or\nwhere detection of PPH has been delayed10.\nIf the haemorrhage is ongoing, subsequent FFP\ntransfusion should be guided by the results of clotting\ntests aiming to maintain prothrombin time (PT) and\nactivated partial thromboplastin time (APTT) ratios at\nless than 1.5 times normal8. It is essential that\nregular full blood counts and coagulation screens (PT,\nAPTT and fibrinogen) are performed during the\nbleeding episode. The drawbacks of early FFP are\nthat the majority of women with PPH will have normal\ncoagulation at the time of FFP administration and that\nit is associated with an increased risk of transfusion-\nassociated circulatory overload (TACO) and trans-\nfusion-related acute lung injury (TRALI). FFP results\nin a relatively small increment in fibrinogen level10,11.\nCryoprecipitate at a standard dose of 10 units should\nbe administered relatively early in major obstetric\nhaemorrhage. Subsequent cryoprecipitate transfusion\nshould be guided by fibrinogen results, aiming to keep\nlevels above 2g/l. RCTs do not support the early\nunselected use of fibrinogen replacement therapy, and\nadministering fibrinogen supplementation to women\nwith PPH who have fibrinogen levels of >2 g/l is unlikely\nto have added benefit8,12,13.\nFFP should ideally be of the same ABO group as the\nrecipient. If unavailable, FFP of a compatible ABO group\nis acceptable. The blood group of cryoprecipitate is\nnot considered in the local context, considering the\nproduction method.\nClinicians should be aware that these blood components\nmust be ordered as soon as a need for them is\nanticipated, as there will always be a short delay in\nsupply because of the need for thawing and recons-\ntituting.\n5.3. When should platelets be used?\nAim to maintain the platelet count above 50×109/l in an\nacutely bleeding patient. A platelet transfusion trigger\nof 75×109/l is recommended to provide a margin of\nsafety. If results of point-of-care testing or haemostatic\ntesting are not available and haemorrhage is continuing,\nfour units of platelet concentrates should be adminis-\ntered after eight or more units of red cell concentrates14.\nThe platelets should be ABO group identical or\ncompatible. To avoid the development of anti-D\nantibodies, RhD-negative platelet concentrates should\nbe given where possible to RhD-negative women of\nchildbearing potential.\nPlatelets may not be readily available in some hospitals;\ntherefore, their need should be anticipated, and good\ncommunication with the transfusion team should be\nmaintained. The platelet count should not be allowed\nto fall below 50×109/l in the acutely bleeding patient,\nas this represents the critical level for haemostasis.\nSuch a low platelet count may be anticipated when\napproximately two blood volumes have been replaced\nby fluid or blood components. A platelet transfusion\ntrigger of 75×109/l is recommended in a patient with\nongoing bleeding to provide a margin of safety.\nIf RhD-positive platelets are transfused to a RhD-\nnegative woman of childbearing potential, anti-D\nimmunoglobulin should be administered. A dose of 250\niu anti-D immunoglobulin is sufficient to cover 5 adult\ntherapeutic doses of platelets given within a 6-week\nperiod. This may be given subcutaneously to minimise\nbruising and haematomas in thrombocytopenic women.",
  "A dose of 250\niu anti-D immunoglobulin is sufficient to cover 5 adult\ntherapeutic doses of platelets given within a 6-week\nperiod. This may be given subcutaneously to minimise\nbruising and haematomas in thrombocytopenic women.\n\n--- Page 5 ---\n146\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n6. How should intrapartum anaemia be\nmanaged?\nIn anaemic women who are not actively bleeding, if\nthe Hb is less than 8g/dL in labour or in the immediate\npostpartum period, the decision to transfuse should\nbe made according to the individual’s medical history\nand symptoms. Where transfusion is indicated,\ntransfusion of a single unit of red cell concentrate\nshould be followed by clinical reassessment to\ndetermine the need for further transfusions.\n7. How should women with postpartum\nanaemia be managed in the postnatal\nperiod?\nIf the Hb is more than 7g/dL in the postnatal period,\nwhere there is no ongoing or threat of bleeding, the\ndecision to transfuse should be made on an informed\nindividual basis. The risk of RBC alloimmunisation\nand the potential clinical impact should be considered\nwhen balancing the risks and benefits of RBC trans-\nfusion. Non-transfusion therapies, such as iron, should\nbe considered as a part of the treatment of postpartum\nanaemia.\n8. How should women who decline blood\nproducts be managed?\nHb should be optimised prior to delivery to prevent\navoidable anaemia. Consent/refusal of blood compo-\nnents or other transfusion-sparing techniques should\nbe discussed in detail and clearly documented during\nthe antenatal period. The use of pharmacological,\nmechanical and surgical procedures to avert the use\nof banked blood and blood components should be\nconsidered early. Medicolegally, withholding blood\nproducts in life-saving situations is not permitted.",
  "The use of pharmacological,\nmechanical and surgical procedures to avert the use\nof banked blood and blood components should be\nconsidered early. Medicolegally, withholding blood\nproducts in life-saving situations is not permitted.\n\n--- Page 6 ---\n147\nVol. 45, No. 3, September 2023\nSLCOG Guideline\nAppendix 1. Massive obstetric haemorrhage protocol\n\n--- Page 7 ---\n148\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nAppendix 2. Algorithm for Rotem-guided PPH management\n\n--- Page 8 ---\n149\nVol. 45, No. 3, September 2023\nSLCOG Guideline\nAppendix 3. Sample consent form for transfusion of blood and blood components",
  "3, September 2023\nSLCOG Guideline\nAppendix 3. Sample consent form for transfusion of blood and blood components\n\n--- Page 9 ---\n150\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nReferences\n1.\nAnnual Health Bulletin 2020. Ministry of Health,\nSri Lanka.\n2.\nAmarasinghe GS, Agampodi TC, Mendis V,\nMalawanage K, Kappagoda C, Agampodi SB.\nPrevalence and aetiologies of anaemia among first\ntrimester pregnant women in Sri Lanka; the need\nfor revisiting the current control strategies. BMC\nPregnancy Childbirth. 2022; 22(1): 16.\n3.\nPavord S, Daru J, Prasannan N, Robinson S,\nStanworth S, Girling J, et al. UK guidelines on the\nmanagement of iron deficiency in pregnancy. Br J\nHaematol. 2020; 188(6): 819-30.\n4.\nHaider BA, Olofin I, Wang M, Spiegelman D, Ezzati\nM, Fawzi WW. Anaemia, prenatal iron use, and\nrisk of adverse pregnancy outcomes: systematic\nreview and meta-analysis. BMJ: British Medical\nJournal. 2013; 346: f3443.\n5.\nRoyal College of Obstetricians and Gynaecologists.\nBlood Transfusion in Obstetrics. Green-top\nGuideline No. 47. London: RCOG; 2015.\n6.\nCarroll C, Young F. Intraoperative cell salvage. BJA\nEduc. 2021; 21(3): 95-101.\n7.\nGuidelines for the Blood Transfusion Services in\nthe United Kingdom.\nwww.transfusionguidelines.org.uk\n8.\nStanworth SJ, Dowling K, Curry N, Doughty H,\nHunt BJ, Fraser L, et al. Haematological\nmanagement of major haemorrhage: a British\nSociety for Haematology Guideline. Br J Haematol.\n2022; 198(4): 654-67.\n9.\nSnegovskikh D, Souza D, Walton Z, Dai F, Rachler\nR, Garay A, et al. Point-of-care viscoelastic testing\nimproves the outcome of pregnancies complicated\nby severe postpartum hemorrhage. J Clin Anesth.\n2018; 44: 50-6.\n10. Mavrides E, Allard S, Chandraharan E, Collins P,\nGreen L, Hunt BJ, Riris S, Thomson AJ on behalf\nof the Royal College of Obstetricians and Gynae-\ncologists. Prevention and management of post-\npartum haemorrhage. BJOG 2016; 124: e106-e149.\n11. McNamara H, Kenyon C, Smith R, Mallaiah S,\nBarclay P. Four years’ experience of a ROTEM.\nAnaesthesia. 2019; 74(8): 984-91.\n12. Collins PW, Cannings-John R, Bruynseels D,\nMallaiah S, Dick J, Elton C, et al. Viscoelastometric-\nguided early fibrinogen concentrate replacement\nduring postpartum haemorrhage: OBS2, a double-\nblind randomized controlled trial. Br J Anaesth.\n2017; 119(3): 411-21.\n13. Wikkelso AJ, Edwards HM, Afshari A, Stensballe\nJ, Langhoff-Roos J, Albrechtsen C, et al. Pre-\nemptive treatment with fibrinogen concentrate for\npostpartum haemorrhage: randomized controlled\ntrial. Br J Anaesth. 2015; 114(4): 623-33.\n14. Collins P, Abdul-Kadir R, Thachil J, Coagulation\nSoWsHIiTaHaoDI. Management of coagulopathy\nassociated with postpartum hemorrhage: guidance\nfrom the SSC of the ISTH. J Thromb Haemost.\n2016; 14(1): 205-10.",
  "--- Page 1 ---\nSLCOG \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nPlease cite this paper as:  de Silva PHP, Waththuhewa DY, Lanerolle S, Dodampahala HS, Silva R, \nMathota C, on behalf of the Sri Lanka College of Obstetricians and Gynaecologists. Thyroid Disorders in \nPregnancy and Postpartum Period \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nSri Lanka College of Obstetricians and Gynaecologists               \nThyroid Disease in Pregnancy and the \nPostpartum Period \nGuideline No: 02 \nJune 2022 \nSri Lanka Journal of Obstetrics and Gynaecology\n\n--- Page 2 ---",
  "--- Page 1 ---\nSLCOG \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nPlease cite this paper as:  de Silva PHP, Waththuhewa DY, Lanerolle S, Dodampahala HS, Silva R, \nMathota C, on behalf of the Sri Lanka College of Obstetricians and Gynaecologists. Thyroid Disorders in \nPregnancy and Postpartum Period \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nSri Lanka College of Obstetricians and Gynaecologists               \nThyroid Disease in Pregnancy and the \nPostpartum Period \nGuideline No: 02 \nJune 2022 \nSri Lanka Journal of Obstetrics and Gynaecology\n\n--- Page 2 ---\n\n--- Page 3 ---\n117\nVol. 44, No. 2, June 2022\nSLCOG Guideline\nThyroid disease in pregnancy and the postpartum period\nP H P de Silvaa, D Y Waththuhewab, Sanath Lanerollec, H S Dodampahalad, Ruwan Silvae, C Mathotaf\non behalf of the Sri Lanka College of Obstetricians and Gynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2022; 44: 117-123\na Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nb Senior Registrar, Colombo North Teaching Hospital, Ragama, Sri Lanka\nc Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka\nd Professor in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology, University of Colombo,\nSri Lanka\ne Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nf Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nSLCOG Guideline\nBackground\nThyroid disease in pregnancy, Hypothyroidism and\nHyperthyroidism (thyrotoxicosis) can lead to adverse\npregnancy outcomes. It can also affect foetal\ndevelopment and contribute to negative outcomes in\ninfancy and childhood1.\nWorldwide, the most common cause of hypo-\nthyroidism is an inadequate dietary intake of iodine.\nUniversal Salt Iodination (USI) was first introduced in\nSri Lanka in 1995, which led to a remarkable decrease\nin the prevalence of iodine deficiency and goitre2.\nUpdated data regarding the prevalence of thyroid\ndisease in the Sri Lankan population is relatively sparse.\nAccording to population-based studies done in Sri\nLanka, prevalence of goitre was found to be around\n6.8% while that of subclinical hypothyroidism was\nfound to be approximately 4-5% with females being\nthe most commonly affected group3,4,5. It is also\ninteresting to note that the prevalence of the presence\nof thyroid auto-antibodies has been observed to be\nrising following the introduction of USI4.\nPhysiological changes of thyroid function\nduring pregnancy\nDuring an average pregnancy, the volume of the thyroid\ngland increases by 10-30% and the iodine uptake rises\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v44i2.8055\nby three-fold. Maternal Thyroid-Binding Globulin level\nincreases due to the increased hepatic synthesis under\noestrogen stimulation. TSH receptors in the thyroid\ngland are weakly stimulated by Human Chorionic\nGonadotropin (hCG) hormone. Therefore, the total\nthyroxine (T4) and triiodothyronine (T3) levels\nincrease, although free T4 levels are altered slightly\nand usually fall during the late course of pregnancy1.\nDuring pregnancy, Thyroid Stimulating Hormone\n(TSH) levels initially rise with conception and then fall\nduring the first trimester as the increased T4, T3 levels\nsuppress the hypothalamic Thyroid Releasing Hormone\n(TRH) thus in turn suppressing the release of TSH\nfrom the pituitary gland6.\nAfter the first trimester, TSH levels normalize to\nbaseline levels and can increase gradually in the third\ntrimester due to the presence of Placental Deiodinase.\nIn Hyperemesis Gravidarum, increased hCG levels can\nresult in a benign transient biochemical hyperthyroidism\nin around 60% of cases.\nFoetal thyroid gland starts functioning at about 12\nweeks after gestation. However, maternal T4 is\ntransferred to the foetus throughout the pregnancy and\nis considered to be important factor for foetal neural\ndevelopment. This is of particular significance during\nthe first 12 weeks. At birth, about 30% of umbilical",
  "This is of particular significance during\nthe first 12 weeks. At birth, about 30% of umbilical\n\n--- Page 4 ---\n118\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nHormone\n1st trimester 2nd trimester\n3rd trimester\nTSH\n0.1 - 2.5 mIU/L 0.2 - 3.0 mIU/L\n0.3 - 3.0 mIU/L\nTotal T 4\n6.5 - 10.1 ug/dl 7.5 - 10.3 ug/dl\n6.3 - 9.7 ug/dl\nTotal T 3\n97 - 149 ng/dl 117 - 169 ng/dl\n123 - 162 ng/dl\nFree T 4\n0.8 - 1.7 ng/dl 0.6 - 1.0 ng/dl\n0.5 - 0.8 ng/dl\nFree T 3\n4.1 - 4.4 pg/ml 4.0 - 4.4 pg/ml\n4.0 - 4.4 pg/ml\nEarly Gestational Hyperthyroidism (EGH)\nEGH is a recognized new entity in the spectrum of thyroid disease in pregnancy, usually presenting with Hyperemesis\nGravidarum and mildly symptomatic hyperthyroidism. It is more common in people of Asian descent. Management\nincludes supportive care and hydration. We recommend not starting antithyroid medications for this condition.\nHowever, many with symptoms would require beta blockers to control symptoms which can generally be\ndiscontinued in the second trimester1.\nWith regard to thyroid functions, four clinical entities can be deduced apart from the normal euthyroid status.\nThese are\n• Overt Hyperthyroidism\n• Subclinical Hyperthyroidism\n• Overt Hypothyroidism\n• Subclinical Hypothyroidism\nTable 1 demonstrates the associated changes in thyroid function tests for each condition.\nTable 1. Pregnancy associated changes in thyroid function\ntests in thyroid disorders indicated above\nMaternal Status\nThyroid Stimulating\nFree T4 Level\n Hormone (TSH) Status\n• Overt Hyperthyroidism\nDecrease\nIncrease\n• Subclinical Hyperthyroidism\nDecrease\nUnchanged\n• Overt Hypothyroidism\nIncrease\nDecrease\n• Subclinical Hypothyroidism\nIncrease\nUnchanged\nTable 1. Abbreviations: T4, thyroxine; TSH, thyroid-stimulating hormone. *The level of TSH decreases in early pregnancy\nbecause of weak TSH receptor stimulation due to substantial quantities of human chorionic gonadotropin during the first\n12 weeks of gestation. After the first trimester, TSH levels return to baseline values.\ncord-measured T4 is derived from the maternal thyroid. Therefore, a history of anti-thyroid drugs or presence of\nThyroid Receptor Antibodies in the mother should be communicated to the neonatal physician.\nThyroid function tests during pregnancy\nSLCOG recommends the following cut-off limits in Thyroid Function Tests during pregnancy in accor-dance\nwith the reference ranges accepted by the American Thyroid Association7.",
  "After the first trimester, TSH levels return to baseline values.\ncord-measured T4 is derived from the maternal thyroid. Therefore, a history of anti-thyroid drugs or presence of\nThyroid Receptor Antibodies in the mother should be communicated to the neonatal physician.\nThyroid function tests during pregnancy\nSLCOG recommends the following cut-off limits in Thyroid Function Tests during pregnancy in accor-dance\nwith the reference ranges accepted by the American Thyroid Association7.\n\n--- Page 5 ---\n119\nVol. 44, No. 2, June 2022\nSLCOG Guideline\nHyperthyroidism\nHyperthyroidism occurs in about 1 in 500 pregnancies\nand is most commonly due to Graves’ Disease. De\nnovo cases can be due to solitary toxic adenomas,\ntoxic multinodular goitre, subacute thyroiditis, acute\nthyroiditis (viral/de Quervain’s) or due to medications\n(Iodine/Lithium/Amiodarone). Increased thyroid\nactivity in pregnancy can lead to the aggravation of\nGrave’s thyrotoxicosis in the first trimester and puer-\nperium. Generally, auto-immune thyroid diseases are\nrelatively quiescent during pregnancy due to the\nrelatively immune-suppressive state of pregnancy.\nWell controlled disease can achieve good maternal and\nfoetal outcomes. If untreated however, can lead to\nmiscarriage, fetal loss, fetal growth restriction, preterm\nlabour and increased perinatal mortality. Thyroid\nantibodies can cross the placenta and result in foetal\nand neonatal thyrotoxicosis.\nHyperthyroidism will lead to maternal sinus tachycardia,\nsupraventricular tachycardia, atrial fibrillation, thyroid\nstorm and heart failure.\nClinical features\nResembles early normal pregnancy symptoms; heat\nintolerance, palpitations, tachycardia, palmar erythema,\nvomiting, emotional lability and goitre. De novo cases\nusually present in the early second trimester.\nDiscriminating features;\n•\nWeight loss\n•\nPersistent tachycardia\n•\nSleeping pulse > 100 per minute\n•\nTremor\n•\nLid lag\n•\nExophthalmos\n•\nSymptoms predating the pregnancy\nManagement\n• Normal ranges for pregnancy trimesters should be\nused for assessment and the diagnosis is by raised\nlevels of free T4 and T3 and suppressed TSH.\nAntithyroid Drugs (ATD)\n•\nMedications used are Carbimazole, Methimazole\nand Propylthiouracil (PTU).\n•\nAim to achieve rapid and optimal control with\nthe lowest dose of medications to maintain\neuthyroid state with free T4 level at upper limit\nof normal range.\n•\nAntithyroid medication response is delayed and\ntakes 3-4 weeks. Once response is achieved,\ndose should be gradually reduced to main-\ntenance dose for 12-18 months6.\nEg: Carbimazole starting dose 15-40 mg, then\nreduced to 5-15mg,\nPTU starting dose 150-400 mg, then reduced to\n50-150 mg.\n•\nBoth drugs can cross the placenta (PTU less\nthan Carbimazole) and can result in foetal\nhypothyroidism and goitre.\n•\nBoth drugs can cause congenital abnormalities\n(2-4%) although more severe with Carbimazole.\n•\nCarbimazole and Methimazole, when used in the\nfirst trimester can cause a rare side effect;\nAplasia Cutis of the foetus (Foetus is born with\nthe absence of certain layers of skin, most often\non the scalp, but also on the trunk, and/or arms\nand legs).\n•\nPTU can cause a rare complication i.e. liver\nfailure of the mother (1 in 10,000).\n•\nDoses below 15mg/day of Carbimazole and\n150mg/ day of PTU are unlikely to cause foetal\neffects.\n•\nWe recommend starting PTU for newly diag-\nnosed cases in the first trimester and then con-\nverting to Carbimazole in the second trimester\nand onwards. It is preferable to continue low\ndose Carbimazole without changing drugs if\nalready diagnosed and under control with\nCarbimazole since preconception period.\n•\n“Block and replace” therapy is not recom-\nmended.\n•\nBoth drugs can cause a drug urticaria in 1-5%\nof patients and the medication should be\nchanged to a different preparation.\n•\nRarely both drugs may cause agranulocytosis\nand result in neutropenia, thus patients should\nbe monitored for symptoms with Full Blood\nCount at an early point of the treatment process.\n•\nGrave’s Disease can relapse in postpartum,\ntherefore all mothers should be re-tested in 2-4\nmonths after delivery.",
  "liver\nfailure of the mother (1 in 10,000).\n•\nDoses below 15mg/day of Carbimazole and\n150mg/ day of PTU are unlikely to cause foetal\neffects.\n•\nWe recommend starting PTU for newly diag-\nnosed cases in the first trimester and then con-\nverting to Carbimazole in the second trimester\nand onwards. It is preferable to continue low\ndose Carbimazole without changing drugs if\nalready diagnosed and under control with\nCarbimazole since preconception period.\n•\n“Block and replace” therapy is not recom-\nmended.\n•\nBoth drugs can cause a drug urticaria in 1-5%\nof patients and the medication should be\nchanged to a different preparation.\n•\nRarely both drugs may cause agranulocytosis\nand result in neutropenia, thus patients should\nbe monitored for symptoms with Full Blood\nCount at an early point of the treatment process.\n•\nGrave’s Disease can relapse in postpartum,\ntherefore all mothers should be re-tested in 2-4\nmonths after delivery.\n\n--- Page 6 ---\n120\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n•\nBreastfeeding is safe if it is on low doses of\ndrugs and needs foetal thyroid function\nmonitoring in the case of mother taking higher\ndoses.\nBeta Blockers\n•\nWill provide symptom control in the early phase\nof treatment and during relapse. Eg: Propranolol\n40mg three times daily.\n•\nIt will also reduce peripheral conversion of T4.\n•\nCan be discontinued after the achievement of\nthe antithyroid medication response. As it is used\nfor a short duration, it will not cause harmful\nfoetal effects.\nSurgery\n•\nCan be done for those who present with large\ngoitre causing dysphagia and stridor, confirmed\nor suspected thyroid malignancy or if allergic\nto antithyroid medication. If indicated it is done\nin the second trimester. Need close follow up\nand treatment for hypothyroidism as 25-50%\nwill be hypothyroid following surgery.\n•\n1-2% of patients will develop hypocalcemia due\nto removal of the parathyroid gland.\nRadio-active Iodine\n•\nAs it is taken up by foetal thyroid and causes\nfoetal thyroid ablation, radio-iodine therapy is\ncontra-indicated in pregnancy and post-partum.\n•\nRadio-iodine scans for diagnostic purposes are\nalso contra-indicated in pregnancy and\nbreastfeeding. Breastfeeding should be withheld\nfor 24 hrs if radio iodine tests done postpartum.\nThyroid Storm – Diagnosis and Management\nA rare disorder with a mortality rate of 8-25% which\npresents with multi-organ dysfunction. Symptoms\ninclude; pyrexia, tachycardia, arrhythmia, heart failure,\ndelirium, stupor or coma, liver failure, vomiting and\ndiarrhoea.\nPrecipitants; sudden withdrawal of ATD, following\nradio-iodine treatment, stress due trauma (surgery) or\nacute febrile illness. Thus, ensuring euthyroid status\nof the mother at the elective caesarean section or at\nlabour is of paramount importance.\nDiagnosis should be made clinically in severe-level\nthyrotoxicosis patients with evidence of decom-\npensation. Burch-Wartofsky point scale or Japanese\nThyroid Association categories can be used to decide\non the need for aggressive treatment.\nSupportive care, starting PTU recommended for\ncontrol of thyroxin production from both in gland and\nperipheral conversion (preferred over Carbimazole/\nMethimazole), beta blockers, glucocorticoid therapy\nwith strict ICU / HDU care is useful for control of\neffect or symptoms and to revive decompensated\nsystems.\nPoor respondents should be offered plasmapheresis\nand emergency surgery10.\nFoetal/ Neonatal monitoring\n•\nTransplacental passage of thyroid stimulating\nantibodies results in foetal or neonatal\nthyrotoxicosis which will cause a 25% mortality\nif untreated.\n•\nMothers known to be positive for thyroid anti-\nbodies, antibody level testing should be done in\nearly pregnancy. If titers are high or do not fall\nwith treatment, foetal ultrasound should be\noffered to detect foetal growth restriction in\nsecond and third trimesters. Looking for Goitre\nand tachycardia should be done after delivery.\nThyroid function tests in cord blood and neonate\nshould be performed11.\n•\nFoetal thyrotoxicosis should be treated with\nantithyroid medications to the mother, with\nthyroxine replacement if she is euthyroid.\n•\nNeonate should be closely monitored by the\nPaediatric team. Following diagnosis of thyroid\ndisease, it should be treated as soon as possible.\nHowever, the abnormalities will settle once\nmaternal antibodies are completely cleared after\naround 4th month of life.\nSubclinical Hyperthyroidism\nSubclinical Hyperthyroidism is reported in about\n0.8-1.7 percent of pregnant women12,13. Diagnosis is\ndone using low TSH levels with normal free T4, T3\nlevels. This diagnosis not shown to be associated with\nan effect on pregnancy. Therefore, treatment is not\nrecommended.",
  "This diagnosis not shown to be associated with\nan effect on pregnancy. Therefore, treatment is not\nrecommended.\n\n--- Page 7 ---\n121\nVol. 44, No. 2, June 2022\nSLCOG Guideline\nHypothyroidism\nHypothyroidism affects around 1% of pregnancies.\nMost women will have a positive family history of\nauto-immune hypothyroidism and will be diagnosed\nand placed on treatment prenatally. Most common types\nare Atrophic Thyroiditis and Hashimoto’s Thyroiditis\n(Auto-Immune Thyroiditis and goitre). Hashimoto’s\nThyroiditis is the most common cause of hypothy-\nroidism in developed countries. In contrast, worldwide,\nthe most common cause of hypothyroidism is the\ninadequate dietary intake of iodine.\nHypothyroidism can also be iatrogenic; due to radio-\niodine therapy, thyroidectomy, and due to medications\n(Antithyroid drugs, Iodine, Lithium, Amiodarone). It\ncan also be associated with other auto-immune\ndiseases.\nHashimoto Thyroiditis is an autoimmune disease that\ndestroys thyroid cells by cell and antibody-mediated\nimmune responses. The pathology of the disease\ninvolves the formation of antithyroid antibodies that\ntarget and destroy the thyroid tissue, causing pro-\ngressive fibrosis. Most patients develop antibodies to\na variety of thyroid antigens, the most common of\nwhich is anti-thyroid peroxidase (anti-TPO, previously\nnamed Anti-microsomal antibody). Many also form\nantithyroglobulin (anti-Tg) and TSH receptor-blocking\nantibodies (TBII).\nPregnancy has no effect on hypothyroidism. Twenty-\nfive percent of women will require higher requirements\nof thyroxine dosing during the course of the preg-\nnancy. If untreated, it can lead to miscarriage, fetal\nloss, foetal anaemia and low birthweight. Foetal thyroid\nfunctions begin around the 12th week of gestation.\nThus, the foetus is dependent on maternal thyroxine\nduring early gestation. Therefore, if untreated, hypothy-\nroidism and severe maternal iodine deficiency will\naffect fetal neuro-development leading to cretinism\n(condition of severe physical and mental retardation\nspecifically due to deficiency of thyroid hormones\nduring early pregnancy, hypothyroidism, spastic motor\ndisorder and deaf mutism-congenital deafness that\nresults in inability to speak). Untreated maternal\nhypothyroidism has a higher chance of low birth-\nweight. In rare cases, maternal thyroid antibodies could\ncross the placenta and cause foetal hypothyroidism\nbut this is extremely rare.\nMothers who are well controlled and euthyroid at\nconception can achieve good maternal and foetal\noutcomes.\nDiagnosis of hypothyroidism is done when TSH level\nis over the reference range for the gestational age of\npregnancy and the free T4/T3 levels are below the\nlower limit of normal.\nAdverse perinatal outcomes could be reduced by\nappropriate therapy.\nClinical features\nSymptoms may resemble normal pregnancy symptoms;\nlethargy, tiredness, weight gain, hair loss, dry skin,\nconstipation, fluid retention and goitre.\nDiscriminating features;\n•\nCold intolerance\n•\nBradycardia\n•\nDelayed ankle reflex\nManagement\n•\nNormal ranges for pregnancy trimesters should\nbe used for assessment, and diagnosed by\nreduced levels of free T4, T3 and increased\nTSH.\n•\nPresence of auto-antibodies will help the\ndiagnosis but is not recommended to be per-\nformed (anti-thyroid peroxidase antibody)\nroutinely.\n•\nThyroxine does not freely cross the placenta\nexcept for very slight amounts. This will not\ncause foetal thyrotoxicosis.\n•\nWomen who are already on levothyroxine\ntherapy can continue the same dose guided by\nthyroid function tests (TFT).\n•\nWomen who are under replacement therapy need\nadjustment of dose and TFT should be repeated\nafter 4-6 weeks.\n•\nImmediate replacement therapy should be\nstarted for newly diagnosed hypothyroidism\nwith a starting dose of 100 μg/day. If in case\nof history of cardiac disease, a lower dose\nshould be introduced.\n•\nIf dose adjustments are made during pregnancy,\nthe dose should be reduced to pre-pregnancy\ndose after delivery to prevent hyperthyroidism.",
  "This will not\ncause foetal thyrotoxicosis.\n•\nWomen who are already on levothyroxine\ntherapy can continue the same dose guided by\nthyroid function tests (TFT).\n•\nWomen who are under replacement therapy need\nadjustment of dose and TFT should be repeated\nafter 4-6 weeks.\n•\nImmediate replacement therapy should be\nstarted for newly diagnosed hypothyroidism\nwith a starting dose of 100 μg/day. If in case\nof history of cardiac disease, a lower dose\nshould be introduced.\n•\nIf dose adjustments are made during pregnancy,\nthe dose should be reduced to pre-pregnancy\ndose after delivery to prevent hyperthyroidism.\n\n--- Page 8 ---\n122\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nSubclinical Hypothyroidism\nInclude the group of women who do not have\nsymptoms and signs suggestive of thyroid dysfunction\nand who present with high TSH and normal thyroxine\nlevels. It is common in the presence of anti-thyroid\nantibodies. Evidence reports improved pregnancy\noutcome in women supplemented with thyroxine in\nthe presence of anti-thyroid antibodies. However, TSH\nlevel between 2.5-4.0 mU/L in asymptomatic patients\ndoes not require treatment5.\nControlled Anti Thyroid Screening trial (CATS) and\nMaternal-Foetal Medicine Units Networks randomized\ntrials published in 2017 demonstrated no difference in\nneuro cognitive functions of babies born to mothers\nwith sub clinical hypothyroidism up to the age of 5 in\nboth arms of treatment or no treatment. Recently CATs\nstudy in its publication of follow up at 9 years also\nconfirmed no difference in the neurodevelopment of\nthe offspring. However, reading through published trials\nsome have shown higher incidences of preterm birth,\nabruption, admission to (PBU) premature baby unit,\nPreeclampsia and gestational diabetes14,15,16,17. But some\nstudies have not shown the same results18,19,20. There-\nfore our conclusion is at present there is no clinical\nadvantage in treatment of subclinical hypothy-\nroidism unless there is the presence of anti-thyroid\nantibodies of the mother.\nWe recommend thyroxine replacement with 25-50\nmicrogram/ day for prenatal women with positive\nantibodies and subclinical hypothyroidism and titration\nof TSH to normal levels.\nUntreated severe hypothyroidism in the mother can\nlead to impaired brain development in the foetus. Given\nambiguity in outcome of many studies in evaluating\npros and cons of treating subclinical hypothyroidism,\nthere is no world-wide consensus of opinion regarding\nscreening all women for hypothyroidism during\npregnancy.\nGeneral recommendation is to check a woman’s TSH\nas soon as pregnancy is confirmed in women at high\nrisk for thyroid disease, such as those with prior\ntreatment for hyper- or hypothyroidism, a family history\nof thyroid disease, a personal history of autoimmune\ndisease, and those with a goiter.\nWomen with established hypothyroidism should have\na TSH test as soon as pregnancy is confirmed. They\nalso should immediately increase their levothyroxine\ndose, because thyroid hormone requirements increase\nduring pregnancy. If new onset hypothyroidism has\nbeen detected, the woman should be treated with\nlevothyroxine to normalize her TSH values.\nFoetal / Neonatal Hypothyroidism\nOccur due to transplacental passage of maternal anti-\nthyroid antibodies with incidence of 1 in 180,000\npregnancies.\nWe recommend screening of all neonates with TSH\nlevels via Guthrie Heel Prick Neonatal Screening test.\nPostpartum Thyroiditis\nIncidence around 1-17% of pregnancies and is more\ncommon among women with anti-thyroid peroxidase\n(anti-TPO) antibodies. It is usually asymptomatic and\npresent around 3-4 months postpartum. It can present\nas transient hyperthyroidism, transient hypothyroidism\nor as a biphasic disease (first hyperthyroidism followed\nby prolonged hypothyroidism). Small, painless goitre\ncan be present in about 50% of women.\nTreatment should be guided by symptom control while\nmost recover spontaneously without treatment. 3-4%\nof women will have permanent hypothyroidism and\nabout 10-25% of women will have recurrence in future\npregnancies.\nMost women with positive antibodies will develop\npostpartum depression despite thyroid status.\nSLCOG is of the view, that uncomplicated thyroid\ndisease could be managed by the Obstetrics and\nGynaecology Consultant with clear knowledge of the\ndisease process.\nReferences\n1.\nStudd L. Progress in Obstetrics and Gynaecology.\nVolume 18.\n2.\nICCIDD, UNICEF, WHO. Assessment of iodine\ndeficiency disorders and monitoring their\nelimination: a guide for programme managers.\nGeneva: World Health Organisation; 2007.\n3.\nChandrasinghe P, Fernando R, Nandasena S,\nPathmeswaran A. Epidemiology of goitres in Sri\nLanka with geographic information system\nmapping: population-based cross-sectional study.\nWorld J Endocr Surg 2015; 7(3): 55-9.",
  "Assessment of iodine\ndeficiency disorders and monitoring their\nelimination: a guide for programme managers.\nGeneva: World Health Organisation; 2007.\n3.\nChandrasinghe P, Fernando R, Nandasena S,\nPathmeswaran A. Epidemiology of goitres in Sri\nLanka with geographic information system\nmapping: population-based cross-sectional study.\nWorld J Endocr Surg 2015; 7(3): 55-9.\n\n--- Page 9 ---\n123\nVol. 44, No. 2, June 2022\nSLCOG Guideline\n4.\nFernando RF, Chandrasinghe PC, Pathmeswaran\nAA. The prevalence of autoimmune thyroiditis after\nuniversal salt iodisation in Sri Lanka. Ceylon Med\nJ 2012; 57(3): 116-19.\n5.\nGunawardane IK, Somasundaram N. Update on\nsubclinical thyroid disease. Sri Lanka Journal of\nDiabetes, Endocrinology and Metabolism 2013; 3:\n84-7.\n6.\nThyroid disease in pregnancy. ACOG Practice\nBulletin No.223. American College of Obstetricians\nand Gynaecologists. Obstet Gynecol 2020; 135:\ne261-74.\n7.\nAlexander EK, Pearce EN, Brent GA, Brown RS,\nChen H, Dosiou C, et al. 2017 guidelines of the\nAmerican Thyroid Association for the diagnosis\nand management of thyroid disease during\npregnancy and the postpartum. Thyroid 2017; 27:\n315-89.\n8.\nDong AC, Stagnaro-Green A. Differences in\ndiagnostic criteria mask the true prevalence of\nthyroid disease in pregnancy: a systematic review\nand meta-analysis. Thyroid 2019; 29: 278-89.\n9.\nHarding KB, Peña?Rosas JP, Webster AC, Yap CM,\nPayne BA, Ota E, et al. Iodine supplementation\nfor women during the preconception, pregnancy\nand postpartum period.\nCochrane Database of Systematic Reviews 2017,\nIssue 3. Art. No.: CD011761. DOI: 10.1002/\n14651858.CD011761.\n10. Ross DS, Burch HB, Cooper DS, Greenlee MC,\nLaurberg P, Maia AL, Rivkees SA, Samuels M,\nSosa JA, Stan MN, Walter MA. 2016 American\nThyroid Association Guidelines for Diagnosis and\nManagement of Hyperthyroidism and Other Causes\nof Thyrotoxicosis. Thyroid 2016; 25: 10\nDOI: 10.1089/thy.2016.0229.\n11. Pearce EN. Management of thyrotoxicosis:\npreconception, pregnancy, and the postpartum\nperiod. Endocr Pract 2019; 25: 62-8.\n12. Casey BM, Dashe JS, Wells CE, McIntire DD,\nLeveno KJ, Cunningham FG. Subclinical\nhyperthyroidism and pregnancy outcomes. Obstet\nGynecol 2006; 107: 337-41. (Level II-2)\n13. Diéguez M, Herrero A, Avello N, Suárez P, Delgado\nE, Menéndez E. Prevalence of thyroid dysfunction\nin women in early pregnancy: does it increase with\nmaternal age? Clin Endocrinol (Oxf) 2016; 84:\n121-6. (Level II-3)\n14. Tudela CM, Casey BM, McIntire DD, Cunningham\nFG. Relationship of subclinical thyroid disease to\nthe incidence of gestational diabetes. Obstet\nGynecol 2012; 119: 983-8. (Level II-3)\n15. Wilson KL, Casey BM, McIntire DD, Halvorson\nLM, Cunningham FG. Subclinical thyroid disease\nand the incidence of hypertension in pregnancy.\nObstet Gynecol 2012; 119: 315-20. (Level II-3)\n16. Casey BM, Dashe JS, Wells CE, McIntire DD,\nByrd W, Leveno KJ, et al. Subclinical hypothy-\nroidism and pregnancy outcomes. Obstet Gynecol\n2005; 105: 239-45. (Level II-2)\n17. Korevaar TI, Derakhshan A, Taylor PN, Meima\nM, Chen L, Bliddal S, et al. Association of thyroid\nfunction test abnormalities and thyroid auto-\nimmunity with preterm birth: a systematic review\nand meta-analysis. Consortium on Thyroid and\nPregnancy-Study Group on Preterm Birth\n[published erratum appears in JAMA 2019; 322:\n1718]. JAMA 2019; 322: 632-41. (Systematic\nReview and MetaAnalysis\n18. Sheehan PM, Nankervis A, Araujo Júnior E, Da\nSC. Maternal thyroid disease and preterm birth:\nsystematic review and meta-analysis. J Clin\nEndocrinol Metab 2015; 100: 4325-31.\n(Systematic Review and Meta-Analysis)\n19. Cleary-Goldman J, Malone FD, Lambert-\nMesserlian G, Sullivan L, Canick J, Porter TF, et al.\nMaternal thyroid hypofunction and pregnancy\noutcome. Obstet Gynecol 2008; 112: 85-92. (Level\nII-3)\n20. Casey BM, Dashe JS, Spong CY, McIntire DD,\nLeveno KJ, Cunningham GF. Perinatal significance\nof isolated maternal hypothyroxinemia identified\nin the first half of pregnancy. Obstet Gynecol\n2007; 109: 1129-35. (Level II3)\n21. Leung AKC, Leung AAC. Evaluation and\nmanagement of the child with hypothyroidism.\nWorld J Pediatr. 2019; 15(2): 124-134. [PubMed]\n22. Yuan J, Sun C, Jiang S, Lu Y, Zhang Y, Gao XH,\nWu Y, Chen HD. The Prevalence of Thyroid\nDisorders in Patients With Vitiligo: A Systematic\nReview and Meta-Analysis. Front Endocrinol\n(Lausanne). 2018; 9: 803.",
  "Front Endocrinol\n(Lausanne). 2018; 9: 803.\n\n--- Page 10 ---",
  "--- Page 1 ---\nNATIONAL GUIDELINES FOR\nMATERNAL CARE\nVOLUME I\nMINISTRY OF HEALTH\n2013\n• Management of Labour\n• Management of Hypertension, Pre Eclampsia \nand Eclampsia in Pregnancy\n• Management of Diabetes During Pregnancy\n• Management of Post-Partum Haemorrhage\nWorld Health\nOrganization\nFamily Health Bureau\n\n--- Page 2 ---\n\n--- Page 3 ---\nNATIONAL GUIDELINE FOR MATERNAL CARE\nVOLUME I\n• \nManagement of Labour\n \n \nNormal Labour \n \n \nInduction of Labour\n \n \nUse of Oxytocins in Induction and Augmentation\n \n \nFoetal Monitoring in Labour\n \n \nPain Relief\n \n \nAcute Inversion of Uterus\n• \nManagement of Hypertension, Pre Eclampsia and \nEclampsia in Pregnancy\n• \nManagement of Diabetes in Pregnancy\n• \nManagement of Post-Partum Haemorrhage\nMINISTRY OF HEALTH\n2013\nWorld Health\nOrganization\nFamily Health Bureau",
  "--- Page 4 ---\nNational Guideline for Maternal Care - Volume I\nii\nThese guidelines are published by the Family Health Bureau, Ministry of \nHealth, 231, De Saram Place, Colombo 10, Sri Lanka.\nWeb: www.familyhealth.gov.lk\nPrepared by Sri Lanka College of Obstetrians and Gynaecologists\nEdited By Dr. Nilmini Hemachnadra, Consultant Community Physician, \nFamily Health Bureau & Prof. Hemantha Senanayake, President, Sri Lan-\nka College of Obstetricians & Gynaecologists.\nCopyright@2013 Ministry of Health\nISBN 978 - 955 - 1503 - 15 - 4\nStatement of Intent\nThe main purpose of these guidelines are to improve the quality of \nclinical care provided by the health care providers at all levels. These \nparameters of practice should be considered recommendations \nonly. The ultimate judgement regarding a particular clinical \nprocedure or a treatment plan must be made by the clinician in \nlight of the clinical data gathered from the patient and the diagnosis \nand treatment options available.\nPrinted by Lazergraphic (PVT) Ltd.",
  "These \nparameters of practice should be considered recommendations \nonly. The ultimate judgement regarding a particular clinical \nprocedure or a treatment plan must be made by the clinician in \nlight of the clinical data gathered from the patient and the diagnosis \nand treatment options available.\nPrinted by Lazergraphic (PVT) Ltd.\n\n--- Page 5 ---\nNational Guideline for Maternal Care - Volume I\niii\nForeword from the Secretary to the Ministry of Health\nAs a country with a mainly government owned health system, maintenance \nof the uniformity of practices is essential to avoid incurring unnecessary \nexpenditure. Incorporation and practice of evidence based cost effective \ninterventions in maternal care will ensure further improvement of the \nmaternal care indicators.  \nThe availability and use of guidelines will ensure the quality of the care \nprovided at each level and facilitate the care provision of practicing \nclinicians for better care. The Ministry of Health having achieved a \nsatisfactory level in the coverage of services and geared to improve it \nfurther, is currently moving towards improving the quality of services \nprovided. With this view, most of the institutions are now implementing \nquality improvement programmes.\nTherefore, this set of guidelines will assist such programmes and auditing \nsystems in the maternal care such as maternal mortality reviews, \nconfidential inquiry into maternal deaths, near-miss inquiries and \nensure a more objective assessment. These guidelines should be link with \nthe quality standards and the implementation at each level needs to be \nensured.\nSri Lanka College of Obstetricians and Gynaecologists has managed to in \nco-operate the currently available best scientific evidence and the practical \nexperience of a large number of experts into these guidelines.\nI wish all the healthcare providers would make maximum use of these \nguidelines and contribute to the further improvement of the maternal care \nin our country.\nDr. Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka",
  "Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka\n\n--- Page 6 ---\nNational Guideline for Maternal Care - Volume I\niv",
  "Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka\n\n--- Page 6 ---\nNational Guideline for Maternal Care - Volume I\niv\n\n--- Page 7 ---\nNational Guideline for Maternal Care - Volume I\nv\nPreface\nThis national guideline on maternal care is very well-timed, as a greater \nemphasis is being given for improving the quality of maternal and \nnewborn care services for further reduction of maternal and newborn \nmortality and morbidity in Sri Lanka. This set of guidelines includes \nthe revised versions of some guidelines published in 2007 under HSDP \nPhase I and newly developed guidelines. This is an attempt to improve the \nquality and uniformity of clinical care with efficiency, cost effectiveness \nand accountability.\nI highly appreciate the contribution made by the Sri Lanka College of \nObstetricians and Gynaecologists in developing these guidelines. Their \nexperience and updated scientific knowledge is reflected in the guidelines. \nFurther, these guidelines have been developed considering the policies, \nfacilities and resources available in the country. As such this set of \nguidelines will be considered as national guidelines for the conditions \ndescribed.  \nDr. P. G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka.",
  "G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka.\n\n--- Page 8 ---\nNational Guideline for Maternal Care - Volume I\nvi\nMessage from the president of Sri Lanka College of \nObstetricians\nIt is with a great sense of achievement that I issue this statement for the \nSri Lanka National Guidelines in obstetrics. There is evidence that the \nintroduction of guideline-based practice will reduce maternal mortality. \nWe hope that this effect will be duplicated in Sri Lanka.\nI must compliment the Guideline Development Group of our College. \nThis document is testimony to their hard work and their commitment to \nimproving the quality of care delivered to our women. The group consisted \nof obstetricians from varying seniority and from hospitals representing \nall categories of specialist units in the country. We were therefore able to \ndevelop our guidelines taking into considerations the ground realities in \nSri Lanka. I was heartened by the maturity shown by the younger members, \nwho contributed immensely to the many points that were debated while \nthese were being developed. We have used the latest available evidence \nand taken into account what would be feasible in a Sri Lankan Unit. For \nwhat we have recommended as improvements to the existing practice we \nhave had agreement from the Ministry of Health to procure these. \nI wish also to acknowledge our general membership who contributed to \nthese guidelines via email and at a meeting where their views were sought. \nIt is always a challenge to produce guidelines that will be put into use in \neveryday practice and it is probable we have achieved this primary goal by \nhaving a broad based input. \nThe World Health Organization and the UNFPA supported this activity. \nDr. Nilmini Hemachandra of the Family Health Bureau helped get the \nfinal product into a form that was easily understood by the non-specialist. \nWe are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja",
  "We are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja\n\n--- Page 9 ---\nNational Guideline for Maternal Care - Volume I\nvii\nJayasinghe and Ramani Pallemulla. The guideline on diabetes mellitus \ncomplicating pregnancy had major inputs from the Nirogi Matha project \nand many endocrinologists. \nTo conclude I wish to restate my wish and fervent hope that these \nguidelines will help save the lives of many Sri Lankan mothers. \nProf. Hemantha Senanayake\nPresident,\nSri Lanka College of Obstetricians & Gynaecologists\n\n--- Page 10 ---\nNational Guideline for Maternal Care - Volume I\nviii\nGuideline Development Committee\nDr. Asoka Weerakkody (Chairman)\nProf. Hemantha Senanayake\nProf. Malik Goonawardena\nDr. Ananda Ranatunga\nDr.UDP Ratnasiri\nDr. Sunil Fernando\nDr. Harsha Atapattu\nDr. Mangala Dissanayake\nDr. Chandina Wedamistri\nDr. Jeevan Marasinghe\nDr. Tiran Dias\nDr. Asanka Jayawardena",
  "Tiran Dias\nDr. Asanka Jayawardena\n\n--- Page 11 ---\nNational Guideline for Maternal Care - Volume I\nix\nContent page \n \n \n \n \nPage\n \nMessage from the Secretary of Ministry of Health \niii\n \nPreface \n \nv\n \nMessage from the President of the Sri Lanka College of \n \nObstetricians and Gynecologists \nvi \n \nGuideline Development Committee \nviii\n \nList of Abbreviations \nxiii\n \nList of Tables \nxiv\n \nDisclaimer \nxv\n \nIntroduction \nxvi\n A\t\nManagement of Labour\t\n3\n1. \nIntroduction \n3\n2. \nDiagnosis of labour \n3\n3. \nManagement of Labour \n4\n3.1 \nGeneral considerations \n4\n3.1.1 \nCommunication between women and healthcare  \n  \nprofessionals/workers \n4\n3.1.2 \nPreparation of mothers to transfer to labour room \n4\n3.1.3 \nDocumentation \n5\n3.1.4  \nMobilization and Positioning \n5\n3.1.6 \nHygiene during labour \n5\n3.1.7 \nPain relief in labour \n6\n3.2. \nManagement of the three stages of labour \n6\n3.2.1.  \nManagement of the first stage of labour \n6\n3.2.1.1 \nLatent phase  \n6\n3.2.1.2 \nActive phase \n7\n3.2.1.2a.  Admitting women to the Labour room \n7\n3.2.1.2b.  Management of active phase of first stage \n8\n3.2.1.3.  \nDelayed progress of first stage of labour \n9\n3.2.2.  \nManagement of second stage of labour \n10\n3.2.2.1.  \nPassive second stage of labour (descent phase) \n10\n3.2.2.2.  \nActive second stage of labour (expulsive phase) \n11\n3.2.2.3.  \nObservations for women and babies in the second stage of labour \n12\n3.2.2.4.  \nWomen’s position and pushing in the second stage of labour \n12\n3.2.2.5.  \nIntrapartum interventions to reduce perineal trauma \n13\n3.2.2.6.  \nDelivery \n13\n3.2.3 \nThird stage of Labour \n14\n3.2.3.1 \nActive management of third stage of labour \n14\n3.2.3.2 \nDelayed third stage \n15\n4 \nCare for the newborn baby \n15\n5 \nPerineal care \n17",
  "Intrapartum interventions to reduce perineal trauma \n13\n3.2.2.6.  \nDelivery \n13\n3.2.3 \nThird stage of Labour \n14\n3.2.3.1 \nActive management of third stage of labour \n14\n3.2.3.2 \nDelayed third stage \n15\n4 \nCare for the newborn baby \n15\n5 \nPerineal care \n17\n\n--- Page 12 ---\nNational Guideline for Maternal Care - Volume I\nx\n B\t\nGuideline on Induction of Labour \n19\n1 \nIntroduction \n19\n2 \nDefinition \n19\n3 \nGeneral Principles \n19\n4 \nIndications \n19\n4.1 \nOtherwise uncomplicated pregnancy continuing \n  \nbeyond 40 weeks \n19\n4.2 \nPre labour rupture of membranes at term \n20\n4.3 \nPreterm prelabour rupture of membranes (PPROM) \n20\n4.4   \nIntrauterine death \n20\n4.5   \nHistory of precipitate labour \n20\n4.6   \nSuspected macrosomia \n20\n4.7   \nFetal growth restriction \n21\n4.8   \nOlder mothers \n21\n5 \nInduction under specific circumstances \n21\n5.1   \nBreech presentation \n21\n5.2 \nPrevious CS \n21\n6.   \nMethods of induction \n21\n6.1 \nMechanical \n21\n6.2   \nSurgical \n22\n6.3   \nPharmacological \n22\n6.3.1   \nOxytocin \n22\n6.3.2 \nProstaglandins \n22\n6.3.3 \nMifepristone \n23\n7.   \nComplications \n24\n7.1 \nHyperstimulation \n24\n7.2 \nCord prolapse \n24\n7.3 \nUterine rupture \n25\n7.4 \nFailed induction \n25\n C\t\nGuideline for Use of Oxytocin for Induction and Augmentation \n\t\nof labour\t \t\n27\n D\t\nGuideline on fetal monitoring in labour\t\n30\n\t\n E\t\nGuideline on Pain Relief in Labour \n34\n1 \nMethods of pain relief in labour \n34\n1.1 \nNon-pharmacological methods of pain relief \n35\n1.2 \nPharmacological methods of pain relief in labour \n35\n1.2.1 \nOral paracetamol/paracetamol& codeine compound \n35\n1.2.2 \nOpioids \n35\n1.2.2.A. \nPethidine \n35\n1.2.2.B. \nMorphine \n36\n1.2.2.C. \nFentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37",
  "Morphine \n36\n1.2.2.C. \nFentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37\n\n--- Page 13 ---\nNational Guideline for Maternal Care - Volume I\nxi\n F\t\nGuidelines to maintain the partograph\t\n39\n\t\n G\t\nGuideline on acute puerperal inversion of the uterus \n41\n1 \nIntroduction \n41\n2 \nDefinition \n41\n3 \nPrevention \n41\n4 \nPathophysiology (and clinical correlation) \n41\n5 \nClassification \n42\n6 \nClinical Presentation and diagnosis \n42\n7 \nManagement \n43\n7.1 \nGeneral measures \n43\n7.2 \nRepositioning the uterus \n43\n7.2.1 \nManual replacement of uterus \n43\n7.2.2 \nHydrostatc reduction \n44\n7.2.3 \nTocolytics \n45\n7.2.4 \nGeneral Anaesthesia \n45\n7.2.5 \nSurgical methods \n45\n8 \nDebriefing \n46\n H\t\nManagement of Hypertensive Disease in Pregnancy \n47\n1 \nIntroduction \n49\n2 \nDefinitions \n49\n3 \nScreening for Hypertension during pregnancy \n50\n4 \nPrevention of hypertensive disorders in pregnancy \n50\n5 \nManagement of Chronic Hypertension  \n51\n6 \nManagement of severe pre eclampsia \n52\n6.1 \nGeneral Considerations \n52\n6.2 \nSpecific Management \n52\n6.2.1 \nAnti-hypertensive drugs \n53\n6.2.1.1 \nLabetalol orally or intravenously \n53\n6.2.1.2 \nHydralazine intravenously \n54\n6.2.1.3 \nOral Nifedipine \n55\n6.2.2 \nPrevention of convulsions \n55\n6.2.3 \nFluid Balance \n56\n6.2.4 \nIn utero/neonatal transfer \n56\n6.2.5 \nDelivery \n57\n6.2.6 \nPost-delivery \n57\n6.2.7 \nFollow up \n58\n \n I\t\nManagement of Eclampsia \n59\n1 \nDefinition \n59\n2 \nDiagnosis \n59\n3 \nTime of onset of eclampsia \n59\n4 \nComorbidities \n59\n5 \nPrevention \n60\n6 \nManagement \n60\n6.1 \nGeneral considerations \n60\n6.2. \nDuring the seizure \n61",
  "Fentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37\n\n--- Page 13 ---\nNational Guideline for Maternal Care - Volume I\nxi\n F\t\nGuidelines to maintain the partograph\t\n39\n\t\n G\t\nGuideline on acute puerperal inversion of the uterus \n41\n1 \nIntroduction \n41\n2 \nDefinition \n41\n3 \nPrevention \n41\n4 \nPathophysiology (and clinical correlation) \n41\n5 \nClassification \n42\n6 \nClinical Presentation and diagnosis \n42\n7 \nManagement \n43\n7.1 \nGeneral measures \n43\n7.2 \nRepositioning the uterus \n43\n7.2.1 \nManual replacement of uterus \n43\n7.2.2 \nHydrostatc reduction \n44\n7.2.3 \nTocolytics \n45\n7.2.4 \nGeneral Anaesthesia \n45\n7.2.5 \nSurgical methods \n45\n8 \nDebriefing \n46\n H\t\nManagement of Hypertensive Disease in Pregnancy \n47\n1 \nIntroduction \n49\n2 \nDefinitions \n49\n3 \nScreening for Hypertension during pregnancy \n50\n4 \nPrevention of hypertensive disorders in pregnancy \n50\n5 \nManagement of Chronic Hypertension  \n51\n6 \nManagement of severe pre eclampsia \n52\n6.1 \nGeneral Considerations \n52\n6.2 \nSpecific Management \n52\n6.2.1 \nAnti-hypertensive drugs \n53\n6.2.1.1 \nLabetalol orally or intravenously \n53\n6.2.1.2 \nHydralazine intravenously \n54\n6.2.1.3 \nOral Nifedipine \n55\n6.2.2 \nPrevention of convulsions \n55\n6.2.3 \nFluid Balance \n56\n6.2.4 \nIn utero/neonatal transfer \n56\n6.2.5 \nDelivery \n57\n6.2.6 \nPost-delivery \n57\n6.2.7 \nFollow up \n58\n \n I\t\nManagement of Eclampsia \n59\n1 \nDefinition \n59\n2 \nDiagnosis \n59\n3 \nTime of onset of eclampsia \n59\n4 \nComorbidities \n59\n5 \nPrevention \n60\n6 \nManagement \n60\n6.1 \nGeneral considerations \n60\n6.2. \nDuring the seizure \n61\n\n--- Page 14 ---\nNational Guideline for Maternal Care - Volume I\nxii\n6.3.  \nAs soon as possible following a seizure \n61\n6.4. \nManagement of seizures in women receiving \n  \nmagnesium sulphate \n62\n7. \nDelivery \n62\n8. \nTransfer of a woman who has had a seizure to another institution \n63\n9. \nPostpartum management \n63\n10. \nCounselling  \n64\n J\t\nManagement of Diabetes during Pregnancy  \n67\n1 \nPurpose \n67\n2 \nScreening \n67\n2.1 \nTarget groups for screening \n67\n2.2 \nRecommended tests \n68\n3 \nManagement – Women with established Diabetes \n70\n3.1 \nPre Pregnancy care \n70\n3.2 \nAntenatal Care \n71\n3.3 \nMedical nutrition therapy (MNT) \n72\n3.4 \nExercise \n72\n4 \nGlyceamic control and Monitoring  \n73\n4.1 \nGlyceamic Control \n73\n4.2 \nMonitoring of glycaemic control \n74\n5 \nDelivery and intra natal care \n74\n5.1 \nTiming of delivery \n74\n5.2 \nLabour care \n75\n6 \nPost natal care \n75\n6.1.a \nNeonatal care \n75\n6.1.b \nImmediate post partum care \n76\n6.2 \nAt hospital discharge \n76\n6.3 \nLate Postnatal care and follow up \n77\n7 \nFamily Planning \n77\n K\t\nManagement of Primary Post Partum Haemorrhage \n81\n1 \nIntroduction \n81\n2 \nDefinition \n81\n3 \nPrevention of Post Partum Haemorrhage \n81\n4 \nPrediction of Post Partum Haemorrhage \n82\n5 \nManagement of Primary PPH \n83\n5.1 \nGeneral measures \n83\n5.2 \nSpecific measures \n84\n5.2.1 \nEstablish a cause for the bleeding  \n84\n5.2.2. \nManagement of atonic haemorrhage \n85\n5.2.3 \nManagement of traumatic PPH \n86\n5.2.4 \nRupture of the uterus \n87\n5.2.5 \nCoagulopathy causing PPH \n87\n6. \nResuscitation and Fluid management \n87\n7. \nDebriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume I\nxiv\nList of Tables\nGuidelines for ruse of oxytocin for induction and augmentation of labour\nTable 1 \nmU/minute administered at different rates of administration \naccording to drop rate\nTable 2 \nmU/minute infused per minute when administered via an infusion \npump\nGuideline on fetal monitoring in labour\nTable 1 \nDefinitions of normal, suspicious and pathological FHR rates\nTable 2 \nClassification of fetal heart rate patterns\nGuideline for screening, diagnosis and management of diabetes in pregnant \nwomen\nTable 1 \nTarget values in glycaemic control",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume I\nxiv\nList of Tables\nGuidelines for ruse of oxytocin for induction and augmentation of labour\nTable 1 \nmU/minute administered at different rates of administration \naccording to drop rate\nTable 2 \nmU/minute infused per minute when administered via an infusion \npump\nGuideline on fetal monitoring in labour\nTable 1 \nDefinitions of normal, suspicious and pathological FHR rates\nTable 2 \nClassification of fetal heart rate patterns\nGuideline for screening, diagnosis and management of diabetes in pregnant \nwomen\nTable 1 \nTarget values in glycaemic control\n\n--- Page 17 ---\nNational Guideline for Maternal Care - Volume I\nxv\nDisclaimer\nThese guidelines are based on current best available evidence and \nconsensus opinion of the Guideline Development committee of \nthe Sri Lanka College of Obstetricians & Gynaecologists. They are \nneither intended to replace the process of critical evaluation of \nevery case and nor it is intended to dictate an exclusive course of \nmanagement or treatment. It must be interpreted with reference to \nindividual patient needs, available resources and limitations unique \nto the institution and variations in local populations.\nMedicine is a continually evolving science and the users must have \nregard to relevant information, research or material, which may \nhave been published or become available subsequently.",
  "They are \nneither intended to replace the process of critical evaluation of \nevery case and nor it is intended to dictate an exclusive course of \nmanagement or treatment. It must be interpreted with reference to \nindividual patient needs, available resources and limitations unique \nto the institution and variations in local populations.\nMedicine is a continually evolving science and the users must have \nregard to relevant information, research or material, which may \nhave been published or become available subsequently.\n\n--- Page 18 ---\nNational Guideline for Maternal Care - Volume I\nxvi\nIntroduction\nClinical Guidelines are systematically developed statements which assist \nclinicians and patients in making decisions about appropriate treatment \nfor specific conditions based on the best scientific evidence at the time of \ndevelopment. Guidelines are not intended to limit the clinical freedom; \nhowever, clinicians are expected to follow these recommendations as the \nbasis for their decision making. Availability of resources, the existing \nsituations, and the expectations of individual client needs to be considered. \nThe guidelines are intended to guide all health care workers in all levels \nof institutions where maternity care is being provided. Although these \nguidelines are mainly targeted for the government sector institutions, use \nin the private sector institutions where maternity care is being provided, \nis also encouraged.\nThese guidelines are developed by the guideline development committee \nof the Sri Lanka College of Obstetricians and Gynaecologists in \nconsultation with other relevant specialists such as anaesthesiologists, \nphysicians, endocrinologists, and haematologists etc. The existing \nnational guidelines developed in 2007, NICE guidelines on intranatal \ncare, WHO guidelines and RCOG guidelines were perused and mixed \nwith the local scenarios and expert opinion. The latest available scientific \nevidences were considered and included where ever necessary. Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.",
  "Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 19 ---\nNational Guideline for Maternal Care - Volume I\n1\nManagement of Labour\n\n--- Page 20 ---\nNational Guideline for Maternal Care - Volume I\n2",
  "Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 19 ---\nNational Guideline for Maternal Care - Volume I\n1\nManagement of Labour\n\n--- Page 20 ---\nNational Guideline for Maternal Care - Volume I\n2\n\n--- Page 21 ---\nNational Guideline for Maternal Care - Volume I\n3\nManagement of Normal Labour\n1.\t Introduction\nThe aim of this guideline is to provide recommendations to care providers \nin the management of a healthy woman with a single fetus in labour at \nterm (37-42weeks). It does not cover the care of women with complicated \npregnancies. \nThe objective of this guideline is to ensure optimal management of \nwomen in labour, detect any abnormalities, take appropriate action, \nprevent complications and thus make childbirth safer; and also to make \nsure that these women are treated with respect and compassion, and kept \nwell informed and well supported throughout labour. \n2.\t Diagnosis of Labour\nLabour is diagnosed by the presence of regular, painful intermittent \ncontractions, which are of increasing frequency, duration and intensity, \nleading to progressive cervical effacement and dilatation. \nNote:  for the purpose of this guideline, labour is also diagnosed in the \npresence of painful contractions occurring at a frequency of 2 in 10 \nminutes or more.\nDefinitions: \nLatent phase of the first stage of labour – from the commencement \nof labour to a cervical dilatation of up to 4 cm. (This is a period \nof time, not necessarily continuous, when there are painful \ncontractions and some cervical changes including cervical \neffacement and dilatation up to 4cm take place)\nActive phase of the first stage of labour – commences at a cervical \ndilatation of 4cm and ends with full dilatation. (There are regular \npainful contractions and progressive cervical dilatation from 4cm \nup to full dilatation).",
  "(This is a period \nof time, not necessarily continuous, when there are painful \ncontractions and some cervical changes including cervical \neffacement and dilatation up to 4cm take place)\nActive phase of the first stage of labour – commences at a cervical \ndilatation of 4cm and ends with full dilatation. (There are regular \npainful contractions and progressive cervical dilatation from 4cm \nup to full dilatation).\n\n--- Page 22 ---\nNational Guideline for Maternal Care - Volume I\n4\nIf the diagnosis of labour is uncertain, observation should continue and \nreassessment made in four hours. \nAny woman who is diagnosed as not being in labour, but continues to \ncomplain of pain, would require careful reassessment by an experienced \nmedical officer. Possible diagnoses of placental abruption and non-\nobstetric causes should be considered. Fetal compromise should be \nexcluded. \n3.\t\nManagement of labour\n3.1. \nGeneral considerations\n3.1.1. Communication between women and healthcare professionals/\nworkers\n• \nGreet the mother with a smile and a personal welcome\n• \nTreat them with respect and dignity \n• \nAssure privacy \n• \nEstablish a good rapport with the laboring women asking \nabout their wants and concerns and address them \n• \nMaintain a calm and confident approach which will reassure \nwomen that the situation is under control\n• \nAssess the woman’s knowledge of strategies for coping with \npain and provide balanced information to find out which \navailable approaches are acceptable to her\n• \nAsk her permission before all  procedures and observations, \nfocusing on the woman rather than technology or the \ndocumentation\n3.1.2. Preparation of mothers to transfer to labour room\n• \nShaving or trimming of perineal hair may be necessary to \nfacilitate unhindered performance and repair of the episiotomy.\n• \nEfforts must be made to minimize faecal soiling. Where \nan enema is deemed necessary, a medicated enema is \nrecommended. \n      (These two steps should not be considered mandatory)",
  "Where \nan enema is deemed necessary, a medicated enema is \nrecommended. \n      (These two steps should not be considered mandatory)\n\n--- Page 23 ---\nNational Guideline for Maternal Care - Volume I\n5\n• \nWomen should be encouraged to have a companion of her \nchoice during labour, depending on the facilities and clinical \nsituation.\n3.1. 3. Documentation \n• \nAdmit the mother to the labour room and complete the \n‘handing over’ form \n• \nEnter relevant notes on the BHT and start a partogragh (see \npage 39)\n• \nReview clinical notes and reassess risk factors.\n• \nAccurate documentation of all observations and interventions \nmust be made, with timing.\n• \nAll obstetric examinations and procedures carried out must \nbe documented in the clinical notes. Each entry must be \naccompanied by a plan for management and be signed by the \nresponsible person.  \n3.1.4. Mobilization and Positioning\n• \nWomen should be encouraged and helped to move about \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nThey need to be encouraged to void urine at regular intervals.\n3.1.5. Eating and drinking in labour\n• \nMothers must be encouraged to consume clear, non-\nfizzy liquids during labour. Isotonic solutions such as oral \nrehydration fluid and king coconut water are more beneficial \nthan water. \n• \nIn addition to clear fluids, women in the latent phase may \nconsume light solids e.g. biscuits and fruits. \n3.1.6. Hygiene measures during labour\n• \nStrict asepsis must be maintained during labour. \n• \nInstruments should be available in packets",
  "Hygiene measures during labour\n• \nStrict asepsis must be maintained during labour. \n• \nInstruments should be available in packets\n\n--- Page 24 ---\nNational Guideline for Maternal Care - Volume I\n6\n• \nUse proper hand washing technique.\n• \nUse of double gloves and disposable gloves is encouraged.  \n3.1.7. Pain relief in labour\nRelief of pain should be a major consideration (please refer guidelines on \npain relief during labour in page 34)\n3.2. \nManagement of the three stages of labour\nThe practice of maintaining a labour room ‘notice board’ - a ‘white \nboard’ on which the status of all women in labour is summarized \nand updated regularly is encouraged. This would convey at a glance \nto all care providers women who require additional attention. The \nage, parity status, risk factors, salient findings at each assessment \nand any abnormalities noted must be included in this.\n3.2.1. Management of first stage of labour\n3.2.1. 1. Latent phase \nIt is important to recognize the latent phase of labour, since its prolongation \ncould lead to maternal exhaustion, dehydration and acidosis, leading to \nfetal compromise and dysfunctional labour. \n \nWomen in the latent phase of labour would be best managed in the \nantenatal ward.\nWomen in the latent phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse half hourly\n• \nCheck  temperature four hourly\n• \nConsider vaginal examination four hourly, depending on the \ncontraction pattern and initial cervical dilatation\n• \nDocument the colour of amniotic fluid if the membranes \nrupture",
  "Latent phase \nIt is important to recognize the latent phase of labour, since its prolongation \ncould lead to maternal exhaustion, dehydration and acidosis, leading to \nfetal compromise and dysfunctional labour. \n \nWomen in the latent phase of labour would be best managed in the \nantenatal ward.\nWomen in the latent phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse half hourly\n• \nCheck  temperature four hourly\n• \nConsider vaginal examination four hourly, depending on the \ncontraction pattern and initial cervical dilatation\n• \nDocument the colour of amniotic fluid if the membranes \nrupture\n\n--- Page 25 ---\nNational Guideline for Maternal Care - Volume I\n7\n• \nUse of a sanitary pad may indicate early, the presence of \nmeconium. \n• \nConsider the requirement for analgesia.\nIt is important to inform the mother and reassure her that it is common to \nhave slow progress in the latent phase.  \nThe latent phase is considered prolonged when it lasts more than 12 hours \nin a primigravida and 8 hours in a multigravida. In these situations an \nexperienced medical officer (with a minimum one year of experience in \nthe field) must reassess the mother with a view of augmentation of labour. \n3.2.1.2. Active phase\n3.2.1.2a. Admitting women to the Labour Room\nAll pregnant women diagnosed as being in active phase of the first stage of \nlabour need to be admitted to the labour room.\nThe initial assessment of a woman in the labour room should include:\n• \nListening to her story, considering her emotional and \npsychological needs and reviewing her clinical records\n• \nPhysical observation: temperature, pulse, blood pressure\n• \nLength, strength and frequency of contractions\n• \nAbdominal palpation: fundal height, lie, presentation, position \nand station\n• \nVaginal loss: show, liquor, blood\n• \nAssessment of woman’s pain including her wishes for coping \nwith labour along with the range of options for pain relief\n• \nThe fetal heart rate (FHR)  should be auscultated preferably with \na hand held Doppler for a minimum of 1 minute immediately \nafter a contraction\n• \nThe maternal pulse should be recorded to differentiate between \nmaternal pulse and FHR\n• \nA vaginal examination should be offered",
  "Active phase\n3.2.1.2a. Admitting women to the Labour Room\nAll pregnant women diagnosed as being in active phase of the first stage of \nlabour need to be admitted to the labour room.\nThe initial assessment of a woman in the labour room should include:\n• \nListening to her story, considering her emotional and \npsychological needs and reviewing her clinical records\n• \nPhysical observation: temperature, pulse, blood pressure\n• \nLength, strength and frequency of contractions\n• \nAbdominal palpation: fundal height, lie, presentation, position \nand station\n• \nVaginal loss: show, liquor, blood\n• \nAssessment of woman’s pain including her wishes for coping \nwith labour along with the range of options for pain relief\n• \nThe fetal heart rate (FHR)  should be auscultated preferably with \na hand held Doppler for a minimum of 1 minute immediately \nafter a contraction\n• \nThe maternal pulse should be recorded to differentiate between \nmaternal pulse and FHR\n• \nA vaginal examination should be offered\n\n--- Page 26 ---\nNational Guideline for Maternal Care - Volume I\n8\nHealth care Professionals who conduct vaginal examination should:\n• \nBe sure that there is a valid indication for vaginal examination \nthat it will add important information to the decision making \nprocess\n• \nBe aware that for many women who may already in pain, \nhighly anxious and in an unfamiliar environment, vaginal \nexamination can be very distressing\n• \nEnsure the woman’s consent, privacy, dignity and comfort\n• \nExplain the reason for examination and what will be involved, \nand\n• \nExplain the findings and their impact sensitively to the woman\n3.2.1.2b.  Management of active phase of first stage\nMonitoring must be conducted as instructed in the partogram and \nfindings recorded accordingly. \nUse of a sanitary pad may indicate presence of meconium early. \nWomen in the active phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse every 15 minutes ;\n• \nCheck temperature and blood pressure four hourly;\n• \nVaginal examination four hourly or earlier, depending on the \nclinical situation; \n• \nFrequency of contractions should be monitored as follows:\n \nThe interval between two contractions should be assessed by \npalpation of the abdomen\n \nDuring active labor usually there are at least three contractions \nper ten minutes. In other words the interval between two \ncontractions should be three minutes\n• \nDocument the colour of amniotic fluid if the membranes \nrupture;\n• \nConsider the requirement for analgesia, (which now becomes \nmore important).",
  "Women in the active phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse every 15 minutes ;\n• \nCheck temperature and blood pressure four hourly;\n• \nVaginal examination four hourly or earlier, depending on the \nclinical situation; \n• \nFrequency of contractions should be monitored as follows:\n \nThe interval between two contractions should be assessed by \npalpation of the abdomen\n \nDuring active labor usually there are at least three contractions \nper ten minutes. In other words the interval between two \ncontractions should be three minutes\n• \nDocument the colour of amniotic fluid if the membranes \nrupture;\n• \nConsider the requirement for analgesia, (which now becomes \nmore important).\n\n--- Page 27 ---\nNational Guideline for Maternal Care - Volume I\n9\nIntermittent auscultation of the fetal heart is best performed using \nhand-held Doppler devices. The fetal heart rate must be counted \nfor one minute, beginning immediately after a contraction.\nThe mother may continue to consume clear fluids in the active phase. \nShe must be encouraged to assume any position that she is comfortable in \nand to avoid the dorsal position. \nWomen who have the following conditions are recommended to be have \nto continuous electronic fetal monitoring: \n• \nSignificant meconium staining of amniotic fluid, \n• \nAbnormal Fetal heart rate detected by intermittent \nauscultation (< 110 beats per minute; > 160 beats per minute; \nany decelerations after a contraction)\n• \nFresh vaginal bleeding and \n• \nMaternal pyrexia. \nIn women with spontaneous labour progressing normally, routine \nearly amniotomy and use of oxytocin is not recommended.\n3.2.1.3. Delayed progress of first stage of labour\nDelayed progress is diagnosed when there is progress of less than \ntwo cm in four hours. Slowing of progress in a woman who has \npreviously been progressing satisfactorily must also be considered \nas a delay.\nIt is extremely important that delay in progress is assessed by an \nexperienced medical officer. \nThis assessment must take into account:\n• \nthe uterine contractions, \n• \ndescent and position of the fetal head  \n• \nfeatures of early obstruction of labor (caput and moulding), and \n• \nThe fetal condition",
  "Slowing of progress in a woman who has \npreviously been progressing satisfactorily must also be considered \nas a delay.\nIt is extremely important that delay in progress is assessed by an \nexperienced medical officer. \nThis assessment must take into account:\n• \nthe uterine contractions, \n• \ndescent and position of the fetal head  \n• \nfeatures of early obstruction of labor (caput and moulding), and \n• \nThe fetal condition\n\n--- Page 28 ---\nNational Guideline for Maternal Care - Volume I\n10\nIn women with delay in the active phase of the first stage, every effort must \nbe made to find a cause for the delay. This may either be due to inadequate \ncontractions or obstruction due to CPD, mal-presentation or malposition \n(such as occipito-posterior position), or a combination of these. \nIn cases of inadequate contractions:\n• \nAmniotomy must be performed if membranes are still intact. \n• \nFollowing that, the woman must be reassessed in two hours \n• \nIn case there is inadequate progress, augmentation with \noxytocin must be considered. \n• \nThe situation must be reassessed after four hours or earlier if \nrequired.\nMultiparous women with delayed progress: \n• \nMust be viewed with extreme caution. \n• \nIt is very important to exclude mechanical causes of delay \nbefore considering oxytocin. \n• \nUse of oxytocin in multipara with obstructed labour could be \nextremely dangerous. \nIn all cases where progress is slow in spite of adequate contractions a \ncareful assessment must be made to exclude obstruction of labour. \nAttention must be paid to effective pain relief and to correcting dehydration \nin those situations.\nAfter paying attention to the above,Cesarean section must be considered \nwhere the progress continues to be slow after four hours (less than two \ncm) of commencing oxytocin. \n3.2.2. Management of second stage of labour\n3.2.2.1. Passive second stage of labour (descent phase)\n• \nIs diagnosed when full cervical dilatation is reached in the \nabsence of involuntary expulsive efforts by the mother. \n• \nBearing down must be discouraged at this stage.",
  "Passive second stage of labour (descent phase)\n• \nIs diagnosed when full cervical dilatation is reached in the \nabsence of involuntary expulsive efforts by the mother. \n• \nBearing down must be discouraged at this stage.\n\n--- Page 29 ---\nNational Guideline for Maternal Care - Volume I\n11\n• \nIntermittent auscultation of the fetal heart should be done \nimmediately after a contraction for at least one minute, at least \nevery 10 minutes. The maternal pulse should be palpated if \nthere is suspected fetal bradycardia or any other FHR anomaly \nto differentiate the two heart rates. \n• \nPresence of meconium must be noted. \n3.2.2.2. Active second stage of labour (expulsive phase) \n• \nIs diagnosed when the mother gets the urge to bear down with \nfull dilatation.\n• \nIntermittent auscultation of the fetal heart should be done \nimmediately after a contraction for at least one minute, at least \nevery 5 minutes. The maternal pulse should be palpated if there \nis fetal bradycardia or any other FHR anomaly \n• \nPresence of meconium must be noted. \nUse of a hand-held Doppler device is recommended (in preference to a \nPinnard) for fetal heart rate monitoring in the second stage. \nWomen must be encouraged to continue consuming clear fluids during \nthe second stage. \nSupport by the labour companion must be continued. \nTotal time durations allowed for the second stage of labour are as follows:\nPrimigravida: \n• \nBirth would be expected to take place within 2 hours of the \nstart of the active second stage in most women.\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 1 hour and need to seek the advice from a \nhealth professional trained in the assisted/ Operative vaginal \nbirth if birth is not imminent.\nMultigravida:\n• \nBirth would be expected to take place within 1 hours of the \nstart of the active second stage in most women.",
  "Support by the labour companion must be continued. \nTotal time durations allowed for the second stage of labour are as follows:\nPrimigravida: \n• \nBirth would be expected to take place within 2 hours of the \nstart of the active second stage in most women.\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 1 hour and need to seek the advice from a \nhealth professional trained in the assisted/ Operative vaginal \nbirth if birth is not imminent.\nMultigravida:\n• \nBirth would be expected to take place within 1 hours of the \nstart of the active second stage in most women.\n\n--- Page 30 ---\nNational Guideline for Maternal Care - Volume I\n12\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 30 minutes and requires advice from a health \nprofessional trained in assisted/ operative vaginal birth if birth \nis not imminent.\n• \nDelay in the second stage in a multiparous woman must raise \nsuspicion of disproportion or malposition.\nOne further hour is permitted for women in each category with an \nepidural analgesia.\n3.2.2.3. Observations for women and babies in the second stage of \nlabour:\nAll observations should be documented on the partogragh.\n• \nChart blood pressure and pulse hourly\n• \nContinue four hourly temperature recording \n• \nVaginal examination must be offered after an hour in the active \nsecond stage after abdominal palpation and assessment of \nvaginal loss\n• \nHalf hourly documentation of frequency of contractions\n• \nOngoing consideration of the woman’s  emotional and \npsychological needs\nIn addition:\n• \nAssessment of progress should include maternal behavior, \neffectiveness of pushing and fetal wellbeing, taking into \naccount fetal position and station at the onset of the second \nstage. These factors will assist in deciding the timing of further \nvaginal examination and the need for obstetric review.\n• \nOngoing consideration should be given to the woman’s position, \nhydration, coping strategies and pain relief throughout the \nsecond stage.\n3.2.2.4. Women’s position and pushing in the second stage of labour:\nAlthough most deliveries in Sri Lanka are conducted in the dorsal/\nMcRobert’s position, women may be encouraged to adopt squatting, semi \nupright or lateral positions to aid the expulsion phase.",
  "These factors will assist in deciding the timing of further \nvaginal examination and the need for obstetric review.\n• \nOngoing consideration should be given to the woman’s position, \nhydration, coping strategies and pain relief throughout the \nsecond stage.\n3.2.2.4. Women’s position and pushing in the second stage of labour:\nAlthough most deliveries in Sri Lanka are conducted in the dorsal/\nMcRobert’s position, women may be encouraged to adopt squatting, semi \nupright or lateral positions to aid the expulsion phase.\n\n--- Page 31 ---\nNational Guideline for Maternal Care - Volume I\n13\nWomen should be informed that in the second stage, they should be \nguided by their own urge to push.\nIf pushing is ineffective, strategies to assist birth such as support and \nencouragement and change of position can be used.\nIn primigravida in whom contractions have become weak and there \nis no evidence of fetal compromise or obstruction, oxytocin may \nbe administered as an infusion. In this case, the expulsive phase \nmay be continued under close observation for a further 30 minutes. \nDelivery must be considered at the end of this period.\n3.2.2.5. Intrapartum interventions to reduce perineal trauma\nEither the ‘hands on’ (guarding the perineum and flexing the baby’s head) \nor the ‘hands poised’ (with hands off the perineum and baby’s head but in \nreadiness) techniques can be used to facilitate spontaneous birth.\nA routine episiotomy should not be carried out during spontaneous \nvaginal birth.\nEpisiotomy should only be performed selectively, in women in whom there \nis a clinical need such as instrumental birth or suspected fetal compromise \nor a high chance of perineal tears.  \nWhere episiotomy is performed, Mediolateral episiotomy, performed at \n45 – 60 degrees from the midline directed to the right side, beginning at \nthe vaginal fourchette is preferred to the median episiotomy.  It should be \nperformed at the time of crowning of the fetal head.\nEpisiotomy should be performed after infiltration of the perineum up to \n20 ml of 1% lignocaine. \n3.2.2.6. Delivery\nThe fetal head should not be allowed to extend till occiput is felt below \nthe symphysis pubis. The perineum should be supported during delivery \nof the head. Once the head is delivered the woman should be discouraged \nfrom bearing down. Following restitution and external rotation, shoulders",
  "Once the head is delivered the woman should be discouraged \nfrom bearing down. Following restitution and external rotation, shoulders\n\n--- Page 32 ---\nNational Guideline for Maternal Care - Volume I\n14\nmust be delivered appropriately with directed traction on the fetal head. \nThe baby must be delivered onto the mother’s abdomen. Breastfeeding \nshould be initiated within 30 minutes of birth. \n3.2.3. \nThird stage of Labour\nThe third stage of labour is the period from the complete delivery of the \nbaby to the complete delivery of the placenta and membranes.\n3.2.3.1. Active Management of the third stage of labour\nActive management of the third stage of labour is recommended for all \nmothers. \nThis includes;\n• \nRoutine use of uterotonic drugs: Oxytocin 5 IU intravenously \nsoon after the delivery of the baby   or 10 IU intramuscularly, \n• \nDelayed cord clamping (2 minutes after the birth) and cutting \nof the cord\n• \nFollowed by controlled cord traction. This must be followed by \nuterine massage.\nDelayed clamping of the cord allows for placental transfusion, \nwhich reduces neonatal and infant iron deficiency and anemia. \nThis policy should be followed unless the baby is born in a poor \ncondition or if the mother is bleeding or is Rhesus iso-immunized.\nClamp and cut the cord close to the perineum.  A hand should be placed \nabove the symphysis pubis to stabilize the uterus by applying counter \ntraction during controlled cord traction. Application of cord traction \nwhen the uterus is relaxed could lead to acute inversion of the uterus.\nAfter delivery, the placenta must be placed on a flat surface and the maternal \nsurface examined for completeness. On the fetal surface the blood vessels \nmust be traced to exclude a succenturiate lobe. Completeness of the fetal \nmembranes must be ensured.",
  "On the fetal surface the blood vessels \nmust be traced to exclude a succenturiate lobe. Completeness of the fetal \nmembranes must be ensured.\n\n--- Page 33 ---\nNational Guideline for Maternal Care - Volume I\n15\nObservations in the immediate postpartum period include:\n• \nInspection for continued fresh bleeding, \n• \nCheck pulse, blood pressure, uterine contraction,  and the level \nof the fundus every 15 minutes up to 2 hours\n• \nHer general  physical condition, as shown by her colour, \nrespiration and her own report of how she feels \nExperienced medical personnel should be informed in any one the \nfollowing instances: \n• \nContinuing fresh bleeding;\n• \nElevation of the level of the fundus;\n• \nIncrease of pulse rate above 100 or by 30 beats per minute;\n• \nDrop in systolic blood pressure below 100 or by 30 mmHg. \nThe level of the fundus must be marked on the skin using a marker to \nmake observations more objective. \n3.2.3.2. Delayed third stage\nDelayed third stage is diagnosed when the placenta is not delivered within \n30 minutes of active management. \nThe first step in managing delayed third stage of labour is:\n• \nTo proceed to intraumbilical vein oxytocin, in a dose of 50 IU \nin 30 ml of 0.9% sodium chloride solution. \n• \nA period of 30 minutes is allowed and controlled cord traction \nis attempted again. \n• \nIf the placenta is not delivered by this method, manual removal \nof placenta is proceeded to. \n4.\t\nCare for the newborn baby\nEffective care at birth is needed in anticipation of problems with the \ntransition from in utero dependent life to extra utero independent \nexistence and to provide support to ensure stabilization.",
  "• \nIf the placenta is not delivered by this method, manual removal \nof placenta is proceeded to. \n4.\t\nCare for the newborn baby\nEffective care at birth is needed in anticipation of problems with the \ntransition from in utero dependent life to extra utero independent \nexistence and to provide support to ensure stabilization.\n\n--- Page 34 ---\nNational Guideline for Maternal Care - Volume I\n16\n• \nSkilled birth attendant (Medical Officer, Nursing Officer and \nMidwive) is responsible for the care. \n• \nThe care at birth is same irrespective of birthing place or person \nattending to birth. \n• \nAt least one health care provider trained in neonatal \nresuscitation must be physically available at the time of birth of \nall infants irrespective of risk status.\n• \nThis person must actually be present in the delivery room \nbefore the birth of the baby.\n• \nThe attending personnel should document the details of the \nbaby such as time of birth, weight, gender and any other \nrelevant information in all cases.\nThe aims of neonatal care following birth include the following:\n• \nEstablishment of respiration (as per NRP guidelines) \n• \nPrevention of hypothermia (Refer to newborn guideline)\n• \nEstablishment of breast feeding (Refer to newborn guideline)\n• \nPrevention of infection (Refer to newborn guideline)\n• \nDetection of danger signs (Refer to newborn guideline)\nFollowing basic steps should be followed at the time of birth;\n1. Call out the time of birth\n2. Deliver the baby onto the mother’s abdomen or into her arms\n3. Dry baby with a warm towel or a warm piece of cloth\n4. Wipe baby’s eye\n5. Assess baby’s breathing while drying \n6. Make sure that there is no second baby\n7. Change gloves or remove the first layer of gloves\n8. Clamp and cut the umbilical cord\n9. Put the baby between mother’s breast for skin to skin care\n10. Place an identity label on baby\n11. Cover mother and baby with warm clothes\n12. Put a hat on baby’s head\nThe Apgar score at 1 and 5 minutes should be recorded for all births.",
  "Cover mother and baby with warm clothes\n12. Put a hat on baby’s head\nThe Apgar score at 1 and 5 minutes should be recorded for all births.\n\n--- Page 35 ---\nNational Guideline for Maternal Care - Volume I\n17\nInitiation of breast feeding should be aimed for within 1hour after birth. \nHead circumference, birth weight, length and other measurements should \nbe carried out once the first feed is complete. A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.",
  "Head circumference, birth weight, length and other measurements should \nbe carried out once the first feed is complete. A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.\n\n--- Page 36 ---\nNational Guideline for Maternal Care - Volume I\n18\nThe preferred suture material is rapidly absorbable polyglactin acid.\nThe following basic principles should be observed when performing \nperineal repairs:\n• \nPerineal trauma should be repaired using aseptic techniques.\n• \nEquipment should be checked and swabs and needles counted \nbefore and after the procedure\n• \nGood lighting is essential to see and identify the structures \ninvolved.\n• \nDifficult injuries should be repaired by an experienced medical \nofficer in the theatre under regional or general anaesthesia. An \nindwelling catheter should be inserted for 24 hours to prevent \nurinary retention.\n• \nGood anatomical alignment of the wound should be achieved, \nand consideration  given to the cosmetic result.\n• \nRectal examination should be carried out after completing the \nrepair to ensure that suture material has not accidently been \ninserted through the rectal mucosa.\n• \nFollowing completion of repair, an accurate detailed account \nshould be documented covering the extent of the trauma, the \nmethod of repair and the materials used.\n• \nInformation should be given to the woman regarding the extent \nof the trauma, pain relief, diet, hygiene and the importance of \npelvic floor exercises.",
  "A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.\n\n--- Page 36 ---\nNational Guideline for Maternal Care - Volume I\n18\nThe preferred suture material is rapidly absorbable polyglactin acid.\nThe following basic principles should be observed when performing \nperineal repairs:\n• \nPerineal trauma should be repaired using aseptic techniques.\n• \nEquipment should be checked and swabs and needles counted \nbefore and after the procedure\n• \nGood lighting is essential to see and identify the structures \ninvolved.\n• \nDifficult injuries should be repaired by an experienced medical \nofficer in the theatre under regional or general anaesthesia. An \nindwelling catheter should be inserted for 24 hours to prevent \nurinary retention.\n• \nGood anatomical alignment of the wound should be achieved, \nand consideration  given to the cosmetic result.\n• \nRectal examination should be carried out after completing the \nrepair to ensure that suture material has not accidently been \ninserted through the rectal mucosa.\n• \nFollowing completion of repair, an accurate detailed account \nshould be documented covering the extent of the trauma, the \nmethod of repair and the materials used.\n• \nInformation should be given to the woman regarding the extent \nof the trauma, pain relief, diet, hygiene and the importance of \npelvic floor exercises.\n\n--- Page 37 ---\nNational Guideline for Maternal Care - Volume I\n19\nGuideline on Induction of Labour\n1.\t\nIntroduction \nThis guideline aims to provide evidence based guidance on induction of \nlabour to make the process more logical, effective and safer. It also aims to \nempower women undergoing induction of labour. \n2.\t\nDefinition\nInduction of labour is defined as initiation of labour by artificial means.\n3.\t\nGeneral Principles\n• \nInduction of labour should be performed only in specialist \nobstetric units when there is a clear indication that its benefits \noutweigh risks.\n• \nA senior clinician must make the decision.\n• \nThe reason/s should be clearly explained to the patient, who \nshould give her consent.\n• \nMaternal and fetal wellbeing should be monitored closely.\n• \nAdequate pain relief should be an essential part of the \nmanagement plan, since it is recognized that labor is more \npainful when it is induced.\n• \nPrior to induction of labour, the cervix should be favourable \n(Modified Bishop score 7 or more). If it is not, an attempt should \nbe made to ripen the cervix. \n• \nDecisions regarding induction of labour should be made taking \ninto account not only the clinical scenario but also the woman’s \nviews, the availability of local facilities and cost effectiveness of \nthe available methods.\n4.\t\nIndications\n4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\nInduction of labour is recommended for low-risk women who are known \nwith certainty to have reached 41 weeks of gestation.",
  "If it is not, an attempt should \nbe made to ripen the cervix. \n• \nDecisions regarding induction of labour should be made taking \ninto account not only the clinical scenario but also the woman’s \nviews, the availability of local facilities and cost effectiveness of \nthe available methods.\n4.\t\nIndications\n4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\nInduction of labour is recommended for low-risk women who are known \nwith certainty to have reached 41 weeks of gestation.\n\n--- Page 38 ---\nNational Guideline for Maternal Care - Volume I\n20\nHowever, it is good practice to assess fetal wellbeing around 40 weeks to \nselect women for conservative management until 41 weeks gestation. \nThe recommended assessments include fetal biometry (at least abdominal \ncircumference) and amniotic fluid index (lower cut-off = 7 cm). \n4.2 Prelabour rupture of membranes at term\nIn the absence of evidence fetal compromise or maternal infection delayed \ninduction of labour after 24 hours is acceptable. \nThis may be carried out using either oxytocin infusion or prostaglandins.\n4.3 Preterm prelabour rupture of membranes (PPROM)\nPatients with PPROM without evidence of infection or fetal compromise \nshould be offered induction after the completion 34 weeks.\n4.4 Intrauterine death\nThis is a very traumatic time for the woman. Most women would want \nto be delivered as early as possible and their wishes need to be respected. \nAmniotomy and repeated vaginal examinations are best avoided. \nProstaglandins are preferred for induction of labour in these women. \nAmniotomy is preferred in the presence of abruption placentae. \n4.5 History of precipitate labour\nThere are no studies comparing outcomes in induced versus spontaneous \nlabour.\n4.6 Suspected macrosomia\nIn the presence of good clinical and ultrasound evidence of macrosomia \nor a history of previous shoulder dystocia, there should be a low threshold \nfor early induction of labour.",
  "Amniotomy is preferred in the presence of abruption placentae. \n4.5 History of precipitate labour\nThere are no studies comparing outcomes in induced versus spontaneous \nlabour.\n4.6 Suspected macrosomia\nIn the presence of good clinical and ultrasound evidence of macrosomia \nor a history of previous shoulder dystocia, there should be a low threshold \nfor early induction of labour.\n\n--- Page 39 ---\nNational Guideline for Maternal Care - Volume I\n21\n4.7 Fetal growth restriction\nThe decision for induction of labour in a growth restricted fetus should be \nindividualized based on period of gestation at onset, presence or absence \nof fetal compromise. \n4.8 Older mothers\nThere is growing evidence that the risk of stillbirth is higher in older (>40 \nyrs) women near term. \nWomen over 40 years should be offered induction between 39-40 weeks.\n5.\t\nInduction under specific circumstances\n5.1 Breech presentation\nPresentation per se, is not a contraindication to induction. \n5.2 Previous CS\nThere is no contraindication to induction of labour in a woman with a \npast caesarean section. \nUse of either oxytocin or prostaglandins increases the risk of scar \ndehiscence or rupture. \nThis risk may be lower with artificial separation of membranes or Foley \ncatheter. \n6.\t\nMethods of induction\nThis section does not make a distinction between methods of ripening the \ncervix and induction of labour. \n6.1 Mechanical\nThere is good evidence that artificial separation of membranes reduces the \nneed for formal induction. This method is recommended to be performed \nwith due regard to asepsis, at 40 weeks gestation.",
  "6.1 Mechanical\nThere is good evidence that artificial separation of membranes reduces the \nneed for formal induction. This method is recommended to be performed \nwith due regard to asepsis, at 40 weeks gestation.\n\n--- Page 40 ---\nNational Guideline for Maternal Care - Volume I\n22\nWhere the cervix will not admit a finger, massaging around the cervix in \nthe vaginal fornices will have a similar effect.\nExtra-amniotic balloon catheter is an effective method of ripening of the \ncervix. A Foley catheter is inserted through the cervix and the balloon \ninflated with 40 – 60 ml of saline. This may be left in situ for a maximum \nof 48 hours. Following its removal, induction of labour may be proceeded \nto using another method. \nIn the presence of evidence of infection, artificial separation of membranes \nand extra-amniotic Foley catheter must not be used. \n6.2 Surgical\n \nAmniotomy is a definitive mode of induction of labour. It should be \nundertaken only if one is committed to deliver within 24 hours. Therefore \nit should be done only when the cervix is ripe and prior cervical assessment \nby an experienced clinician is essential.\nThe risk of cord prolapse should be appreciated and steps taken to \nminimise or to recognize it early.\nAmniotomy alone may be capable of initiation of labour and it is \nrecommended that oxytocin be started after a period of observation of at \nleast two hours. \n6.3 Pharmacological\n6.3.1 Oxytocin\nUse of oxytocin when membranes are intact is not recommended. \nFor details of how to use oxytocin please refer to the guideline on oxytocin\n6.3.2 Prostaglandins\nProstaglandin E2 (PGE2)\nThese are very effective in inducing labour and are available as vaginal gel, \ntablet or controlled release pessary.",
  "6.3 Pharmacological\n6.3.1 Oxytocin\nUse of oxytocin when membranes are intact is not recommended. \nFor details of how to use oxytocin please refer to the guideline on oxytocin\n6.3.2 Prostaglandins\nProstaglandin E2 (PGE2)\nThese are very effective in inducing labour and are available as vaginal gel, \ntablet or controlled release pessary.\n\n--- Page 41 ---\nNational Guideline for Maternal Care - Volume I\n23\nAll preparations carry a risk of hyperstimulation.\nIntracervical route does not offer any increase in efficacy.\nCombined use with oxytocin is particularly dangerous. A minimum of six \nhours from the last vaginal tablet/gel should be allowed before oxytocin \nis started.\nPrior to use of prostaglandins the Bishop score should be assessed and \nthe woman should be monitored electronically to determine the fetal \ncondition and frequency of contractions.\nAfter administration the fetal heart should be monitored electronically \nwhen contractions begin. After confirmation of normal heart rate pattern \nmonitoring should be done by intermittent auscultation.\nA second dose may be considered after a minimum interval of 6 hours \nafter the first, depending on the change of Bishop score, the condition of \nthe fetus and frequency of contractions.\nThe dosages are 3 mg for vaginal tablets and 0.5 mg for vaginal gel.\nMisoprostol\nThis drug is widely used worldwide for a variety of indications in \npregnancy. (In Sri Lanka, it is not licensed at present).\nNevertheless, it is very effective in inducing labour (more than PGE2), \nespecially in mid trimester fetal death. \nSensitivity of the uterus increases markedly with advancing pregnancy.\nThis guideline recommends that it should not be used for induction of \nlabour with a mature live fetus.\n6.3.3 Mifepristone\nIt is a powerful anti-progesterone and is very useful as an adjunct to \nmisoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka \nat present)",
  "Sensitivity of the uterus increases markedly with advancing pregnancy.\nThis guideline recommends that it should not be used for induction of \nlabour with a mature live fetus.\n6.3.3 Mifepristone\nIt is a powerful anti-progesterone and is very useful as an adjunct to \nmisoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka \nat present)\n\n--- Page 42 ---\nNational Guideline for Maternal Care - Volume I\n24\n8.\t\nComplications\n8.1 Hyperstimulation\nThis is a well-recognized complication of induction of labour with \npharmacological methods. It could have serious consequences including \nrupture of the uterus, aminiotic fluid embolism, precipitate labor and fetal \ncompromise. \nIt is defined either as a contraction free interval of less than sixty seconds \nand/or contractions lasting more than ninety seconds.\nIf diagnosed, the prostaglandin tablet must be retrieved from the vagina \nor oxytocin infusion stopped immediately and a rapid infusion of 0.9% \nsodium chloride via a fresh giving set administered.    \nIf still not resolved, tocolytics should be given if available e.g. terbutaline \n250 µg IV or SC.  Since this is not available in Sri Lanka, salbutamol \ninhaler may be tried.\n8.2  Cord prolapse\nThis is more likely with amniotomy when the head is high and poorly \napplied to the cervix. \nPrecautions to avoid and to detect this early include palpation for cord \npresentation, palpation for the cord immediately after amniotomy and the \nfetal heart sounds auscultated immediately afterwards.\n \nIf cord prolapse is diagnosed help must be called immediately. Assess \ncervical dilatation and effect delivery if fully dilated. If not fully dilated \nand cord pulsations are present, insert a Foley catheter into the bladder \nand fill it with 500 ml saline. Place the mother in the knee-elbow position \nand displace the presenting part away from the pelvis by keeping pressure \ninserting a hand in the vagina. Transport for immediate caesarean section \nin this position.",
  "Place the mother in the knee-elbow position \nand displace the presenting part away from the pelvis by keeping pressure \ninserting a hand in the vagina. Transport for immediate caesarean section \nin this position.\n\n--- Page 43 ---\nNational Guideline for Maternal Care - Volume I\n25\n8.3 Uterine rupture\nPlease also refer to section 5.2 in this guideline\nExtra care must be exercised in grandmultipara and in women with \nscarred uteri.\n8.4 Failed induction\nFailed induction is defined as labour failing to start after one cycle of \ntreatment with medical methods or for 12 hours of amniotomy. \nIt does not necessarily indicate caesarean section in case medical or \nmechanical methods.\nThe clinical situation (maternal and fetal condition) must be reassessed \nand discussed with the woman. \nIn case of failure to induce labor using one cycle of prostaglandins another \ncycle may be administered as described  above. Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.",
  "Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.\n\n--- Page 44 ---\nNational Guideline for Maternal Care - Volume I\n26",
  "Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.\n\n--- Page 44 ---\nNational Guideline for Maternal Care - Volume I\n26\n\n--- Page 45 ---\nNational Guideline for Maternal Care - Volume I\n27\nGuideline for Use of Oxytocin for Induction and \nAugmentation of labour\nOxytocin is an invaluable drug when used carefully. However, it has \nthe potential to cause uterine hyperstimulation, which could result in \namniotic fluid embolism, uterine rupture and fetal distress, all of which \nare life threatening. \nMultigravidae are particularly susceptible to the above consequences \nand extra care must be taken to exclude obstruction before a decision is \nmade to use oxytocin in a multigravid woman during labour. Experienced \npersonnel must be involved in this decision. \nUse of oxytocin for induction and/or augmentation of labour results in \na higher risk of rupture of a scarred uterus. Therefore, in such women \noxytocin should be used only with the concurrence of a Consultant. \nIts effects will depend on the concentration of the infusion and the volume \ninfused per minute. \nTo achieve this predictably, use of infusion pumps is recommended. \nWhere a gravity-assisted drip system is used, a burette may be used to \nimprove accuracy. Such systems however, may deliver variable volumes \ndepending on many factors including the position of the arm into which \nit is infused.  \nIrrespective of the method of administration, oxytocin must be \nadministered in incremental doses at intervals of 30 minutes, to achieve \na contraction free interval of two minutes. Once this level is reached, the \ninfusion rate may be continued at the same level, while closely monitoring \nthe contractions. \nHyperstimulation is defined either as a contraction free interval of less \nthan sixty seconds and/or contractions lasting more than ninety seconds. \nIn this situation the infusion must be stopped immediately. \nOxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride \nsolution. In situations where infusion pumps are not available, oxytocin",
  "Oxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride \nsolution. In situations where infusion pumps are not available, oxytocin\n\n--- Page 46 ---\nNational Guideline for Maternal Care - Volume I\n28\nmay be administered starting at a drop rate of 15 per minute and increased \nat rates of 15 drops per minute every 30 minutes, up to a maximum of 60 \ndrops per minute.  An approximate conversion to mU/minute is given in \ntable 1.\nTable 1: mU/minute administered at different rates of administration \naccording to drop rate\n \nDrop rate/min \nEquivalent  mU/min.\n \n15 \n7.5\n \n30 \n15 \n \n45 \n22.5 \n \n60 \n30 \n \n            (based on 5U of oxytocin in 500 ml saline)\nTable 2 gives mU infused per minute when administered via an infusion \npump. \nTable 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.",
  "Table 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.\n\n--- Page 47 ---\nNational Guideline for Maternal Care - Volume I\n29\nContinuous EFM during administration of oxytocin:\n• \nIf the CTG is normal, oxytocin may be continued in incremental \ndoses until the woman is experiencing 4 or 5 contractions every \n10 minutes.\n• \nIf the FHR trace is suspicious, this should be reviewed by an \nexperienced medical officer \n• \nIf the FHR trace is classified as abnormal/pathological oxytocin \ninfusion should be stopped and a full assessment of the fetal \ncondition undertaken by an experienced medical officer.",
  "Table 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.\n\n--- Page 47 ---\nNational Guideline for Maternal Care - Volume I\n29\nContinuous EFM during administration of oxytocin:\n• \nIf the CTG is normal, oxytocin may be continued in incremental \ndoses until the woman is experiencing 4 or 5 contractions every \n10 minutes.\n• \nIf the FHR trace is suspicious, this should be reviewed by an \nexperienced medical officer \n• \nIf the FHR trace is classified as abnormal/pathological oxytocin \ninfusion should be stopped and a full assessment of the fetal \ncondition undertaken by an experienced medical officer.\n\n--- Page 48 ---\nNational Guideline for Maternal Care - Volume I\n30\nGuideline on fetal monitoring in labour\nFetal monitoring in labour could be done by :\n• \nIntermittent auscultation (preferably by a hand held Doppler \ndevice) \n• \nIntermittent or continuous electronic monitoring  \nIntermittent auscultation is recommended for low-risk women in \nspontaneous labour. \nElectronic monitoring is recommended when:\n• \nThe baby’s  growth is restricted  \n• \nThere is significant meconium staining of amniotic fluid \n• \nAbnormal fetal heart rate detected by intermittent auscultation \n• \nFresh vaginal bleeding \n• \nMaternal pyrexia \n• \nUse of oxytocin for augmentation or induction of labour \n• \nWomen with a scarred uterus \n• \nWomen on epidural analgesia \nIntermittent auscultation \nThis could be done by using either a Pinnard’s stethoscope or preferably a \nhand-held Doppler device. \nAuscultation should be carried out immediately after a contraction for \none full minute. \nThe maternal pulse should be palpated if there is suspected fetal \nbradycardia or any other FHR anomaly to differentiate the two heart rates.\nThe normal rate is between 110 – 160 beats per minute in a term fetus. \nThe frequency of auscultation should be as specified in the partogram.",
  "The maternal pulse should be palpated if there is suspected fetal \nbradycardia or any other FHR anomaly to differentiate the two heart rates.\nThe normal rate is between 110 – 160 beats per minute in a term fetus. \nThe frequency of auscultation should be as specified in the partogram.\n\n--- Page 49 ---\nNational Guideline for Maternal Care - Volume I\n31\nElectronic fetal monitoring (EFM)\nEFM is carried out by external cardiotocography (CTG). \nThe following are recommended at the commencement of a CTG.\n1. The paper speed must be set at 1 cm per minute.\n2. The date and time settings on the machine must be validated.\n3. The CTG must be labeled with the mother’s name, BHT number \nand date and time. \n4. Maternal heart rate should be noted on the CTG.\n5. The presence and the point at which the fetal heart rate is best \nheard must be delineated by auscultation and the probe placed \nat that point.\n6. Ensure that the contraction probe is functioning properly and \nused for the recording.\n7. The woman should be positioned in such a way that aortocaval \ncompression is avoided.\n8. It should be interpreted without delay and the categorization \nrecorded as either normal or suspicious or pathological, as per \ntable 1, and signed by the responsible officer. The entry on the \nBHT must include a plan for management. \n9. If the CTG is categorized as suspicious or abnormal, the \nConsultant must be informed. \n10. For the management plan the overall clinical picture must be \ntaken into account. e.g. the rate of progress of labour, presence \nor absence of fetal growth restriction, meconium staining of \namniotic fluid and the evolution of the CTG abnormalities. \nTable 1: Definitions of normal, suspicious and pathological FHR traces\nCategory  \nDefinition \nNormal  \nAn FHR trace in which all four features are classified as \nreassuring \nSuspicious  \nAn FHR trace with one feature classified as non-reassuring \nand the remaining features classified as reassuring \nPathological  \nAn FHR trace with two or more features classified as non-\nreassuring or one or more classified as abnormal",
  "the rate of progress of labour, presence \nor absence of fetal growth restriction, meconium staining of \namniotic fluid and the evolution of the CTG abnormalities. \nTable 1: Definitions of normal, suspicious and pathological FHR traces\nCategory  \nDefinition \nNormal  \nAn FHR trace in which all four features are classified as \nreassuring \nSuspicious  \nAn FHR trace with one feature classified as non-reassuring \nand the remaining features classified as reassuring \nPathological  \nAn FHR trace with two or more features classified as non-\nreassuring or one or more classified as abnormal\n\n--- Page 50 ---\nNational Guideline for Maternal Care - Volume I\n32\nTable 2: Classification of fetal heart rate patterns\nFurther useful information on FHR patterns\n• \nIf repeated accelerations are present with reduced variability, \nthe FHR trace should be regarded as reassuring.\n• \nTrue early uniform decelerations are rare and benign, and \ntherefore they are not significant.\n• \nMost decelerations that occur during labor are variable.\n• \nIf a bradycardia occurs in the baby for more than 3 minutes, \nurgent medical aid should be sought and preparations \nshould be made to urgently expedite the birth of the baby, i.e. \nimmediate commencement of cesarean section.  This could \ninclude moving the woman to theatre if the fetal heart has \nnot recovered by 9 minutes. If the fetal heart recovers within \n9 minutes the decision to deliver should be reconsidered in \nconjunction with the woman if the post-recovery tracing is \nreassuring.\n• \nA tachycardia in the baby of 160–180 bpm, where accelerations \nare present and no other adverse features appear, should not be \nregarded as suspicious. However, an increase in the baseline \nFeature  \nBaseline \n(bpm)  \nVariability \n(bpm)  \nDecelerations  \nAccelerations  \nReassuring  \n110–160  \n≥ 5  \nNone  \nPresent  \nNon-reassuring  \n100–109  \n161–180  \n< 5 for 40 –90 \nminutes  \nTypical variable \ndecelerations with \nover 50% of \ncontractions, \noccurring for over \n90 minutes  \nTe absence of \naccelerations \nwith otherwise \nnormal trace is \nof uncertain \nsignificance  \nAbnormal \n< 100  \n> 180  \nSinusoidal \npattern ≥ _10 \nminutes \n< 5 for 90 \nminutes \nEither atypical \nvariable \ndecelerations with \nover 50% of \ncontractions or late \ndecelerations, both \nfor over 30 \nminutes",
  "If the fetal heart recovers within \n9 minutes the decision to deliver should be reconsidered in \nconjunction with the woman if the post-recovery tracing is \nreassuring.\n• \nA tachycardia in the baby of 160–180 bpm, where accelerations \nare present and no other adverse features appear, should not be \nregarded as suspicious. However, an increase in the baseline \nFeature  \nBaseline \n(bpm)  \nVariability \n(bpm)  \nDecelerations  \nAccelerations  \nReassuring  \n110–160  \n≥ 5  \nNone  \nPresent  \nNon-reassuring  \n100–109  \n161–180  \n< 5 for 40 –90 \nminutes  \nTypical variable \ndecelerations with \nover 50% of \ncontractions, \noccurring for over \n90 minutes  \nTe absence of \naccelerations \nwith otherwise \nnormal trace is \nof uncertain \nsignificance  \nAbnormal \n< 100  \n> 180  \nSinusoidal \npattern ≥ _10 \nminutes \n< 5 for 90 \nminutes \nEither atypical \nvariable \ndecelerations with \nover 50% of \ncontractions or late \ndecelerations, both \nfor over 30 \nminutes\n\n--- Page 51 ---\nNational Guideline for Maternal Care - Volume I\n33\nheart rate, even within the normal range, with other non-\nreassuring or abnormal features should increase concern. In \nsuch cases inquiry must be made to ascertain if the fetus was \nactive during the recording.  \nWhen women are having continuous EFM, systematic assessment of above \ndefinitions and classification should be undertaken with every review.\nDuring episodes of abnormal FHR patterns, if woman is lying supine, \nadvise her to adopt the left lateral position",
  "In \nsuch cases inquiry must be made to ascertain if the fetus was \nactive during the recording.  \nWhen women are having continuous EFM, systematic assessment of above \ndefinitions and classification should be undertaken with every review.\nDuring episodes of abnormal FHR patterns, if woman is lying supine, \nadvise her to adopt the left lateral position\n\n--- Page 52 ---\nNational Guideline for Maternal Care - Volume I\n34\nGuideline on Pain Relief in Labour\nAdequate relief of pain is a basic right of every mother in labour. It is the \nduty of every member of the obstetric team to endeavor to achieve this. \nPoor management of pain during labour will result in maternal exhaustion \nleading to:\n• \nacidosis, \n• \ndysfunctional labour and \n• \nfetal distress. \n• \nLoss of morale and a negative birth experience could have \nsignificant long-term effects. \nA well-informed, well supported mother will be more in control of events \nand in a better position to deal with pain than one who is not. Therefore, \nit is important to keep the mother informed of the progress of labour and \nthe condition of the fetus throughout the process. \nReassurance plays a major adjunctive role in pain relief.\nPrenatal education should include information regarding the available \nmethods of pain relief and their accessibility.\nNon pharmacological methods of pain relief such as breathing and \nrelaxation techniques should be introduced during the antenatal period.\nIt is well recognized that women who have a birth companion will tolerate \npain better and require less analgesia. The policy of allowing a birth \ncompanion must therefore be encouraged.\n1.\t\nMethods of pain relief in labour\nThe selection of the method of pain relief should be based on the patient \npreference, availability of resources and the institutional protocols. \nFollowing methods can be used.",
  "The policy of allowing a birth \ncompanion must therefore be encouraged.\n1.\t\nMethods of pain relief in labour\nThe selection of the method of pain relief should be based on the patient \npreference, availability of resources and the institutional protocols. \nFollowing methods can be used.\n\n--- Page 53 ---\nNational Guideline for Maternal Care - Volume I\n35\n1.1 \n Non-pharmacological methods of pain relief\n• \nBreathing techniques, \n• \nTranscutaneous electrical nerve stimulation (TENS), \n• \nMassaging, \n• \nRelaxation techniques, \n• \nPositioning and movement\nAny of these methods can be used to relieve pain during labour\n1.2. \nPharmacological methods of pain relief in labour\n1.2.1. \nOral paracetamol/paracetamol & codeine compound: \nThese oral preparations can be used safely in the latent phase of labour.\n1.2.2. \nOpioids\n1.2.2.A. Pethidine\nPethidine is safe and effective in the latent and early active phase. The dose \nis 1-1.5 mg/kg IM, repeated after 4 – 6 hours. Administration of a third \ndose should be done only with the concurrence of senior personnel. \nIt is generally avoided where delivery is anticipated within 4 hours. \nMaternal side effects include nausea, vomiting and a reduction in gastric \nmotility with a subsequent increase in gastric acidity. Therefore, it should \nbe administered coupled with metoclopramide 5 mg IV or 10 mg  IM.\nNeonatal respiratory depression is a recognized consequence of \nadministration of opioids to the mother. Naloxone, a pure opioid \nantagonist should be available for treatment in all facilities administering \nopioids for analgesia. Naloxone is given to the baby in a dose of 100μg /kg \nIV. It has a short duration of action and additional doses may be required. \nIf no improvement is seen with the first dose of naloxone, the cause of \nneonatal respiratory depression is more likely to be a factor other than \nopioids.",
  "It has a short duration of action and additional doses may be required. \nIf no improvement is seen with the first dose of naloxone, the cause of \nneonatal respiratory depression is more likely to be a factor other than \nopioids.\n\n--- Page 54 ---\nNational Guideline for Maternal Care - Volume I\n36\n1.2.2.B. Morphine \nThis has a longer duration of action than pethidine and may be particularly \nuseful in women who require analgesia in early labour. \nThe dose is 0.15 mg/kg IM should be administered with metoclopramide. \nThe side effects and neonatal effects are similar to those of pethidine.\n1.2.2.C. Fentanyl \nIntravenous fentanyl/ramifentanyl may be administered in either a High \nDependency or Intensive Care Unit settings under the supervision of an \nanaesthesiologist. \nThe dose is 50-100μg per hour as an intravenous infusion.\nPain relief occurs in 3-5 minutes after commencement.\n \n1.2.3. \nInhalational analgesia – Entonox\nEntonox is a 50:50 mixture of nitrous oxide and oxygen and it has a very \nshort half-life. The onset of action is 30sec to one minute. \n \nThe mother should receive clear and definite instructions about its correct \nuse. It should only be self-administered.\nShe should start using entonox through the controlled valve at the very \nbeginning of the contraction. The mother should be advised to stop using \nEntonox inhalation in the contraction free interval.\nLonger and deeper breaths give better result. There is no limit on the \nduration of its use.  \nWomen should be informed that Entonox will make them feel nauseous \nand light-headed.\nEntonox is contraindicated in women with intestinal obstruction, \npneumothorax, middle ear and sinus disease, and following cerebral air-\ncontrast studies.",
  "There is no limit on the \nduration of its use.  \nWomen should be informed that Entonox will make them feel nauseous \nand light-headed.\nEntonox is contraindicated in women with intestinal obstruction, \npneumothorax, middle ear and sinus disease, and following cerebral air-\ncontrast studies.\n\n--- Page 55 ---\nNational Guideline for Maternal Care - Volume I\n37\n1.2.4. Regional Anaesthesia\n \nA.   Epidural analgesia \nEpidural analgesia is the most effective form of pain relief in labour. \nTherefore, Its greater use should be encouraged. \nIt can be given either as a bolus with top-ups or as a continuous infusion. \nContinuous administration via a syringe pump is preferred to ‘top-ups’, \nsince it is safer. \nThe continuous availability of an anesthesiologist is a prerequisite to \noffering epidural analgesia. It is also essential that staff on site is trained for \nits setting up, monitoring and to recognize complications early.  Facilities \nshould be available for emergency resuscitation.\nBefore offering epidural  analgesia, women should be informed its risks \nand benefits and its implications on labour:\n• \nIt provides more effective pain relief than other methods\n• \nIt will not increase the length of the first and the passive second \nstages of labour. \n• \nIt may however increase the length of the expulsive phase \nand increase the likelihood of an instrumental delivery. An \nadditional hour is allowed in the expulsive phase therefore.\n• \nIt does not increase the chance of cesarean section \n• \nIt does not cause long-term backache. \n• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.",
  "An \nadditional hour is allowed in the expulsive phase therefore.\n• \nIt does not increase the chance of cesarean section \n• \nIt does not cause long-term backache. \n• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph\n\n--- Page 58 ---\nNational Guideline for Maternal Care - Volume I\n40",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph\n\n--- Page 58 ---\nNational Guideline for Maternal Care - Volume I\n40\n\n--- Page 59 ---\nNational Guideline for Maternal Care - Volume I\n41\nGuideline on Acute Puerperal Inversion of the Uterus\n1.\t\nIntroduction\nThe aim of this guideline is to provide recommendations for the \nmanagement of acute puerperal inversion of the uterus, which is a rare \nand life threatening condition. The main reason for its high mortality rate \nis delay in instituting appropriate treatment, which leads to postpartum \nhemorrhage and rapid development of shock out of proportion to \nhaemorrhage. \n2.\t\nDefinition\nIt is defined as ‘the turning inside out of the fundus into the uterine cavity’.\n3.\t\nPrevention\nMismanagement of the third stage of labor is recognized as the main \ncause, although 50% have no identifiable cause. The common initiating \nfactor seems to be a traction force on the fundus of a relaxed uterus. \nProper retraction of the uterus in the third stage is the primary factor in \npreventing an inversion. There is no reliable data to suggest that it recurs \nin a future pregnancy.\nThe importance of the active management of the third stage could not be \nover-emphasized. (Please refer Section 3 of the PPH Guideline and the \nsection on management of delayed third stage (section 3.2.3 in the Normal \nLabor Guideline for details) \n4.\t\nPathophysiology (and clinical correlation)\nAs the inversion progresses, the adnexae with their ligaments get drawn \ninto the inverting uterine fundus and become increasingly stretched. This \nproduces significant pain and vagal stimulation, leading to neurogenic \nshock. \nAn inverted uterus becomes trapped within the cervix creating \nprogressive oedema and congestion due to interruption of venous and \nlymphatic drainage. Oedema and congestion will increase the firmness \nof the inverted segment, making reduction more difficult. Interruption",
  "Oedema and congestion will increase the firmness \nof the inverted segment, making reduction more difficult. Interruption\n\n--- Page 60 ---\nNational Guideline for Maternal Care - Volume I\n42\nof the venous drainage will lead to significant haemorrhage. A partially \nseparated placenta would add to this.\n5.\t\nClassification\nAlthough acute, subacute and chronic varieties have been described, this \nguideline would address only the acute variety as it is life threatening. \nThis occurs soon after birth, just before or after the delivery of the placenta.\nThree degrees of inversion have been described, depending on the \nlevel of the inverted fundus. In practice, second-degree inversion is the \ncommonest. The fundus has come past the cervical os, but is still within \nthe vagina.\n6.\t\nClinical Presentation and Diagnosis\nPrompt diagnosis is vital.\nThe key to diagnosis is awareness and a high degree of suspicion.\nThe following are early warnings:\n• \nA degree of shock that is out of proportion to overt blood loss\n• \nA retained placenta\n• \nPlacenta delivered but ‘with some difficulty’\n• \nSevere, sustained unexplained pain in the third stage.\nIn this situation:\n• \nFeel for the fundus. If absent or ‘cupped’, acute inversion is \nprobable diagnosis;\n• \nConfirm by a vaginal examination:\n• \nLook for a hard mass which looks and feels like a huge \nulcerated fibroid polyp (sometimes described as a foetal \nhead); \n• \nThe cervix is not to be seen or felt in the normal position, \ninstead it could be felt as a ring around the base of the \n‘mass’;\n• \nIn incomplete cases, the inverted fundus may be felt \nthrough the cervical canal in the lower uterine cavity.",
  "The fundus has come past the cervical os, but is still within \nthe vagina.\n6.\t\nClinical Presentation and Diagnosis\nPrompt diagnosis is vital.\nThe key to diagnosis is awareness and a high degree of suspicion.\nThe following are early warnings:\n• \nA degree of shock that is out of proportion to overt blood loss\n• \nA retained placenta\n• \nPlacenta delivered but ‘with some difficulty’\n• \nSevere, sustained unexplained pain in the third stage.\nIn this situation:\n• \nFeel for the fundus. If absent or ‘cupped’, acute inversion is \nprobable diagnosis;\n• \nConfirm by a vaginal examination:\n• \nLook for a hard mass which looks and feels like a huge \nulcerated fibroid polyp (sometimes described as a foetal \nhead); \n• \nThe cervix is not to be seen or felt in the normal position, \ninstead it could be felt as a ring around the base of the \n‘mass’;\n• \nIn incomplete cases, the inverted fundus may be felt \nthrough the cervical canal in the lower uterine cavity.\n\n--- Page 61 ---\nNational Guideline for Maternal Care - Volume I\n43\n7.\t\nManagement\n7.1 General measures:\nEarly diagnosis is vital. Treat it as a life-threatening emergency.\nFirst attempts at reduction should be made at the place where it is \ndiagnosed, without moving to theatre.\nIf these attempts fail, move to theatre and give a general anesthetic without \ndelay (see section 7.2.4). \nEarly involvement of experienced personnel and teamwork are absolutely \nessential.\nTreat shock aggressively, not forgetting the neurogenic element.\nProvide adequate pain relief\nReplace the blood loss, which could be considerable, especially if the \nplacenta has partially or completely separated.\nDo not attempt to remove the placenta, if still attached.\n7.2 Repositioning the uterus\nReposition the uterus as soon as possible; the sooner it is done the easier \nand better. It reverses the shock and reduces PPH.\nNon-surgical methods\n7.2.1  Manual replacement of uterus.\n(Johnson’s maneuver)\nThe operator introduces two thirds of his forearm in to the vagina and \nextends the hand at the wrist to place the palm on the inverted fundus and \nfingertips at the utero-cervical junction. Lifting the uterus above the level \nof the umbilicus creates adequate tension for the cervical ring to dilate and \nfor the fundus to revert to its normal position.",
  "It reverses the shock and reduces PPH.\nNon-surgical methods\n7.2.1  Manual replacement of uterus.\n(Johnson’s maneuver)\nThe operator introduces two thirds of his forearm in to the vagina and \nextends the hand at the wrist to place the palm on the inverted fundus and \nfingertips at the utero-cervical junction. Lifting the uterus above the level \nof the umbilicus creates adequate tension for the cervical ring to dilate and \nfor the fundus to revert to its normal position.\n\n--- Page 62 ---\nNational Guideline for Maternal Care - Volume I\n44\nThis could be helped by ‘working the fingers up’ gradually from the cervical \nring towards the fundus, with gentle but persistent pressure applied.\nWhere the uterus is too hard to respond, consider tocolytics (see below).\nOnce reduced, hold the fundus in place for a few minutes (making a fist \ninside the uterus with upward pressure on the fundus helps).\nAdminister uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v \nfollowed by oxytocin infusion at the rate of 10 IU per hour), whilst the \nhand is still inside. When the uterus begins to contract, slowly remove the \nhand. \nThis manouvre is possible only soon after the event, and would need \nadequate analgesia. Unless it is possible to administer either a general \nanesthetic immediately, administer pethidine 50 mg iv slow and proceed \nwith the maneuvres. \nGive antibiotics (e.g. cephradine 1g and metronidazole 500 mg IV).\n7.2.2   Hydrostatc reduction (O’Sullivan 1945)\nSeveral novel and useful modifications have been made to this procedure \nlately, principally to circumvent the problem of inadequate water seal, \nwhich has been the major cause of failure in the past. \nInsert 6 cm silastic ventouse cup into vagina, making sure that it is directed \nat the posterior vaginal fornix and not at, or cupping the fundus. Place \nhand at introitus to maintain seal between cup and vagina.\n(Alternatively 500ml balloon catheter can be placed in vagina. If neither is \navailable, use a wide tube; a standard giving set will not do).\nConnect via IV giving set to a bag of warmed normal saline placed 1- 1.5 \nmetres above the patient.\nInfuse normal saline (typically 2 litres) into vagina to reduce the uterus by \nhydrostatic pressure.",
  "Place \nhand at introitus to maintain seal between cup and vagina.\n(Alternatively 500ml balloon catheter can be placed in vagina. If neither is \navailable, use a wide tube; a standard giving set will not do).\nConnect via IV giving set to a bag of warmed normal saline placed 1- 1.5 \nmetres above the patient.\nInfuse normal saline (typically 2 litres) into vagina to reduce the uterus by \nhydrostatic pressure.\n\n--- Page 63 ---\nNational Guideline for Maternal Care - Volume I\n45\nOnce reduced, remove the placenta if still attached and proceed as in the \nprevious section.\nWhere a balloon is used, it would be advisable to leave it for 12-24 hours \nto prevent re-inversion and reduce haemorrhage. \nSaline embolisation and fluid overload leading to pulmonary oedema are \nonly theoretical risks as long as one sticks to hydrostatic pressure only.\n7.2.3  Tocolytics\nWhere repositioning is difficult due to retraction of the uterine muscle \nand the constriction of the cervical ring, tocolytics could be helpful. But \ngiven this could cause PPH, it would have to be a considered and a senior \ndecision. They are safest given in the theatre setting. \nVarious preparations have been used; ideally it should be readily available, \nwith quick onset and short duration of action. E.g.\nTurbutaline 0 .25mg i.v. slowly (not available in Sri Lanka at present);\nSalbutamol 0.25mg in 10 ml saline i.v. slowly;\nNitroglycerine 0.1mg i.v. slowly or sublingually (acts within 90 seconds)\n7.2.4  General Anaesthesia\nIf the initial attempt at manual replacement fails, it is safest to move the \npatient to the theatre and to administer general anaesthesia. This allows \nfor muscle relaxation, pain relief and elimination of the neurogenic \ncontribution to the shock. \n7.2.5  Surgical methods\nIf managed properly in the early stages, resort to surgery should be a rare \noccurrence.",
  "This allows \nfor muscle relaxation, pain relief and elimination of the neurogenic \ncontribution to the shock. \n7.2.5  Surgical methods\nIf managed properly in the early stages, resort to surgery should be a rare \noccurrence.\n\n--- Page 64 ---\nNational Guideline for Maternal Care - Volume I\n46\nHuntingdon’s operation\nAfter a laparotomy, the indrawn uterine cup is identified near the region \nof the cervix with the tubes and round ligaments pulled into the cup.  By \nthe use of two Allis forceps the uterus is pulled out of the constriction ring \nin a progressive fashion and restored to its normal position. The serosa of \nthe uterus will invariably sustain lacerations and these are repaired with \nabsorbable sutures. \nUse of a silastic vacuum cup from above instead of Allis forceps has been \nshown to circumvent this problem.\nHaultain’s operation\nIn this procedure the constriction in the region of cervix is incised \nposteriorly using a longitudinal incision. As in the Huntingdon’s method \ntwo Allis forceps are used to pull the uterus to its normal position. The \nincision is repaired with interrupted sutures. Uterotonics are given to \nmaintain contraction of the uterus.\nHysterectomy\nWhen all the above methods fail, a hysterectomy will become the only \nviable option. However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.",
  "However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume I\n47\nManagement of \nHypertensive disease \nduring pregnancy\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume I\n48",
  "However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume I\n47\nManagement of \nHypertensive disease \nduring pregnancy\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume I\n48\n\n--- Page 67 ---\nNational Guideline for Maternal Care - Volume I\n49\nManagement of Hypertensive Disease in  Pregnancy\n1.\t\nIntroduction\nHypertension in pregnancy is an important cause of direct maternal deaths \nin Sri Lanka. Early identification, aggressive and intensive treatment of \nits complications is important in reducing the resulting morbidity and \nmortality.\n2.\t\nDefinitions\nChronic Hypertension:\nWomen with pre-existing hypertension or hypertension detected before \n20th week of gestation in the absence of trophoblastic disease and \npersisting more than 42 days post partum. \nGestational Hypertension\nA)   Pregnancy Induced Hypertension:\nHypertension unaccompanied by proteinuria developing after 20 weeks of \ngestation and resolving within 42 days of delivery.\nB)   Pre Eclampsia:\nPregnancy induced hypertension associated with significant proteinuria \n(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\nSevere Preeclampsia:\nDefined as Pre-eclampsia with severe hypertension and/or with symptoms, \nand/or biochemical and/or haematological impairment. \nThe clinical features of severe pre-eclampsia (in addition to hypertension \nand proteinuria) are:",
  "Gestational Hypertension\nA)   Pregnancy Induced Hypertension:\nHypertension unaccompanied by proteinuria developing after 20 weeks of \ngestation and resolving within 42 days of delivery.\nB)   Pre Eclampsia:\nPregnancy induced hypertension associated with significant proteinuria \n(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\nSevere Preeclampsia:\nDefined as Pre-eclampsia with severe hypertension and/or with symptoms, \nand/or biochemical and/or haematological impairment. \nThe clinical features of severe pre-eclampsia (in addition to hypertension \nand proteinuria) are:\n\n--- Page 68 ---\nNational Guideline for Maternal Care - Volume I\n50\n• \nSevere headache\n• \nVisual disturbance such as blurring or flashing before eyes, \nscotomas\n•  Epigastric or hypochondrial pain and/or nausea & vomiting\n•  Clonus (3 beats or more)\n•  Papilloedema\n•  Liver tenderness\n• \nOliguria (less than 400 ml per day or 0.5 mg/Kg/hour over a 4 \nhour period)\n•  Platelet count falling to below 100 x 106/l \n•  Abnormal liver enzymes (ALT or AST rising to above 70IU/l)\n•  HELLP syndrome\nSevere Hypertension:\nDefined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood \npressure ≥110 mmHg. \nEclampsia: \nDefined as the development of convulsions and/or unexplained coma \nduring pregnancy or postpartum in patients with features of preeclampsia.\n3.\t\nScreening for Hypertension during pregnancy\nBlood pressure must be measured in every clinic visit by a Medical Officer \nand results recorded and plotted in the pregnancy record. \nProteinuria must be tested for at every clinic visit.\nIf blood pressure is more than 140/90 mmHg on two occasions at least 2 \nhours apart, refer for specialist care.\n4.\t\nPrevention of hypertensive disorders in pregnancy\nAdvise women at high risk of pre-eclampsia to take 75 mg of aspirin daily \nfrom 12 weeks until delivery of the baby. Women at high risk are:",
  "Proteinuria must be tested for at every clinic visit.\nIf blood pressure is more than 140/90 mmHg on two occasions at least 2 \nhours apart, refer for specialist care.\n4.\t\nPrevention of hypertensive disorders in pregnancy\nAdvise women at high risk of pre-eclampsia to take 75 mg of aspirin daily \nfrom 12 weeks until delivery of the baby. Women at high risk are:\n\n--- Page 69 ---\nNational Guideline for Maternal Care - Volume I\n51\n Those with any one of the following risk factors:\n• \nHypertensive disease during a previous pregnancy\n• \nChronic kidney disease\n• \nAutoimmune disease such as systemic lupus erythematosis or \nantiphospholipid syndrome\n• \nType 1 or type 2 diabetes\n• \nChronic hypertension\n• \nMultiple pregnancy\nOr, any TWO or more of the following \n• \n First pregnancy\n• \nAge 40 years or older\n• \nPregnancy interval of more than 10 years\n• \nBody mass index (BMI) of 35 kg/m² or more at first visit\n• \nFamily history of preeclampsia\nContraindications such as allergy, gastritis, peptic ulcer disease must be \ntaken into account.\nAdvice women who have the above risk factors to ensure a higher intake of \ncalcium to achieve a daily intake of at least 1000 mg taking into account the \naverage intake by Sri Lankan women the recommended supplementation \nlevel is 600 mg. \n5.\t\nManagement of Chronic Hypertension \nWomen with chronic hypertension must be managed in specialist units. \nAnticipate the development of superimposed pre eclampsia in these \nwomen. This combination adds risks to both mother and baby. ACE \ninhibitors should be discontinued in women who are planning pregnancy \nand its use avoided during pregnancy. \nTreatment of mild to moderate hypertension\nSince there is no consensus on the value of treating mild to moderate \nhypertension, this guideline will not address this issue.",
  "ACE \ninhibitors should be discontinued in women who are planning pregnancy \nand its use avoided during pregnancy. \nTreatment of mild to moderate hypertension\nSince there is no consensus on the value of treating mild to moderate \nhypertension, this guideline will not address this issue.\n\n--- Page 70 ---\nNational Guideline for Maternal Care - Volume I\n52\n6.\t\nManagement of Severe Pre-Eclampsia\nThe basic outline of management\n• Admit to hospital and inform Consultant\n• Observe and monitor\n• Control blood pressure\n• Prevent seizures\n• Look for complications – such as HELLP / pulmonary oedema/\ncerebral haemorrhage\n• Strict fluid balance\n• In utero transfer where necessary and safe\n• Timing of Delivery\n• Continue vigilance post delivery\n• Follow up\n6.1. General Considerations\n• \nSevere preeclampsia is a life threatening condition.\n• \nThe only known cure is delivery of the baby.\n• \nThe immediate task is to determine the urgency to effect \ndelivery.\n• \nStabilization of the mother’s condition within an acceptable \ntime frame prevents maternal complications and may improve \nfetal condition.  \n• \nThe management has to be individualized depending on the \nclinical condition and available resources.\n• \nThe dangers will continue into the immediate postpartum \nperiod.\n6.2. Specific Management\nAdmit women who have severe preeclampsia and inform the Consultant.\nTreat hypertension if:\n• \nSystolic blood pressure ≥ 160 mmHg, or if\n• \nDiastolic blood pressure ≥ 110 mmHg, or if\n• \nMean arterial pressure ≥ 125 mmHg,",
  "• \nThe management has to be individualized depending on the \nclinical condition and available resources.\n• \nThe dangers will continue into the immediate postpartum \nperiod.\n6.2. Specific Management\nAdmit women who have severe preeclampsia and inform the Consultant.\nTreat hypertension if:\n• \nSystolic blood pressure ≥ 160 mmHg, or if\n• \nDiastolic blood pressure ≥ 110 mmHg, or if\n• \nMean arterial pressure ≥ 125 mmHg,\n\n--- Page 71 ---\nNational Guideline for Maternal Care - Volume I\n53\nAim to maintain blood pressure at around 130-140/90-100 mmHg.\nThe main cause of maternal death in severe preeclampsia is poorly \ncontrolled systolic hypertension causing cerebral haemorrhage. \nA rapid fall in maternal blood pressure as a result of antihypertensive \ntreatment may cause fetal heart rate abnormalities & compromise, \nespecially in growth restricted/compromised fetuses.\nWhere resources allow, it is recommended to monitor fetal heart with \ncontinuous CTG during and for 60 minutes after commencing anti-\nhypertensive therapy.\nAim to stabilize blood pressure before delivery.\n6.2.1. \nAnti-hypertensive drugs\nOral anti hypertensives may be used when the blood pressure is <180/110 \nmmHg. Blood pressure must be monitored at 15-minute intervals and \nintravenous anti hypertensives resorted to in case of an adequate response \nis not obtained within 30 minutes.\nThe commonly used antihypertensive drugs for acute control are given \nbelow. One or the other may be used depending on availability and \nfamiliarity. \n6.2.1.1 Labetalol orally or intravenously\nThis should be avoided in women with a history of bronchial asthma.\n- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n- repeated hourly for up to 4 hours\n \nor\n- 20 mg IV over two minutes\n• \nRecord blood pressure after 10 minutes.\n• \nIf either value is still above 160 mm Hg systolic and/or 110 \nmmHg diastolic, give 40 mg iv over 2 minutes.\n• \nRecord blood pressure after 10 minutes.",
  "One or the other may be used depending on availability and \nfamiliarity. \n6.2.1.1 Labetalol orally or intravenously\nThis should be avoided in women with a history of bronchial asthma.\n- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n- repeated hourly for up to 4 hours\n \nor\n- 20 mg IV over two minutes\n• \nRecord blood pressure after 10 minutes.\n• \nIf either value is still above 160 mm Hg systolic and/or 110 \nmmHg diastolic, give 40 mg iv over 2 minutes.\n• \nRecord blood pressure after 10 minutes.\n\n--- Page 72 ---\nNational Guideline for Maternal Care - Volume I\n54\n• \nIf the blood pressure is still above 160 mm Hg systolic and/or \n110 mmHg diastolic, give hydralazine 10 mg iv. For instructions \nregarding giving a fluid bolus with i.v. hydralazine, see the next \nsection of this guideline. \n• \nIf the blood pressure is still above 160 mm Hg systolic and/\nor 110 mmHg diastolic, start an IV infusion of labetolol, \nstarting at 40 mg/hour, doubling dose at half hourly intervals \nas required to a maximum of 160 mg/hour. \n• \nWhere these measures fail, the mother must be moved to a \nhigh-dependency area or an intensive care unit.\nIf blood pressure is controlled by the above, continue monitoring the \nblood pressure at 15 minute intervals for 1 hour and at 30 minute intervals \nthereafter. \nAdditional bolus doses as described above may be administered if the \nblood pressure increases above 160 mmHg systolic and/or 110 mmHg \ndiastolic.\n6.2.1.2. Hydralazine intravenously:\n• \n5 - 10 mg IV bolus over 2 minutes.\n• \nThis must be accompanied by a fluid bolus of 5ml/kg of 0.9% \nsodium chloride or ringer lactate solution over 30 min, started \nat the same time as iv hydralazine (this helps vasodilatation & \nprevents drastic hypotension). This should not be used in the \npresence of pulmonary oedema. \n• \nRecord blood pressure at 15 minute intervals.\n• \nRepeat boluses of 5 - 10 mg IV after a 15 minute interval may \nbe given if necessary up to a maximum of 20 mg (the effect of \na single dose can last up to 6 hours).\n• \nIf the response to above doses is inadequate, give labetolol \nbolus doses as described above.\n• \nIf no lasting effect with above boluses, consider an infusion of \nhydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required \n(2-20 mg/hour usually required).",
  "This should not be used in the \npresence of pulmonary oedema. \n• \nRecord blood pressure at 15 minute intervals.\n• \nRepeat boluses of 5 - 10 mg IV after a 15 minute interval may \nbe given if necessary up to a maximum of 20 mg (the effect of \na single dose can last up to 6 hours).\n• \nIf the response to above doses is inadequate, give labetolol \nbolus doses as described above.\n• \nIf no lasting effect with above boluses, consider an infusion of \nhydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required \n(2-20 mg/hour usually required).\n\n--- Page 73 ---\nNational Guideline for Maternal Care - Volume I\n55\n6.2.1.3. Oral Nifedipine\n• \nOral nifedipine may be used where the blood pressure is < \n180/110 mm Hg, in asymptomatic patients.\n• \nGive 10 mg orally.\n• \nRepeat at 20 minute intervals up to a maximum of 40 mg.\n• \nIf there is no response proceed to intravenous labetalol or \nhydralazine.\n6.2.2. \nPrevention of convulsions\n \nMagnesium sulphate\n• \nMagnesium sulphate is the anticonvulsant of choice.\n• \nIt should be given to any woman with features of impending/\nimminent eclampsia (presence of clonus, severe headache, \nvisual disturbances, and dizziness). \n• \nThe loading dose may be given even when the status of renal \nfunction is uncertain, since it is unlikely that toxic levels of \nmagnesium could be reached with this dose alone.\n• \nGive loading dose of 4 G IV over 10 minutes. There are two \nmethods of giving magnesium sulphate intravenously. \no \nDiluted to a total volume of 20 ml with 0.9% sodium \nchloride solution, given via an infusion pump or ‘manually’. \no \nDiluted to a total volume of 80 ml with 0.9% sodium \nchloride solution via a burette\n• \nImmediately after the loading dose, start infusion of 1 G IV per \nhour.  Continue this infusion for at least 24 hours after delivery.\n• \nWhere there are difficulties with intravenous access, magnesium \nsulphate may be administered intramuscularly. Give 5 G deep \nintramuscularly into each buttock with 1 ml of 2% lignocaine \nin the same syringe.  \n• \nIf intramuscular magnesium sulphate is continued as \nmaintenance therapy, give 5G to alternate buttocks 4 hourly, \nwith 1ml of 2% lignocaine in the same syringe.",
  "Give 5 G deep \nintramuscularly into each buttock with 1 ml of 2% lignocaine \nin the same syringe.  \n• \nIf intramuscular magnesium sulphate is continued as \nmaintenance therapy, give 5G to alternate buttocks 4 hourly, \nwith 1ml of 2% lignocaine in the same syringe.\n\n--- Page 74 ---\nNational Guideline for Maternal Care - Volume I\n56\n• \nMonitor the mother to ensure hourly urine output of 30 ml per \nhour, respiratory rate >16/ minute, oxygen saturation >90% \nand presence of patellar reflexes. \n• \nThese should be recorded every 30 minutes.\n• \nShould signs of toxicity appear, the antidote is calcium \ngluconate, 1 G intravenously (10 ml of 10% solution), given \nover 10 minutes. \n• \nMagnesium sulphate may be used safely in women who have \npreviously received nifedipine\n6.2.3. \nFluid Balance\n• \nRestrict total fluid intake to 80 ml per hour.\n• \nAccurate recording of fluid balance is essential.\n• \nSelective colloid expansion may be necessary prior to \npharmacological \nvasodilatation \nto \nprevent \nmaternal \nhypotension and fetal compromise or in oliguria with a low \ncentral venous pressure.\n• \nThe volumes of all drugs administered must be taken into \naccount and appropriate reduction of the volume of crystalloids \nmust be made.\n• \nColloid (e.g. Hetastarch) should be administered only after \ndiscussion with the anaesthetist.\n• \nDiuretics must be restricted to specific instances only e.g. for \nwomen with pulmonary oedema.\n• \nAvoid non-steroidal analgesia until fluid recovery.\n6.2.4. \nIn utero/neonatal transfer:\n• \nIf a Unit does not have access to HDU/ICU or is unable to \ncope with maternal complications, or with maturity of the \nbaby, it may be appropriate to consider antenatal transfer of \nthe mother. \n• \nHowever, maternal safety must not be jeopardised and each \ncase should be considered on its clinical merits.",
  "In utero/neonatal transfer:\n• \nIf a Unit does not have access to HDU/ICU or is unable to \ncope with maternal complications, or with maturity of the \nbaby, it may be appropriate to consider antenatal transfer of \nthe mother. \n• \nHowever, maternal safety must not be jeopardised and each \ncase should be considered on its clinical merits.\n\n--- Page 75 ---\nNational Guideline for Maternal Care - Volume I\n57\n• \nSteps must be taken to bring down blood pressure from very \nhigh levels (e.g. using nifedipine). \n• \nWomen with imminent/impending eclampsia must be \nadministered a loading dose of magnesium (IM or IV) before \ntransfer (see 6.2.2) \n• \nIt is recommended that where possible telephone advice is \nobtained from the relevant specialist unit before transfer.\n• \nThe patient must be accompanied by a member of staff who is \ncapable of dealing with a seizure while the patient in transit. \nThe required drugs and equipment must be made available.  \n• \nFull details of the case, including treatment given should \naccompany the patient.\n \n6.2.5. \nDelivery\n• \nUrgency of delivery depends on the maternal and fetal \nconditions.\n• \nEither caesarean section or induction of labour is appropriate \ndepending on the urgency and favourability of the cervix.\n• \nInstitute adequate pain relief. Severe preeclampsia is not a \ncontraindication for opioid or epidural anaesthesia (see below). \nIt is accepted that epidural anaesthesia helps to bring down the \nblood pressure.\n• \nSpinal or epidural anaesthesia is safe in the presence of a \nplatelet count >80,000/dl.\n• \nMaternal condition should be optimised before delivery. \n• \nIt is inappropriate to deliver an unstable mother for foetal \nreasons.\n• \nErgometrine should not be used during the third stage.\n6.2.6. \nPost-delivery\n• \nMaintain vigilance as a high proportion of eclamptic seizures \noccur after delivery. \n• \nHigh dependency care should be provided as clinically \nindicated.",
  "Post-delivery\n• \nMaintain vigilance as a high proportion of eclamptic seizures \noccur after delivery. \n• \nHigh dependency care should be provided as clinically \nindicated.\n\n--- Page 76 ---\nNational Guideline for Maternal Care - Volume I\n58\n• \nContinue close monitoring, including fluid balance, platelets, \nliver enzymes and creatinine until they have returned to \nnormal values. \n• \nMagnesium sulphate if started should be continued for 24 \nhours after the delivery or after the last fit, whichever is later.\n• \nReview anti-hypertensive medication as indicated. Some may \nneed to continue oral medication for a few weeks. Methyldopa \nis best avoided following delivery because of its tendency to \ncause depression. \n• \nReview magnesium sulphate medication as indicated.\n6.2.7. \nFollow up\n• \nInform Public Health Midwife and/or Medical Officer of \nHealth.\n• \nReview in 2 weeks (instead of 4 weeks) if discharged on \nantihypertensives.\n• \nDepending on the clinical picture, some patients may need:\no \nLong term follow up for blood pressure\no \nHematological investigations for conditions such as anti-\nphospholipid syndrome, thrombophilia \n• \nDebrief the patient. \n• \nAdvice preconceptual counseling & check prior to the next \npregnancy.\n• \nWomen may be advised regarding the risk of developing \nhypertensive disease in a future pregnancy as follows:\no \nRisk of gestational hypertension - 53% (1 in 2)\no \nRisk of preeclampsia – 16% (1 in 6)\no \nRisk of preeclampsia if she had severe hypertension or \nHELLP syndrome or eclampsia or the birth occurred \nbefore 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth \noccurred before 28 weeks gestation.",
  "Follow up\n• \nInform Public Health Midwife and/or Medical Officer of \nHealth.\n• \nReview in 2 weeks (instead of 4 weeks) if discharged on \nantihypertensives.\n• \nDepending on the clinical picture, some patients may need:\no \nLong term follow up for blood pressure\no \nHematological investigations for conditions such as anti-\nphospholipid syndrome, thrombophilia \n• \nDebrief the patient. \n• \nAdvice preconceptual counseling & check prior to the next \npregnancy.\n• \nWomen may be advised regarding the risk of developing \nhypertensive disease in a future pregnancy as follows:\no \nRisk of gestational hypertension - 53% (1 in 2)\no \nRisk of preeclampsia – 16% (1 in 6)\no \nRisk of preeclampsia if she had severe hypertension or \nHELLP syndrome or eclampsia or the birth occurred \nbefore 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth \noccurred before 28 weeks gestation.\n\n--- Page 77 ---\nNational Guideline for Maternal Care - Volume I\n59\nManagement of Eclampsia\n1.\t\nDefinition:\nEclampsia is defined as the development of convulsions and/or \nunexplained coma during pregnancy or postpartum in patients with \nfeatures of preeclampsia.\n2.\t\nDiagnosis:\n• \nHypertension is considered the hallmark for the diagnosis of \neclampsia. However, in 16% of the cases hypertension may be \nabsent.\n• \nEclampsia is usually associated with proteinuria, but this may \nbe absent in 14% of cases.\n• \nClinical features of imminent eclampsia include:\n \nSevere frontal headache, \n \nVisual symptoms (halos, scotomas etc.) \n \nEpigastric or right hypochondrial pain,\n \nLiver tenderness,\n \t\nClonus (3 beats or more) \n3.\t\nTime of onset of eclampsia\nThe onset of eclamptic convulsions can be antepartum, intrapartum, or \npostpartum. \nAntepartum eclampsia \nAlmost all cases (91%) develop eclampsia at or beyond 28 weeks \nPostpartum eclampsia \nAlthough most cases of postpartum eclampsia occur within the first 48 \nhours, some cases develop beyond 48 hours, up to 4 weeks postpartum \n(late postpartum eclampsia). In these cases, an extensive neurological \nevaluation is needed to rule out the presence of other cerebral pathology.",
  "Antepartum eclampsia \nAlmost all cases (91%) develop eclampsia at or beyond 28 weeks \nPostpartum eclampsia \nAlthough most cases of postpartum eclampsia occur within the first 48 \nhours, some cases develop beyond 48 hours, up to 4 weeks postpartum \n(late postpartum eclampsia). In these cases, an extensive neurological \nevaluation is needed to rule out the presence of other cerebral pathology.\n\n--- Page 78 ---\nNational Guideline for Maternal Care - Volume I\n60\n4.\t\nComorbidities \n• \nEclampsia is often complicated by comorbidities (Box 1). \n• \nThese are more common among women who develop eclampsia \nat earlier periods of gestation.\nBox 1.\n• Abruptio placentae \n• Disseminated intravascular coagulopathy  \n• Pulmonary oedema \n• Acute renal failure \n• Aspiration pneumonia \n• HELLP syndrome (Haemolysis, elevated liver enzymes, low \nplatelets)\n5.\t\nPrevention\nAdministration of magnesium sulphate to women with features of \nimpending/imminent eclampsia (presence of clonus, severe headache, \nvisual disturbances, dizziness) is the only known preventive measure.\n6.\t\nManagement\n6.1 General considerations\n6.1.1 The priorities in management are to support respiratory and \ncardiovascular function, prevent injury and further seizures \nand to control hypertension. \n6.1.2 Magnesium sulphate is the anticonvulsant of choice. It must \nbe administered as soon as possible. See section 6.2.2 of the \nsevere preeclampsia guideline for details.\n6.1.3 The bolus dose of magnesium sulphate must be given even \nto women with unknown renal function or oliguria/anuria \nsince this dose is unlikely to elevate magnesium levels to toxic \nranges.",
  "It must \nbe administered as soon as possible. See section 6.2.2 of the \nsevere preeclampsia guideline for details.\n6.1.3 The bolus dose of magnesium sulphate must be given even \nto women with unknown renal function or oliguria/anuria \nsince this dose is unlikely to elevate magnesium levels to toxic \nranges.\n\n--- Page 79 ---\nNational Guideline for Maternal Care - Volume I\n61\n6.1.4 Eclampsia dictates delivery (or induction) once the maternal \ncondition is stabilized, irrespective of the foetal condition or \nmaturity. A decision regarding the mode and time of delivery \nwill require to be made early. \n6.1.5 There is no place for prolongation of the pregnancy in these \nwomen, unless under rare, exceptional circumstances.\n6.1.6 For details on administration of medications and intravenous \nfluids and care of women receiving magnesium sulphate and \nintravenous antihypertensives, refer the guideline on severe \npreeclampsia.\n6.2.  During the seizure – \no \nTurn the patient to a side and support her in that position.\no \nSuck out secretions from the mouth.\no \nAdminister oxygen via a face mask.\no \nMost eclamptic seizures resolve spontaneously.\no \nIt is imprudent to diagnose fetal hypoxia based on fetal \nbradycardia during a seizure. This usually recovers \nspontaneously following the seizure\no \nFetal bradycardia persisting beyond 10 minutes following \nthe seizure should raise suspicion of abruptio placentae.\n6.3. As soon as possible following a seizure\no \nAttempt to establish intravenous access. \no \nObtain blood for full blood count, liver transaminases, \nblood urea, electrolytes and blood for cross-match.\no \nStart magnesium sulphate (intravenous bolus and \ninfusion or intramuscular – details in guideline on severe \npreeclampsia section 6.2.2.). \no \nTreat blood pressure as appropriate. \no \nInsert an indwelling catheter.\no \nMonitor respiratory rate, urine output, reflexes, SpO2. \n(Please refer the guideline on severe preeclampsia for \nfurther details).",
  "o \nInsert an indwelling catheter.\no \nMonitor respiratory rate, urine output, reflexes, SpO2. \n(Please refer the guideline on severe preeclampsia for \nfurther details).\n\n--- Page 80 ---\nNational Guideline for Maternal Care - Volume I\n62\no \nCheck for comorbidities (Box 1). \no \nInform the Consultant and establish a plan of management\n6.4. Management of seizures in women receiving magnesium sulphate\n6.4.1 Women developing a seizure while on magnesium sulphate\no \n10% of women receiving magnesium sulphate will develop \na second seizure.\no \nAdminister magnesium sulphate 2 grams diluted to 10 ml \nwith 0.9% sodium chloride solution over 5 minutes. \no \nIncrease the magnesium sulphate infusion to 2 grams per \nhour with monitoring as above.\n6.4.2 Women developing more than one seizure while on magnesium \nsulphate \no \nCall a Neurology team for advice. If one is not available, \nobtain advice from a medical team.\no \nConsultant must be informed.\no \nInform the anaesthetic team if still not in an intensive care \nsetting. \no \nSecond line anticonvulsants must be considered after \ndiscussing with anaesthetist.\no \nIf the woman develops further seizures, consider moving to \nintensive care for neuromuscular paralysis and ventilation.\no \nThese women will require a full neurological evaluation, \nincluding imaging.\n7.\t\nDelivery\no \nEclampsia is not an indication for caesarean section.\no \nConsider caesarean section in women who are not in \nlabour with a Bishop score below 7.\no \nWomen who are in labour may be allowed to continue to \ndelivery, in the absence of obstetric complications.",
  "If one is not available, \nobtain advice from a medical team.\no \nConsultant must be informed.\no \nInform the anaesthetic team if still not in an intensive care \nsetting. \no \nSecond line anticonvulsants must be considered after \ndiscussing with anaesthetist.\no \nIf the woman develops further seizures, consider moving to \nintensive care for neuromuscular paralysis and ventilation.\no \nThese women will require a full neurological evaluation, \nincluding imaging.\n7.\t\nDelivery\no \nEclampsia is not an indication for caesarean section.\no \nConsider caesarean section in women who are not in \nlabour with a Bishop score below 7.\no \nWomen who are in labour may be allowed to continue to \ndelivery, in the absence of obstetric complications.\n\n--- Page 81 ---\nNational Guideline for Maternal Care - Volume I\n63\no \nLabour may be induced where necessary using either \nprostaglandins or amniotomy and oxytocin infusion. \no \nEpidural or spinal anaesthesia may be administered in \nwomen with platelet counts above 80,000/cu mm. \no \nGeneral anaesthesia is best avoided where possible since it \nincreases the risk of aspiration and failed intubation due to \nairway oedema. It is also associated with marked increases \nin systemic and cerebral pressures during intubation and \nextubation. Women with airway or laryngeal oedema may \nrequire ‘awake intubation’ under fibre optic observation \nwith  facilities available  for immediate tracheostomy. The \nlevel of increase in systemic or cerebral pressures may be \nreduced by pretreatment with labetalol or nitroglycerine \ninjections.\n8.\t\nTransfer of a woman who has had a seizure to another institution\no \nIn case it is required to transfer a woman who has \nhad an eclamptic seizure, this must be done only after \nadministering a bolus of magnesium sulphate. (See section \n6.2.2 of the severe preeclampsia guideline for details). The \npatient should ideally be accompanied by a doctor and \nemergency drugs/equipment (e.g. Ambu bag) must be \navailable.\n9.\t\nPostpartum management\no \nContinue administration of magnesium sulphate and \nmonitoring as described in the guideline on severe \npreeclampsia. \no \nWomen with abnormal renal function, preexisting \nhypertension and abruption placentae (due to use of larger \nthan normal volumes of fluids) are at particularly high \nrisk of pulmonary oedema. They will require appropriate \nmonitoring\no \nAntihypertensive therapy may be changed to oral and \ncontinued .",
  "o \nWomen with abnormal renal function, preexisting \nhypertension and abruption placentae (due to use of larger \nthan normal volumes of fluids) are at particularly high \nrisk of pulmonary oedema. They will require appropriate \nmonitoring\no \nAntihypertensive therapy may be changed to oral and \ncontinued .\n\n--- Page 82 ---\nNational Guideline for Maternal Care - Volume I\n64\n10.\t Counselling \n10.1.  Women should be advised that in a subsequent pregnancy:\no \nThe rate of preeclampsia is approximately 25%.\no \nRate of eclampsia is 2%.\no \nThese rates are substantially higher in women who develop \neclampsia in the second trimester.\no \nTaking high-dose calcium from early pregnancy (600 mg \ndaily) and aspirin (75 mg daily) may reduce this risk.\n10.2. Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.",
  "Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.\n\n--- Page 83 ---\nNational Guideline for Maternal Care - Volume I\n65\nManagement of Diabetes \nduring Pregnancy\n\n--- Page 84 ---\nNational Guideline for Maternal Care - Volume I\n66",
  "Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.\n\n--- Page 83 ---\nNational Guideline for Maternal Care - Volume I\n65\nManagement of Diabetes \nduring Pregnancy\n\n--- Page 84 ---\nNational Guideline for Maternal Care - Volume I\n66\n\n--- Page 85 ---\nNational Guideline for Maternal Care - Volume I\n67\nGuideline for screening, diagnosis and management of \ndiabetes in pregnant women\n1.\t\nPurpose\nThe purpose of this guideline is to provide guidance on screening for \ngestational diabetes mellitus (GDM) and the management of pregnancies \ncomplicated pre-gestational (PGDM) and GDM in the Sri Lankan setting. \n2.\t\nScreening\n2.1 Target groups for screening\nBeing South Asian and pregnant places a woman in Sri Lanka at a higher \nrisk for diabetes during pregnancy. Therefore, universal screening, using a \ndiagnostic test is recommended for all Sri Lankan women. \nA. All pregnant women should be screened for diabetes at the \nfirst visit unless they are already known to have Diabetes*. This \nshould be performed as early as possible, preferably before 12 \nweeks, in order to diagnose previously undetected diabetes.\nB. Screening using fasting blood glucose, random blood glucose, \n50g glucose challenge test, HBAIC or urinalysis for reducing \nsubstances is not recommended.\nC. Those who are negative for diabetes at the first visit should be \nscreened for GDM again at 24-28 weeks.\nD. Women who are known diabetics should not undergo further \nscreening or diagnostic tests. They should be commenced \non glycaemic control measures immediately under the \nsupervision of obstetrician or physician.\n*Diagnostic criteria for pre pregnancy diabetes are \nany one of the following\n \nFBS \n \n≥126mg/dl\n \nRBS \n \n>200mg/dl\n \nHbA1c \n \n>6.1%",
  "Women who are known diabetics should not undergo further \nscreening or diagnostic tests. They should be commenced \non glycaemic control measures immediately under the \nsupervision of obstetrician or physician.\n*Diagnostic criteria for pre pregnancy diabetes are \nany one of the following\n \nFBS \n \n≥126mg/dl\n \nRBS \n \n>200mg/dl\n \nHbA1c \n \n>6.1%\n\n--- Page 86 ---\nNational Guideline for Maternal Care - Volume I\n68\n2.2 Recommended tests\nA. One stage, non- fasting 75g OGCT as described by the \nDiabetes in Pregnancy Study Group of India (DIPSI) is \nrecommended for screening at the first visit and at 28 weeks. \nA 2- hour blood glucose of more than 140mg/dl confirms \ngestational diabetes. This is the recommended test for both \nfield and institutional levels.\nOne stage Non- fasting 75 g OGCT\n \nIn this method 75g oral glucose load is given to the woman \nirrespective of the fasting status. Therefore a woman could be \nsubjected to a GTT at any time, without the woman having to \nfast. \n \nA load of 75g of glucose dissolved in 300 ml water is given over \n3-5 minutes. The water may be flavoured with lime juice. \n \n \nThe plasma glucose level is measured after a period of two \nhours. \n(The main advantage of this test is that it would be the best way to \nensure universal screening. The advantages include reduced cost, the \nability to make a diagnosis in one test and the woman not requiring \nto fast for the test. The test has been validated against the WHO and \nHAPO criteria and been found to correlate well with them (3),(4). \nData also shows that glucose levels are not significantly affected by \nthe fasting status and that the non-fasting glucose level effectively \npredicts adverse effects for the mother and baby (5),(6).)\nB. Three-point oral GTT - In the event of an equivocal screening \nresult or when resources permit, the three point OGTT is \nrecommended. For those who undergo three point OGTT the \nfollowing cut off should be used for diagnosis.",
  "Three-point oral GTT - In the event of an equivocal screening \nresult or when resources permit, the three point OGTT is \nrecommended. For those who undergo three point OGTT the \nfollowing cut off should be used for diagnosis.\n\n--- Page 87 ---\nNational Guideline for Maternal Care - Volume I\n69\nThree-point oral GTT\nThis is probably the most accepted diagnostic test in the world \ntoday. \nThe woman should attend for the test having fasted for eight hours \nor more, having had a diet unrestricted in carbohydrates. \nBlood is first drawn for estimation of fasting plasma glucose. \nThe woman is then given a solution of 75 G glucose dissolved in \n300 ml of water to be taken within 10 minutes. Squeezing a lime \ninto this water will make the solution more palatable without \ninterfering with the result. \nBlood is then drawn at 60 and 120 minutes for estimation of \nplasma glucose.\nC. In situations where neither of the above tests is possible, \n(Inability to tolerate glucose or non availability of facilities) \ntwo-stage screening using a 2 hour PPBS is an alternative.  The \ncut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n2 hour Post Prandial Blood Glucose Testing (PPBS)\nAdvice the woman to have normal diet\nThe time of starting the meal needs to be noted. The meal should \nbe completed within 15 minutes.\nThe two-hour cut off is calculated from the time of starting the \nmeal.\nAt the end of two hours blood sample should be tested for blood \nsugar levels using glucometer or other laboratory method.",
  "The \ncut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n2 hour Post Prandial Blood Glucose Testing (PPBS)\nAdvice the woman to have normal diet\nThe time of starting the meal needs to be noted. The meal should \nbe completed within 15 minutes.\nThe two-hour cut off is calculated from the time of starting the \nmeal.\nAt the end of two hours blood sample should be tested for blood \nsugar levels using glucometer or other laboratory method.\n\n--- Page 88 ---\nNational Guideline for Maternal Care - Volume I\n70\n3.\t\nManagement – Women with established Diabetes\n3.1. Pre Pregnancy care\nThe importance of avoiding unplanned pregnancy is an essential \ncomponent of diabetes education for women with diabetes.\nWomen with diabetes who are planning to become pregnant and their \nfamilies should be offered information on how diabetes affects pregnancy \nand how pregnancy affects diabetes.\nDiscuss their plans for pregnancy and reinforce an appropriate \ncontraceptive method. Any type of contraception can be used except for \nwomen BMI > 25kg/m2 where DMPA should not be used. Pregnancy is \ncontraindicated if the woman has proliferative retinopathy, stage 2 or \nabove Chronic kidney Disease or major cardiac disease. \nAll women with diabetes wishing to conceive MUST be encouraged to \nseek specialist advice to ensure satisfactory glycaemic control (HbA1C < \n6.1%) before conception. \nIdeally the decision to embark on pregnancy in known diabetics should be \ndecided on based on her HbA1C .  A value of 6.1 or below would be ideal \nif safely achievable. Women whose levels are above 10% should be strongly \nadvised against conception until good glycaemic control is achieved,  in \nview of higher risk of congenital anomalies. \nStress that good planning and control will help to achieve pregnancy \noutcome to be equivalent to that of a non-diabetic women. They should \nbe informed that establishing good glycaemic control before conception \nand maintaining this  throughout pregnancy will reduce the risk of \nmiscarriage, congenital malformation, still births and neonatal deaths.\nWomen who are using either metformin or insulin for glycaemic control \nshould be advised that these are safe for use during the peri-conception \nperiod and into their pregnancy.\nSelf-testing of blood sugar should be encouraged where ever economically \nfeasible.",
  "Stress that good planning and control will help to achieve pregnancy \noutcome to be equivalent to that of a non-diabetic women. They should \nbe informed that establishing good glycaemic control before conception \nand maintaining this  throughout pregnancy will reduce the risk of \nmiscarriage, congenital malformation, still births and neonatal deaths.\nWomen who are using either metformin or insulin for glycaemic control \nshould be advised that these are safe for use during the peri-conception \nperiod and into their pregnancy.\nSelf-testing of blood sugar should be encouraged where ever economically \nfeasible.\n\n--- Page 89 ---\nNational Guideline for Maternal Care - Volume I\n71\nWomen must be encouraged to achieve a normal weight before becoming \npregnant, especially those with a body mass index above 25 kg/m2. They \nmust receive advice about reducing weight using lifestyle modification. \nKnown diabetics should be assessed for diabetic nephropathy and \nretinopathy before and during pregnancy. (see below)\nStart Folic acid 5 mg daily when trying to conceive.\n3.2.\t Antenatal Care\nAt the first visit \n• \nRefer for specialist care immediately once identified. These \nwomen are best managed with combined inputs from a \nphysician and an obstetrician. \n• \nStart/ continue Folic acid 5 mg daily up-to 12 weeks of \ngestation. Change to 1mg daily from 12 weeks onwards.\n• \nLow dose Aspirin 75mg should be commenced, if there is no \ncontraindication.\n• \nCheck HbA1c (ideally 6.1% or less).\n• \nDating ultrasound scan using either crown rump length or \nhead circumference is recommended.\n• \nWomen with pre-existing diabetes mellitus must be screened \nfor diabetic end-organ damage (retinopathy, nephropathy and \ncardiovascular disease)\n• \nRetinopathy screening is recommended at least twice during \npregnancy (at first contact and at 28 weeks). \n• \nWomen with serum creatinine >120 µmol/litre or 24 hour \nurinary protein excretion exceeding 300mg must be referred \nfor renal specialist’s advice.\n• \nWomen with complicated diabetes should be managed at a \ntertiary care institution by a multidisciplinary team\nAntenatal Appointments\n• \nThese women must be identified as high risk and managed \nalmost entirely by a specialist Obstetrician led team.",
  "Change to 1mg daily from 12 weeks onwards.\n• \nLow dose Aspirin 75mg should be commenced, if there is no \ncontraindication.\n• \nCheck HbA1c (ideally 6.1% or less).\n• \nDating ultrasound scan using either crown rump length or \nhead circumference is recommended.\n• \nWomen with pre-existing diabetes mellitus must be screened \nfor diabetic end-organ damage (retinopathy, nephropathy and \ncardiovascular disease)\n• \nRetinopathy screening is recommended at least twice during \npregnancy (at first contact and at 28 weeks). \n• \nWomen with serum creatinine >120 µmol/litre or 24 hour \nurinary protein excretion exceeding 300mg must be referred \nfor renal specialist’s advice.\n• \nWomen with complicated diabetes should be managed at a \ntertiary care institution by a multidisciplinary team\nAntenatal Appointments\n• \nThese women must be identified as high risk and managed \nalmost entirely by a specialist Obstetrician led team.\n\n--- Page 90 ---\nNational Guideline for Maternal Care - Volume I\n72\n• \nPublic Health Midwife should visit such women once in every \n2 weeks (refer guideline on domiciliary care for high risk \npregnancies).\n• \nReview by the obstetric/diabetic team once every 2 weeks \nthroughout the pregnancy \n• \nAnomaly scans at 18-20 weeks and Obstetric reviews at 22-24, \n28, 32 and 36-37 weeks with ultrasound growth assessments. \n• \nIf required, antenatal steroids for fetal lung maturity may be \nused. Women should be admitted to hospital for glycaemic \ncontrol during therapy since glucose levels rise in response to \nsteroids. \n• \nMore attention should be given to the woman with diabetes \nduring antenatal preparation for breast feeding as they \nneed to start and establish breast feeding quickly to prevent \nhypoglycaemia of newborn. \n• \nRefer to dental surgeon for screening and maintenance of oral \nhygiene.\n3.3.\t Medical nutrition therapy (MNT) \nMNT is the cornerstone of the management of diabetes in pregnancy. \nWomen must be referred to a dietician/ diabetic educator nurse  where \none is available. \nEmphasis the importance of small frequent meals, food with low glycaemic \nindex and the  dietary advice should be culture sensitive. \n3.4.\t Exercise \nExercise has an insulin-like action and women with GDM and pre-existing \ndiabetes complicating pregnancy. Therefore,  diabetic women must be \nencouraged to engage in regular exercise. \nThe intensity of exercise would depend on the woman’s level of fitness, \npresence of complications and familiarity with exercise. \nIdeally this should be at least 30 minutes per day of an activity, which \nleaves her slightly breathless.",
  "The intensity of exercise would depend on the woman’s level of fitness, \npresence of complications and familiarity with exercise. \nIdeally this should be at least 30 minutes per day of an activity, which \nleaves her slightly breathless.\n\n--- Page 91 ---\nNational Guideline for Maternal Care - Volume I\n73\nWomen on insulin must be aware of the  tendency to hypoglycaemia \nduring exercise. \n4.\t\nGlyceamic control and Monitoring \n4.1. Glyceamic Control\n4.1.1. The aim is to achieve optimum glycaemic control throughout the \nday for the duration of the pregnancy (avoiding hypoglycaemia).\nThe target values for glycaemic control are given below:\nTable 1. Target values in glycemic control\n \n  Fasting and pre-meal \n           2 hour post meal\nVenous plasma \n70 - 90 (3.9 – 5.0 mMol/L) \nBelow 120 mg/dl (6.7 mMol/L)\nCapillary blood \n80 – 103 (4.4 – 5.7 mMol/L) \n118 mg/dl (6.5 mMol/L)\n(The equivalent capillary blood values were derived  using a conversion \nformula7)\nRefer to Diabetic Educator Nursing Officer (DENO) where one is available. \nAt diagnosis, offer diet/ lifestyle advice with a recorded glycaemic \nassessment within 1-2 weeks.\nMajority of these women can achieve optimal glycaemia with modest \nchanges in diet and exercise.\nConsider insulin and /or metformin treatment if suboptimal glycaemia \npersists despite diet and exercise modifications. The choice of these \ntreatments will depend on physician and patient preferences. \nIdeally the  insulin regimen should be adjusted to achieve targets: in most \ncases with moderate to severe hyperglycaemia three doses of short acting \npre prandial insulin combined with a single dose of basal insulin at bed \ntime is required. However, twice daily dose of pre mixed 30:70 insulin \nhas high patient compliance with adequate control of blood sugar in most \ncases. If blood sugar is not controlled by this twice daily regimen, adding \nmetformin or soluble insulin to cover lunch is an alternative.",
  "However, twice daily dose of pre mixed 30:70 insulin \nhas high patient compliance with adequate control of blood sugar in most \ncases. If blood sugar is not controlled by this twice daily regimen, adding \nmetformin or soluble insulin to cover lunch is an alternative.\n\n--- Page 92 ---\nNational Guideline for Maternal Care - Volume I\n74\nACE inhibitors, statins and ARBs are contraindicated during pregnancy\n4.2.\t Monitoring of glycaemic control\nSelf-monitoring of blood glucose (SMBG) with close liaison with the \ndiabetic team is recommended for those who are able to afford a glucometer \nand test strips. (However, in view of variable quality of glucometers women \nmust be advised to crosscheck the values occasionally with estimations \nmade by a reliable laboratory. \nFor women who cannot afford the cost of SMBG, monitoring with regular \n6 point blood glucose monitoring should be offered. \nThe frequency of such monitoring should be decided by the overall \nglyceamic control, presence or absence of fetal macrosomia and the period \nof gestation;: with at least four weekly  reviews  in pregnancy two weekly \nreviews  in late pregnancy\nSchedule ultrasound measurement of AC at 28, 32 and 36 weeks. If AC > \n90 centile at any stage, consider insulin therapy to target 2 hour PPBS to \nbe less than 100mg/dl but avoiding hypoglycaemia.\nIf crossing centiles or AC <10 centile, do AFI and request obstetrician \nreview.\nInsulin requirements change throughout the pregnancy. If requirements \nare falling (or maternal hypoglycaemia occurs frequently) request early \nobstetrician review for fetal assessment.\nHbA1c is not a reliable indicator of glycaemic control in the second \nand third trimesters. \n5.\t\nDelivery and intra natal care\n6.1. Timing of delivery\nFor women with pre-pregnancy diabetes or who receive insulin therapy, \nschedule obstetrician review at 36-37 weeks for planning their delivery at \n38-39 weeks.",
  "5.\t\nDelivery and intra natal care\n6.1. Timing of delivery\nFor women with pre-pregnancy diabetes or who receive insulin therapy, \nschedule obstetrician review at 36-37 weeks for planning their delivery at \n38-39 weeks.\n\n--- Page 93 ---\nNational Guideline for Maternal Care - Volume I\n75\nFor women on diet control and/or women having optimal glycaemic \ncontrol and, carrying a normally grown baby, there is insufficient evidence \nto suggest the best time for delivery. \nDiabetes alone is not an indication for a caesarean section.\nThe obstetrician should make the decision after discussing with the \nwoman.\nDelivery should be arranged in the day time, when all supports are more \neasily available.\n5.2. Labour care\nSecond tier obstetric on-call (SHO/Registrar) should be informed of any \nwoman with diabetes at  the onset of labour. He/she should be present \nfor the delivery. It is recommended to involve the medical team in the \nmanagement of difficult cases.\nInform on-call neonatal team of any planned/ imminent delivery of a \ndiabetic mother.\nDuring labour and birth, capillary blood glucose should be monitored \n1-2 hourly in women with diabetes and maintained at between 4 and 7 \nmmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the \npartogram. \nHartmann’s/ normal saline or Insulin-dextrose – potassium (GIK) \ninfusion should be started if the values are lower or higher respectively.\n6.\t\nPost natal care\n6.1a. Neonatal care\nHandover care of newborn, to neonatal team.\nEnsure delivery-to-abdomen and initiate breastfeeding as early as possible \n(within first ½ to 1 hour) unless specific concerns prevent such action.\nTake all suitable ENC measures to avoid hypothermia.",
  "Hartmann’s/ normal saline or Insulin-dextrose – potassium (GIK) \ninfusion should be started if the values are lower or higher respectively.\n6.\t\nPost natal care\n6.1a. Neonatal care\nHandover care of newborn, to neonatal team.\nEnsure delivery-to-abdomen and initiate breastfeeding as early as possible \n(within first ½ to 1 hour) unless specific concerns prevent such action.\nTake all suitable ENC measures to avoid hypothermia.\n\n--- Page 94 ---\nNational Guideline for Maternal Care - Volume I\n76\nBlood glucose testing should be carried out routinely in babies of women \nwith diabetes at 2–4 hours after birth. The mother must be informed about \nthis antenatally to avoid unnecessary distress.\nNeonatal blood glucose values below 36 mg/dl (2 mMol/L) should trigger \naction. \n \nBlood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and \nhypomagnesaemia should be carried out for babies with clinical signs.\n6.1b. Immediate post partum care \nIt is recommended that the mother be tested for RBS within 4 hours of \ndelivery. The decision to manage maternal diabetes with insulin or oral \nmedication should be made within the first 48 hours after delivery and \nprior to discharge from hospital.\nIf the mother received insulin in the antenatal period, it is recommended \nthat the dose needs adjustments to pre pregnant doses in those with type \n2 diabetes mellitus or be maintained on diet alone in those with GDM. \nThis decision should be based on her post partum blood glucose value. If \nFBG exceed 126mg/dl or RBS exceeds 200mg/dl, insulin in a lower dose \n(usually half of the antenatal dose) or metformin would be required. This \ndecision is best left to the managing physician who should be responsible \nfor the woman’s long term care. \n6.2. At hospital discharge\nInform MOH and area public health midwife (PHM) through woman’s \npregnancy record.\nFor women with pre- gestational diabetes, prescribe suitable hypoglycaemic \nagent, restart statins, schedule follow up clinic date at the medical clinic.\nFor women who developed GDM, give a date or make arrangements to \nscreen for DM at 6 weeks postpartum. \nDiscuss and help to decide on the suitable contraceptive method.",
  "At hospital discharge\nInform MOH and area public health midwife (PHM) through woman’s \npregnancy record.\nFor women with pre- gestational diabetes, prescribe suitable hypoglycaemic \nagent, restart statins, schedule follow up clinic date at the medical clinic.\nFor women who developed GDM, give a date or make arrangements to \nscreen for DM at 6 weeks postpartum. \nDiscuss and help to decide on the suitable contraceptive method.\n\n--- Page 95 ---\nNational Guideline for Maternal Care - Volume I\n77\n6.3. Late Postnatal care and follow up\nAt 6 -8 weeks postpartum, all women with GDM are screened for diabetes \nmellitus. The test of screening is ideally the 75g OGTT.  FBS is an alternative \nif resources are limited. Women whose fasting venous plasma glucose is \nabove 100 mg/dl (5.5 mMol/L) must be referred for further evaluation. \nWomen who have been diagnosed with GDM and are screen-negative at \nthe 6 week review should receive lifestyle advice and screening for diabetes \nmellitus annually with at least a FBS. The importance of maintaining a \nnormal BMI and the contribution of breastfeeding to weight loss must be \nemphasized.\n7.\t\nFamily Planning\n8.1 All reliable methods of family planning can be used as \nappropriate for the needs    of the individual woman with \ndiabetes.\n8.2  For women with BMI >25kg/m2, DMPA is best avoided.\n8.3 Women with type 2 diabetes should be advised to complete \ntheir family within  5-10 years   of diagnosis of diabetes in view \nof possible development of complications.\nReferences (need to add the sections taken from NIROGI guide)\n1. \nNICE, clinical guideline 63 Diabetes in pregnancy: management \nof diabetes and its complications from pre-conception to the \npostnatal period. 2008, National Institute for Health and \nClinical Excellence.\n2. \nSeshiah V., Das AK.,BalajiV et al., Gestational Diabetes Mellitus \n- Guidelines. Journal of the Association of Physicians of India. \n2006. 54: 622- 628\n3. \nIADPSGCP, International Association of Diabetes and \nPregnancy Study Groups Recommendations on the Diagnosis \nand Classification of Hyperglycemia in Pregnancy. Diabetes \nCare, 2010. 33(3): p. 676-682.\n4. \nKuhl C. Insulin Secretion and insulin resistance inpregnancy \nand GDM. Implications for diagnosis andmanagement. \nDiabetes 1991;40(December (Suppl. 2)):18–24.",
  "Diabetes 1991;40(December (Suppl. 2)):18–24.\n\n--- Page 96 ---\nNational Guideline for Maternal Care - Volume I\n78\n5. \nGough WW, Shack MJ, Bennett PH, Burch TA, Miller \nM.Evaluation of glucose in the Pima Indians by longitudinal \nstudies. Diabetes 1970;19(Suppl. 1):388.\n6. \nPettitt DJ, Bennett PH, Hanson RL, Narayan KM, KnowlerWC. \nComparison of World Health Organization and National \nDiabetes Data Group procedures to detect abnormalities \nof glucose tolerance during pregnancy. Diabetes Care \n1994;17(November (11)):1264–8.\n7. \nHaeckel R.,  Brinck U, Colic D. et al.,  Comparability of Blood \nGlucose Concentrations Measured in Different Sample Systems \nfor Detecting Glucose Intolerance. Clinical Chemistry 2002. 48: \n(6); 936-939.\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume I\n79\nManagement of \nPostparum Haemorrhage\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume I\n80",
  "Clinical Chemistry 2002. 48: \n(6); 936-939.\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume I\n79\nManagement of \nPostparum Haemorrhage\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume I\n80\n\n--- Page 99 ---\nNational Guideline for Maternal Care - Volume I\n81\nGuideline on Managementof Primary post Partum \nHaemorrhage\n1.\t\nIntroduction\nThe aim of this guideline is to provide evidence based recommendations \nin the management of primary post partum haemorrhage (PPH). This is \nthe commonest direct cause of maternal death globally and in Sri Lanka. \nThe objective of this guideline is to ensure anticipation, prevention, early \ndetection and timely and appropriate management of PPH. \n2. \t\nDefinition\nFor the purpose of this guideline PPH is defined as blood loss of 500 ml or \nmore from the genital tract within 24 hours of the birth of a baby. Blood \nloss of over 1000 ml is defined as major PPH. \nIrrespective of blood loss, the appearance of cardiovascular instability (i.e. \ntachycardia and hypotension) signifies major obstetric hemorrhage.\n• Since blood volume differs between persons, blood loss must \nbe individualized. \n \nIn general, blood volume = body weight in Kg÷12 (e.g. in a 60 \nkg woman 60/12 = 5 litres)\n• The loss of 40% or more of the blood volume is life threatening \nand will be defined as a massive obstetric hemorrhage e.g. \n2400 ml in a 60 Kg woman.\n3.\t\nPrevention of Post Partum Haemorrhage\nActive management of the third stage of labour is the cornerstone \nof prevention of primary PPH. For details please refer guideline on \nmanagement of third stage of labor.\nAnemia in pregnancy should be corrected during antenatal period.",
  "2400 ml in a 60 Kg woman.\n3.\t\nPrevention of Post Partum Haemorrhage\nActive management of the third stage of labour is the cornerstone \nof prevention of primary PPH. For details please refer guideline on \nmanagement of third stage of labor.\nAnemia in pregnancy should be corrected during antenatal period.\n\n--- Page 100 ---\nNational Guideline for Maternal Care - Volume I\n82\n4.\t\nPrediction of Post Partum Haemorrhage\nPPH occurs most often in women without risk factors. Therefore the \nblood group of every woman who goes into labor must be known.\nHowever, there are known risk factors associated with PPH, as listed in \nBox 1. Such women should be advised to deliver in a specialist obstetric \nunit under extra vigilance. Out of these, abruptio placentae and placenta \npraevia have a particularly higher risk.\nBox 1\nRisk Factors for PPH\nRisks existing prior to labour\nGrand multiparity\nPrevious PPH \nFibroids complicating pregnancy\nAnaemia complicating pregnancy\nPre-existing haemorrhagic conditions \nTreatment with anticoagulants \nObesity \nPre-eclampsia/gestational hypertension\nUterine over distension e.g. multiple pregnancy, etc.\nLarge baby (>4 kg)\nChorio-amnionitis\nDengue infection\nAny woman with risk factors should have intravenous access established \nwith either a 16 or 14-gauge cannula and a sample of blood taken and \npreserved.",
  "Out of these, abruptio placentae and placenta \npraevia have a particularly higher risk.\nBox 1\nRisk Factors for PPH\nRisks existing prior to labour\nGrand multiparity\nPrevious PPH \nFibroids complicating pregnancy\nAnaemia complicating pregnancy\nPre-existing haemorrhagic conditions \nTreatment with anticoagulants \nObesity \nPre-eclampsia/gestational hypertension\nUterine over distension e.g. multiple pregnancy, etc.\nLarge baby (>4 kg)\nChorio-amnionitis\nDengue infection\nAny woman with risk factors should have intravenous access established \nwith either a 16 or 14-gauge cannula and a sample of blood taken and \npreserved.\n\n--- Page 101 ---\nNational Guideline for Maternal Care - Volume I\n83\n5.\t\nManagement of Primary Pph\nIn Sri Lanka, the usual practice has been to commence treatment when \nthere is continuing bleeding despite uterine massage irrespective of the \namount of blood lost. It is recommended that this practice be continued. \nIt is good practice to estimate and record blood loss in all deliveries.\n5.1 General measures\n• \nCall for help.\n• \nMaintain a calm atmosphere.\n• \nKeep the mother (and labor companion/family) informed and \nreassure the mother regularly.\n• \nAssess, monitor and record: general condition, estimated \nblood loss, pulse, blood pressure and respiratory rate (every 15 \nminutes)\n• \nInsert a Foley catheter and monitor urine output hourly. \n• \nCommence an ongoing chronological record of patient’s \ncondition and interventions. It is recommended that one \nmember of staff is delegated specifically for this task and to \ncoordinate with other relevant disciplines.\n• \nEnsure there is intravenous access with two wide (14 – 16 G) \nbore cannulae. \n• \nSend blood for cross matching and baseline full blood count. \nIn cases of massive haemorrahge, other investigations such as \nclotting profile will be needed.\n• \nStart Ringer’s lactate (Hartmann’s) solution.\n• \nIdentify the cause of bleeding. \n• \nKeep the woman warm.\n• \nPay attention to the temperature of labor room, operating \ntheatre, intravenous fluids, blood, blood products and \nfluids used for lavage. Hypothermia is known to promote \ncoagulopathy.\n• \nWhere available, the early involvement of the anesthetic team, \neven while the patient is still in the labor room is recommended.",
  "• \nKeep the woman warm.\n• \nPay attention to the temperature of labor room, operating \ntheatre, intravenous fluids, blood, blood products and \nfluids used for lavage. Hypothermia is known to promote \ncoagulopathy.\n• \nWhere available, the early involvement of the anesthetic team, \neven while the patient is still in the labor room is recommended.\n\n--- Page 102 ---\nNational Guideline for Maternal Care - Volume I\n84\n• \nGive oxygen via a face mask at a minimum rate of 8L/minute \n(where suitable masks are available, oxygen must be given at a \nrate of10-15L/min).\n• \nIf deterioration of the patient is greater than expected for the \nvisible blood loss, internal hemorrhage is the probable cause. \n• \nCheck for completeness of the placenta. If incomplete or in \ndoubt consider exploration of the uterus under anesthesia.\n• \nThe Consultant must be informed in the situations listed in \nBox 2.\nBox 2. Situations in which the Consultant must be informed\n1. Blood loss of >1000 ml\n2. Pulse rate of >100/minute\n3. Systolic blood pressure <100 mm Hg\n4. Drop of systolic blood pressure by 30 mmHg\n5. Increase of pulse rate by >30 beats/minute \n6. Increasing fundal height  \n7. Deterioration of the patient out of proportion to the overt \nblood loss.\n5.2\t Specific measures\n5.2.1 Establish a cause for the bleeding \nPalpate the uterine fundus.\nA poorly contracted uterus usually indicates atonic PPH, which is the \ncommonest cause. However, the possibility of concomitant genital tract \ntrauma needs to be considered. \nIf the uterus is well contracted, the genital tract must be inspected for \ntrauma with adequate exposure, in good light.",
  "However, the possibility of concomitant genital tract \ntrauma needs to be considered. \nIf the uterus is well contracted, the genital tract must be inspected for \ntrauma with adequate exposure, in good light.\n\n--- Page 103 ---\nNational Guideline for Maternal Care - Volume I\n85\n5.2.2. Management of atonic haemorrhage\n• \nStart uterine massage by ‘rubbing up the fundus’.\n• \nClear the cervical canal and vagina of blood clots by vaginal \nexamination.\n• \nAdminister either ergometrine maleate 0.5 mg slow IV or \nmethyl ergometrine 0.2 mg slow IV or oxytocin 5 IU IV and \nstart an infusion of 40 IU in 500 ml of Hartmann’s solution at \n125 ml per hour via an infusion pump.\n• \nStart bimanual compression of uterus.\n• \nIf the bleeding fails to abate completely in 5- 10 minutes \nadminister/repeat ergometrine 0.5mg IV.\n• \nIf the bleeding fails to abate completely in a further 10 minutes \nadminister misoprostol 800µg per rectally or sublingually.\n• \nIf the bleeding fails to abate completely in a further 10 minutes \nproceed to uterine balloon tamponade and inform the \nConsultant. At the same time, administer tranexamic acid 1 \ng by slow IV over 10 minutes. This dose may be repeated after \n30 minutes if necessary and later if bleeding recommences. \nFor details of the method of balloon tamponade please refer \nappendix 1.  \n• \nBalloon tamponade is an important step in managing patients \nwho continue to bleed despite medical measures. It should \nalways be considered before resorting to surgical measures. \n• \nIf the institution does not have personnel trained in the use \nof balloon tamponade, the woman must be transferred to a \nhigher institution, at the point where the administration of \nergometrine and oxytocin infusion has failed to stop bleeding. \n• \nTemporizing measures such as manual aortic compression and \nsand bags to compress the uterus are recommended while the \npatient is in transit.\n• \n Inform the receiving institution.\n• \nAfter the balloon is inserted and the vagina packed (to keep \nthe balloon in the uterus), the woman’s vital parameters and \nthe level of the fundus must be monitored carefully. Where \nthese indicate the woman is continuing to bleed, she should",
  "• \nTemporizing measures such as manual aortic compression and \nsand bags to compress the uterus are recommended while the \npatient is in transit.\n• \n Inform the receiving institution.\n• \nAfter the balloon is inserted and the vagina packed (to keep \nthe balloon in the uterus), the woman’s vital parameters and \nthe level of the fundus must be monitored carefully. Where \nthese indicate the woman is continuing to bleed, she should\n\n--- Page 104 ---\nNational Guideline for Maternal Care - Volume I\n86\nbe moved to the theatre, since the situation would indicate the \nneed for a laparotomy. \n• \nShe should be shifted to the theatre without delay in this \nsituation. \n• \nPrior to laparotomy the woman must be examined under \nanesthesia for tears in the genital tract. \n• \nIn case laparotomy is needed it is best to keep the patient in \nthe modified Lloyd Davis position so that observations for \nbleeding could be done with minimum inconvenience and \ndelay.\n• \nThe surgical measures would depend on the woman’s condition. \n“Too little too late” is the main contributor to mortality in \nPPH. Surgical measures include brace (compression) sutures \n(see appendix 2), uterine de-vascularization (See appendix \n3), haemostatic mattress sutures to bleeding sinusoids, box \nsutures to include the bleeding lower segment in placenta \nprevia, internal iliac ligation and hysterectomy. \n• \nThe “sandwich technique” involves inserting a balloon \ntamponade after the application of brace sutures.\n• \nIt is important that hysterectomy is resorted to sooner than \nlater.\n• \nHypothermia is a particular risk in the theatre environment. \nMeasures must be taken to minimize the loss of heat from the \nwoman. \n5.2.3 Management of traumatic PPH\n• \nExclude high vaginal and cervical tears before suturing \nepisiotomy.\n• \nWhen the apex of the tear or episiotomy is not visible, apply a \nsuture at the highest visible point, pull downwards and apply \ncontinuous sutures at progressively higher points until the \napex is reached. \n• \nExamine for paravaginal and broad ligament haematomata \nwith a combined per vaginal and per rectal examination. \n• \nThe management should be individualized according to the \nsituation.",
  "• \nExamine for paravaginal and broad ligament haematomata \nwith a combined per vaginal and per rectal examination. \n• \nThe management should be individualized according to the \nsituation.\n\n--- Page 105 ---\nNational Guideline for Maternal Care - Volume I\n87\n• \nParavaginal hematomas of more than 5 cm diameter will \nusually require surgical evacuation. A bleeding point is usually \npresent and must be looked for. In cases where it is difficult to \ncontrol bleeding, a Foley catheter with its balloon inflated may \nbe left in the cavity. Packing of the vagina may also be useful. \n• \nCervical tears must be identified by systematic inspection of \nthe cervix using Green-Armytage forceps and sutured. \n• \nIn case of multiple tears with venous oozing, it may be better to \ninsert a balloon catheter into the vagina or to pack the vagina \nwith moistened vaginal packs than to try to suture all the tears. \n5.2.4 Rupture of the uterus\n• \nRupture of the uterus must be suspected when the general \ncondition is deteriorating out of proportion to the visible \nblood loss and there is continuing bleeding in the presence of a \ncontracted uterus.\n• \nThis is particularly so in a woman with a scarred uterus.\n• \nImmediate involvement of a Consultant and surgical \nintervention are important in this situation.\n5.2.5 Coagulopathy causing PPH\n• \nThis could be due to coagulopathy following death in utero, \nabruptio placentae, severe preeclampsia, HELLP syndrome, \nsepsis, amniotic fluid embolism, acute fatty liver, pulmonary \nimmune thrombocytopenia, Von Willebrand’s disease etc. \n• \nIt could also be due to suboptimal management of the PPH. \n• \nEarly involvement of a haematologist or transfusion medicine \nspecialist will be important in this situation. Where available, \nthromboelastometry would be useful in this situation. \n6.\t\nResuscitation and Fluid management\n \nPPH up to 1000 ml\n• \nCommence a crystalloid infusion of 2-3 times the estimated \nblood loss.",
  "Where available, \nthromboelastometry would be useful in this situation. \n6.\t\nResuscitation and Fluid management\n \nPPH up to 1000 ml\n• \nCommence a crystalloid infusion of 2-3 times the estimated \nblood loss.\n\n--- Page 106 ---\nNational Guideline for Maternal Care - Volume I\n88\nPPH of more than 1000 ml\n• \nPPH of over 1000 ml should be managed in consultation with \nother relevant specialists e.g. anesthesiologists, hematologists, \ntransfusion specialists etc. \n• \nAssess airway, breathing and circulation.\n• \nGive oxygen via face mask. \n• \nKeep the woman warm and flat.\n• \nTransfuse warmed blood as soon as possible.\n• \nUntil blood is available, warm crystalloids (up to 2 litres) \nand colloids (up to 1-2 litres) may be transfused as rapidly as \nrequired, up to a maximum of 3.5 litres in total.\n• \nDepending on urgency, group-specific blood may be given \nuntil cross-matched blood is available.\n• \nIf group-specific blood is not available, O Rhesus D negative \nblood could be given.\n• \nBlood transfusion should be individualized according to the \nsituation. When available, involve blood transfusion specialist/\nHaematologist. Where three or more units of blood are being \ntransfused, an equal number of packs of fresh frozen plasma \nmust also be transfused. If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.",
  "If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.\n\n--- Page 107 ---\nNational Guideline for Maternal Care - Volume I\n89\n8.\t\nRisk Management\n• \nIt is good practice to conduct a case review with the members \nof the team involved in the management and other staff as soon \nas possible after the event.\n \n \nThe spirit of such a meeting should be one of lessons learnt rather \nthan of apportioning blame.",
  "If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.\n\n--- Page 107 ---\nNational Guideline for Maternal Care - Volume I\n89\n8.\t\nRisk Management\n• \nIt is good practice to conduct a case review with the members \nof the team involved in the management and other staff as soon \nas possible after the event.\n \n \nThe spirit of such a meeting should be one of lessons learnt rather \nthan of apportioning blame.\n\n--- Page 108 ---\nNational Guideline for Maternal Care - Volume I\n90\nAppendix 1\nInsertion of a ‘condom catheter’\nThis may be performed as an independent procedure or following \ninspection of the cervix and upper vagina for trauma.\nTherefore, whenever it is planned to inspect the cervix, or where there is \nan indication that medical therapy may fail to bring the bleeding under \ncontrol, keep the materials needed for insertion of a condom catheter \nready.\n1. Explain to the mother the need to insert a condom catheter \nand explain the procedure briefly. Be reassuring.\n2. Wear a pair of sterile gloves.\n3. The required items are:\n• \nSize 20 – 22 (or largest available) Foley catheter, \n• \nA condom, \n• \nSterile  No. 0 or 1 suture, \n• \nA bottle of warmed saline,\n• \nIntravenous infusion set released from the pack \n• \nArrange these items on a sterile towel laid on a side trolley.\n4. Take the Foley catheter out of the packing.\n5. Unfold the condom over the end of the Foley catheter to about \ntwo thirds of its length. Hand tie it to the catheter firmly, using \nseveral rounds of sterile suture at a point about 2 cm distal to \nthe open end of the condom. \n6. Have an assistant connect the infusion set to the bottle of \nwarmed normal saline suspended 4-6 feet above the patient.\n7. Connect the other end to the catheter, run saline into the \ncondom to make sure the system is water tight by holding the \ncatheter tip upwards.\n8. Afterwards, empty the balloon of the saline and leave it on the \nsterile trolley, ready for insertion.\n9. Wash the condom with either warm saline or 5% povidone \niodine lotion.",
  "Afterwards, empty the balloon of the saline and leave it on the \nsterile trolley, ready for insertion.\n9. Wash the condom with either warm saline or 5% povidone \niodine lotion.\n\n--- Page 109 ---\nNational Guideline for Maternal Care - Volume I\n91\n10. Place the woman either in the dorsal or lithotomy position and \nexpose the cervix by using one or two Sim’s speculae.\n11. Grasp the anterior lip of the cervix with a sponge holder.\n12. Now insert the entire condom catheter system into the uterus. \nYou may keep the condom catheter between the index and \nmiddle fingers and introduce it like exploring the uterus (or \ndoing a pelvic examination). \n13. Reconnect the catheter to a giving set and start filling the \ncondom with warmed saline.\n14. Keep watching the cervix for the balloon to bulge out of it and \nstop filling it any further for now. You may notice cessation of \nbleeding from the uterine cavity. \n15. At this point pack the vagina with a moist vaginal pack (Two \ninch ribbon gauze pack or a gauze towel) around the catheter \nin a circumferential manner. \n16. Continue filling till the gravity aided filling stops. Usually 400 \n– 500 ml is needed.\n17. Proximal end of the catheter is folded and a tight tie placed on \nit to prevent backflow.\n18.  Insert a size 12 Foley catheter to the bladder.\n19. Mark the level of the fundus on the abdomen with a marker \npen. Start a pulse and blood pressure chart.\n20. Give tranexamic acid 1 G slow i.v. and repeat after 8 hours.\n21. Keep pack and the condom catheter for 12 – 18 hours.\n22. Consider appropriate antibiotic prophylaxis.\n23. If there is no vaginal bleeding and vital signs are stable, plan to \nremove the catheter at a convenient time, after 12 hours.\n24. Release half the instilled volume of saline. Do not remove the \npack at this stage.\n25. Observe for bleeding through the pack.\n26. 30 minutes later remove the vaginal pack, without removing \nthe condom catheter.\n27. If there is no further bleeding for another 30 minutes, release \nthe total volume of instilled saline and remove the condom \ncatheter gently.",
  "30 minutes later remove the vaginal pack, without removing \nthe condom catheter.\n27. If there is no further bleeding for another 30 minutes, release \nthe total volume of instilled saline and remove the condom \ncatheter gently.\n\n--- Page 110 ---\nNational Guideline for Maternal Care - Volume I\n92\nAppendix 2\nBrace sutures, the best known of which is the modified B-Lynch sutures \nare very useful in the presence of a bleeding atonic uterus.\nThe uterus is exteriorized.  An absorbable No. 2 suture (or highest gauge \navailable) on a curved ‘hand-needle’ is passed anteroposteriorly through \nthe uterus above the reflection of the bladder about 2 cm medial to the \nlateral edge. \nThe process is repeated on the contralateral side. The sutures are tied \ntightly over the fundus, with an assistant manually squeezing the uterus. \nAdditional sutures may be applied medially.\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume I\n93",
  "The sutures are tied \ntightly over the fundus, with an assistant manually squeezing the uterus. \nAdditional sutures may be applied medially.\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume I\n93\n\n--- Page 112 ---\nNational Guideline for Maternal Care - Volume I\n94\nAppendix 3\nSteps of uterine de-vascularization technique\n \n(Adapted from: Salah A. AbdRabbo.Stepwise uterine devascularization: \nA novel technique for management of uncontrollable postpartum \nhemorrhage with preservation of the uterus AJOG 1994 Volume 171 \nNumber 3)\nStep 1: Bilateral uterine vessel ligation\nIn this step the uterine arteries are ligated at the level where they run along \nthe uterine border beside the upper part of the lower uterine segment (Fig. \n1 Note: Steps I and II in the diagram constitute step 1 in our description. \nWe recommend that both sides are done in one step.).\nFig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3 \n(lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine \nsegment.",
  "We recommend that both sides are done in one step.).\nFig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3 \n(lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine \nsegment.\n\n--- Page 113 ---\nNational Guideline for Maternal Care - Volume I\n95\nWith the surgeon on the right side of the patient, the uterus is grasped and \nelevated to the contralateral side. A large needle (48 mm or greater) with \nnumber 1 absorbable suture is passed through the avascular area of the \nleft broad ligament from anterior to posterior and then brought forward, \nguided by the four fingers of the left hand, through the myometrium from \nposterior to anterior 2 cm medial to the left uterine vessels, and the suture \nis tied.\nThis process is repeated on the contralateral side.\nIn these two steps there is no need for bladder mobilization, because the \nsutures were not placed low. Also, there is no need for a peritoneal incision \nin cases having vaginal deliveries; however, in cases having caesarean \nsection the suture should be placed below the level of the transverse \nuterine incision, under the reflected peritoneal flap.\nStep 2: Low bilateral uterine vessel ligation\nThis step is reserved only for cases having continued lower uterine segment \nhaemorrhage diagnosed at caesarean section and not controlled by step 1.\nIn this step the bladder is reflected downwards and lower bilateral uterine \nvessel ligation is performed at the lower part of the lower uterine segment, \n3 to 5 cm below the upper ligatures, with the same technique in step 1. At \nthis level the uterine artery is ligated after its cervicovaginal branch turns \nabruptly upward to extend along the uterine margin. This ligature would \nobliterate most of the branches of the uterine artery to the lower uterine \nsegment and a branch of considerable size that extends to the upper \nportion of the cervix. It is important to include a significant amount of \nmyometrium to avoid damage to the uterine vessels and to obliterate some \nof the intramyometrial ascending arterial branches of the cervicovaginal \nartery (Fig. 1).",
  "It is important to include a significant amount of \nmyometrium to avoid damage to the uterine vessels and to obliterate some \nof the intramyometrial ascending arterial branches of the cervicovaginal \nartery (Fig. 1).\n\n--- Page 114 ---\nNational Guideline for Maternal Care - Volume I\n96\nStep 3: Ligation of uterine/ovarian arterial anastomosis\nThis step is indicated in continued uterine bleeding in spite of performing \nstep 1.The uterus is grasped and pulled to the contralateral side by the \nleft hand, and a large needle with a number 1 absorbable suture is passed \nthrough the avascular area in the broad ligament from anterior to posterior, \nat the level of the ovarian ligament. The needle is then passed anteriorly 2 \ncm medial to the edge of the uterine wall, to include the uterine muscle. \nThe suture is tied anteriorly.\n\n--- Page 115 ---\nNational Guideline for Maternal Care - Volume I\n97\n\n--- Page 116 ---\nNational Guideline for Maternal Care - Volume I\n98",
  "--- Page 1 ---\nManagement of Uncomplicated labour \n \n \n \n \n \n \n \n \n \n Episiotomy \n- \nMedio-lateral Episiotomy \n2.Cord clamp At the time of crowning  \n \n \n \n \n• Painful contractions \n• Show \n• Effacement & progressive \ndilatation of cervix \n \n \n \n \n \n \nMonitoring by Partogram \nFetal condition \no Intermittent auscultation of fetal heart \no Liquor volume \no Meconeum in liquor \nMaternal condition  \no Pulse, BP, Temperature & hydration. \no Evaluation of drugs(oxytocin, antibiotics, \nAnti hypertensives, Analgesics \no Undistended bladder-catheterize if \nindicated \nProgress of labour \no Cervical dilatation \no Decent of the presenting part \no Uterine contractions \nDelivery \nPain relief \nOpioid -Pethidine \nRegional analgesia-Epidural \nOther-spinal analgesia \nCombined spinal-epidural analgesia \nInhalational analgesia-Entonox \nPudendal block for \nepisiotomy/forceps/vacuum \n \n \nDelivery \nDescent phase-\n-Not to bear down \n-Fetal heart assessed \nevery 15 mints \nReview after 2 hours \nEstablished labour\nTransfer to the labour suite \nIdentify risk factors by,  \no Review antenatal records. \no Detailed clinical history \no Examination \nUrine for protein \no Avoiding faecal soiling \no Shaving of perineal hair \no Oral fluids \no IV access \no Left Lateral recombinant \nposition\n \n \n \n \n \nRoutine \ncare in \nlabour suit \nEpisiotomy\n- Medio-lateral \nEpisiotomy \nAt the time of \ncrowning \nExpulsive phase-\n-Encourage to bear down \n-Fetal heart assessed after \neach contraction \nSecond stage \nPositioning \nMost comfortable \nposition \nSupine position-avoided \nDiagnosis \n9 Vaginal examination \nfor full dilatation \n9 Perineal distention \n9 Anal dilatation \n1.Oxytocics \n2.Cord clamp \n3.Controlled \ncord traction \n5. Observation for signs of  \no Haemorrhage \no Utrine fundal level \no Evidence of collapse \no Respiratory difficulty \no Unusual behaviouror  \no Abdominal pain \nThird stage \nActive \nmanagement \nMaintain Partogram*(X) \nMonitoring\nMother should be \nclosely monitored in \nthe labour room for \nat least two hours \nAll steps in the management of labour should be documented in the bed head ticket\nAll steps in the management of labour should be carried out under aseptic conditions\nSecond stage of labour \nThird stage of labour \nPost-partum \nSri Lanka College of Obstetrics and Gynaecology \nHealth sector development Project \nGuidelines- Management of Uncomplicated labour \nUncertain \nNot in labour \nObserve in antenatal ward \n \nAdmission CTG to be \ndone in all three groups \nand \ninterpreted \nbefore \ndecision is made (Y) \n4.Examine the \nplacenta",
  "--- Page 1 ---\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nHyperglycaemia \nin Pregnancy \nNational Consensus Document \nBy \nSri Lanka College of Endocrinologists \nSri Lanka College of Obstetricians and Gynaecologists \nCeylon College of Physicians \nSri Lanka Medical Nutrition Association \nCollege of Chemical Pathologists of Sri Lanka",
  "--- Page 2 ---\n1 \n \n \n \n \n \n \nHyperglycaemia in Pregnancy \nNational Consensus Document \nPage No \nRecommendation 1 -Screening of pre-gestational Diabetes……        3 \nRecommendation 2 –Preconception care for women with diabetes 4 \nRecommendation 3 –Screening and diagnosis of GDM ....................... 5 \nRecommendation 4 –Management of HIP............................................ 6 \nRecommendation 5- Pharmacological treatment of HIP ..................... 9 \nRecommendation 6- Antenatal care ....................................................... 12 \nRecommendation 7 –Intrapartum management ................................... 13 \nRecommendation 8 –Postpartum management .................................... 15 \nRecommendation 9 –Child care ............................................................... 17 \nRecommendation 10 –Women with GDM and fetal loss ...................... 18 \nDisclaimer: National consensus document on hyperglycemia in pregnancy is developed \nto be of assistance to health care professionals by providing guidance and \nrecommendations for particular areas of practice. This document should not be \nconsidered inclusive of all proper approaches or methods, or exclusive of others. National \nconsensus document cannot guarantee any specific outcome, nor do they establish a \nstandard of care. This document is not intended to dictate the treatment of a particular \npatient. Treatment decisions must be made based on the independent judgment of health \ncare providers and each patient’s individual circumstances.",
  "This document is not intended to dictate the treatment of a particular \npatient. Treatment decisions must be made based on the independent judgment of health \ncare providers and each patient’s individual circumstances.\n\n--- Page 3 ---\n2 \n \n \n \nHyperglycaemia in Pregnancy \n \nIntroduction \n \nHyperglycaemia in Pregnancy (HIP) is a common medical condition during pregnancy \nand the prevalence is rising in Sri Lanka. The majority is gestational diabetes mellitus \n(GDM) with the remainder being primarily pre-gestational diabetes (Flow chart 1). HIP is \nassociated with adverse fetal outcomes such as macrosomia, intrauterine fetal death, \nshoulder \ndystocia, \nbirth \ninjuries, \nhyperbilirubinemia, \npolycythemia, \nneonatal \nhypoglycemia, respiratory distress syndrome, childhood obesity, glucose intolerance and \ndiabetes in later adolescence. Maternal complications associated with HIP are increased \nincidence of miscarriages, pre-eclampsia, cesarean delivery, increased chance of \ndeveloping type 2 DM later in life (approximately 50% in 5 to 10 years). \n \n \n \n \nFlow chart 1-Classifiacation of hyperglycaemia in pregnancy",
  "Maternal complications associated with HIP are increased \nincidence of miscarriages, pre-eclampsia, cesarean delivery, increased chance of \ndeveloping type 2 DM later in life (approximately 50% in 5 to 10 years). \n \n \n \n \nFlow chart 1-Classifiacation of hyperglycaemia in pregnancy\n\n--- Page 4 ---\n3 \n \n \n \n \n \nRecommendation 1 -Screening for pre-gestational diabetes mellitus \n \n1.1. Undiagnosed diabetes mellitus in the community is on the rise .Undiagnosed pre- \ngestational diabetes is diagnosed if the diagnostic criteria for diabetes mellitus are met \nduring the first trimester. \n \n1.2. Patients who are already diagnosed with type 1 diabetes and type 2 diabetes are \nunder this category and they do not need further investigations for diagnosis during \npregnancy. \n \n1.3. Fetal complications, mostly congenital anomalies are seen in this category.Therefore, \nuniversal screening at the booking visit is essential to diagnose pre-gestational diabetes \nmellitus. \n \n1.4. Standard diagnostic criteria used for non pregnant adults are used for diagnosis of \npre-gestational diabetes mellitus \n \n1.5. Tests recommended are \n \nFBS ≥ 126 mg/dL \nOR \nPPBS ≥ 200 mg/dL \nOR \nHbA1c ≥ 6.5% \n \n \n \n1.6. If, FBS is between 100 -125 mg/dL OR PPBS is 140-199 mg/dL proceed to 75 g \ntwo hour OGTT  and diagnose GDM as per table 1. \nDiagnose Pregestational DM",
  "If, FBS is between 100 -125 mg/dL OR PPBS is 140-199 mg/dL proceed to 75 g \ntwo hour OGTT  and diagnose GDM as per table 1. \nDiagnose Pregestational DM\n\n--- Page 5 ---\n4 \n \n \n \n \n \nRecommendation 2- Preconception care for women with diabetes \nmellitus \n \nPreconception care includes detection and management of \nhyperglycemia,other \nmetabolic and weight abnormalities prior to conception. \n \nScreening of women in the reproductive age who are planning pregnancy \n \n2.1. FBS / 75 g 2 hour OGTT should be carried out prior to pregnancy to detect \nundiagnosed diabetes. \n2.2. This should be advocated through the eligible couple registry maintained by the \nprimary health care staff. \n \n \nWomen with diabetes \nPrior to conception, women with preexisting diabetes will need the following: \n \n2.3. Optimization of HbA1c to < 6.5%, if it can be achieved without significant \nhypoglycemia. \n \n \n2.4. Medications which are not safe at conception or embryopathic drugs should be \ndiscontinued. \n \n2.5. \nChange of antihyperglycaemic drugs which are not safe during pregnancy to \ninsulin. \n \n2.6. Folic acid supplementation with 5mg/day \n \n2.7. \nBaseline screening for retinopathy, nephropathy and appropriate treatment as \nneeded. \n \n2.8. Cardiac screening and treatment as needed in symptomatic women or pre-existing \nheart disease. \n \n \n2.9. Self-monitoring of blood glucose is recommended. Targets for fasting and post- \nprandial glucose can be individualized. FBG: <100mg/dL & 2 hour PPBG <140 mg/dL \nare recommended.",
  "Targets for fasting and post- \nprandial glucose can be individualized. FBG: <100mg/dL & 2 hour PPBG <140 mg/dL \nare recommended.\n\n--- Page 6 ---\n5 \n \nAll pregnant women should be screened for \nhyperglycemia in pregnancy \n \nRecommendation 3 – Diagnosis of GDM \n \n3.1. Any degree of glucose intolerance with onset or first recognition during \npregnancy can be termed GDM ,whether or not the condition persists after \npregnancy. \n3.2. All pregnant women should be routinely screened for GDM as Sri Lankan \npopulation falls under high risk group. \n \n \n \n \n \n3.3. Standard 75g 2 hour OGTT   ( Fasting - minimum of 8 hour / 1 hour / 2 \nhour) should be used for diagnosis of GDM and the procedure is given in detail in \nannexure.. \n \n \n3.4. In women with negative pre pregnancy screening and who had normal \nrange of FBS/PPBS in early pregnancy ,75 g 2 hour OGTT is to be carried out \nbetween 20 to 28 weeks of gestation If that is normal, need to repeat OGTT in \nthird trimester is only if clinically indicated. \n \n3.5. Diagnostic criteria for diagnosis of GDM are given in Table 1. \n \n \nTable 1–Diagnostic criteria to diagnose GDM \n \n \n \nTest \nFPG \n1 h PG \n2 h PG \nDiagnosis \n75g 2h \nOGTT \n≥ 100 mg/dL \n≥ 180 mg/dL \n≥ 140 mg/dL \n1 or more \npositive \nvalue(s)",
  "Diagnostic criteria for diagnosis of GDM are given in Table 1. \n \n \nTable 1–Diagnostic criteria to diagnose GDM \n \n \n \nTest \nFPG \n1 h PG \n2 h PG \nDiagnosis \n75g 2h \nOGTT \n≥ 100 mg/dL \n≥ 180 mg/dL \n≥ 140 mg/dL \n1 or more \npositive \nvalue(s)\n\n--- Page 7 ---\n6 \n \n \n \n \nRecommendation 4 –Management of HIP \n \n4.1. Recommended therapeutic targets- self monitoring of blood glucose (SMBG) \n \n4.1.1. Self monitoring of blood glucose (SMBG) should be done fasting /pre \nbreakfast and 2 hour post-prandial (4 times per day) to achieve glycemic targets \nand improve pregnancy outcomes. Daily SMBG is superior to less frequent \nmonitoring. \n \n4.1.2. Monitoring blood glucose before going to bed at night could be done to \nprevent nocturnal hypoglycemia in patients on Insulin. \n \n4.1.3. Frequency of SMBG will vary according to treatment plan and availability \nof resources. \n \n \n4.2. Plasma glucose targets \n \n4.2.1 Fasting and 2 h PPG monitoring is recommended with target values as per \nTable 2 \n \nTable 2 Plasma glucose targets (applies to both venous and capillary) \n \n \nmg/dL \nFasting / Premeal \n< 95 \n1 h PPG \n< 140 \n2 h PPG \n< 120 \n \n \n \n*(Please report to SLCOG /SLCE regarding difficulties in achieving recommended \nblood sugar targets for revision) \n \n \n4.3. HbA1c \n \nHbA1c is not recommended for diagnosis of GDM,",
  "Plasma glucose targets \n \n4.2.1 Fasting and 2 h PPG monitoring is recommended with target values as per \nTable 2 \n \nTable 2 Plasma glucose targets (applies to both venous and capillary) \n \n \nmg/dL \nFasting / Premeal \n< 95 \n1 h PPG \n< 140 \n2 h PPG \n< 120 \n \n \n \n*(Please report to SLCOG /SLCE regarding difficulties in achieving recommended \nblood sugar targets for revision) \n \n \n4.3. HbA1c \n \nHbA1c is not recommended for diagnosis of GDM,\n\n--- Page 8 ---\n7 \n \n4.4. Non-pharmacological treatment of HIP \n \n4.4.1. Medical Nutrition Therapy (MNT) should be started soon after the \ndiagnosis of HIP by a nutritionist /qualified personnel and reviewed in each \ntrimester. \n \n4.4.2. Aim of MNT is to achieve normoglycemia, provide adequate maternal \nweight gain, provide adequate fetal growth, prevent ketosis and achieving other \ngeneral aims of MNT. \n \n4.4.3. MNT is the cornerstone of treatment, especially for GDM. 80%-90% of \nGDM could be managed with MNT alone. .Hypocaloric diet leading to ketosis is \nnot recommended. \n4.4.4. MNT is a diet-based approach to patients, considering their medical, \npsychological ,dietary history, body weight and period of gestation. \n4.4.5. A tailored diet should be created individually for each patient and \nmonitored \n4.4.6. MNT should be continued throughout the pregnancy. \n \n4.4.7. An ideal dietary composition is 45-55% carbohydrates, 15-20% protein and \n20-30 % fat with less than 10% of saturated fat from total daily calorie \nrequirement. Consistent carbohydrate diet is important to maintain a consistent \nblood glucose level throughout the day. Adjusting the type and amount of \ncarbohydrate to achieve the desired postprandial blood sugars is important. \nDistribute carbohydrate-containing foods into smaller, frequent meals evenly \nspaced throughout the day. \n4.4.8. It is best not to allow more than 10-12 hours between the last evening meal \nand the next morning meal. \n4..4.9. Complex carbohydrates with low glycemic index are preferred. \n \n4.4.10. Plate model for diet can be used to educate patients about the composition \nof each meal. \n4.4.11. Calorie allowance varied according to the nutritional status of pregnant women. \n Underweight - 40 Kcal / present pregnant weight (Kg) / day",
  "Calorie allowance varied according to the nutritional status of pregnant women. \n Underweight - 40 Kcal / present pregnant weight (Kg) / day\n\n--- Page 9 ---\n8 \n \n \nNormal weight- 30 Kcal / present pregnant weight (Kg) / day \n \n \nOverweight- 24 Kcal / present pregnant weight (Kg)/ day \n \n \nObese- \n12-15 Kcal / present pregnant weight (Kg) / day \n \n4.4.12. MNT for HIP to be supervised by trained professionals in nutrition and \nfrequency of reviewing depends on the blood sugar control and weight gain. \n4.4.13. Sample diet plan for sedentary mothers is given in the annexure. \n \n \n4.5. Exercise /physical activity \n \n4.5.1. Planned physical activity of 30 mins per day is recommended ( based on \nobstetrician’s evaluation of the patient’s physical capacity). \n \nE.g. walking briskly, arm exercises while seated in a chair for 10 mins after each \nmeal will achieve this goal. \n4.5.2 .Other exercises which the pregnant woman can carry out are flexibility and \nstrength training, yoga and deep breathing. While doing exercises excessive \nabdominal muscular contraction should be avoided. \n4.5.3. Exercises can be performed in the standing, sitting or lying positions. \n \n4.5.4. Exercise may not be recommended if any medical or obstetric contra \nindication exists.",
  "4.5.4. Exercise may not be recommended if any medical or obstetric contra \nindication exists.\n\n--- Page 10 ---\n9 \n \n \n \n \n \n \nRecommendation 5- Pharmacological treatment of HIP \n \n5.1. Pharmacological therapy should be considered if one fails to achieve glycemic \ntargets with non-pharmacological therapy  within target days. \n \n5.2. Pharmacological treatment should be started if capillary plasma glucose targets are \nnot achieved at any point of pregnancy after a trial MNT alone. \n \n5.3 Algorithm based guidance on initiation of treatment considering fasting or 2 h PPBG \nis suggested (flowchart 2).",
  "Pharmacological treatment should be started if capillary plasma glucose targets are \nnot achieved at any point of pregnancy after a trial MNT alone. \n \n5.3 Algorithm based guidance on initiation of treatment considering fasting or 2 h PPBG \nis suggested (flowchart 2).\n\n--- Page 11 ---\n1 \n \nStart \nnon pharmacological treatment \nAnd \nInsulin \nFBS ≥ 110-125mg/dL \nor \n2h PPG ≥ 140-199 mg/dL \nFBS ≥ 126 mg/dL \nor \n2h PPG ≥ 200 mg/dL \nT1& T3 -3 days \nT2 - \n1 week \nBlood glucose control \nnot achieved \nBlood glucose control \nachieved \nUncomplicated T2- 2 weeks \n1 week \nT1 & T3 \ncomplicated T2 \nStart \nnon pharmacological treatment \nFBS ≥ 95-109 mg/dL \nor \n2h PPG ≥ 120- 139mg/dL \n \n \nPharmacological treatment of HIP based on SMBG \n \n \n \n \n \nFlow chart 2-Algorithm based guidance on initiation of treatment in HIP \n(T1/T2/T3 -Trimesters) \nStart Pharmacological \ntreatment",
  "Pharmacological treatment should be started if capillary plasma glucose targets are \nnot achieved at any point of pregnancy after a trial MNT alone. \n \n5.3 Algorithm based guidance on initiation of treatment considering fasting or 2 h PPBG \nis suggested (flowchart 2).\n\n--- Page 11 ---\n1 \n \nStart \nnon pharmacological treatment \nAnd \nInsulin \nFBS ≥ 110-125mg/dL \nor \n2h PPG ≥ 140-199 mg/dL \nFBS ≥ 126 mg/dL \nor \n2h PPG ≥ 200 mg/dL \nT1& T3 -3 days \nT2 - \n1 week \nBlood glucose control \nnot achieved \nBlood glucose control \nachieved \nUncomplicated T2- 2 weeks \n1 week \nT1 & T3 \ncomplicated T2 \nStart \nnon pharmacological treatment \nFBS ≥ 95-109 mg/dL \nor \n2h PPG ≥ 120- 139mg/dL \n \n \nPharmacological treatment of HIP based on SMBG \n \n \n \n \n \nFlow chart 2-Algorithm based guidance on initiation of treatment in HIP \n(T1/T2/T3 -Trimesters) \nStart Pharmacological \ntreatment\n\n--- Page 12 ---\n1 \n \n \n \n5.4. Insulin and Metformin are recommended for treatment of HIP (pre- \ngestational / GDM) as pharmacological therapy. \n \n5.5. Recommended Insulins: Soluble / rapid acting insulin, human intermediate \nacting insulin (Isophane), pre-mix insulin are recommended for use during \npregnancy. Among ultra-short acting analogues aspart and lispro are safe. Among \nlong acting analogues, detemir is recommended. Required initial dose of \nintermediate acting/long acting insulin is 0.2 to 0.5 U/kg. Obese women may need \nhigher doses. Treatment should be titrated to reach the targets. \n \n5.6. Recommended approach to initiate insulin: \n \nStep 1: Fasting hyperglycemia should be controlled first by Isophane/ basal \ninsulin detemir at bed time at a dose of 0.2U/kg or Metformin.. The dose should \nbe titrated twice a week to reach the target blood glucose. \n \nStep 2: Post meal blood glucose should be controlled by bolus insulins ( short \nacting insulin or ultra short acting analogue insulin ) and the dose should be \ntitrated as frequently as possible to reach the post-meal targets. This is the gold \nstandard basal bolus regimen recommended in pregnancy. \n \n Only bolus insulin may be needed in some cases of HIP where FPG is well \ncontrolled with non-pharmacological therapy and only PPG targets are to be \nachieved. \n Premixed insulin can be considered on individual basis where patients are \nunwilling to or unable to take basal bolus regimen. \n \n \n5.7. Oral antidiabetic drugs (OAD): Metformin could be continued for women \nwith PCOS who were already on metformin prior to conception. Insulin is added \nif, metformin alone is inadequate to maintain target PG levels. Metformin is the \nonly oral medication recommended for use during pregnancy. Use of \nsulphonylureas are not recommended.",
  "Metformin is the \nonly oral medication recommended for use during pregnancy. Use of \nsulphonylureas are not recommended.\n\n--- Page 13 ---\n1 \n \n \n \n \n \nRecommendation 6- Antenatal care \n \n \n6.1 -First appointment: (joint diabetes and antenatal clinic) \n \nCounseling should be given about need for glycaemic control preferably at the first \nantenatal visit in early T1. Thorough clinical history should be taken. Medications should \nbe reviewed. \n \n16 weeks: Routine clinical and laboratory assessment should be done. \n20 weeks: Fetal anomaly scan should be done as per available expertise. \n24 weeks: Routine care to be offered. \n28 weeks: Ultrasound/ monitoring of fetal growth and amniotic fluid volume should be \noffered. \n32 weeks: Ultrasound /monitoring of fetal growth and amniotic fluid volume should be \noffered. \n34 weeks: Routine care should be offered. \n36 weeks: Ultrasound /monitoring of fetal growth and amniotic fluid volume should be \noffered. \n \n6.2. Aspirin 75/100 mg a day from 12 weeks on wards is recommended as diabetes is a \nrisk factor for pre-eclampsia. \n \n6.3 Counseling and planning should be done with regard to following issues: \n–timing, mode and management of delivery. \n–analgesia and anaesthesia (including anaesthetic assessment for women with \ncomorbidities, such as obesity or autonomic neuropathy). \n–changes to therapy during and after delivery. \n–initial care of the baby. \n–initiation of breastfeeding and the effect of breastfeeding on glycemic control. \n- contraception and follow-up. \n \n6.3 -Other maternal assessment \n \nUrine for ketone bodies during severe hyperglycemia, during weight loss treatment or to \ndetect possible starvation ketosis should be done. Psychological assessment is \nrecommended to detect anxiety, depression, eating disorders and stress.",
  "6.3 -Other maternal assessment \n \nUrine for ketone bodies during severe hyperglycemia, during weight loss treatment or to \ndetect possible starvation ketosis should be done. Psychological assessment is \nrecommended to detect anxiety, depression, eating disorders and stress.\n\n--- Page 14 ---\n1 \n \n \nRecommendation 7 –Intrapartum management \n \n7.1. Timing and route of delivery: \n \n7.1.1. In general, women with pre-pregnancy diabetes or who receive insulin therapy, \nschedule obstetrician review at 36-37 weeks for planning their delivery be accomplished \nby 40 weeks. In a women with HIP if elective delivery is indicated it is to be considered \nby 38 weeks + 6 days of gestation. . \n \n7.1.2. For women on diet control and/or women having optimal glycaemic control and, \ncarrying a normally grown baby, there is insufficient evidence to suggest the best time for \ndelivery. \n \n7.1.3. Diabetes alone is not an indication for a caesarean section. \n \n7.1.4. The obstetrician should make the decision after discussing with the woman. \n \n7.1.5. Planned delivery should be arranged in the day time, when all supports are more \neasily available. \n \n \n \nRecommendation 7.2 - Delivery: \n \n7.2.1. Patients on MNT with good glycemic control do not require active glucose \nmanagement during labor. \n \n7.2.2. If the patient is on MNT, plasma glucose monitoring is recommended 4 to 6 \nhourly.Those on medication, frequent glucose monitoring, ideally hourly monitoring is \nneeded. \n \n7.2.3. Glycemia is managed with IV insulin infusion with dextrose aiming to keep target \ncapillary BG values if required.. \n \n7.2.4. Goal of intra-partum capillary plasma glucose level is between 72-126 mg/dL. \n \n7.2.5. Assessment for anesthesia should be done on 3rd trimester if GDM/ pre-existing \ndiabetes is complicated with co-morbid conditions. If LSCS is carried out , plasma \nglucose should be monitored every 30 to 60 minutes.",
  "Assessment for anesthesia should be done on 3rd trimester if GDM/ pre-existing \ndiabetes is complicated with co-morbid conditions. If LSCS is carried out , plasma \nglucose should be monitored every 30 to 60 minutes.\n\n--- Page 15 ---\n1 \n \n \n \n7.2.6. Steroid usage during pregnancy \n \nIf Dexamethasone/Bethamethasone (Celestone Chronodose®) is prescribed by the \nobstetric consultant, pre-empt consequent hyperglycaemia by intensifying management \n12 hours after first steroid dose as follows: \n• Women with optimal glycaemic control on diet alone: intensify Medical Nutritional \nTherapy \n• Women with suboptimal glycaemic control on diet alone: commence insulin \n• Women on insulin: increase total daily insulin dose by 20-40% . \n \nReturn to previous management after 5 days in those who do not deliver before this.",
  "Steroid usage during pregnancy \n \nIf Dexamethasone/Bethamethasone (Celestone Chronodose®) is prescribed by the \nobstetric consultant, pre-empt consequent hyperglycaemia by intensifying management \n12 hours after first steroid dose as follows: \n• Women with optimal glycaemic control on diet alone: intensify Medical Nutritional \nTherapy \n• Women with suboptimal glycaemic control on diet alone: commence insulin \n• Women on insulin: increase total daily insulin dose by 20-40% . \n \nReturn to previous management after 5 days in those who do not deliver before this.\n\n--- Page 16 ---\n1 \n \n \nRecommendation 8–Postpartum management \n \n \n8.1 –Day after delivery \n8.1.1. Those who were on metformin could stop the medication. \n \n8.1.2. Mothers on MNT and metformin can reduce the intensity of glucose \nmonitoring.. \n \n \n8.1.3. Mothers who were on low dose insulin (<0.5units/kg/day) can stop and \nmonitor glucose levels. \n \n8.1.4. Mothers who were on > 1unit/kg/day may reduce the dose to 50% while \nthose on 0.5-1unit/kg/day need individualized clinical decision. \n \n \n8.2 –Breastfeeding recommendation \n8.2.1. All types of insulins and metformin can be safely used in lactating women. \n \n8.2.2. Women with diabetes who are breastfeeding should continue to avoid any \ndrugs for the treatment of diabetes complications that were discontinued for safety \nreasons in the pre-conception period. \n \n \n8.3- All mothers with history of gestational diabetes should be counseled about screening \nfor diabetes during every subsequent pregnancy \n. \n8.3.1. After delivery at least 1 fasting and 1 postprandial PG should be measured \nbefore discharge in mothers who were managed with MNT. \n-Fasting and PPPG should be monitored for at least 24 hours who were \nmanaged with insulin. \n-When the mother is back on her regular diet prescribed, if blood glucose \nremains elevated, continued monitoring is warranted and possibility of type 2 \ndiabetes should be considered. \n-If immediate post-delivery blood glucose is suggestive of DM, then it \nshould be confirmed by FPG or post-prandial plasma glucose.",
  "-When the mother is back on her regular diet prescribed, if blood glucose \nremains elevated, continued monitoring is warranted and possibility of type 2 \ndiabetes should be considered. \n-If immediate post-delivery blood glucose is suggestive of DM, then it \nshould be confirmed by FPG or post-prandial plasma glucose.\n\n--- Page 17 ---\n1 \n \n \n \n8.3.2. Women with GDM should be screened for diabetes 6 to 12 weeks’ post- \npartum (linked to child immunization) with 75g 2 hour OGTT using non- \npregnant OGTT criteria. Using A1c% is not recommended because of pre-partum \nmanagement of hyperglycemia during pregnancy, . \n \n8.3.3. If plasma glucose is normal, re-assessment should be done annually with \nstandard investigations. \n \n8.3.4. If pre-diabetes is detected, mothers should be put on MNT and/or \nmetformin and should be followed accordingly to standard protocol. \n \n8.3.4. Incorporating a post-partum calendar to ensure screening after index GDM \nand synchronizing with immunization calendar is advised. \n \n8.3.5. Family planning \n-All reliable methods of family planning can be used as appropriate for the \nneeds of the individual woman with diabetes. \n \n8.3.6. Screening for all components of metabolic syndrome should be offered.",
  "8.3.6. Screening for all components of metabolic syndrome should be offered.\n\n--- Page 18 ---\n1 \n \n9.1.4 .If capillary plasma glucose values are below 2.0 mmol/litre on 2 consecutive \nreadings despite maximal support for feeding, if there are abnormal clinical signs or if the \nbaby will not feed orally effectively, use additional measures such as cup/tube feeding or \nintravenous dextrose. \n \n \n \nRecommendation 9 –Child care \n \n9.1. HIP is associated with increased risk of newborn complications including excessive \nbirthweight/ \nmacrosomia, \nbirth \ninjuries, \nbirth \nasphyxia, \nrespiratory \ndistress, \nhypoglycemia, hypocalcaemia, hypomagnesemia, polycythemia, hyperbilirubinemia, \nthrombocytopenia, congenital anomalies and cardiomyopathy. \n \nIt is also associated with an increased risk of obesity, and metabolic syndrome in the \noffspring during childhood and adulthood. \n \n \n9.1.1. At the time of delivery, birth weight, gestational age, congenital abnormalities if \nany, and blood glucose at birth should be noted. \n \n \n9.1.2 Women with diabetes should breast feed their babies a soon as possible (within 30 \nminutes) after birth, and then at frequent intervals   (every 2-3-hours) for the first few \ndays of life. \n \n \n9.1.3. First newborn blood glucose should be checked after the first feed and then before \neach subsequent feed for the first 24- 48 hours of life, to ensure that pre-feed BG is \nmaintained at a minimum of 2.0 mmol/L (36 mg/dl). Glucometer calibrated for neonatal \nuse should be utilized for this purpose. \n \n \n9.1.5. Test blood glucose levels in babies of women with diabetes who present with \nclinical signs of hypoglycaemia (jitteriness, staring, apnea, siezures ect. ) and treat those \nwho are hypoglycaemic with intravenous dextrose as soon as possible. \n \n \n9.1.6. Blood tests for polycythemia, hyperbilirubinemia, hypocalcemia, hypomagnesemia \nshould be carried out if clinical signs are present \n \n \n9.1.7. Regular medical check-ups of baby/child should be carried out to monitor weight \nfor age to detect childhood obesity. Parental counseling should be done at every visit to \nadopt healthy lifestyle and healthy eating habits to avoid obesity.",
  "Regular medical check-ups of baby/child should be carried out to monitor weight \nfor age to detect childhood obesity. Parental counseling should be done at every visit to \nadopt healthy lifestyle and healthy eating habits to avoid obesity.\n\n--- Page 19 ---\n1 \n \n \nRecommendation 10 –Women with GDM and fetal loss \n \n \nThese women require special attention of the health care professionals. Special attention \nshould be paid to their psychological well-being with referral to a mental health \nprofessional as and when needed. Since there is no subsequent baby immunization visits, \nthese women should be screening with standard OGTT 6-12 weeks after pregnancy loss.",
  "Special attention \nshould be paid to their psychological well-being with referral to a mental health \nprofessional as and when needed. Since there is no subsequent baby immunization visits, \nthese women should be screening with standard OGTT 6-12 weeks after pregnancy loss.\n\n--- Page 20 ---\n1 \n \nAnnexure \n1. Procedure of 75 g two hour OGTT \n \n  The woman should have had no diet restrictions in the previous 3 days and \nparticipated in usual physical activity. \n  The pregnant woman must reach the laboratory early morning, after overnight \nfasting. She must not have taken even coffee/tea. \n Minimum time required for fasting is 8 hours and fasting should not exceed 14 hours. \n \n On arrival at the laboratory, a blood sample is drawn and she is given a drink \nconsisting of 75 gm of anhydrous glucose dissolved in a large glass of water (300 \nml). \n Two more blood samples are drawn at one hour and two hours respectively, after \ndrinking the glucose drink. The time is measured from the moment she begins to \ndrink the glucose solution. \n If the patient arrives non fasting, only the two-hour blood samples should be taken \nafter the glucose drink. \n The woman must be seated during this period with minimal physical activity. \n \n She must refrain from eating or drinking anything else, until the test is completed.",
  " The woman must be seated during this period with minimal physical activity. \n \n She must refrain from eating or drinking anything else, until the test is completed.\n\n--- Page 21 ---\n2 \n \n \n2, Suggested daily meal plans for sedentary normal weight, underweight and \noverweight pregnant mothers. \n \nFood Group \nMeal \nNormal \nweight \nUnderweigh \nt \nOver \nweight \nBreakfast \nCereals \nBoiled cowpea/green gram \n1 cup \n1 cup \n1 cup \nOil \nScraped Coconut \n1 tbs \n1 tbs \n1 tbs \nSnack \nCereal & oil \nThriposha (with coconut 1 tbs)( without sugar) \n3 tbs \n3 tbs \n3 tbs \nFruit \npapaw \n1 piece \n1 piece \n1 piece \nLunch \nCereal \nRice \n1 ⅓cups \n1⅔ cups \n1 cups \nVegetable \nGreen leaves \n3 tbs \n3 tbs \n3 tbs \nBeans/long beans/wing beans \n2 tbs \n2 tbs \n2 tbs \nCarrots/ pumpkin/beet root \n2 tbs \n2 tbs \n2 tbs \nFish/meat \nFish/ chicken \n2 pieces \n2 pieces \n2 pieces \nOil \nGravy \n2tbs \n3 tbs \n2 tbs \nSnack \nMilk \nFull cream Milk powder 2 tbs( without sugar) \n1 cup \n1 cup \n1 cup \nFruit \nGuava \n1 small \n1 small \n1 small \nOil \nPeanuts \n- \n1 tbs \n- \nDinner \nCereal \nRice \n1 ⅓ cups \n1⅔ cups \n1 cup \nVegetable \nVegetable \n6 tbs \n6 tbs \n6 tbs \nFish/meat/egg \nFish/ chicken \n1 pieces \n2 pieces \n1 pieces \nOil \nGravy \n2tbs \n3tbs \n2 tbs \nSnack \nMilk \nFull cream Milk powder 2 tbs ( without sugar) \n1 cup \n1 cup \n1 cup \nWater minimum of 8 glasses per day \n \n*This menu is only an example for sedentary pregnant mothers. Amounts and the type of the \nfoods are varying according the individuals’ height, current weight, activity levels, culture, \npreferences and availability.",
  "Food Group \nMeal \nNormal \nweight \nUnderweigh \nt \nOver \nweight \nBreakfast \nCereals \nBoiled cowpea/green gram \n1 cup \n1 cup \n1 cup \nOil \nScraped Coconut \n1 tbs \n1 tbs \n1 tbs \nSnack \nCereal & oil \nThriposha (with coconut 1 tbs)( without sugar) \n3 tbs \n3 tbs \n3 tbs \nFruit \npapaw \n1 piece \n1 piece \n1 piece \nLunch \nCereal \nRice \n1 ⅓cups \n1⅔ cups \n1 cups \nVegetable \nGreen leaves \n3 tbs \n3 tbs \n3 tbs \nBeans/long beans/wing beans \n2 tbs \n2 tbs \n2 tbs \nCarrots/ pumpkin/beet root \n2 tbs \n2 tbs \n2 tbs \nFish/meat \nFish/ chicken \n2 pieces \n2 pieces \n2 pieces \nOil \nGravy \n2tbs \n3 tbs \n2 tbs \nSnack \nMilk \nFull cream Milk powder 2 tbs( without sugar) \n1 cup \n1 cup \n1 cup \nFruit \nGuava \n1 small \n1 small \n1 small \nOil \nPeanuts \n- \n1 tbs \n- \nDinner \nCereal \nRice \n1 ⅓ cups \n1⅔ cups \n1 cup \nVegetable \nVegetable \n6 tbs \n6 tbs \n6 tbs \nFish/meat/egg \nFish/ chicken \n1 pieces \n2 pieces \n1 pieces \nOil \nGravy \n2tbs \n3tbs \n2 tbs \nSnack \nMilk \nFull cream Milk powder 2 tbs ( without sugar) \n1 cup \n1 cup \n1 cup \nWater minimum of 8 glasses per day \n \n*This menu is only an example for sedentary pregnant mothers. Amounts and the type of the \nfoods are varying according the individuals’ height, current weight, activity levels, culture, \npreferences and availability.\n\n--- Page 22 ---\n2 \n \n \nReferences \n \n1. Metzger BE. Proceedings of the third international workshop-conference on \ngestational diabetes mellitus. Diabetes. 1991;40( 2):1–201. \n2. Clinical practice recommendations 2001: gestational diabetes mellitus.Diabetes \nCare 2001; 24 (1): 77–79. \n3. Metzger BE, Coustan DR.Summary and recommendations of the Fourth \nInternational Workshop Conference on Gestational Diabetes Mellitus. Diabetes \nCare 1998; 21 (2) : 161–167. \n4.  Mitanchez D.Foetal and neonatal complications in gestational diabetes: perinatal \nmortality, congenital malformations, macrosomia, shoulder dystocia, birth \ninjuries, neonatal complications. Diabetes Metab. 2010 ;36(6 ):617-27. \n5. IADPSGCP, International Association of Diabetes and Pregnancy Study Groups \nRecommendations on the Diagnosis and Classification of Hyperglycemia in \nPregnancy. Diabetes Care 2010;33(3): 676-682. \n6. National Institute for Health and Care Excellence (NICE) (2015) Diabetes in \npregnancy: management of diabetes and its complications from preconception to \nthe postnatal period. Clinical guideline NG3 (2015). \n7. American Diabetes Association (2014) Standards of medical care in diabetes— \n2016.Diabetes Care 2016;39( 1):94–98 . \n8. South Asian Federation of Endocrine Societies (SAFES) GDM action plan and \nrecommendations 2017.",
  "8. South Asian Federation of Endocrine Societies (SAFES) GDM action plan and \nrecommendations 2017.\n\n--- Page 23 ---\n2",
  "--- Page 1 ---\nManagement of Breech Presentation \n \n \n \n \n \n \n \n \nDelivery \n38 weeks \nTHE DIAGNOSIS OF BREECH CONFIRMED\nClinical \n• Abdominal examination: the head of the fetus is in \nthe upper part of the uterus.  \n• Auscultation locates the fetal heart at a higher \nlocation than expected with a vertex presentation. \n• Vaginal examination: the buttocks and/or feet are \nfelt. Thick, dark meconium is normal when \nmembranes rupture in the second stage of labour. \nUltra sound\n• conform the presenting part \n• localizatiion of placenta  \n• exclusion of \nabnormalities,etc. \nuncomplicated ( no extended or \nflexed leg) breech presentation \nat term \nuncomplicated breech\nat 37 to 40 weeks \nexternal cephalic \nversion (ECV) \nElectronic foetal \nmonitoring (EFM) \nprior to 36 \ncompleted \n \nVaginal delivery \nAbsolute indications for \nCaesarean section \nFeto-pelvic disproportion \n-When the fetal weight is estimated to \nbe 3.8 kg or more \nMajor degree placenta praevia \nPelvic or uterine tumors preventing \ndescent of presenting part. \nMajor degrees of pelvic deformities. \n \n \nDocumentation Mandatory\n36 weeks \nWait till 36 \ncompleted weeks \nExternal \ncephalic \nversion not \nrecommended1 \nMay be offered tocolysis \n(with beta mimetic drugs) \nto increase the success of \nexternal cephalic version \n(ECV) \nNo indication \nfor L.S.C.S \nIndication for \nLS.C.S \npresent \n \ncomplicated (extended or \nflexed leg) breech presentation \nat term \n \nCaesarean section \n \nRelative indications for \nCaesarean section \nIntrauterine growth restriction. \nPrevious uterine scar  \nHyperextension of the fetal head \n(Star gazer) \n-When the head cannot be flexed \nSmall pelvis or suspicious pelvic \nadequacy \nFootling presentation \nGestation less than 34 weeks \nInformed Decision Making is Essential\nSri Lanka College of Obstetrics and Gynaecology \nHealth sector development Project \nGuidelines- Management of breech presentation \nUnsuccessful \nX-ray of the \npelvis to \nconfirm \npresentation is \nto be avoided.",
  "--- Page 1 ---\nNATIONAL GUIDELINES FOR\nMATERNAL CARE\nVOLUME I\nMINISTRY OF HEALTH\n2013\n• Management of Labour\n• Management of Hypertension, Pre Eclampsia \nand Eclampsia in Pregnancy\n• Management of Diabetes During Pregnancy\n• Management of Post-Partum Haemorrhage\nWorld Health\nOrganization\nFamily Health Bureau\n\n--- Page 2 ---\n\n--- Page 3 ---\nNATIONAL GUIDELINE FOR MATERNAL CARE\nVOLUME I\n• \nManagement of Labour\n \n \nNormal Labour \n \n \nInduction of Labour\n \n \nUse of Oxytocins in Induction and Augmentation\n \n \nFoetal Monitoring in Labour\n \n \nPain Relief\n \n \nAcute Inversion of Uterus\n• \nManagement of Hypertension, Pre Eclampsia and \nEclampsia in Pregnancy\n• \nManagement of Diabetes in Pregnancy\n• \nManagement of Post-Partum Haemorrhage\nMINISTRY OF HEALTH\n2013\nWorld Health\nOrganization\nFamily Health Bureau",
  "--- Page 4 ---\nNational Guideline for Maternal Care - Volume I\nii\nThese guidelines are published by the Family Health Bureau, Ministry of \nHealth, 231, De Saram Place, Colombo 10, Sri Lanka.\nWeb: www.familyhealth.gov.lk\nPrepared by Sri Lanka College of Obstetrians and Gynaecologists\nEdited By Dr. Nilmini Hemachnadra, Consultant Community Physician, \nFamily Health Bureau & Prof. Hemantha Senanayake, President, Sri Lan-\nka College of Obstetricians & Gynaecologists.\nCopyright@2013 Ministry of Health\nISBN 978 - 955 - 1503 - 15 - 4\nStatement of Intent\nThe main purpose of these guidelines are to improve the quality of \nclinical care provided by the health care providers at all levels. These \nparameters of practice should be considered recommendations \nonly. The ultimate judgement regarding a particular clinical \nprocedure or a treatment plan must be made by the clinician in \nlight of the clinical data gathered from the patient and the diagnosis \nand treatment options available.\nPrinted by Lazergraphic (PVT) Ltd.",
  "These \nparameters of practice should be considered recommendations \nonly. The ultimate judgement regarding a particular clinical \nprocedure or a treatment plan must be made by the clinician in \nlight of the clinical data gathered from the patient and the diagnosis \nand treatment options available.\nPrinted by Lazergraphic (PVT) Ltd.\n\n--- Page 5 ---\nNational Guideline for Maternal Care - Volume I\niii\nForeword from the Secretary to the Ministry of Health\nAs a country with a mainly government owned health system, maintenance \nof the uniformity of practices is essential to avoid incurring unnecessary \nexpenditure. Incorporation and practice of evidence based cost effective \ninterventions in maternal care will ensure further improvement of the \nmaternal care indicators.  \nThe availability and use of guidelines will ensure the quality of the care \nprovided at each level and facilitate the care provision of practicing \nclinicians for better care. The Ministry of Health having achieved a \nsatisfactory level in the coverage of services and geared to improve it \nfurther, is currently moving towards improving the quality of services \nprovided. With this view, most of the institutions are now implementing \nquality improvement programmes.\nTherefore, this set of guidelines will assist such programmes and auditing \nsystems in the maternal care such as maternal mortality reviews, \nconfidential inquiry into maternal deaths, near-miss inquiries and \nensure a more objective assessment. These guidelines should be link with \nthe quality standards and the implementation at each level needs to be \nensured.\nSri Lanka College of Obstetricians and Gynaecologists has managed to in \nco-operate the currently available best scientific evidence and the practical \nexperience of a large number of experts into these guidelines.\nI wish all the healthcare providers would make maximum use of these \nguidelines and contribute to the further improvement of the maternal care \nin our country.\nDr. Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka",
  "Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka\n\n--- Page 6 ---\nNational Guideline for Maternal Care - Volume I\niv",
  "Y.D. Nihal Jayathilake\nSecretary,\nMinistry of Health,\nSri Lanka\n\n--- Page 6 ---\nNational Guideline for Maternal Care - Volume I\niv\n\n--- Page 7 ---\nNational Guideline for Maternal Care - Volume I\nv\nPreface\nThis national guideline on maternal care is very well-timed, as a greater \nemphasis is being given for improving the quality of maternal and \nnewborn care services for further reduction of maternal and newborn \nmortality and morbidity in Sri Lanka. This set of guidelines includes \nthe revised versions of some guidelines published in 2007 under HSDP \nPhase I and newly developed guidelines. This is an attempt to improve the \nquality and uniformity of clinical care with efficiency, cost effectiveness \nand accountability.\nI highly appreciate the contribution made by the Sri Lanka College of \nObstetricians and Gynaecologists in developing these guidelines. Their \nexperience and updated scientific knowledge is reflected in the guidelines. \nFurther, these guidelines have been developed considering the policies, \nfacilities and resources available in the country. As such this set of \nguidelines will be considered as national guidelines for the conditions \ndescribed.  \nDr. P. G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka.",
  "G. Mahipala\nDirector General of Health Services,\nMinistry of Health,\nSri Lanka.\n\n--- Page 8 ---\nNational Guideline for Maternal Care - Volume I\nvi\nMessage from the president of Sri Lanka College of \nObstetricians\nIt is with a great sense of achievement that I issue this statement for the \nSri Lanka National Guidelines in obstetrics. There is evidence that the \nintroduction of guideline-based practice will reduce maternal mortality. \nWe hope that this effect will be duplicated in Sri Lanka.\nI must compliment the Guideline Development Group of our College. \nThis document is testimony to their hard work and their commitment to \nimproving the quality of care delivered to our women. The group consisted \nof obstetricians from varying seniority and from hospitals representing \nall categories of specialist units in the country. We were therefore able to \ndevelop our guidelines taking into considerations the ground realities in \nSri Lanka. I was heartened by the maturity shown by the younger members, \nwho contributed immensely to the many points that were debated while \nthese were being developed. We have used the latest available evidence \nand taken into account what would be feasible in a Sri Lankan Unit. For \nwhat we have recommended as improvements to the existing practice we \nhave had agreement from the Ministry of Health to procure these. \nI wish also to acknowledge our general membership who contributed to \nthese guidelines via email and at a meeting where their views were sought. \nIt is always a challenge to produce guidelines that will be put into use in \neveryday practice and it is probable we have achieved this primary goal by \nhaving a broad based input. \nThe World Health Organization and the UNFPA supported this activity. \nDr. Nilmini Hemachandra of the Family Health Bureau helped get the \nfinal product into a form that was easily understood by the non-specialist. \nWe are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja",
  "We are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja\n\n--- Page 9 ---\nNational Guideline for Maternal Care - Volume I\nvii\nJayasinghe and Ramani Pallemulla. The guideline on diabetes mellitus \ncomplicating pregnancy had major inputs from the Nirogi Matha project \nand many endocrinologists. \nTo conclude I wish to restate my wish and fervent hope that these \nguidelines will help save the lives of many Sri Lankan mothers. \nProf. Hemantha Senanayake\nPresident,\nSri Lanka College of Obstetricians & Gynaecologists\n\n--- Page 10 ---\nNational Guideline for Maternal Care - Volume I\nviii\nGuideline Development Committee\nDr. Asoka Weerakkody (Chairman)\nProf. Hemantha Senanayake\nProf. Malik Goonawardena\nDr. Ananda Ranatunga\nDr.UDP Ratnasiri\nDr. Sunil Fernando\nDr. Harsha Atapattu\nDr. Mangala Dissanayake\nDr. Chandina Wedamistri\nDr. Jeevan Marasinghe\nDr. Tiran Dias\nDr. Asanka Jayawardena",
  "Tiran Dias\nDr. Asanka Jayawardena\n\n--- Page 11 ---\nNational Guideline for Maternal Care - Volume I\nix\nContent page \n \n \n \n \nPage\n \nMessage from the Secretary of Ministry of Health \niii\n \nPreface \n \nv\n \nMessage from the President of the Sri Lanka College of \n \nObstetricians and Gynecologists \nvi \n \nGuideline Development Committee \nviii\n \nList of Abbreviations \nxiii\n \nList of Tables \nxiv\n \nDisclaimer \nxv\n \nIntroduction \nxvi\n A\t\nManagement of Labour\t\n3\n1. \nIntroduction \n3\n2. \nDiagnosis of labour \n3\n3. \nManagement of Labour \n4\n3.1 \nGeneral considerations \n4\n3.1.1 \nCommunication between women and healthcare  \n  \nprofessionals/workers \n4\n3.1.2 \nPreparation of mothers to transfer to labour room \n4\n3.1.3 \nDocumentation \n5\n3.1.4  \nMobilization and Positioning \n5\n3.1.6 \nHygiene during labour \n5\n3.1.7 \nPain relief in labour \n6\n3.2. \nManagement of the three stages of labour \n6\n3.2.1.  \nManagement of the first stage of labour \n6\n3.2.1.1 \nLatent phase  \n6\n3.2.1.2 \nActive phase \n7\n3.2.1.2a.  Admitting women to the Labour room \n7\n3.2.1.2b.  Management of active phase of first stage \n8\n3.2.1.3.  \nDelayed progress of first stage of labour \n9\n3.2.2.  \nManagement of second stage of labour \n10\n3.2.2.1.  \nPassive second stage of labour (descent phase) \n10\n3.2.2.2.  \nActive second stage of labour (expulsive phase) \n11\n3.2.2.3.  \nObservations for women and babies in the second stage of labour \n12\n3.2.2.4.  \nWomen’s position and pushing in the second stage of labour \n12\n3.2.2.5.  \nIntrapartum interventions to reduce perineal trauma \n13\n3.2.2.6.  \nDelivery \n13\n3.2.3 \nThird stage of Labour \n14\n3.2.3.1 \nActive management of third stage of labour \n14\n3.2.3.2 \nDelayed third stage \n15\n4 \nCare for the newborn baby \n15\n5 \nPerineal care \n17",
  "Intrapartum interventions to reduce perineal trauma \n13\n3.2.2.6.  \nDelivery \n13\n3.2.3 \nThird stage of Labour \n14\n3.2.3.1 \nActive management of third stage of labour \n14\n3.2.3.2 \nDelayed third stage \n15\n4 \nCare for the newborn baby \n15\n5 \nPerineal care \n17\n\n--- Page 12 ---\nNational Guideline for Maternal Care - Volume I\nx\n B\t\nGuideline on Induction of Labour \n19\n1 \nIntroduction \n19\n2 \nDefinition \n19\n3 \nGeneral Principles \n19\n4 \nIndications \n19\n4.1 \nOtherwise uncomplicated pregnancy continuing \n  \nbeyond 40 weeks \n19\n4.2 \nPre labour rupture of membranes at term \n20\n4.3 \nPreterm prelabour rupture of membranes (PPROM) \n20\n4.4   \nIntrauterine death \n20\n4.5   \nHistory of precipitate labour \n20\n4.6   \nSuspected macrosomia \n20\n4.7   \nFetal growth restriction \n21\n4.8   \nOlder mothers \n21\n5 \nInduction under specific circumstances \n21\n5.1   \nBreech presentation \n21\n5.2 \nPrevious CS \n21\n6.   \nMethods of induction \n21\n6.1 \nMechanical \n21\n6.2   \nSurgical \n22\n6.3   \nPharmacological \n22\n6.3.1   \nOxytocin \n22\n6.3.2 \nProstaglandins \n22\n6.3.3 \nMifepristone \n23\n7.   \nComplications \n24\n7.1 \nHyperstimulation \n24\n7.2 \nCord prolapse \n24\n7.3 \nUterine rupture \n25\n7.4 \nFailed induction \n25\n C\t\nGuideline for Use of Oxytocin for Induction and Augmentation \n\t\nof labour\t \t\n27\n D\t\nGuideline on fetal monitoring in labour\t\n30\n\t\n E\t\nGuideline on Pain Relief in Labour \n34\n1 \nMethods of pain relief in labour \n34\n1.1 \nNon-pharmacological methods of pain relief \n35\n1.2 \nPharmacological methods of pain relief in labour \n35\n1.2.1 \nOral paracetamol/paracetamol& codeine compound \n35\n1.2.2 \nOpioids \n35\n1.2.2.A. \nPethidine \n35\n1.2.2.B. \nMorphine \n36\n1.2.2.C. \nFentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37",
  "Morphine \n36\n1.2.2.C. \nFentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37\n\n--- Page 13 ---\nNational Guideline for Maternal Care - Volume I\nxi\n F\t\nGuidelines to maintain the partograph\t\n39\n\t\n G\t\nGuideline on acute puerperal inversion of the uterus \n41\n1 \nIntroduction \n41\n2 \nDefinition \n41\n3 \nPrevention \n41\n4 \nPathophysiology (and clinical correlation) \n41\n5 \nClassification \n42\n6 \nClinical Presentation and diagnosis \n42\n7 \nManagement \n43\n7.1 \nGeneral measures \n43\n7.2 \nRepositioning the uterus \n43\n7.2.1 \nManual replacement of uterus \n43\n7.2.2 \nHydrostatc reduction \n44\n7.2.3 \nTocolytics \n45\n7.2.4 \nGeneral Anaesthesia \n45\n7.2.5 \nSurgical methods \n45\n8 \nDebriefing \n46\n H\t\nManagement of Hypertensive Disease in Pregnancy \n47\n1 \nIntroduction \n49\n2 \nDefinitions \n49\n3 \nScreening for Hypertension during pregnancy \n50\n4 \nPrevention of hypertensive disorders in pregnancy \n50\n5 \nManagement of Chronic Hypertension  \n51\n6 \nManagement of severe pre eclampsia \n52\n6.1 \nGeneral Considerations \n52\n6.2 \nSpecific Management \n52\n6.2.1 \nAnti-hypertensive drugs \n53\n6.2.1.1 \nLabetalol orally or intravenously \n53\n6.2.1.2 \nHydralazine intravenously \n54\n6.2.1.3 \nOral Nifedipine \n55\n6.2.2 \nPrevention of convulsions \n55\n6.2.3 \nFluid Balance \n56\n6.2.4 \nIn utero/neonatal transfer \n56\n6.2.5 \nDelivery \n57\n6.2.6 \nPost-delivery \n57\n6.2.7 \nFollow up \n58\n \n I\t\nManagement of Eclampsia \n59\n1 \nDefinition \n59\n2 \nDiagnosis \n59\n3 \nTime of onset of eclampsia \n59\n4 \nComorbidities \n59\n5 \nPrevention \n60\n6 \nManagement \n60\n6.1 \nGeneral considerations \n60\n6.2. \nDuring the seizure \n61",
  "Fentanyl \n36\n1.2.3 \nInhalational analgesia – Entonox \n36\n1.2.4 \nRegional Anaesthesia \n37\n\n--- Page 13 ---\nNational Guideline for Maternal Care - Volume I\nxi\n F\t\nGuidelines to maintain the partograph\t\n39\n\t\n G\t\nGuideline on acute puerperal inversion of the uterus \n41\n1 \nIntroduction \n41\n2 \nDefinition \n41\n3 \nPrevention \n41\n4 \nPathophysiology (and clinical correlation) \n41\n5 \nClassification \n42\n6 \nClinical Presentation and diagnosis \n42\n7 \nManagement \n43\n7.1 \nGeneral measures \n43\n7.2 \nRepositioning the uterus \n43\n7.2.1 \nManual replacement of uterus \n43\n7.2.2 \nHydrostatc reduction \n44\n7.2.3 \nTocolytics \n45\n7.2.4 \nGeneral Anaesthesia \n45\n7.2.5 \nSurgical methods \n45\n8 \nDebriefing \n46\n H\t\nManagement of Hypertensive Disease in Pregnancy \n47\n1 \nIntroduction \n49\n2 \nDefinitions \n49\n3 \nScreening for Hypertension during pregnancy \n50\n4 \nPrevention of hypertensive disorders in pregnancy \n50\n5 \nManagement of Chronic Hypertension  \n51\n6 \nManagement of severe pre eclampsia \n52\n6.1 \nGeneral Considerations \n52\n6.2 \nSpecific Management \n52\n6.2.1 \nAnti-hypertensive drugs \n53\n6.2.1.1 \nLabetalol orally or intravenously \n53\n6.2.1.2 \nHydralazine intravenously \n54\n6.2.1.3 \nOral Nifedipine \n55\n6.2.2 \nPrevention of convulsions \n55\n6.2.3 \nFluid Balance \n56\n6.2.4 \nIn utero/neonatal transfer \n56\n6.2.5 \nDelivery \n57\n6.2.6 \nPost-delivery \n57\n6.2.7 \nFollow up \n58\n \n I\t\nManagement of Eclampsia \n59\n1 \nDefinition \n59\n2 \nDiagnosis \n59\n3 \nTime of onset of eclampsia \n59\n4 \nComorbidities \n59\n5 \nPrevention \n60\n6 \nManagement \n60\n6.1 \nGeneral considerations \n60\n6.2. \nDuring the seizure \n61\n\n--- Page 14 ---\nNational Guideline for Maternal Care - Volume I\nxii\n6.3.  \nAs soon as possible following a seizure \n61\n6.4. \nManagement of seizures in women receiving \n  \nmagnesium sulphate \n62\n7. \nDelivery \n62\n8. \nTransfer of a woman who has had a seizure to another institution \n63\n9. \nPostpartum management \n63\n10. \nCounselling  \n64\n J\t\nManagement of Diabetes during Pregnancy  \n67\n1 \nPurpose \n67\n2 \nScreening \n67\n2.1 \nTarget groups for screening \n67\n2.2 \nRecommended tests \n68\n3 \nManagement – Women with established Diabetes \n70\n3.1 \nPre Pregnancy care \n70\n3.2 \nAntenatal Care \n71\n3.3 \nMedical nutrition therapy (MNT) \n72\n3.4 \nExercise \n72\n4 \nGlyceamic control and Monitoring  \n73\n4.1 \nGlyceamic Control \n73\n4.2 \nMonitoring of glycaemic control \n74\n5 \nDelivery and intra natal care \n74\n5.1 \nTiming of delivery \n74\n5.2 \nLabour care \n75\n6 \nPost natal care \n75\n6.1.a \nNeonatal care \n75\n6.1.b \nImmediate post partum care \n76\n6.2 \nAt hospital discharge \n76\n6.3 \nLate Postnatal care and follow up \n77\n7 \nFamily Planning \n77\n K\t\nManagement of Primary Post Partum Haemorrhage \n81\n1 \nIntroduction \n81\n2 \nDefinition \n81\n3 \nPrevention of Post Partum Haemorrhage \n81\n4 \nPrediction of Post Partum Haemorrhage \n82\n5 \nManagement of Primary PPH \n83\n5.1 \nGeneral measures \n83\n5.2 \nSpecific measures \n84\n5.2.1 \nEstablish a cause for the bleeding  \n84\n5.2.2. \nManagement of atonic haemorrhage \n85\n5.2.3 \nManagement of traumatic PPH \n86\n5.2.4 \nRupture of the uterus \n87\n5.2.5 \nCoagulopathy causing PPH \n87\n6. \nResuscitation and Fluid management \n87\n7. \nDebriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume I\nxiv\nList of Tables\nGuidelines for ruse of oxytocin for induction and augmentation of labour\nTable 1 \nmU/minute administered at different rates of administration \naccording to drop rate\nTable 2 \nmU/minute infused per minute when administered via an infusion \npump\nGuideline on fetal monitoring in labour\nTable 1 \nDefinitions of normal, suspicious and pathological FHR rates\nTable 2 \nClassification of fetal heart rate patterns\nGuideline for screening, diagnosis and management of diabetes in pregnant \nwomen\nTable 1 \nTarget values in glycaemic control",
  "Debriefing \n88\n8. \nRisk Management \n89\n  \nAppendix 1 \n90\n  \nAppendix 2 \n92\n  \nAppendix 3 \n94\n\n--- Page 15 ---\nNational Guideline for Maternal Care - Volume I\nxiii\nList of Abbreviations\nWHO \nWorld Health Organization\nUNFPA \nUnited Nations Population Fund\nUNICEF \nUnited Nations Children’s Fund\nSLCOG \nSri Lanka College of Obstetricians and Gynaecologists\nNICE \nNational Institutive of Clinical excellency\nRCOG \nRoyal College of Obstetricians and Gynaecologists\nFHR \nFetal Heart Rate\nCPD \nCephalo Pelvic Disproportion\nNALS \nNeonatal Advanced Life Support\nPPROM \nPreterm prelabour  rapture of the Membranes\nCS \nCaesarean Section\nCTG \nCardiotocography\nIV \nIntravenous\nIM \nIntra muscular\nIU \nInternational Units\nEFM \nElectronic Fetal Monitoring\nTENS \nTranscutaneous electrical nerve stimulation\nHELLP \nHaemolysis, elevated liver enzymes and low platelet\nHDU \nHigh dependency unit\nICU \nIntensive care unit\nPGDM  \nPre gestational diabetes mellitus\nGDM \nGestational Diabetes Mellitus\nOGCT \nOral glucose Challenge Test\nOGTT \nOral Glucose Tolerance test\nPPBS \nPost Prandial Blood Sugar\nMNT \nMedical Nutrition therapy\nDENO \nDiabetic Educator Nursing officer\nSMBG \nSelf-monitoring of blood glucose\nAC \nAbdominal Circumference\nSHO \nSenior House Officer\nCBG \nCapillary Blood Glucose\nENC \nEssential  New-born  Care\nDM \nDiabetes Mellitus\nDMPA \nDepot Medroxy Progesterone Acetate\nBMI \nBody Mass Index\nPPH \nPost Partum Haemorrhage\n\n--- Page 16 ---\nNational Guideline for Maternal Care - Volume I\nxiv\nList of Tables\nGuidelines for ruse of oxytocin for induction and augmentation of labour\nTable 1 \nmU/minute administered at different rates of administration \naccording to drop rate\nTable 2 \nmU/minute infused per minute when administered via an infusion \npump\nGuideline on fetal monitoring in labour\nTable 1 \nDefinitions of normal, suspicious and pathological FHR rates\nTable 2 \nClassification of fetal heart rate patterns\nGuideline for screening, diagnosis and management of diabetes in pregnant \nwomen\nTable 1 \nTarget values in glycaemic control\n\n--- Page 17 ---\nNational Guideline for Maternal Care - Volume I\nxv\nDisclaimer\nThese guidelines are based on current best available evidence and \nconsensus opinion of the Guideline Development committee of \nthe Sri Lanka College of Obstetricians & Gynaecologists. They are \nneither intended to replace the process of critical evaluation of \nevery case and nor it is intended to dictate an exclusive course of \nmanagement or treatment. It must be interpreted with reference to \nindividual patient needs, available resources and limitations unique \nto the institution and variations in local populations.\nMedicine is a continually evolving science and the users must have \nregard to relevant information, research or material, which may \nhave been published or become available subsequently.",
  "They are \nneither intended to replace the process of critical evaluation of \nevery case and nor it is intended to dictate an exclusive course of \nmanagement or treatment. It must be interpreted with reference to \nindividual patient needs, available resources and limitations unique \nto the institution and variations in local populations.\nMedicine is a continually evolving science and the users must have \nregard to relevant information, research or material, which may \nhave been published or become available subsequently.\n\n--- Page 18 ---\nNational Guideline for Maternal Care - Volume I\nxvi\nIntroduction\nClinical Guidelines are systematically developed statements which assist \nclinicians and patients in making decisions about appropriate treatment \nfor specific conditions based on the best scientific evidence at the time of \ndevelopment. Guidelines are not intended to limit the clinical freedom; \nhowever, clinicians are expected to follow these recommendations as the \nbasis for their decision making. Availability of resources, the existing \nsituations, and the expectations of individual client needs to be considered. \nThe guidelines are intended to guide all health care workers in all levels \nof institutions where maternity care is being provided. Although these \nguidelines are mainly targeted for the government sector institutions, use \nin the private sector institutions where maternity care is being provided, \nis also encouraged.\nThese guidelines are developed by the guideline development committee \nof the Sri Lanka College of Obstetricians and Gynaecologists in \nconsultation with other relevant specialists such as anaesthesiologists, \nphysicians, endocrinologists, and haematologists etc. The existing \nnational guidelines developed in 2007, NICE guidelines on intranatal \ncare, WHO guidelines and RCOG guidelines were perused and mixed \nwith the local scenarios and expert opinion. The latest available scientific \nevidences were considered and included where ever necessary. Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.",
  "Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 19 ---\nNational Guideline for Maternal Care - Volume I\n1\nManagement of Labour\n\n--- Page 20 ---\nNational Guideline for Maternal Care - Volume I\n2",
  "Then, the \ndraft guidelines were presented to the wider forum of obstetricians and \nconsensuses were arrived. After that the guidelines were handed over to \nthe Ministry of Health and consensus was built with the participation \nof multi-disciplinary team including medical administrators, provincial \nhealth authorities, representatives from SLCOG and  other relevant \nprofessional colleges, and national programme managers.\n\n--- Page 19 ---\nNational Guideline for Maternal Care - Volume I\n1\nManagement of Labour\n\n--- Page 20 ---\nNational Guideline for Maternal Care - Volume I\n2\n\n--- Page 21 ---\nNational Guideline for Maternal Care - Volume I\n3\nManagement of Normal Labour\n1.\t Introduction\nThe aim of this guideline is to provide recommendations to care providers \nin the management of a healthy woman with a single fetus in labour at \nterm (37-42weeks). It does not cover the care of women with complicated \npregnancies. \nThe objective of this guideline is to ensure optimal management of \nwomen in labour, detect any abnormalities, take appropriate action, \nprevent complications and thus make childbirth safer; and also to make \nsure that these women are treated with respect and compassion, and kept \nwell informed and well supported throughout labour. \n2.\t Diagnosis of Labour\nLabour is diagnosed by the presence of regular, painful intermittent \ncontractions, which are of increasing frequency, duration and intensity, \nleading to progressive cervical effacement and dilatation. \nNote:  for the purpose of this guideline, labour is also diagnosed in the \npresence of painful contractions occurring at a frequency of 2 in 10 \nminutes or more.\nDefinitions: \nLatent phase of the first stage of labour – from the commencement \nof labour to a cervical dilatation of up to 4 cm. (This is a period \nof time, not necessarily continuous, when there are painful \ncontractions and some cervical changes including cervical \neffacement and dilatation up to 4cm take place)\nActive phase of the first stage of labour – commences at a cervical \ndilatation of 4cm and ends with full dilatation. (There are regular \npainful contractions and progressive cervical dilatation from 4cm \nup to full dilatation).",
  "(This is a period \nof time, not necessarily continuous, when there are painful \ncontractions and some cervical changes including cervical \neffacement and dilatation up to 4cm take place)\nActive phase of the first stage of labour – commences at a cervical \ndilatation of 4cm and ends with full dilatation. (There are regular \npainful contractions and progressive cervical dilatation from 4cm \nup to full dilatation).\n\n--- Page 22 ---\nNational Guideline for Maternal Care - Volume I\n4\nIf the diagnosis of labour is uncertain, observation should continue and \nreassessment made in four hours. \nAny woman who is diagnosed as not being in labour, but continues to \ncomplain of pain, would require careful reassessment by an experienced \nmedical officer. Possible diagnoses of placental abruption and non-\nobstetric causes should be considered. Fetal compromise should be \nexcluded. \n3.\t\nManagement of labour\n3.1. \nGeneral considerations\n3.1.1. Communication between women and healthcare professionals/\nworkers\n• \nGreet the mother with a smile and a personal welcome\n• \nTreat them with respect and dignity \n• \nAssure privacy \n• \nEstablish a good rapport with the laboring women asking \nabout their wants and concerns and address them \n• \nMaintain a calm and confident approach which will reassure \nwomen that the situation is under control\n• \nAssess the woman’s knowledge of strategies for coping with \npain and provide balanced information to find out which \navailable approaches are acceptable to her\n• \nAsk her permission before all  procedures and observations, \nfocusing on the woman rather than technology or the \ndocumentation\n3.1.2. Preparation of mothers to transfer to labour room\n• \nShaving or trimming of perineal hair may be necessary to \nfacilitate unhindered performance and repair of the episiotomy.\n• \nEfforts must be made to minimize faecal soiling. Where \nan enema is deemed necessary, a medicated enema is \nrecommended. \n      (These two steps should not be considered mandatory)",
  "Where \nan enema is deemed necessary, a medicated enema is \nrecommended. \n      (These two steps should not be considered mandatory)\n\n--- Page 23 ---\nNational Guideline for Maternal Care - Volume I\n5\n• \nWomen should be encouraged to have a companion of her \nchoice during labour, depending on the facilities and clinical \nsituation.\n3.1. 3. Documentation \n• \nAdmit the mother to the labour room and complete the \n‘handing over’ form \n• \nEnter relevant notes on the BHT and start a partogragh (see \npage 39)\n• \nReview clinical notes and reassess risk factors.\n• \nAccurate documentation of all observations and interventions \nmust be made, with timing.\n• \nAll obstetric examinations and procedures carried out must \nbe documented in the clinical notes. Each entry must be \naccompanied by a plan for management and be signed by the \nresponsible person.  \n3.1.4. Mobilization and Positioning\n• \nWomen should be encouraged and helped to move about \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nThey need to be encouraged to void urine at regular intervals.\n3.1.5. Eating and drinking in labour\n• \nMothers must be encouraged to consume clear, non-\nfizzy liquids during labour. Isotonic solutions such as oral \nrehydration fluid and king coconut water are more beneficial \nthan water. \n• \nIn addition to clear fluids, women in the latent phase may \nconsume light solids e.g. biscuits and fruits. \n3.1.6. Hygiene measures during labour\n• \nStrict asepsis must be maintained during labour. \n• \nInstruments should be available in packets",
  "Hygiene measures during labour\n• \nStrict asepsis must be maintained during labour. \n• \nInstruments should be available in packets\n\n--- Page 24 ---\nNational Guideline for Maternal Care - Volume I\n6\n• \nUse proper hand washing technique.\n• \nUse of double gloves and disposable gloves is encouraged.  \n3.1.7. Pain relief in labour\nRelief of pain should be a major consideration (please refer guidelines on \npain relief during labour in page 34)\n3.2. \nManagement of the three stages of labour\nThe practice of maintaining a labour room ‘notice board’ - a ‘white \nboard’ on which the status of all women in labour is summarized \nand updated regularly is encouraged. This would convey at a glance \nto all care providers women who require additional attention. The \nage, parity status, risk factors, salient findings at each assessment \nand any abnormalities noted must be included in this.\n3.2.1. Management of first stage of labour\n3.2.1. 1. Latent phase \nIt is important to recognize the latent phase of labour, since its prolongation \ncould lead to maternal exhaustion, dehydration and acidosis, leading to \nfetal compromise and dysfunctional labour. \n \nWomen in the latent phase of labour would be best managed in the \nantenatal ward.\nWomen in the latent phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse half hourly\n• \nCheck  temperature four hourly\n• \nConsider vaginal examination four hourly, depending on the \ncontraction pattern and initial cervical dilatation\n• \nDocument the colour of amniotic fluid if the membranes \nrupture",
  "Latent phase \nIt is important to recognize the latent phase of labour, since its prolongation \ncould lead to maternal exhaustion, dehydration and acidosis, leading to \nfetal compromise and dysfunctional labour. \n \nWomen in the latent phase of labour would be best managed in the \nantenatal ward.\nWomen in the latent phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse half hourly\n• \nCheck  temperature four hourly\n• \nConsider vaginal examination four hourly, depending on the \ncontraction pattern and initial cervical dilatation\n• \nDocument the colour of amniotic fluid if the membranes \nrupture\n\n--- Page 25 ---\nNational Guideline for Maternal Care - Volume I\n7\n• \nUse of a sanitary pad may indicate early, the presence of \nmeconium. \n• \nConsider the requirement for analgesia.\nIt is important to inform the mother and reassure her that it is common to \nhave slow progress in the latent phase.  \nThe latent phase is considered prolonged when it lasts more than 12 hours \nin a primigravida and 8 hours in a multigravida. In these situations an \nexperienced medical officer (with a minimum one year of experience in \nthe field) must reassess the mother with a view of augmentation of labour. \n3.2.1.2. Active phase\n3.2.1.2a. Admitting women to the Labour Room\nAll pregnant women diagnosed as being in active phase of the first stage of \nlabour need to be admitted to the labour room.\nThe initial assessment of a woman in the labour room should include:\n• \nListening to her story, considering her emotional and \npsychological needs and reviewing her clinical records\n• \nPhysical observation: temperature, pulse, blood pressure\n• \nLength, strength and frequency of contractions\n• \nAbdominal palpation: fundal height, lie, presentation, position \nand station\n• \nVaginal loss: show, liquor, blood\n• \nAssessment of woman’s pain including her wishes for coping \nwith labour along with the range of options for pain relief\n• \nThe fetal heart rate (FHR)  should be auscultated preferably with \na hand held Doppler for a minimum of 1 minute immediately \nafter a contraction\n• \nThe maternal pulse should be recorded to differentiate between \nmaternal pulse and FHR\n• \nA vaginal examination should be offered",
  "Active phase\n3.2.1.2a. Admitting women to the Labour Room\nAll pregnant women diagnosed as being in active phase of the first stage of \nlabour need to be admitted to the labour room.\nThe initial assessment of a woman in the labour room should include:\n• \nListening to her story, considering her emotional and \npsychological needs and reviewing her clinical records\n• \nPhysical observation: temperature, pulse, blood pressure\n• \nLength, strength and frequency of contractions\n• \nAbdominal palpation: fundal height, lie, presentation, position \nand station\n• \nVaginal loss: show, liquor, blood\n• \nAssessment of woman’s pain including her wishes for coping \nwith labour along with the range of options for pain relief\n• \nThe fetal heart rate (FHR)  should be auscultated preferably with \na hand held Doppler for a minimum of 1 minute immediately \nafter a contraction\n• \nThe maternal pulse should be recorded to differentiate between \nmaternal pulse and FHR\n• \nA vaginal examination should be offered\n\n--- Page 26 ---\nNational Guideline for Maternal Care - Volume I\n8\nHealth care Professionals who conduct vaginal examination should:\n• \nBe sure that there is a valid indication for vaginal examination \nthat it will add important information to the decision making \nprocess\n• \nBe aware that for many women who may already in pain, \nhighly anxious and in an unfamiliar environment, vaginal \nexamination can be very distressing\n• \nEnsure the woman’s consent, privacy, dignity and comfort\n• \nExplain the reason for examination and what will be involved, \nand\n• \nExplain the findings and their impact sensitively to the woman\n3.2.1.2b.  Management of active phase of first stage\nMonitoring must be conducted as instructed in the partogram and \nfindings recorded accordingly. \nUse of a sanitary pad may indicate presence of meconium early. \nWomen in the active phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse every 15 minutes ;\n• \nCheck temperature and blood pressure four hourly;\n• \nVaginal examination four hourly or earlier, depending on the \nclinical situation; \n• \nFrequency of contractions should be monitored as follows:\n \nThe interval between two contractions should be assessed by \npalpation of the abdomen\n \nDuring active labor usually there are at least three contractions \nper ten minutes. In other words the interval between two \ncontractions should be three minutes\n• \nDocument the colour of amniotic fluid if the membranes \nrupture;\n• \nConsider the requirement for analgesia, (which now becomes \nmore important).",
  "Women in the active phase of labour must be assessed on a regular basis, \nas follows: \n• \nCheck the fetal heart and maternal pulse every 15 minutes ;\n• \nCheck temperature and blood pressure four hourly;\n• \nVaginal examination four hourly or earlier, depending on the \nclinical situation; \n• \nFrequency of contractions should be monitored as follows:\n \nThe interval between two contractions should be assessed by \npalpation of the abdomen\n \nDuring active labor usually there are at least three contractions \nper ten minutes. In other words the interval between two \ncontractions should be three minutes\n• \nDocument the colour of amniotic fluid if the membranes \nrupture;\n• \nConsider the requirement for analgesia, (which now becomes \nmore important).\n\n--- Page 27 ---\nNational Guideline for Maternal Care - Volume I\n9\nIntermittent auscultation of the fetal heart is best performed using \nhand-held Doppler devices. The fetal heart rate must be counted \nfor one minute, beginning immediately after a contraction.\nThe mother may continue to consume clear fluids in the active phase. \nShe must be encouraged to assume any position that she is comfortable in \nand to avoid the dorsal position. \nWomen who have the following conditions are recommended to be have \nto continuous electronic fetal monitoring: \n• \nSignificant meconium staining of amniotic fluid, \n• \nAbnormal Fetal heart rate detected by intermittent \nauscultation (< 110 beats per minute; > 160 beats per minute; \nany decelerations after a contraction)\n• \nFresh vaginal bleeding and \n• \nMaternal pyrexia. \nIn women with spontaneous labour progressing normally, routine \nearly amniotomy and use of oxytocin is not recommended.\n3.2.1.3. Delayed progress of first stage of labour\nDelayed progress is diagnosed when there is progress of less than \ntwo cm in four hours. Slowing of progress in a woman who has \npreviously been progressing satisfactorily must also be considered \nas a delay.\nIt is extremely important that delay in progress is assessed by an \nexperienced medical officer. \nThis assessment must take into account:\n• \nthe uterine contractions, \n• \ndescent and position of the fetal head  \n• \nfeatures of early obstruction of labor (caput and moulding), and \n• \nThe fetal condition",
  "Slowing of progress in a woman who has \npreviously been progressing satisfactorily must also be considered \nas a delay.\nIt is extremely important that delay in progress is assessed by an \nexperienced medical officer. \nThis assessment must take into account:\n• \nthe uterine contractions, \n• \ndescent and position of the fetal head  \n• \nfeatures of early obstruction of labor (caput and moulding), and \n• \nThe fetal condition\n\n--- Page 28 ---\nNational Guideline for Maternal Care - Volume I\n10\nIn women with delay in the active phase of the first stage, every effort must \nbe made to find a cause for the delay. This may either be due to inadequate \ncontractions or obstruction due to CPD, mal-presentation or malposition \n(such as occipito-posterior position), or a combination of these. \nIn cases of inadequate contractions:\n• \nAmniotomy must be performed if membranes are still intact. \n• \nFollowing that, the woman must be reassessed in two hours \n• \nIn case there is inadequate progress, augmentation with \noxytocin must be considered. \n• \nThe situation must be reassessed after four hours or earlier if \nrequired.\nMultiparous women with delayed progress: \n• \nMust be viewed with extreme caution. \n• \nIt is very important to exclude mechanical causes of delay \nbefore considering oxytocin. \n• \nUse of oxytocin in multipara with obstructed labour could be \nextremely dangerous. \nIn all cases where progress is slow in spite of adequate contractions a \ncareful assessment must be made to exclude obstruction of labour. \nAttention must be paid to effective pain relief and to correcting dehydration \nin those situations.\nAfter paying attention to the above,Cesarean section must be considered \nwhere the progress continues to be slow after four hours (less than two \ncm) of commencing oxytocin. \n3.2.2. Management of second stage of labour\n3.2.2.1. Passive second stage of labour (descent phase)\n• \nIs diagnosed when full cervical dilatation is reached in the \nabsence of involuntary expulsive efforts by the mother. \n• \nBearing down must be discouraged at this stage.",
  "Passive second stage of labour (descent phase)\n• \nIs diagnosed when full cervical dilatation is reached in the \nabsence of involuntary expulsive efforts by the mother. \n• \nBearing down must be discouraged at this stage.\n\n--- Page 29 ---\nNational Guideline for Maternal Care - Volume I\n11\n• \nIntermittent auscultation of the fetal heart should be done \nimmediately after a contraction for at least one minute, at least \nevery 10 minutes. The maternal pulse should be palpated if \nthere is suspected fetal bradycardia or any other FHR anomaly \nto differentiate the two heart rates. \n• \nPresence of meconium must be noted. \n3.2.2.2. Active second stage of labour (expulsive phase) \n• \nIs diagnosed when the mother gets the urge to bear down with \nfull dilatation.\n• \nIntermittent auscultation of the fetal heart should be done \nimmediately after a contraction for at least one minute, at least \nevery 5 minutes. The maternal pulse should be palpated if there \nis fetal bradycardia or any other FHR anomaly \n• \nPresence of meconium must be noted. \nUse of a hand-held Doppler device is recommended (in preference to a \nPinnard) for fetal heart rate monitoring in the second stage. \nWomen must be encouraged to continue consuming clear fluids during \nthe second stage. \nSupport by the labour companion must be continued. \nTotal time durations allowed for the second stage of labour are as follows:\nPrimigravida: \n• \nBirth would be expected to take place within 2 hours of the \nstart of the active second stage in most women.\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 1 hour and need to seek the advice from a \nhealth professional trained in the assisted/ Operative vaginal \nbirth if birth is not imminent.\nMultigravida:\n• \nBirth would be expected to take place within 1 hours of the \nstart of the active second stage in most women.",
  "Support by the labour companion must be continued. \nTotal time durations allowed for the second stage of labour are as follows:\nPrimigravida: \n• \nBirth would be expected to take place within 2 hours of the \nstart of the active second stage in most women.\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 1 hour and need to seek the advice from a \nhealth professional trained in the assisted/ Operative vaginal \nbirth if birth is not imminent.\nMultigravida:\n• \nBirth would be expected to take place within 1 hours of the \nstart of the active second stage in most women.\n\n--- Page 30 ---\nNational Guideline for Maternal Care - Volume I\n12\n• \nA diagnosis of delay in the active second stage should be made \nwhen it has lasted 30 minutes and requires advice from a health \nprofessional trained in assisted/ operative vaginal birth if birth \nis not imminent.\n• \nDelay in the second stage in a multiparous woman must raise \nsuspicion of disproportion or malposition.\nOne further hour is permitted for women in each category with an \nepidural analgesia.\n3.2.2.3. Observations for women and babies in the second stage of \nlabour:\nAll observations should be documented on the partogragh.\n• \nChart blood pressure and pulse hourly\n• \nContinue four hourly temperature recording \n• \nVaginal examination must be offered after an hour in the active \nsecond stage after abdominal palpation and assessment of \nvaginal loss\n• \nHalf hourly documentation of frequency of contractions\n• \nOngoing consideration of the woman’s  emotional and \npsychological needs\nIn addition:\n• \nAssessment of progress should include maternal behavior, \neffectiveness of pushing and fetal wellbeing, taking into \naccount fetal position and station at the onset of the second \nstage. These factors will assist in deciding the timing of further \nvaginal examination and the need for obstetric review.\n• \nOngoing consideration should be given to the woman’s position, \nhydration, coping strategies and pain relief throughout the \nsecond stage.\n3.2.2.4. Women’s position and pushing in the second stage of labour:\nAlthough most deliveries in Sri Lanka are conducted in the dorsal/\nMcRobert’s position, women may be encouraged to adopt squatting, semi \nupright or lateral positions to aid the expulsion phase.",
  "These factors will assist in deciding the timing of further \nvaginal examination and the need for obstetric review.\n• \nOngoing consideration should be given to the woman’s position, \nhydration, coping strategies and pain relief throughout the \nsecond stage.\n3.2.2.4. Women’s position and pushing in the second stage of labour:\nAlthough most deliveries in Sri Lanka are conducted in the dorsal/\nMcRobert’s position, women may be encouraged to adopt squatting, semi \nupright or lateral positions to aid the expulsion phase.\n\n--- Page 31 ---\nNational Guideline for Maternal Care - Volume I\n13\nWomen should be informed that in the second stage, they should be \nguided by their own urge to push.\nIf pushing is ineffective, strategies to assist birth such as support and \nencouragement and change of position can be used.\nIn primigravida in whom contractions have become weak and there \nis no evidence of fetal compromise or obstruction, oxytocin may \nbe administered as an infusion. In this case, the expulsive phase \nmay be continued under close observation for a further 30 minutes. \nDelivery must be considered at the end of this period.\n3.2.2.5. Intrapartum interventions to reduce perineal trauma\nEither the ‘hands on’ (guarding the perineum and flexing the baby’s head) \nor the ‘hands poised’ (with hands off the perineum and baby’s head but in \nreadiness) techniques can be used to facilitate spontaneous birth.\nA routine episiotomy should not be carried out during spontaneous \nvaginal birth.\nEpisiotomy should only be performed selectively, in women in whom there \nis a clinical need such as instrumental birth or suspected fetal compromise \nor a high chance of perineal tears.  \nWhere episiotomy is performed, Mediolateral episiotomy, performed at \n45 – 60 degrees from the midline directed to the right side, beginning at \nthe vaginal fourchette is preferred to the median episiotomy.  It should be \nperformed at the time of crowning of the fetal head.\nEpisiotomy should be performed after infiltration of the perineum up to \n20 ml of 1% lignocaine. \n3.2.2.6. Delivery\nThe fetal head should not be allowed to extend till occiput is felt below \nthe symphysis pubis. The perineum should be supported during delivery \nof the head. Once the head is delivered the woman should be discouraged \nfrom bearing down. Following restitution and external rotation, shoulders",
  "Once the head is delivered the woman should be discouraged \nfrom bearing down. Following restitution and external rotation, shoulders\n\n--- Page 32 ---\nNational Guideline for Maternal Care - Volume I\n14\nmust be delivered appropriately with directed traction on the fetal head. \nThe baby must be delivered onto the mother’s abdomen. Breastfeeding \nshould be initiated within 30 minutes of birth. \n3.2.3. \nThird stage of Labour\nThe third stage of labour is the period from the complete delivery of the \nbaby to the complete delivery of the placenta and membranes.\n3.2.3.1. Active Management of the third stage of labour\nActive management of the third stage of labour is recommended for all \nmothers. \nThis includes;\n• \nRoutine use of uterotonic drugs: Oxytocin 5 IU intravenously \nsoon after the delivery of the baby   or 10 IU intramuscularly, \n• \nDelayed cord clamping (2 minutes after the birth) and cutting \nof the cord\n• \nFollowed by controlled cord traction. This must be followed by \nuterine massage.\nDelayed clamping of the cord allows for placental transfusion, \nwhich reduces neonatal and infant iron deficiency and anemia. \nThis policy should be followed unless the baby is born in a poor \ncondition or if the mother is bleeding or is Rhesus iso-immunized.\nClamp and cut the cord close to the perineum.  A hand should be placed \nabove the symphysis pubis to stabilize the uterus by applying counter \ntraction during controlled cord traction. Application of cord traction \nwhen the uterus is relaxed could lead to acute inversion of the uterus.\nAfter delivery, the placenta must be placed on a flat surface and the maternal \nsurface examined for completeness. On the fetal surface the blood vessels \nmust be traced to exclude a succenturiate lobe. Completeness of the fetal \nmembranes must be ensured.",
  "On the fetal surface the blood vessels \nmust be traced to exclude a succenturiate lobe. Completeness of the fetal \nmembranes must be ensured.\n\n--- Page 33 ---\nNational Guideline for Maternal Care - Volume I\n15\nObservations in the immediate postpartum period include:\n• \nInspection for continued fresh bleeding, \n• \nCheck pulse, blood pressure, uterine contraction,  and the level \nof the fundus every 15 minutes up to 2 hours\n• \nHer general  physical condition, as shown by her colour, \nrespiration and her own report of how she feels \nExperienced medical personnel should be informed in any one the \nfollowing instances: \n• \nContinuing fresh bleeding;\n• \nElevation of the level of the fundus;\n• \nIncrease of pulse rate above 100 or by 30 beats per minute;\n• \nDrop in systolic blood pressure below 100 or by 30 mmHg. \nThe level of the fundus must be marked on the skin using a marker to \nmake observations more objective. \n3.2.3.2. Delayed third stage\nDelayed third stage is diagnosed when the placenta is not delivered within \n30 minutes of active management. \nThe first step in managing delayed third stage of labour is:\n• \nTo proceed to intraumbilical vein oxytocin, in a dose of 50 IU \nin 30 ml of 0.9% sodium chloride solution. \n• \nA period of 30 minutes is allowed and controlled cord traction \nis attempted again. \n• \nIf the placenta is not delivered by this method, manual removal \nof placenta is proceeded to. \n4.\t\nCare for the newborn baby\nEffective care at birth is needed in anticipation of problems with the \ntransition from in utero dependent life to extra utero independent \nexistence and to provide support to ensure stabilization.",
  "• \nIf the placenta is not delivered by this method, manual removal \nof placenta is proceeded to. \n4.\t\nCare for the newborn baby\nEffective care at birth is needed in anticipation of problems with the \ntransition from in utero dependent life to extra utero independent \nexistence and to provide support to ensure stabilization.\n\n--- Page 34 ---\nNational Guideline for Maternal Care - Volume I\n16\n• \nSkilled birth attendant (Medical Officer, Nursing Officer and \nMidwive) is responsible for the care. \n• \nThe care at birth is same irrespective of birthing place or person \nattending to birth. \n• \nAt least one health care provider trained in neonatal \nresuscitation must be physically available at the time of birth of \nall infants irrespective of risk status.\n• \nThis person must actually be present in the delivery room \nbefore the birth of the baby.\n• \nThe attending personnel should document the details of the \nbaby such as time of birth, weight, gender and any other \nrelevant information in all cases.\nThe aims of neonatal care following birth include the following:\n• \nEstablishment of respiration (as per NRP guidelines) \n• \nPrevention of hypothermia (Refer to newborn guideline)\n• \nEstablishment of breast feeding (Refer to newborn guideline)\n• \nPrevention of infection (Refer to newborn guideline)\n• \nDetection of danger signs (Refer to newborn guideline)\nFollowing basic steps should be followed at the time of birth;\n1. Call out the time of birth\n2. Deliver the baby onto the mother’s abdomen or into her arms\n3. Dry baby with a warm towel or a warm piece of cloth\n4. Wipe baby’s eye\n5. Assess baby’s breathing while drying \n6. Make sure that there is no second baby\n7. Change gloves or remove the first layer of gloves\n8. Clamp and cut the umbilical cord\n9. Put the baby between mother’s breast for skin to skin care\n10. Place an identity label on baby\n11. Cover mother and baby with warm clothes\n12. Put a hat on baby’s head\nThe Apgar score at 1 and 5 minutes should be recorded for all births.",
  "Cover mother and baby with warm clothes\n12. Put a hat on baby’s head\nThe Apgar score at 1 and 5 minutes should be recorded for all births.\n\n--- Page 35 ---\nNational Guideline for Maternal Care - Volume I\n17\nInitiation of breast feeding should be aimed for within 1hour after birth. \nHead circumference, birth weight, length and other measurements should \nbe carried out once the first feed is complete. A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.",
  "Head circumference, birth weight, length and other measurements should \nbe carried out once the first feed is complete. A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.\n\n--- Page 36 ---\nNational Guideline for Maternal Care - Volume I\n18\nThe preferred suture material is rapidly absorbable polyglactin acid.\nThe following basic principles should be observed when performing \nperineal repairs:\n• \nPerineal trauma should be repaired using aseptic techniques.\n• \nEquipment should be checked and swabs and needles counted \nbefore and after the procedure\n• \nGood lighting is essential to see and identify the structures \ninvolved.\n• \nDifficult injuries should be repaired by an experienced medical \nofficer in the theatre under regional or general anaesthesia. An \nindwelling catheter should be inserted for 24 hours to prevent \nurinary retention.\n• \nGood anatomical alignment of the wound should be achieved, \nand consideration  given to the cosmetic result.\n• \nRectal examination should be carried out after completing the \nrepair to ensure that suture material has not accidently been \ninserted through the rectal mucosa.\n• \nFollowing completion of repair, an accurate detailed account \nshould be documented covering the extent of the trauma, the \nmethod of repair and the materials used.\n• \nInformation should be given to the woman regarding the extent \nof the trauma, pain relief, diet, hygiene and the importance of \npelvic floor exercises.",
  "A health care professional \nshould examine the baby to detect any physical abnormality and to \nidentify any problems that require referral.\n5.\t\nPerineal Care\nPerineal  or genital trauma caused by either episotomy or tearing need to \nbe repaired.\nBefore assessing for genital trauma:\n• \nExplain to the woman what they are going to do and why\n• \nOffer some analgesia\n• \nEnsure good lighting\n• \nPosition the woman so that she is comfortable and the genital \nstructures can be seen clearly.\nThe initial assessment should be performed gently and with sensitivity \nand may be done in the immediate period following birth preferably as \nsoon as the placenta is delivered.\nClassification of perineal trauma\nFirst degree: Injury to skin only\nSecond Degree: Injury to the perineal muscles but not the anal \nsphincter\nThird degree: Injury to the perineum involving the anal sphincter  \ncomplex\nFourth degree: Injury to the perineum involving the anal sphincter \ncomplex and anal epithelium\nPerineal repair should only be undertaken with tested effective analgesia \nin place using infiltration with up to 20ml of 1% lignocaine or equivalent, \nor by topping up the epidural, as soon as possible by a medical officer.\n\n--- Page 36 ---\nNational Guideline for Maternal Care - Volume I\n18\nThe preferred suture material is rapidly absorbable polyglactin acid.\nThe following basic principles should be observed when performing \nperineal repairs:\n• \nPerineal trauma should be repaired using aseptic techniques.\n• \nEquipment should be checked and swabs and needles counted \nbefore and after the procedure\n• \nGood lighting is essential to see and identify the structures \ninvolved.\n• \nDifficult injuries should be repaired by an experienced medical \nofficer in the theatre under regional or general anaesthesia. An \nindwelling catheter should be inserted for 24 hours to prevent \nurinary retention.\n• \nGood anatomical alignment of the wound should be achieved, \nand consideration  given to the cosmetic result.\n• \nRectal examination should be carried out after completing the \nrepair to ensure that suture material has not accidently been \ninserted through the rectal mucosa.\n• \nFollowing completion of repair, an accurate detailed account \nshould be documented covering the extent of the trauma, the \nmethod of repair and the materials used.\n• \nInformation should be given to the woman regarding the extent \nof the trauma, pain relief, diet, hygiene and the importance of \npelvic floor exercises.\n\n--- Page 37 ---\nNational Guideline for Maternal Care - Volume I\n19\nGuideline on Induction of Labour\n1.\t\nIntroduction \nThis guideline aims to provide evidence based guidance on induction of \nlabour to make the process more logical, effective and safer. It also aims to \nempower women undergoing induction of labour. \n2.\t\nDefinition\nInduction of labour is defined as initiation of labour by artificial means.\n3.\t\nGeneral Principles\n• \nInduction of labour should be performed only in specialist \nobstetric units when there is a clear indication that its benefits \noutweigh risks.\n• \nA senior clinician must make the decision.\n• \nThe reason/s should be clearly explained to the patient, who \nshould give her consent.\n• \nMaternal and fetal wellbeing should be monitored closely.\n• \nAdequate pain relief should be an essential part of the \nmanagement plan, since it is recognized that labor is more \npainful when it is induced.\n• \nPrior to induction of labour, the cervix should be favourable \n(Modified Bishop score 7 or more). If it is not, an attempt should \nbe made to ripen the cervix. \n• \nDecisions regarding induction of labour should be made taking \ninto account not only the clinical scenario but also the woman’s \nviews, the availability of local facilities and cost effectiveness of \nthe available methods.\n4.\t\nIndications\n4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\nInduction of labour is recommended for low-risk women who are known \nwith certainty to have reached 41 weeks of gestation.",
  "If it is not, an attempt should \nbe made to ripen the cervix. \n• \nDecisions regarding induction of labour should be made taking \ninto account not only the clinical scenario but also the woman’s \nviews, the availability of local facilities and cost effectiveness of \nthe available methods.\n4.\t\nIndications\n4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\nInduction of labour is recommended for low-risk women who are known \nwith certainty to have reached 41 weeks of gestation.\n\n--- Page 38 ---\nNational Guideline for Maternal Care - Volume I\n20\nHowever, it is good practice to assess fetal wellbeing around 40 weeks to \nselect women for conservative management until 41 weeks gestation. \nThe recommended assessments include fetal biometry (at least abdominal \ncircumference) and amniotic fluid index (lower cut-off = 7 cm). \n4.2 Prelabour rupture of membranes at term\nIn the absence of evidence fetal compromise or maternal infection delayed \ninduction of labour after 24 hours is acceptable. \nThis may be carried out using either oxytocin infusion or prostaglandins.\n4.3 Preterm prelabour rupture of membranes (PPROM)\nPatients with PPROM without evidence of infection or fetal compromise \nshould be offered induction after the completion 34 weeks.\n4.4 Intrauterine death\nThis is a very traumatic time for the woman. Most women would want \nto be delivered as early as possible and their wishes need to be respected. \nAmniotomy and repeated vaginal examinations are best avoided. \nProstaglandins are preferred for induction of labour in these women. \nAmniotomy is preferred in the presence of abruption placentae. \n4.5 History of precipitate labour\nThere are no studies comparing outcomes in induced versus spontaneous \nlabour.\n4.6 Suspected macrosomia\nIn the presence of good clinical and ultrasound evidence of macrosomia \nor a history of previous shoulder dystocia, there should be a low threshold \nfor early induction of labour.",
  "Amniotomy is preferred in the presence of abruption placentae. \n4.5 History of precipitate labour\nThere are no studies comparing outcomes in induced versus spontaneous \nlabour.\n4.6 Suspected macrosomia\nIn the presence of good clinical and ultrasound evidence of macrosomia \nor a history of previous shoulder dystocia, there should be a low threshold \nfor early induction of labour.\n\n--- Page 39 ---\nNational Guideline for Maternal Care - Volume I\n21\n4.7 Fetal growth restriction\nThe decision for induction of labour in a growth restricted fetus should be \nindividualized based on period of gestation at onset, presence or absence \nof fetal compromise. \n4.8 Older mothers\nThere is growing evidence that the risk of stillbirth is higher in older (>40 \nyrs) women near term. \nWomen over 40 years should be offered induction between 39-40 weeks.\n5.\t\nInduction under specific circumstances\n5.1 Breech presentation\nPresentation per se, is not a contraindication to induction. \n5.2 Previous CS\nThere is no contraindication to induction of labour in a woman with a \npast caesarean section. \nUse of either oxytocin or prostaglandins increases the risk of scar \ndehiscence or rupture. \nThis risk may be lower with artificial separation of membranes or Foley \ncatheter. \n6.\t\nMethods of induction\nThis section does not make a distinction between methods of ripening the \ncervix and induction of labour. \n6.1 Mechanical\nThere is good evidence that artificial separation of membranes reduces the \nneed for formal induction. This method is recommended to be performed \nwith due regard to asepsis, at 40 weeks gestation.",
  "6.1 Mechanical\nThere is good evidence that artificial separation of membranes reduces the \nneed for formal induction. This method is recommended to be performed \nwith due regard to asepsis, at 40 weeks gestation.\n\n--- Page 40 ---\nNational Guideline for Maternal Care - Volume I\n22\nWhere the cervix will not admit a finger, massaging around the cervix in \nthe vaginal fornices will have a similar effect.\nExtra-amniotic balloon catheter is an effective method of ripening of the \ncervix. A Foley catheter is inserted through the cervix and the balloon \ninflated with 40 – 60 ml of saline. This may be left in situ for a maximum \nof 48 hours. Following its removal, induction of labour may be proceeded \nto using another method. \nIn the presence of evidence of infection, artificial separation of membranes \nand extra-amniotic Foley catheter must not be used. \n6.2 Surgical\n \nAmniotomy is a definitive mode of induction of labour. It should be \nundertaken only if one is committed to deliver within 24 hours. Therefore \nit should be done only when the cervix is ripe and prior cervical assessment \nby an experienced clinician is essential.\nThe risk of cord prolapse should be appreciated and steps taken to \nminimise or to recognize it early.\nAmniotomy alone may be capable of initiation of labour and it is \nrecommended that oxytocin be started after a period of observation of at \nleast two hours. \n6.3 Pharmacological\n6.3.1 Oxytocin\nUse of oxytocin when membranes are intact is not recommended. \nFor details of how to use oxytocin please refer to the guideline on oxytocin\n6.3.2 Prostaglandins\nProstaglandin E2 (PGE2)\nThese are very effective in inducing labour and are available as vaginal gel, \ntablet or controlled release pessary.",
  "6.3 Pharmacological\n6.3.1 Oxytocin\nUse of oxytocin when membranes are intact is not recommended. \nFor details of how to use oxytocin please refer to the guideline on oxytocin\n6.3.2 Prostaglandins\nProstaglandin E2 (PGE2)\nThese are very effective in inducing labour and are available as vaginal gel, \ntablet or controlled release pessary.\n\n--- Page 41 ---\nNational Guideline for Maternal Care - Volume I\n23\nAll preparations carry a risk of hyperstimulation.\nIntracervical route does not offer any increase in efficacy.\nCombined use with oxytocin is particularly dangerous. A minimum of six \nhours from the last vaginal tablet/gel should be allowed before oxytocin \nis started.\nPrior to use of prostaglandins the Bishop score should be assessed and \nthe woman should be monitored electronically to determine the fetal \ncondition and frequency of contractions.\nAfter administration the fetal heart should be monitored electronically \nwhen contractions begin. After confirmation of normal heart rate pattern \nmonitoring should be done by intermittent auscultation.\nA second dose may be considered after a minimum interval of 6 hours \nafter the first, depending on the change of Bishop score, the condition of \nthe fetus and frequency of contractions.\nThe dosages are 3 mg for vaginal tablets and 0.5 mg for vaginal gel.\nMisoprostol\nThis drug is widely used worldwide for a variety of indications in \npregnancy. (In Sri Lanka, it is not licensed at present).\nNevertheless, it is very effective in inducing labour (more than PGE2), \nespecially in mid trimester fetal death. \nSensitivity of the uterus increases markedly with advancing pregnancy.\nThis guideline recommends that it should not be used for induction of \nlabour with a mature live fetus.\n6.3.3 Mifepristone\nIt is a powerful anti-progesterone and is very useful as an adjunct to \nmisoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka \nat present)",
  "Sensitivity of the uterus increases markedly with advancing pregnancy.\nThis guideline recommends that it should not be used for induction of \nlabour with a mature live fetus.\n6.3.3 Mifepristone\nIt is a powerful anti-progesterone and is very useful as an adjunct to \nmisoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka \nat present)\n\n--- Page 42 ---\nNational Guideline for Maternal Care - Volume I\n24\n8.\t\nComplications\n8.1 Hyperstimulation\nThis is a well-recognized complication of induction of labour with \npharmacological methods. It could have serious consequences including \nrupture of the uterus, aminiotic fluid embolism, precipitate labor and fetal \ncompromise. \nIt is defined either as a contraction free interval of less than sixty seconds \nand/or contractions lasting more than ninety seconds.\nIf diagnosed, the prostaglandin tablet must be retrieved from the vagina \nor oxytocin infusion stopped immediately and a rapid infusion of 0.9% \nsodium chloride via a fresh giving set administered.    \nIf still not resolved, tocolytics should be given if available e.g. terbutaline \n250 µg IV or SC.  Since this is not available in Sri Lanka, salbutamol \ninhaler may be tried.\n8.2  Cord prolapse\nThis is more likely with amniotomy when the head is high and poorly \napplied to the cervix. \nPrecautions to avoid and to detect this early include palpation for cord \npresentation, palpation for the cord immediately after amniotomy and the \nfetal heart sounds auscultated immediately afterwards.\n \nIf cord prolapse is diagnosed help must be called immediately. Assess \ncervical dilatation and effect delivery if fully dilated. If not fully dilated \nand cord pulsations are present, insert a Foley catheter into the bladder \nand fill it with 500 ml saline. Place the mother in the knee-elbow position \nand displace the presenting part away from the pelvis by keeping pressure \ninserting a hand in the vagina. Transport for immediate caesarean section \nin this position.",
  "Place the mother in the knee-elbow position \nand displace the presenting part away from the pelvis by keeping pressure \ninserting a hand in the vagina. Transport for immediate caesarean section \nin this position.\n\n--- Page 43 ---\nNational Guideline for Maternal Care - Volume I\n25\n8.3 Uterine rupture\nPlease also refer to section 5.2 in this guideline\nExtra care must be exercised in grandmultipara and in women with \nscarred uteri.\n8.4 Failed induction\nFailed induction is defined as labour failing to start after one cycle of \ntreatment with medical methods or for 12 hours of amniotomy. \nIt does not necessarily indicate caesarean section in case medical or \nmechanical methods.\nThe clinical situation (maternal and fetal condition) must be reassessed \nand discussed with the woman. \nIn case of failure to induce labor using one cycle of prostaglandins another \ncycle may be administered as described  above. Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.",
  "Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.\n\n--- Page 44 ---\nNational Guideline for Maternal Care - Volume I\n26",
  "Depending on the clinical \nsituation it is best that the second cycle is delayed for 24 hours. In case of \namniotomy, failed induction of labour indicates caesarean section.\n\n--- Page 44 ---\nNational Guideline for Maternal Care - Volume I\n26\n\n--- Page 45 ---\nNational Guideline for Maternal Care - Volume I\n27\nGuideline for Use of Oxytocin for Induction and \nAugmentation of labour\nOxytocin is an invaluable drug when used carefully. However, it has \nthe potential to cause uterine hyperstimulation, which could result in \namniotic fluid embolism, uterine rupture and fetal distress, all of which \nare life threatening. \nMultigravidae are particularly susceptible to the above consequences \nand extra care must be taken to exclude obstruction before a decision is \nmade to use oxytocin in a multigravid woman during labour. Experienced \npersonnel must be involved in this decision. \nUse of oxytocin for induction and/or augmentation of labour results in \na higher risk of rupture of a scarred uterus. Therefore, in such women \noxytocin should be used only with the concurrence of a Consultant. \nIts effects will depend on the concentration of the infusion and the volume \ninfused per minute. \nTo achieve this predictably, use of infusion pumps is recommended. \nWhere a gravity-assisted drip system is used, a burette may be used to \nimprove accuracy. Such systems however, may deliver variable volumes \ndepending on many factors including the position of the arm into which \nit is infused.  \nIrrespective of the method of administration, oxytocin must be \nadministered in incremental doses at intervals of 30 minutes, to achieve \na contraction free interval of two minutes. Once this level is reached, the \ninfusion rate may be continued at the same level, while closely monitoring \nthe contractions. \nHyperstimulation is defined either as a contraction free interval of less \nthan sixty seconds and/or contractions lasting more than ninety seconds. \nIn this situation the infusion must be stopped immediately. \nOxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride \nsolution. In situations where infusion pumps are not available, oxytocin",
  "Oxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride \nsolution. In situations where infusion pumps are not available, oxytocin\n\n--- Page 46 ---\nNational Guideline for Maternal Care - Volume I\n28\nmay be administered starting at a drop rate of 15 per minute and increased \nat rates of 15 drops per minute every 30 minutes, up to a maximum of 60 \ndrops per minute.  An approximate conversion to mU/minute is given in \ntable 1.\nTable 1: mU/minute administered at different rates of administration \naccording to drop rate\n \nDrop rate/min \nEquivalent  mU/min.\n \n15 \n7.5\n \n30 \n15 \n \n45 \n22.5 \n \n60 \n30 \n \n            (based on 5U of oxytocin in 500 ml saline)\nTable 2 gives mU infused per minute when administered via an infusion \npump. \nTable 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.",
  "Table 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.\n\n--- Page 47 ---\nNational Guideline for Maternal Care - Volume I\n29\nContinuous EFM during administration of oxytocin:\n• \nIf the CTG is normal, oxytocin may be continued in incremental \ndoses until the woman is experiencing 4 or 5 contractions every \n10 minutes.\n• \nIf the FHR trace is suspicious, this should be reviewed by an \nexperienced medical officer \n• \nIf the FHR trace is classified as abnormal/pathological oxytocin \ninfusion should be stopped and a full assessment of the fetal \ncondition undertaken by an experienced medical officer.",
  "Table 2: mU infused per minute when administered via an infusion \npump.\n TIME AFTER STARTING \nOXYTOCIN DOSE \nVOLUME INFUSED\n \n(MINS) \n(MU/MIN) DOSE \n(10U IN 500MLS MLS/HR)\n \n \n \nRATE\n \n0 \n1 \n3\n \n30 \n2 \n6\n \n60 \n4 \n12\n \n90 \n8 \n24\n \n120 \n12 \n36\n \n150 \n16 \n48\n \n180 \n20 \n60\n \n210 \n24 \n72\n \n240 \n28 \n84\n \n270 \n32 \n96\nOxytocin must not be administered to women with intact membranes. It is \nrecommended that women on oxytocin infusions should have continuous \nelectronic fetal monitoring.\n\n--- Page 47 ---\nNational Guideline for Maternal Care - Volume I\n29\nContinuous EFM during administration of oxytocin:\n• \nIf the CTG is normal, oxytocin may be continued in incremental \ndoses until the woman is experiencing 4 or 5 contractions every \n10 minutes.\n• \nIf the FHR trace is suspicious, this should be reviewed by an \nexperienced medical officer \n• \nIf the FHR trace is classified as abnormal/pathological oxytocin \ninfusion should be stopped and a full assessment of the fetal \ncondition undertaken by an experienced medical officer.\n\n--- Page 48 ---\nNational Guideline for Maternal Care - Volume I\n30\nGuideline on fetal monitoring in labour\nFetal monitoring in labour could be done by :\n• \nIntermittent auscultation (preferably by a hand held Doppler \ndevice) \n• \nIntermittent or continuous electronic monitoring  \nIntermittent auscultation is recommended for low-risk women in \nspontaneous labour. \nElectronic monitoring is recommended when:\n• \nThe baby’s  growth is restricted  \n• \nThere is significant meconium staining of amniotic fluid \n• \nAbnormal fetal heart rate detected by intermittent auscultation \n• \nFresh vaginal bleeding \n• \nMaternal pyrexia \n• \nUse of oxytocin for augmentation or induction of labour \n• \nWomen with a scarred uterus \n• \nWomen on epidural analgesia \nIntermittent auscultation \nThis could be done by using either a Pinnard’s stethoscope or preferably a \nhand-held Doppler device. \nAuscultation should be carried out immediately after a contraction for \none full minute. \nThe maternal pulse should be palpated if there is suspected fetal \nbradycardia or any other FHR anomaly to differentiate the two heart rates.\nThe normal rate is between 110 – 160 beats per minute in a term fetus. \nThe frequency of auscultation should be as specified in the partogram.",
  "The maternal pulse should be palpated if there is suspected fetal \nbradycardia or any other FHR anomaly to differentiate the two heart rates.\nThe normal rate is between 110 – 160 beats per minute in a term fetus. \nThe frequency of auscultation should be as specified in the partogram.\n\n--- Page 49 ---\nNational Guideline for Maternal Care - Volume I\n31\nElectronic fetal monitoring (EFM)\nEFM is carried out by external cardiotocography (CTG). \nThe following are recommended at the commencement of a CTG.\n1. The paper speed must be set at 1 cm per minute.\n2. The date and time settings on the machine must be validated.\n3. The CTG must be labeled with the mother’s name, BHT number \nand date and time. \n4. Maternal heart rate should be noted on the CTG.\n5. The presence and the point at which the fetal heart rate is best \nheard must be delineated by auscultation and the probe placed \nat that point.\n6. Ensure that the contraction probe is functioning properly and \nused for the recording.\n7. The woman should be positioned in such a way that aortocaval \ncompression is avoided.\n8. It should be interpreted without delay and the categorization \nrecorded as either normal or suspicious or pathological, as per \ntable 1, and signed by the responsible officer. The entry on the \nBHT must include a plan for management. \n9. If the CTG is categorized as suspicious or abnormal, the \nConsultant must be informed. \n10. For the management plan the overall clinical picture must be \ntaken into account. e.g. the rate of progress of labour, presence \nor absence of fetal growth restriction, meconium staining of \namniotic fluid and the evolution of the CTG abnormalities. \nTable 1: Definitions of normal, suspicious and pathological FHR traces\nCategory  \nDefinition \nNormal  \nAn FHR trace in which all four features are classified as \nreassuring \nSuspicious  \nAn FHR trace with one feature classified as non-reassuring \nand the remaining features classified as reassuring \nPathological  \nAn FHR trace with two or more features classified as non-\nreassuring or one or more classified as abnormal",
  "the rate of progress of labour, presence \nor absence of fetal growth restriction, meconium staining of \namniotic fluid and the evolution of the CTG abnormalities. \nTable 1: Definitions of normal, suspicious and pathological FHR traces\nCategory  \nDefinition \nNormal  \nAn FHR trace in which all four features are classified as \nreassuring \nSuspicious  \nAn FHR trace with one feature classified as non-reassuring \nand the remaining features classified as reassuring \nPathological  \nAn FHR trace with two or more features classified as non-\nreassuring or one or more classified as abnormal\n\n--- Page 50 ---\nNational Guideline for Maternal Care - Volume I\n32\nTable 2: Classification of fetal heart rate patterns\nFurther useful information on FHR patterns\n• \nIf repeated accelerations are present with reduced variability, \nthe FHR trace should be regarded as reassuring.\n• \nTrue early uniform decelerations are rare and benign, and \ntherefore they are not significant.\n• \nMost decelerations that occur during labor are variable.\n• \nIf a bradycardia occurs in the baby for more than 3 minutes, \nurgent medical aid should be sought and preparations \nshould be made to urgently expedite the birth of the baby, i.e. \nimmediate commencement of cesarean section.  This could \ninclude moving the woman to theatre if the fetal heart has \nnot recovered by 9 minutes. If the fetal heart recovers within \n9 minutes the decision to deliver should be reconsidered in \nconjunction with the woman if the post-recovery tracing is \nreassuring.\n• \nA tachycardia in the baby of 160–180 bpm, where accelerations \nare present and no other adverse features appear, should not be \nregarded as suspicious. However, an increase in the baseline \nFeature  \nBaseline \n(bpm)  \nVariability \n(bpm)  \nDecelerations  \nAccelerations  \nReassuring  \n110–160  \n≥ 5  \nNone  \nPresent  \nNon-reassuring  \n100–109  \n161–180  \n< 5 for 40 –90 \nminutes  \nTypical variable \ndecelerations with \nover 50% of \ncontractions, \noccurring for over \n90 minutes  \nTe absence of \naccelerations \nwith otherwise \nnormal trace is \nof uncertain \nsignificance  \nAbnormal \n< 100  \n> 180  \nSinusoidal \npattern ≥ _10 \nminutes \n< 5 for 90 \nminutes \nEither atypical \nvariable \ndecelerations with \nover 50% of \ncontractions or late \ndecelerations, both \nfor over 30 \nminutes",
  "If the fetal heart recovers within \n9 minutes the decision to deliver should be reconsidered in \nconjunction with the woman if the post-recovery tracing is \nreassuring.\n• \nA tachycardia in the baby of 160–180 bpm, where accelerations \nare present and no other adverse features appear, should not be \nregarded as suspicious. However, an increase in the baseline \nFeature  \nBaseline \n(bpm)  \nVariability \n(bpm)  \nDecelerations  \nAccelerations  \nReassuring  \n110–160  \n≥ 5  \nNone  \nPresent  \nNon-reassuring  \n100–109  \n161–180  \n< 5 for 40 –90 \nminutes  \nTypical variable \ndecelerations with \nover 50% of \ncontractions, \noccurring for over \n90 minutes  \nTe absence of \naccelerations \nwith otherwise \nnormal trace is \nof uncertain \nsignificance  \nAbnormal \n< 100  \n> 180  \nSinusoidal \npattern ≥ _10 \nminutes \n< 5 for 90 \nminutes \nEither atypical \nvariable \ndecelerations with \nover 50% of \ncontractions or late \ndecelerations, both \nfor over 30 \nminutes\n\n--- Page 51 ---\nNational Guideline for Maternal Care - Volume I\n33\nheart rate, even within the normal range, with other non-\nreassuring or abnormal features should increase concern. In \nsuch cases inquiry must be made to ascertain if the fetus was \nactive during the recording.  \nWhen women are having continuous EFM, systematic assessment of above \ndefinitions and classification should be undertaken with every review.\nDuring episodes of abnormal FHR patterns, if woman is lying supine, \nadvise her to adopt the left lateral position",
  "In \nsuch cases inquiry must be made to ascertain if the fetus was \nactive during the recording.  \nWhen women are having continuous EFM, systematic assessment of above \ndefinitions and classification should be undertaken with every review.\nDuring episodes of abnormal FHR patterns, if woman is lying supine, \nadvise her to adopt the left lateral position\n\n--- Page 52 ---\nNational Guideline for Maternal Care - Volume I\n34\nGuideline on Pain Relief in Labour\nAdequate relief of pain is a basic right of every mother in labour. It is the \nduty of every member of the obstetric team to endeavor to achieve this. \nPoor management of pain during labour will result in maternal exhaustion \nleading to:\n• \nacidosis, \n• \ndysfunctional labour and \n• \nfetal distress. \n• \nLoss of morale and a negative birth experience could have \nsignificant long-term effects. \nA well-informed, well supported mother will be more in control of events \nand in a better position to deal with pain than one who is not. Therefore, \nit is important to keep the mother informed of the progress of labour and \nthe condition of the fetus throughout the process. \nReassurance plays a major adjunctive role in pain relief.\nPrenatal education should include information regarding the available \nmethods of pain relief and their accessibility.\nNon pharmacological methods of pain relief such as breathing and \nrelaxation techniques should be introduced during the antenatal period.\nIt is well recognized that women who have a birth companion will tolerate \npain better and require less analgesia. The policy of allowing a birth \ncompanion must therefore be encouraged.\n1.\t\nMethods of pain relief in labour\nThe selection of the method of pain relief should be based on the patient \npreference, availability of resources and the institutional protocols. \nFollowing methods can be used.",
  "The policy of allowing a birth \ncompanion must therefore be encouraged.\n1.\t\nMethods of pain relief in labour\nThe selection of the method of pain relief should be based on the patient \npreference, availability of resources and the institutional protocols. \nFollowing methods can be used.\n\n--- Page 53 ---\nNational Guideline for Maternal Care - Volume I\n35\n1.1 \n Non-pharmacological methods of pain relief\n• \nBreathing techniques, \n• \nTranscutaneous electrical nerve stimulation (TENS), \n• \nMassaging, \n• \nRelaxation techniques, \n• \nPositioning and movement\nAny of these methods can be used to relieve pain during labour\n1.2. \nPharmacological methods of pain relief in labour\n1.2.1. \nOral paracetamol/paracetamol & codeine compound: \nThese oral preparations can be used safely in the latent phase of labour.\n1.2.2. \nOpioids\n1.2.2.A. Pethidine\nPethidine is safe and effective in the latent and early active phase. The dose \nis 1-1.5 mg/kg IM, repeated after 4 – 6 hours. Administration of a third \ndose should be done only with the concurrence of senior personnel. \nIt is generally avoided where delivery is anticipated within 4 hours. \nMaternal side effects include nausea, vomiting and a reduction in gastric \nmotility with a subsequent increase in gastric acidity. Therefore, it should \nbe administered coupled with metoclopramide 5 mg IV or 10 mg  IM.\nNeonatal respiratory depression is a recognized consequence of \nadministration of opioids to the mother. Naloxone, a pure opioid \nantagonist should be available for treatment in all facilities administering \nopioids for analgesia. Naloxone is given to the baby in a dose of 100μg /kg \nIV. It has a short duration of action and additional doses may be required. \nIf no improvement is seen with the first dose of naloxone, the cause of \nneonatal respiratory depression is more likely to be a factor other than \nopioids.",
  "It has a short duration of action and additional doses may be required. \nIf no improvement is seen with the first dose of naloxone, the cause of \nneonatal respiratory depression is more likely to be a factor other than \nopioids.\n\n--- Page 54 ---\nNational Guideline for Maternal Care - Volume I\n36\n1.2.2.B. Morphine \nThis has a longer duration of action than pethidine and may be particularly \nuseful in women who require analgesia in early labour. \nThe dose is 0.15 mg/kg IM should be administered with metoclopramide. \nThe side effects and neonatal effects are similar to those of pethidine.\n1.2.2.C. Fentanyl \nIntravenous fentanyl/ramifentanyl may be administered in either a High \nDependency or Intensive Care Unit settings under the supervision of an \nanaesthesiologist. \nThe dose is 50-100μg per hour as an intravenous infusion.\nPain relief occurs in 3-5 minutes after commencement.\n \n1.2.3. \nInhalational analgesia – Entonox\nEntonox is a 50:50 mixture of nitrous oxide and oxygen and it has a very \nshort half-life. The onset of action is 30sec to one minute. \n \nThe mother should receive clear and definite instructions about its correct \nuse. It should only be self-administered.\nShe should start using entonox through the controlled valve at the very \nbeginning of the contraction. The mother should be advised to stop using \nEntonox inhalation in the contraction free interval.\nLonger and deeper breaths give better result. There is no limit on the \nduration of its use.  \nWomen should be informed that Entonox will make them feel nauseous \nand light-headed.\nEntonox is contraindicated in women with intestinal obstruction, \npneumothorax, middle ear and sinus disease, and following cerebral air-\ncontrast studies.",
  "There is no limit on the \nduration of its use.  \nWomen should be informed that Entonox will make them feel nauseous \nand light-headed.\nEntonox is contraindicated in women with intestinal obstruction, \npneumothorax, middle ear and sinus disease, and following cerebral air-\ncontrast studies.\n\n--- Page 55 ---\nNational Guideline for Maternal Care - Volume I\n37\n1.2.4. Regional Anaesthesia\n \nA.   Epidural analgesia \nEpidural analgesia is the most effective form of pain relief in labour. \nTherefore, Its greater use should be encouraged. \nIt can be given either as a bolus with top-ups or as a continuous infusion. \nContinuous administration via a syringe pump is preferred to ‘top-ups’, \nsince it is safer. \nThe continuous availability of an anesthesiologist is a prerequisite to \noffering epidural analgesia. It is also essential that staff on site is trained for \nits setting up, monitoring and to recognize complications early.  Facilities \nshould be available for emergency resuscitation.\nBefore offering epidural  analgesia, women should be informed its risks \nand benefits and its implications on labour:\n• \nIt provides more effective pain relief than other methods\n• \nIt will not increase the length of the first and the passive second \nstages of labour. \n• \nIt may however increase the length of the expulsive phase \nand increase the likelihood of an instrumental delivery. An \nadditional hour is allowed in the expulsive phase therefore.\n• \nIt does not increase the chance of cesarean section \n• \nIt does not cause long-term backache. \n• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.",
  "An \nadditional hour is allowed in the expulsive phase therefore.\n• \nIt does not increase the chance of cesarean section \n• \nIt does not cause long-term backache. \n• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph\n\n--- Page 58 ---\nNational Guideline for Maternal Care - Volume I\n40",
  "• \nIt needs to be accompanied by a more intensive level of \nmonitoring.\nCare and observations for women with regional analgesia in labour\n• \nIntravenous access should be secured prior to commencing \nregional analgesia.\n• \nFollowing additional observations should be carried out for \nwomen with regional analgesia\n➢ \nDuring establishment of regional analgesia or after top up \nbolus blood pressure should be measured every 5 minutes \nfor 15 minutes.\n\n--- Page 56 ---\nNational Guideline for Maternal Care - Volume I\n38\n➢ \nIf the woman is not pain free within after each \nadministration, the anaesthetist should be called.\n➢ \nHourly assessment of the level of sensory block should be \nundertaken.\n• \nWomen with regional analgesia should be encouraged to move \nand adopt whatever positions they find most comfortable \nthroughout labour.\n• \nOnce established, regional analgesia should be continued \nuntil after completion of the third stage of labour and when \nnecessary until perineal repair is done.\n• \nWomen should be allowed one additional hour in the second \nstage of labor, depending on maternal and foetal condition. \nThereafter pushing during contractions should be actively \nencouraged.\n• \nContinuous EFM is recommended for at least 30 minutes during \nestablishment of regional analgesia and after administration of \neach bolus.\n\n--- Page 57 ---\nNational Guideline for Maternal Care - Volume I\n39\nGuidelines to maintain the partograph\n\n--- Page 58 ---\nNational Guideline for Maternal Care - Volume I\n40\n\n--- Page 59 ---\nNational Guideline for Maternal Care - Volume I\n41\nGuideline on Acute Puerperal Inversion of the Uterus\n1.\t\nIntroduction\nThe aim of this guideline is to provide recommendations for the \nmanagement of acute puerperal inversion of the uterus, which is a rare \nand life threatening condition. The main reason for its high mortality rate \nis delay in instituting appropriate treatment, which leads to postpartum \nhemorrhage and rapid development of shock out of proportion to \nhaemorrhage. \n2.\t\nDefinition\nIt is defined as ‘the turning inside out of the fundus into the uterine cavity’.\n3.\t\nPrevention\nMismanagement of the third stage of labor is recognized as the main \ncause, although 50% have no identifiable cause. The common initiating \nfactor seems to be a traction force on the fundus of a relaxed uterus. \nProper retraction of the uterus in the third stage is the primary factor in \npreventing an inversion. There is no reliable data to suggest that it recurs \nin a future pregnancy.\nThe importance of the active management of the third stage could not be \nover-emphasized. (Please refer Section 3 of the PPH Guideline and the \nsection on management of delayed third stage (section 3.2.3 in the Normal \nLabor Guideline for details) \n4.\t\nPathophysiology (and clinical correlation)\nAs the inversion progresses, the adnexae with their ligaments get drawn \ninto the inverting uterine fundus and become increasingly stretched. This \nproduces significant pain and vagal stimulation, leading to neurogenic \nshock. \nAn inverted uterus becomes trapped within the cervix creating \nprogressive oedema and congestion due to interruption of venous and \nlymphatic drainage. Oedema and congestion will increase the firmness \nof the inverted segment, making reduction more difficult. Interruption",
  "Oedema and congestion will increase the firmness \nof the inverted segment, making reduction more difficult. Interruption\n\n--- Page 60 ---\nNational Guideline for Maternal Care - Volume I\n42\nof the venous drainage will lead to significant haemorrhage. A partially \nseparated placenta would add to this.\n5.\t\nClassification\nAlthough acute, subacute and chronic varieties have been described, this \nguideline would address only the acute variety as it is life threatening. \nThis occurs soon after birth, just before or after the delivery of the placenta.\nThree degrees of inversion have been described, depending on the \nlevel of the inverted fundus. In practice, second-degree inversion is the \ncommonest. The fundus has come past the cervical os, but is still within \nthe vagina.\n6.\t\nClinical Presentation and Diagnosis\nPrompt diagnosis is vital.\nThe key to diagnosis is awareness and a high degree of suspicion.\nThe following are early warnings:\n• \nA degree of shock that is out of proportion to overt blood loss\n• \nA retained placenta\n• \nPlacenta delivered but ‘with some difficulty’\n• \nSevere, sustained unexplained pain in the third stage.\nIn this situation:\n• \nFeel for the fundus. If absent or ‘cupped’, acute inversion is \nprobable diagnosis;\n• \nConfirm by a vaginal examination:\n• \nLook for a hard mass which looks and feels like a huge \nulcerated fibroid polyp (sometimes described as a foetal \nhead); \n• \nThe cervix is not to be seen or felt in the normal position, \ninstead it could be felt as a ring around the base of the \n‘mass’;\n• \nIn incomplete cases, the inverted fundus may be felt \nthrough the cervical canal in the lower uterine cavity.",
  "The fundus has come past the cervical os, but is still within \nthe vagina.\n6.\t\nClinical Presentation and Diagnosis\nPrompt diagnosis is vital.\nThe key to diagnosis is awareness and a high degree of suspicion.\nThe following are early warnings:\n• \nA degree of shock that is out of proportion to overt blood loss\n• \nA retained placenta\n• \nPlacenta delivered but ‘with some difficulty’\n• \nSevere, sustained unexplained pain in the third stage.\nIn this situation:\n• \nFeel for the fundus. If absent or ‘cupped’, acute inversion is \nprobable diagnosis;\n• \nConfirm by a vaginal examination:\n• \nLook for a hard mass which looks and feels like a huge \nulcerated fibroid polyp (sometimes described as a foetal \nhead); \n• \nThe cervix is not to be seen or felt in the normal position, \ninstead it could be felt as a ring around the base of the \n‘mass’;\n• \nIn incomplete cases, the inverted fundus may be felt \nthrough the cervical canal in the lower uterine cavity.\n\n--- Page 61 ---\nNational Guideline for Maternal Care - Volume I\n43\n7.\t\nManagement\n7.1 General measures:\nEarly diagnosis is vital. Treat it as a life-threatening emergency.\nFirst attempts at reduction should be made at the place where it is \ndiagnosed, without moving to theatre.\nIf these attempts fail, move to theatre and give a general anesthetic without \ndelay (see section 7.2.4). \nEarly involvement of experienced personnel and teamwork are absolutely \nessential.\nTreat shock aggressively, not forgetting the neurogenic element.\nProvide adequate pain relief\nReplace the blood loss, which could be considerable, especially if the \nplacenta has partially or completely separated.\nDo not attempt to remove the placenta, if still attached.\n7.2 Repositioning the uterus\nReposition the uterus as soon as possible; the sooner it is done the easier \nand better. It reverses the shock and reduces PPH.\nNon-surgical methods\n7.2.1  Manual replacement of uterus.\n(Johnson’s maneuver)\nThe operator introduces two thirds of his forearm in to the vagina and \nextends the hand at the wrist to place the palm on the inverted fundus and \nfingertips at the utero-cervical junction. Lifting the uterus above the level \nof the umbilicus creates adequate tension for the cervical ring to dilate and \nfor the fundus to revert to its normal position.",
  "It reverses the shock and reduces PPH.\nNon-surgical methods\n7.2.1  Manual replacement of uterus.\n(Johnson’s maneuver)\nThe operator introduces two thirds of his forearm in to the vagina and \nextends the hand at the wrist to place the palm on the inverted fundus and \nfingertips at the utero-cervical junction. Lifting the uterus above the level \nof the umbilicus creates adequate tension for the cervical ring to dilate and \nfor the fundus to revert to its normal position.\n\n--- Page 62 ---\nNational Guideline for Maternal Care - Volume I\n44\nThis could be helped by ‘working the fingers up’ gradually from the cervical \nring towards the fundus, with gentle but persistent pressure applied.\nWhere the uterus is too hard to respond, consider tocolytics (see below).\nOnce reduced, hold the fundus in place for a few minutes (making a fist \ninside the uterus with upward pressure on the fundus helps).\nAdminister uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v \nfollowed by oxytocin infusion at the rate of 10 IU per hour), whilst the \nhand is still inside. When the uterus begins to contract, slowly remove the \nhand. \nThis manouvre is possible only soon after the event, and would need \nadequate analgesia. Unless it is possible to administer either a general \nanesthetic immediately, administer pethidine 50 mg iv slow and proceed \nwith the maneuvres. \nGive antibiotics (e.g. cephradine 1g and metronidazole 500 mg IV).\n7.2.2   Hydrostatc reduction (O’Sullivan 1945)\nSeveral novel and useful modifications have been made to this procedure \nlately, principally to circumvent the problem of inadequate water seal, \nwhich has been the major cause of failure in the past. \nInsert 6 cm silastic ventouse cup into vagina, making sure that it is directed \nat the posterior vaginal fornix and not at, or cupping the fundus. Place \nhand at introitus to maintain seal between cup and vagina.\n(Alternatively 500ml balloon catheter can be placed in vagina. If neither is \navailable, use a wide tube; a standard giving set will not do).\nConnect via IV giving set to a bag of warmed normal saline placed 1- 1.5 \nmetres above the patient.\nInfuse normal saline (typically 2 litres) into vagina to reduce the uterus by \nhydrostatic pressure.",
  "Place \nhand at introitus to maintain seal between cup and vagina.\n(Alternatively 500ml balloon catheter can be placed in vagina. If neither is \navailable, use a wide tube; a standard giving set will not do).\nConnect via IV giving set to a bag of warmed normal saline placed 1- 1.5 \nmetres above the patient.\nInfuse normal saline (typically 2 litres) into vagina to reduce the uterus by \nhydrostatic pressure.\n\n--- Page 63 ---\nNational Guideline for Maternal Care - Volume I\n45\nOnce reduced, remove the placenta if still attached and proceed as in the \nprevious section.\nWhere a balloon is used, it would be advisable to leave it for 12-24 hours \nto prevent re-inversion and reduce haemorrhage. \nSaline embolisation and fluid overload leading to pulmonary oedema are \nonly theoretical risks as long as one sticks to hydrostatic pressure only.\n7.2.3  Tocolytics\nWhere repositioning is difficult due to retraction of the uterine muscle \nand the constriction of the cervical ring, tocolytics could be helpful. But \ngiven this could cause PPH, it would have to be a considered and a senior \ndecision. They are safest given in the theatre setting. \nVarious preparations have been used; ideally it should be readily available, \nwith quick onset and short duration of action. E.g.\nTurbutaline 0 .25mg i.v. slowly (not available in Sri Lanka at present);\nSalbutamol 0.25mg in 10 ml saline i.v. slowly;\nNitroglycerine 0.1mg i.v. slowly or sublingually (acts within 90 seconds)\n7.2.4  General Anaesthesia\nIf the initial attempt at manual replacement fails, it is safest to move the \npatient to the theatre and to administer general anaesthesia. This allows \nfor muscle relaxation, pain relief and elimination of the neurogenic \ncontribution to the shock. \n7.2.5  Surgical methods\nIf managed properly in the early stages, resort to surgery should be a rare \noccurrence.",
  "This allows \nfor muscle relaxation, pain relief and elimination of the neurogenic \ncontribution to the shock. \n7.2.5  Surgical methods\nIf managed properly in the early stages, resort to surgery should be a rare \noccurrence.\n\n--- Page 64 ---\nNational Guideline for Maternal Care - Volume I\n46\nHuntingdon’s operation\nAfter a laparotomy, the indrawn uterine cup is identified near the region \nof the cervix with the tubes and round ligaments pulled into the cup.  By \nthe use of two Allis forceps the uterus is pulled out of the constriction ring \nin a progressive fashion and restored to its normal position. The serosa of \nthe uterus will invariably sustain lacerations and these are repaired with \nabsorbable sutures. \nUse of a silastic vacuum cup from above instead of Allis forceps has been \nshown to circumvent this problem.\nHaultain’s operation\nIn this procedure the constriction in the region of cervix is incised \nposteriorly using a longitudinal incision. As in the Huntingdon’s method \ntwo Allis forceps are used to pull the uterus to its normal position. The \nincision is repaired with interrupted sutures. Uterotonics are given to \nmaintain contraction of the uterus.\nHysterectomy\nWhen all the above methods fail, a hysterectomy will become the only \nviable option. However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.",
  "However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume I\n47\nManagement of \nHypertensive disease \nduring pregnancy\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume I\n48",
  "However, it must be remembered that given the distorted \nanatomy, this must be undertaken by a surgeon of considerable experience. \n8.\t\nDebriefing\nAlthough there is no evidence of a recurrence risk, it is sensible to advise \nthe woman to deliver in a specialized Unit next time, and the third stage \nto be managed actively by experienced personnel.\n\n--- Page 65 ---\nNational Guideline for Maternal Care - Volume I\n47\nManagement of \nHypertensive disease \nduring pregnancy\n\n--- Page 66 ---\nNational Guideline for Maternal Care - Volume I\n48\n\n--- Page 67 ---\nNational Guideline for Maternal Care - Volume I\n49\nManagement of Hypertensive Disease in  Pregnancy\n1.\t\nIntroduction\nHypertension in pregnancy is an important cause of direct maternal deaths \nin Sri Lanka. Early identification, aggressive and intensive treatment of \nits complications is important in reducing the resulting morbidity and \nmortality.\n2.\t\nDefinitions\nChronic Hypertension:\nWomen with pre-existing hypertension or hypertension detected before \n20th week of gestation in the absence of trophoblastic disease and \npersisting more than 42 days post partum. \nGestational Hypertension\nA)   Pregnancy Induced Hypertension:\nHypertension unaccompanied by proteinuria developing after 20 weeks of \ngestation and resolving within 42 days of delivery.\nB)   Pre Eclampsia:\nPregnancy induced hypertension associated with significant proteinuria \n(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\nSevere Preeclampsia:\nDefined as Pre-eclampsia with severe hypertension and/or with symptoms, \nand/or biochemical and/or haematological impairment. \nThe clinical features of severe pre-eclampsia (in addition to hypertension \nand proteinuria) are:",
  "Gestational Hypertension\nA)   Pregnancy Induced Hypertension:\nHypertension unaccompanied by proteinuria developing after 20 weeks of \ngestation and resolving within 42 days of delivery.\nB)   Pre Eclampsia:\nPregnancy induced hypertension associated with significant proteinuria \n(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\nSevere Preeclampsia:\nDefined as Pre-eclampsia with severe hypertension and/or with symptoms, \nand/or biochemical and/or haematological impairment. \nThe clinical features of severe pre-eclampsia (in addition to hypertension \nand proteinuria) are:\n\n--- Page 68 ---\nNational Guideline for Maternal Care - Volume I\n50\n• \nSevere headache\n• \nVisual disturbance such as blurring or flashing before eyes, \nscotomas\n•  Epigastric or hypochondrial pain and/or nausea & vomiting\n•  Clonus (3 beats or more)\n•  Papilloedema\n•  Liver tenderness\n• \nOliguria (less than 400 ml per day or 0.5 mg/Kg/hour over a 4 \nhour period)\n•  Platelet count falling to below 100 x 106/l \n•  Abnormal liver enzymes (ALT or AST rising to above 70IU/l)\n•  HELLP syndrome\nSevere Hypertension:\nDefined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood \npressure ≥110 mmHg. \nEclampsia: \nDefined as the development of convulsions and/or unexplained coma \nduring pregnancy or postpartum in patients with features of preeclampsia.\n3.\t\nScreening for Hypertension during pregnancy\nBlood pressure must be measured in every clinic visit by a Medical Officer \nand results recorded and plotted in the pregnancy record. \nProteinuria must be tested for at every clinic visit.\nIf blood pressure is more than 140/90 mmHg on two occasions at least 2 \nhours apart, refer for specialist care.\n4.\t\nPrevention of hypertensive disorders in pregnancy\nAdvise women at high risk of pre-eclampsia to take 75 mg of aspirin daily \nfrom 12 weeks until delivery of the baby. Women at high risk are:",
  "Proteinuria must be tested for at every clinic visit.\nIf blood pressure is more than 140/90 mmHg on two occasions at least 2 \nhours apart, refer for specialist care.\n4.\t\nPrevention of hypertensive disorders in pregnancy\nAdvise women at high risk of pre-eclampsia to take 75 mg of aspirin daily \nfrom 12 weeks until delivery of the baby. Women at high risk are:\n\n--- Page 69 ---\nNational Guideline for Maternal Care - Volume I\n51\n Those with any one of the following risk factors:\n• \nHypertensive disease during a previous pregnancy\n• \nChronic kidney disease\n• \nAutoimmune disease such as systemic lupus erythematosis or \nantiphospholipid syndrome\n• \nType 1 or type 2 diabetes\n• \nChronic hypertension\n• \nMultiple pregnancy\nOr, any TWO or more of the following \n• \n First pregnancy\n• \nAge 40 years or older\n• \nPregnancy interval of more than 10 years\n• \nBody mass index (BMI) of 35 kg/m² or more at first visit\n• \nFamily history of preeclampsia\nContraindications such as allergy, gastritis, peptic ulcer disease must be \ntaken into account.\nAdvice women who have the above risk factors to ensure a higher intake of \ncalcium to achieve a daily intake of at least 1000 mg taking into account the \naverage intake by Sri Lankan women the recommended supplementation \nlevel is 600 mg. \n5.\t\nManagement of Chronic Hypertension \nWomen with chronic hypertension must be managed in specialist units. \nAnticipate the development of superimposed pre eclampsia in these \nwomen. This combination adds risks to both mother and baby. ACE \ninhibitors should be discontinued in women who are planning pregnancy \nand its use avoided during pregnancy. \nTreatment of mild to moderate hypertension\nSince there is no consensus on the value of treating mild to moderate \nhypertension, this guideline will not address this issue.",
  "ACE \ninhibitors should be discontinued in women who are planning pregnancy \nand its use avoided during pregnancy. \nTreatment of mild to moderate hypertension\nSince there is no consensus on the value of treating mild to moderate \nhypertension, this guideline will not address this issue.\n\n--- Page 70 ---\nNational Guideline for Maternal Care - Volume I\n52\n6.\t\nManagement of Severe Pre-Eclampsia\nThe basic outline of management\n• Admit to hospital and inform Consultant\n• Observe and monitor\n• Control blood pressure\n• Prevent seizures\n• Look for complications – such as HELLP / pulmonary oedema/\ncerebral haemorrhage\n• Strict fluid balance\n• In utero transfer where necessary and safe\n• Timing of Delivery\n• Continue vigilance post delivery\n• Follow up\n6.1. General Considerations\n• \nSevere preeclampsia is a life threatening condition.\n• \nThe only known cure is delivery of the baby.\n• \nThe immediate task is to determine the urgency to effect \ndelivery.\n• \nStabilization of the mother’s condition within an acceptable \ntime frame prevents maternal complications and may improve \nfetal condition.  \n• \nThe management has to be individualized depending on the \nclinical condition and available resources.\n• \nThe dangers will continue into the immediate postpartum \nperiod.\n6.2. Specific Management\nAdmit women who have severe preeclampsia and inform the Consultant.\nTreat hypertension if:\n• \nSystolic blood pressure ≥ 160 mmHg, or if\n• \nDiastolic blood pressure ≥ 110 mmHg, or if\n• \nMean arterial pressure ≥ 125 mmHg,",
  "• \nThe management has to be individualized depending on the \nclinical condition and available resources.\n• \nThe dangers will continue into the immediate postpartum \nperiod.\n6.2. Specific Management\nAdmit women who have severe preeclampsia and inform the Consultant.\nTreat hypertension if:\n• \nSystolic blood pressure ≥ 160 mmHg, or if\n• \nDiastolic blood pressure ≥ 110 mmHg, or if\n• \nMean arterial pressure ≥ 125 mmHg,\n\n--- Page 71 ---\nNational Guideline for Maternal Care - Volume I\n53\nAim to maintain blood pressure at around 130-140/90-100 mmHg.\nThe main cause of maternal death in severe preeclampsia is poorly \ncontrolled systolic hypertension causing cerebral haemorrhage. \nA rapid fall in maternal blood pressure as a result of antihypertensive \ntreatment may cause fetal heart rate abnormalities & compromise, \nespecially in growth restricted/compromised fetuses.\nWhere resources allow, it is recommended to monitor fetal heart with \ncontinuous CTG during and for 60 minutes after commencing anti-\nhypertensive therapy.\nAim to stabilize blood pressure before delivery.\n6.2.1. \nAnti-hypertensive drugs\nOral anti hypertensives may be used when the blood pressure is <180/110 \nmmHg. Blood pressure must be monitored at 15-minute intervals and \nintravenous anti hypertensives resorted to in case of an adequate response \nis not obtained within 30 minutes.\nThe commonly used antihypertensive drugs for acute control are given \nbelow. One or the other may be used depending on availability and \nfamiliarity. \n6.2.1.1 Labetalol orally or intravenously\nThis should be avoided in women with a history of bronchial asthma.\n- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n- repeated hourly for up to 4 hours\n \nor\n- 20 mg IV over two minutes\n• \nRecord blood pressure after 10 minutes.\n• \nIf either value is still above 160 mm Hg systolic and/or 110 \nmmHg diastolic, give 40 mg iv over 2 minutes.\n• \nRecord blood pressure after 10 minutes.",
  "One or the other may be used depending on availability and \nfamiliarity. \n6.2.1.1 Labetalol orally or intravenously\nThis should be avoided in women with a history of bronchial asthma.\n- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n- repeated hourly for up to 4 hours\n \nor\n- 20 mg IV over two minutes\n• \nRecord blood pressure after 10 minutes.\n• \nIf either value is still above 160 mm Hg systolic and/or 110 \nmmHg diastolic, give 40 mg iv over 2 minutes.\n• \nRecord blood pressure after 10 minutes.\n\n--- Page 72 ---\nNational Guideline for Maternal Care - Volume I\n54\n• \nIf the blood pressure is still above 160 mm Hg systolic and/or \n110 mmHg diastolic, give hydralazine 10 mg iv. For instructions \nregarding giving a fluid bolus with i.v. hydralazine, see the next \nsection of this guideline. \n• \nIf the blood pressure is still above 160 mm Hg systolic and/\nor 110 mmHg diastolic, start an IV infusion of labetolol, \nstarting at 40 mg/hour, doubling dose at half hourly intervals \nas required to a maximum of 160 mg/hour. \n• \nWhere these measures fail, the mother must be moved to a \nhigh-dependency area or an intensive care unit.\nIf blood pressure is controlled by the above, continue monitoring the \nblood pressure at 15 minute intervals for 1 hour and at 30 minute intervals \nthereafter. \nAdditional bolus doses as described above may be administered if the \nblood pressure increases above 160 mmHg systolic and/or 110 mmHg \ndiastolic.\n6.2.1.2. Hydralazine intravenously:\n• \n5 - 10 mg IV bolus over 2 minutes.\n• \nThis must be accompanied by a fluid bolus of 5ml/kg of 0.9% \nsodium chloride or ringer lactate solution over 30 min, started \nat the same time as iv hydralazine (this helps vasodilatation & \nprevents drastic hypotension). This should not be used in the \npresence of pulmonary oedema. \n• \nRecord blood pressure at 15 minute intervals.\n• \nRepeat boluses of 5 - 10 mg IV after a 15 minute interval may \nbe given if necessary up to a maximum of 20 mg (the effect of \na single dose can last up to 6 hours).\n• \nIf the response to above doses is inadequate, give labetolol \nbolus doses as described above.\n• \nIf no lasting effect with above boluses, consider an infusion of \nhydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required \n(2-20 mg/hour usually required).",
  "This should not be used in the \npresence of pulmonary oedema. \n• \nRecord blood pressure at 15 minute intervals.\n• \nRepeat boluses of 5 - 10 mg IV after a 15 minute interval may \nbe given if necessary up to a maximum of 20 mg (the effect of \na single dose can last up to 6 hours).\n• \nIf the response to above doses is inadequate, give labetolol \nbolus doses as described above.\n• \nIf no lasting effect with above boluses, consider an infusion of \nhydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required \n(2-20 mg/hour usually required).\n\n--- Page 73 ---\nNational Guideline for Maternal Care - Volume I\n55\n6.2.1.3. Oral Nifedipine\n• \nOral nifedipine may be used where the blood pressure is < \n180/110 mm Hg, in asymptomatic patients.\n• \nGive 10 mg orally.\n• \nRepeat at 20 minute intervals up to a maximum of 40 mg.\n• \nIf there is no response proceed to intravenous labetalol or \nhydralazine.\n6.2.2. \nPrevention of convulsions\n \nMagnesium sulphate\n• \nMagnesium sulphate is the anticonvulsant of choice.\n• \nIt should be given to any woman with features of impending/\nimminent eclampsia (presence of clonus, severe headache, \nvisual disturbances, and dizziness). \n• \nThe loading dose may be given even when the status of renal \nfunction is uncertain, since it is unlikely that toxic levels of \nmagnesium could be reached with this dose alone.\n• \nGive loading dose of 4 G IV over 10 minutes. There are two \nmethods of giving magnesium sulphate intravenously. \no \nDiluted to a total volume of 20 ml with 0.9% sodium \nchloride solution, given via an infusion pump or ‘manually’. \no \nDiluted to a total volume of 80 ml with 0.9% sodium \nchloride solution via a burette\n• \nImmediately after the loading dose, start infusion of 1 G IV per \nhour.  Continue this infusion for at least 24 hours after delivery.\n• \nWhere there are difficulties with intravenous access, magnesium \nsulphate may be administered intramuscularly. Give 5 G deep \nintramuscularly into each buttock with 1 ml of 2% lignocaine \nin the same syringe.  \n• \nIf intramuscular magnesium sulphate is continued as \nmaintenance therapy, give 5G to alternate buttocks 4 hourly, \nwith 1ml of 2% lignocaine in the same syringe.",
  "Give 5 G deep \nintramuscularly into each buttock with 1 ml of 2% lignocaine \nin the same syringe.  \n• \nIf intramuscular magnesium sulphate is continued as \nmaintenance therapy, give 5G to alternate buttocks 4 hourly, \nwith 1ml of 2% lignocaine in the same syringe.\n\n--- Page 74 ---\nNational Guideline for Maternal Care - Volume I\n56\n• \nMonitor the mother to ensure hourly urine output of 30 ml per \nhour, respiratory rate >16/ minute, oxygen saturation >90% \nand presence of patellar reflexes. \n• \nThese should be recorded every 30 minutes.\n• \nShould signs of toxicity appear, the antidote is calcium \ngluconate, 1 G intravenously (10 ml of 10% solution), given \nover 10 minutes. \n• \nMagnesium sulphate may be used safely in women who have \npreviously received nifedipine\n6.2.3. \nFluid Balance\n• \nRestrict total fluid intake to 80 ml per hour.\n• \nAccurate recording of fluid balance is essential.\n• \nSelective colloid expansion may be necessary prior to \npharmacological \nvasodilatation \nto \nprevent \nmaternal \nhypotension and fetal compromise or in oliguria with a low \ncentral venous pressure.\n• \nThe volumes of all drugs administered must be taken into \naccount and appropriate reduction of the volume of crystalloids \nmust be made.\n• \nColloid (e.g. Hetastarch) should be administered only after \ndiscussion with the anaesthetist.\n• \nDiuretics must be restricted to specific instances only e.g. for \nwomen with pulmonary oedema.\n• \nAvoid non-steroidal analgesia until fluid recovery.\n6.2.4. \nIn utero/neonatal transfer:\n• \nIf a Unit does not have access to HDU/ICU or is unable to \ncope with maternal complications, or with maturity of the \nbaby, it may be appropriate to consider antenatal transfer of \nthe mother. \n• \nHowever, maternal safety must not be jeopardised and each \ncase should be considered on its clinical merits.",
  "In utero/neonatal transfer:\n• \nIf a Unit does not have access to HDU/ICU or is unable to \ncope with maternal complications, or with maturity of the \nbaby, it may be appropriate to consider antenatal transfer of \nthe mother. \n• \nHowever, maternal safety must not be jeopardised and each \ncase should be considered on its clinical merits.\n\n--- Page 75 ---\nNational Guideline for Maternal Care - Volume I\n57\n• \nSteps must be taken to bring down blood pressure from very \nhigh levels (e.g. using nifedipine). \n• \nWomen with imminent/impending eclampsia must be \nadministered a loading dose of magnesium (IM or IV) before \ntransfer (see 6.2.2) \n• \nIt is recommended that where possible telephone advice is \nobtained from the relevant specialist unit before transfer.\n• \nThe patient must be accompanied by a member of staff who is \ncapable of dealing with a seizure while the patient in transit. \nThe required drugs and equipment must be made available.  \n• \nFull details of the case, including treatment given should \naccompany the patient.\n \n6.2.5. \nDelivery\n• \nUrgency of delivery depends on the maternal and fetal \nconditions.\n• \nEither caesarean section or induction of labour is appropriate \ndepending on the urgency and favourability of the cervix.\n• \nInstitute adequate pain relief. Severe preeclampsia is not a \ncontraindication for opioid or epidural anaesthesia (see below). \nIt is accepted that epidural anaesthesia helps to bring down the \nblood pressure.\n• \nSpinal or epidural anaesthesia is safe in the presence of a \nplatelet count >80,000/dl.\n• \nMaternal condition should be optimised before delivery. \n• \nIt is inappropriate to deliver an unstable mother for foetal \nreasons.\n• \nErgometrine should not be used during the third stage.\n6.2.6. \nPost-delivery\n• \nMaintain vigilance as a high proportion of eclamptic seizures \noccur after delivery. \n• \nHigh dependency care should be provided as clinically \nindicated.",
  "Post-delivery\n• \nMaintain vigilance as a high proportion of eclamptic seizures \noccur after delivery. \n• \nHigh dependency care should be provided as clinically \nindicated.\n\n--- Page 76 ---\nNational Guideline for Maternal Care - Volume I\n58\n• \nContinue close monitoring, including fluid balance, platelets, \nliver enzymes and creatinine until they have returned to \nnormal values. \n• \nMagnesium sulphate if started should be continued for 24 \nhours after the delivery or after the last fit, whichever is later.\n• \nReview anti-hypertensive medication as indicated. Some may \nneed to continue oral medication for a few weeks. Methyldopa \nis best avoided following delivery because of its tendency to \ncause depression. \n• \nReview magnesium sulphate medication as indicated.\n6.2.7. \nFollow up\n• \nInform Public Health Midwife and/or Medical Officer of \nHealth.\n• \nReview in 2 weeks (instead of 4 weeks) if discharged on \nantihypertensives.\n• \nDepending on the clinical picture, some patients may need:\no \nLong term follow up for blood pressure\no \nHematological investigations for conditions such as anti-\nphospholipid syndrome, thrombophilia \n• \nDebrief the patient. \n• \nAdvice preconceptual counseling & check prior to the next \npregnancy.\n• \nWomen may be advised regarding the risk of developing \nhypertensive disease in a future pregnancy as follows:\no \nRisk of gestational hypertension - 53% (1 in 2)\no \nRisk of preeclampsia – 16% (1 in 6)\no \nRisk of preeclampsia if she had severe hypertension or \nHELLP syndrome or eclampsia or the birth occurred \nbefore 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth \noccurred before 28 weeks gestation.",
  "Follow up\n• \nInform Public Health Midwife and/or Medical Officer of \nHealth.\n• \nReview in 2 weeks (instead of 4 weeks) if discharged on \nantihypertensives.\n• \nDepending on the clinical picture, some patients may need:\no \nLong term follow up for blood pressure\no \nHematological investigations for conditions such as anti-\nphospholipid syndrome, thrombophilia \n• \nDebrief the patient. \n• \nAdvice preconceptual counseling & check prior to the next \npregnancy.\n• \nWomen may be advised regarding the risk of developing \nhypertensive disease in a future pregnancy as follows:\no \nRisk of gestational hypertension - 53% (1 in 2)\no \nRisk of preeclampsia – 16% (1 in 6)\no \nRisk of preeclampsia if she had severe hypertension or \nHELLP syndrome or eclampsia or the birth occurred \nbefore 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth \noccurred before 28 weeks gestation.\n\n--- Page 77 ---\nNational Guideline for Maternal Care - Volume I\n59\nManagement of Eclampsia\n1.\t\nDefinition:\nEclampsia is defined as the development of convulsions and/or \nunexplained coma during pregnancy or postpartum in patients with \nfeatures of preeclampsia.\n2.\t\nDiagnosis:\n• \nHypertension is considered the hallmark for the diagnosis of \neclampsia. However, in 16% of the cases hypertension may be \nabsent.\n• \nEclampsia is usually associated with proteinuria, but this may \nbe absent in 14% of cases.\n• \nClinical features of imminent eclampsia include:\n \nSevere frontal headache, \n \nVisual symptoms (halos, scotomas etc.) \n \nEpigastric or right hypochondrial pain,\n \nLiver tenderness,\n \t\nClonus (3 beats or more) \n3.\t\nTime of onset of eclampsia\nThe onset of eclamptic convulsions can be antepartum, intrapartum, or \npostpartum. \nAntepartum eclampsia \nAlmost all cases (91%) develop eclampsia at or beyond 28 weeks \nPostpartum eclampsia \nAlthough most cases of postpartum eclampsia occur within the first 48 \nhours, some cases develop beyond 48 hours, up to 4 weeks postpartum \n(late postpartum eclampsia). In these cases, an extensive neurological \nevaluation is needed to rule out the presence of other cerebral pathology.",
  "Antepartum eclampsia \nAlmost all cases (91%) develop eclampsia at or beyond 28 weeks \nPostpartum eclampsia \nAlthough most cases of postpartum eclampsia occur within the first 48 \nhours, some cases develop beyond 48 hours, up to 4 weeks postpartum \n(late postpartum eclampsia). In these cases, an extensive neurological \nevaluation is needed to rule out the presence of other cerebral pathology.\n\n--- Page 78 ---\nNational Guideline for Maternal Care - Volume I\n60\n4.\t\nComorbidities \n• \nEclampsia is often complicated by comorbidities (Box 1). \n• \nThese are more common among women who develop eclampsia \nat earlier periods of gestation.\nBox 1.\n• Abruptio placentae \n• Disseminated intravascular coagulopathy  \n• Pulmonary oedema \n• Acute renal failure \n• Aspiration pneumonia \n• HELLP syndrome (Haemolysis, elevated liver enzymes, low \nplatelets)\n5.\t\nPrevention\nAdministration of magnesium sulphate to women with features of \nimpending/imminent eclampsia (presence of clonus, severe headache, \nvisual disturbances, dizziness) is the only known preventive measure.\n6.\t\nManagement\n6.1 General considerations\n6.1.1 The priorities in management are to support respiratory and \ncardiovascular function, prevent injury and further seizures \nand to control hypertension. \n6.1.2 Magnesium sulphate is the anticonvulsant of choice. It must \nbe administered as soon as possible. See section 6.2.2 of the \nsevere preeclampsia guideline for details.\n6.1.3 The bolus dose of magnesium sulphate must be given even \nto women with unknown renal function or oliguria/anuria \nsince this dose is unlikely to elevate magnesium levels to toxic \nranges.",
  "It must \nbe administered as soon as possible. See section 6.2.2 of the \nsevere preeclampsia guideline for details.\n6.1.3 The bolus dose of magnesium sulphate must be given even \nto women with unknown renal function or oliguria/anuria \nsince this dose is unlikely to elevate magnesium levels to toxic \nranges.\n\n--- Page 79 ---\nNational Guideline for Maternal Care - Volume I\n61\n6.1.4 Eclampsia dictates delivery (or induction) once the maternal \ncondition is stabilized, irrespective of the foetal condition or \nmaturity. A decision regarding the mode and time of delivery \nwill require to be made early. \n6.1.5 There is no place for prolongation of the pregnancy in these \nwomen, unless under rare, exceptional circumstances.\n6.1.6 For details on administration of medications and intravenous \nfluids and care of women receiving magnesium sulphate and \nintravenous antihypertensives, refer the guideline on severe \npreeclampsia.\n6.2.  During the seizure – \no \nTurn the patient to a side and support her in that position.\no \nSuck out secretions from the mouth.\no \nAdminister oxygen via a face mask.\no \nMost eclamptic seizures resolve spontaneously.\no \nIt is imprudent to diagnose fetal hypoxia based on fetal \nbradycardia during a seizure. This usually recovers \nspontaneously following the seizure\no \nFetal bradycardia persisting beyond 10 minutes following \nthe seizure should raise suspicion of abruptio placentae.\n6.3. As soon as possible following a seizure\no \nAttempt to establish intravenous access. \no \nObtain blood for full blood count, liver transaminases, \nblood urea, electrolytes and blood for cross-match.\no \nStart magnesium sulphate (intravenous bolus and \ninfusion or intramuscular – details in guideline on severe \npreeclampsia section 6.2.2.). \no \nTreat blood pressure as appropriate. \no \nInsert an indwelling catheter.\no \nMonitor respiratory rate, urine output, reflexes, SpO2. \n(Please refer the guideline on severe preeclampsia for \nfurther details).",
  "o \nInsert an indwelling catheter.\no \nMonitor respiratory rate, urine output, reflexes, SpO2. \n(Please refer the guideline on severe preeclampsia for \nfurther details).\n\n--- Page 80 ---\nNational Guideline for Maternal Care - Volume I\n62\no \nCheck for comorbidities (Box 1). \no \nInform the Consultant and establish a plan of management\n6.4. Management of seizures in women receiving magnesium sulphate\n6.4.1 Women developing a seizure while on magnesium sulphate\no \n10% of women receiving magnesium sulphate will develop \na second seizure.\no \nAdminister magnesium sulphate 2 grams diluted to 10 ml \nwith 0.9% sodium chloride solution over 5 minutes. \no \nIncrease the magnesium sulphate infusion to 2 grams per \nhour with monitoring as above.\n6.4.2 Women developing more than one seizure while on magnesium \nsulphate \no \nCall a Neurology team for advice. If one is not available, \nobtain advice from a medical team.\no \nConsultant must be informed.\no \nInform the anaesthetic team if still not in an intensive care \nsetting. \no \nSecond line anticonvulsants must be considered after \ndiscussing with anaesthetist.\no \nIf the woman develops further seizures, consider moving to \nintensive care for neuromuscular paralysis and ventilation.\no \nThese women will require a full neurological evaluation, \nincluding imaging.\n7.\t\nDelivery\no \nEclampsia is not an indication for caesarean section.\no \nConsider caesarean section in women who are not in \nlabour with a Bishop score below 7.\no \nWomen who are in labour may be allowed to continue to \ndelivery, in the absence of obstetric complications.",
  "If one is not available, \nobtain advice from a medical team.\no \nConsultant must be informed.\no \nInform the anaesthetic team if still not in an intensive care \nsetting. \no \nSecond line anticonvulsants must be considered after \ndiscussing with anaesthetist.\no \nIf the woman develops further seizures, consider moving to \nintensive care for neuromuscular paralysis and ventilation.\no \nThese women will require a full neurological evaluation, \nincluding imaging.\n7.\t\nDelivery\no \nEclampsia is not an indication for caesarean section.\no \nConsider caesarean section in women who are not in \nlabour with a Bishop score below 7.\no \nWomen who are in labour may be allowed to continue to \ndelivery, in the absence of obstetric complications.\n\n--- Page 81 ---\nNational Guideline for Maternal Care - Volume I\n63\no \nLabour may be induced where necessary using either \nprostaglandins or amniotomy and oxytocin infusion. \no \nEpidural or spinal anaesthesia may be administered in \nwomen with platelet counts above 80,000/cu mm. \no \nGeneral anaesthesia is best avoided where possible since it \nincreases the risk of aspiration and failed intubation due to \nairway oedema. It is also associated with marked increases \nin systemic and cerebral pressures during intubation and \nextubation. Women with airway or laryngeal oedema may \nrequire ‘awake intubation’ under fibre optic observation \nwith  facilities available  for immediate tracheostomy. The \nlevel of increase in systemic or cerebral pressures may be \nreduced by pretreatment with labetalol or nitroglycerine \ninjections.\n8.\t\nTransfer of a woman who has had a seizure to another institution\no \nIn case it is required to transfer a woman who has \nhad an eclamptic seizure, this must be done only after \nadministering a bolus of magnesium sulphate. (See section \n6.2.2 of the severe preeclampsia guideline for details). The \npatient should ideally be accompanied by a doctor and \nemergency drugs/equipment (e.g. Ambu bag) must be \navailable.\n9.\t\nPostpartum management\no \nContinue administration of magnesium sulphate and \nmonitoring as described in the guideline on severe \npreeclampsia. \no \nWomen with abnormal renal function, preexisting \nhypertension and abruption placentae (due to use of larger \nthan normal volumes of fluids) are at particularly high \nrisk of pulmonary oedema. They will require appropriate \nmonitoring\no \nAntihypertensive therapy may be changed to oral and \ncontinued .",
  "o \nWomen with abnormal renal function, preexisting \nhypertension and abruption placentae (due to use of larger \nthan normal volumes of fluids) are at particularly high \nrisk of pulmonary oedema. They will require appropriate \nmonitoring\no \nAntihypertensive therapy may be changed to oral and \ncontinued .\n\n--- Page 82 ---\nNational Guideline for Maternal Care - Volume I\n64\n10.\t Counselling \n10.1.  Women should be advised that in a subsequent pregnancy:\no \nThe rate of preeclampsia is approximately 25%.\no \nRate of eclampsia is 2%.\no \nThese rates are substantially higher in women who develop \neclampsia in the second trimester.\no \nTaking high-dose calcium from early pregnancy (600 mg \ndaily) and aspirin (75 mg daily) may reduce this risk.\n10.2. Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.",
  "Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.\n\n--- Page 83 ---\nNational Guideline for Maternal Care - Volume I\n65\nManagement of Diabetes \nduring Pregnancy\n\n--- Page 84 ---\nNational Guideline for Maternal Care - Volume I\n66",
  "Regarding long term risk of hypertension\no \nThere is no increase of risk in women who were \nnormotensive before the pregnancy.\no \nMultigravidae who develop eclampsia may be at high risk.\nAcknowledgement: \nThe following article was used as a resource in developing this guideline: \nBaha M Sibai, Diagnosis, Prevention and Management of Eclampsia. \nObstetrics & Gynecology, 2005; 105 (2): 402 - 410.\n\n--- Page 83 ---\nNational Guideline for Maternal Care - Volume I\n65\nManagement of Diabetes \nduring Pregnancy\n\n--- Page 84 ---\nNational Guideline for Maternal Care - Volume I\n66\n\n--- Page 85 ---\nNational Guideline for Maternal Care - Volume I\n67\nGuideline for screening, diagnosis and management of \ndiabetes in pregnant women\n1.\t\nPurpose\nThe purpose of this guideline is to provide guidance on screening for \ngestational diabetes mellitus (GDM) and the management of pregnancies \ncomplicated pre-gestational (PGDM) and GDM in the Sri Lankan setting. \n2.\t\nScreening\n2.1 Target groups for screening\nBeing South Asian and pregnant places a woman in Sri Lanka at a higher \nrisk for diabetes during pregnancy. Therefore, universal screening, using a \ndiagnostic test is recommended for all Sri Lankan women. \nA. All pregnant women should be screened for diabetes at the \nfirst visit unless they are already known to have Diabetes*. This \nshould be performed as early as possible, preferably before 12 \nweeks, in order to diagnose previously undetected diabetes.\nB. Screening using fasting blood glucose, random blood glucose, \n50g glucose challenge test, HBAIC or urinalysis for reducing \nsubstances is not recommended.\nC. Those who are negative for diabetes at the first visit should be \nscreened for GDM again at 24-28 weeks.\nD. Women who are known diabetics should not undergo further \nscreening or diagnostic tests. They should be commenced \non glycaemic control measures immediately under the \nsupervision of obstetrician or physician.\n*Diagnostic criteria for pre pregnancy diabetes are \nany one of the following\n \nFBS \n \n≥126mg/dl\n \nRBS \n \n>200mg/dl\n \nHbA1c \n \n>6.1%",
  "Women who are known diabetics should not undergo further \nscreening or diagnostic tests. They should be commenced \non glycaemic control measures immediately under the \nsupervision of obstetrician or physician.\n*Diagnostic criteria for pre pregnancy diabetes are \nany one of the following\n \nFBS \n \n≥126mg/dl\n \nRBS \n \n>200mg/dl\n \nHbA1c \n \n>6.1%\n\n--- Page 86 ---\nNational Guideline for Maternal Care - Volume I\n68\n2.2 Recommended tests\nA. One stage, non- fasting 75g OGCT as described by the \nDiabetes in Pregnancy Study Group of India (DIPSI) is \nrecommended for screening at the first visit and at 28 weeks. \nA 2- hour blood glucose of more than 140mg/dl confirms \ngestational diabetes. This is the recommended test for both \nfield and institutional levels.\nOne stage Non- fasting 75 g OGCT\n \nIn this method 75g oral glucose load is given to the woman \nirrespective of the fasting status. Therefore a woman could be \nsubjected to a GTT at any time, without the woman having to \nfast. \n \nA load of 75g of glucose dissolved in 300 ml water is given over \n3-5 minutes. The water may be flavoured with lime juice. \n \n \nThe plasma glucose level is measured after a period of two \nhours. \n(The main advantage of this test is that it would be the best way to \nensure universal screening. The advantages include reduced cost, the \nability to make a diagnosis in one test and the woman not requiring \nto fast for the test. The test has been validated against the WHO and \nHAPO criteria and been found to correlate well with them (3),(4). \nData also shows that glucose levels are not significantly affected by \nthe fasting status and that the non-fasting glucose level effectively \npredicts adverse effects for the mother and baby (5),(6).)\nB. Three-point oral GTT - In the event of an equivocal screening \nresult or when resources permit, the three point OGTT is \nrecommended. For those who undergo three point OGTT the \nfollowing cut off should be used for diagnosis.",
  "Three-point oral GTT - In the event of an equivocal screening \nresult or when resources permit, the three point OGTT is \nrecommended. For those who undergo three point OGTT the \nfollowing cut off should be used for diagnosis.\n\n--- Page 87 ---\nNational Guideline for Maternal Care - Volume I\n69\nThree-point oral GTT\nThis is probably the most accepted diagnostic test in the world \ntoday. \nThe woman should attend for the test having fasted for eight hours \nor more, having had a diet unrestricted in carbohydrates. \nBlood is first drawn for estimation of fasting plasma glucose. \nThe woman is then given a solution of 75 G glucose dissolved in \n300 ml of water to be taken within 10 minutes. Squeezing a lime \ninto this water will make the solution more palatable without \ninterfering with the result. \nBlood is then drawn at 60 and 120 minutes for estimation of \nplasma glucose.\nC. In situations where neither of the above tests is possible, \n(Inability to tolerate glucose or non availability of facilities) \ntwo-stage screening using a 2 hour PPBS is an alternative.  The \ncut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n2 hour Post Prandial Blood Glucose Testing (PPBS)\nAdvice the woman to have normal diet\nThe time of starting the meal needs to be noted. The meal should \nbe completed within 15 minutes.\nThe two-hour cut off is calculated from the time of starting the \nmeal.\nAt the end of two hours blood sample should be tested for blood \nsugar levels using glucometer or other laboratory method.",
  "The \ncut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n2 hour Post Prandial Blood Glucose Testing (PPBS)\nAdvice the woman to have normal diet\nThe time of starting the meal needs to be noted. The meal should \nbe completed within 15 minutes.\nThe two-hour cut off is calculated from the time of starting the \nmeal.\nAt the end of two hours blood sample should be tested for blood \nsugar levels using glucometer or other laboratory method.\n\n--- Page 88 ---\nNational Guideline for Maternal Care - Volume I\n70\n3.\t\nManagement – Women with established Diabetes\n3.1. Pre Pregnancy care\nThe importance of avoiding unplanned pregnancy is an essential \ncomponent of diabetes education for women with diabetes.\nWomen with diabetes who are planning to become pregnant and their \nfamilies should be offered information on how diabetes affects pregnancy \nand how pregnancy affects diabetes.\nDiscuss their plans for pregnancy and reinforce an appropriate \ncontraceptive method. Any type of contraception can be used except for \nwomen BMI > 25kg/m2 where DMPA should not be used. Pregnancy is \ncontraindicated if the woman has proliferative retinopathy, stage 2 or \nabove Chronic kidney Disease or major cardiac disease. \nAll women with diabetes wishing to conceive MUST be encouraged to \nseek specialist advice to ensure satisfactory glycaemic control (HbA1C < \n6.1%) before conception. \nIdeally the decision to embark on pregnancy in known diabetics should be \ndecided on based on her HbA1C .  A value of 6.1 or below would be ideal \nif safely achievable. Women whose levels are above 10% should be strongly \nadvised against conception until good glycaemic control is achieved,  in \nview of higher risk of congenital anomalies. \nStress that good planning and control will help to achieve pregnancy \noutcome to be equivalent to that of a non-diabetic women. They should \nbe informed that establishing good glycaemic control before conception \nand maintaining this  throughout pregnancy will reduce the risk of \nmiscarriage, congenital malformation, still births and neonatal deaths.\nWomen who are using either metformin or insulin for glycaemic control \nshould be advised that these are safe for use during the peri-conception \nperiod and into their pregnancy.\nSelf-testing of blood sugar should be encouraged where ever economically \nfeasible.",
  "Stress that good planning and control will help to achieve pregnancy \noutcome to be equivalent to that of a non-diabetic women. They should \nbe informed that establishing good glycaemic control before conception \nand maintaining this  throughout pregnancy will reduce the risk of \nmiscarriage, congenital malformation, still births and neonatal deaths.\nWomen who are using either metformin or insulin for glycaemic control \nshould be advised that these are safe for use during the peri-conception \nperiod and into their pregnancy.\nSelf-testing of blood sugar should be encouraged where ever economically \nfeasible.\n\n--- Page 89 ---\nNational Guideline for Maternal Care - Volume I\n71\nWomen must be encouraged to achieve a normal weight before becoming \npregnant, especially those with a body mass index above 25 kg/m2. They \nmust receive advice about reducing weight using lifestyle modification. \nKnown diabetics should be assessed for diabetic nephropathy and \nretinopathy before and during pregnancy. (see below)\nStart Folic acid 5 mg daily when trying to conceive.\n3.2.\t Antenatal Care\nAt the first visit \n• \nRefer for specialist care immediately once identified. These \nwomen are best managed with combined inputs from a \nphysician and an obstetrician. \n• \nStart/ continue Folic acid 5 mg daily up-to 12 weeks of \ngestation. Change to 1mg daily from 12 weeks onwards.\n• \nLow dose Aspirin 75mg should be commenced, if there is no \ncontraindication.\n• \nCheck HbA1c (ideally 6.1% or less).\n• \nDating ultrasound scan using either crown rump length or \nhead circumference is recommended.\n• \nWomen with pre-existing diabetes mellitus must be screened \nfor diabetic end-organ damage (retinopathy, nephropathy and \ncardiovascular disease)\n• \nRetinopathy screening is recommended at least twice during \npregnancy (at first contact and at 28 weeks). \n• \nWomen with serum creatinine >120 µmol/litre or 24 hour \nurinary protein excretion exceeding 300mg must be referred \nfor renal specialist’s advice.\n• \nWomen with complicated diabetes should be managed at a \ntertiary care institution by a multidisciplinary team\nAntenatal Appointments\n• \nThese women must be identified as high risk and managed \nalmost entirely by a specialist Obstetrician led team.",
  "Change to 1mg daily from 12 weeks onwards.\n• \nLow dose Aspirin 75mg should be commenced, if there is no \ncontraindication.\n• \nCheck HbA1c (ideally 6.1% or less).\n• \nDating ultrasound scan using either crown rump length or \nhead circumference is recommended.\n• \nWomen with pre-existing diabetes mellitus must be screened \nfor diabetic end-organ damage (retinopathy, nephropathy and \ncardiovascular disease)\n• \nRetinopathy screening is recommended at least twice during \npregnancy (at first contact and at 28 weeks). \n• \nWomen with serum creatinine >120 µmol/litre or 24 hour \nurinary protein excretion exceeding 300mg must be referred \nfor renal specialist’s advice.\n• \nWomen with complicated diabetes should be managed at a \ntertiary care institution by a multidisciplinary team\nAntenatal Appointments\n• \nThese women must be identified as high risk and managed \nalmost entirely by a specialist Obstetrician led team.\n\n--- Page 90 ---\nNational Guideline for Maternal Care - Volume I\n72\n• \nPublic Health Midwife should visit such women once in every \n2 weeks (refer guideline on domiciliary care for high risk \npregnancies).\n• \nReview by the obstetric/diabetic team once every 2 weeks \nthroughout the pregnancy \n• \nAnomaly scans at 18-20 weeks and Obstetric reviews at 22-24, \n28, 32 and 36-37 weeks with ultrasound growth assessments. \n• \nIf required, antenatal steroids for fetal lung maturity may be \nused. Women should be admitted to hospital for glycaemic \ncontrol during therapy since glucose levels rise in response to \nsteroids. \n• \nMore attention should be given to the woman with diabetes \nduring antenatal preparation for breast feeding as they \nneed to start and establish breast feeding quickly to prevent \nhypoglycaemia of newborn. \n• \nRefer to dental surgeon for screening and maintenance of oral \nhygiene.\n3.3.\t Medical nutrition therapy (MNT) \nMNT is the cornerstone of the management of diabetes in pregnancy. \nWomen must be referred to a dietician/ diabetic educator nurse  where \none is available. \nEmphasis the importance of small frequent meals, food with low glycaemic \nindex and the  dietary advice should be culture sensitive. \n3.4.\t Exercise \nExercise has an insulin-like action and women with GDM and pre-existing \ndiabetes complicating pregnancy. Therefore,  diabetic women must be \nencouraged to engage in regular exercise. \nThe intensity of exercise would depend on the woman’s level of fitness, \npresence of complications and familiarity with exercise. \nIdeally this should be at least 30 minutes per day of an activity, which \nleaves her slightly breathless.",
  "The intensity of exercise would depend on the woman’s level of fitness, \npresence of complications and familiarity with exercise. \nIdeally this should be at least 30 minutes per day of an activity, which \nleaves her slightly breathless.\n\n--- Page 91 ---\nNational Guideline for Maternal Care - Volume I\n73\nWomen on insulin must be aware of the  tendency to hypoglycaemia \nduring exercise. \n4.\t\nGlyceamic control and Monitoring \n4.1. Glyceamic Control\n4.1.1. The aim is to achieve optimum glycaemic control throughout the \nday for the duration of the pregnancy (avoiding hypoglycaemia).\nThe target values for glycaemic control are given below:\nTable 1. Target values in glycemic control\n \n  Fasting and pre-meal \n           2 hour post meal\nVenous plasma \n70 - 90 (3.9 – 5.0 mMol/L) \nBelow 120 mg/dl (6.7 mMol/L)\nCapillary blood \n80 – 103 (4.4 – 5.7 mMol/L) \n118 mg/dl (6.5 mMol/L)\n(The equivalent capillary blood values were derived  using a conversion \nformula7)\nRefer to Diabetic Educator Nursing Officer (DENO) where one is available. \nAt diagnosis, offer diet/ lifestyle advice with a recorded glycaemic \nassessment within 1-2 weeks.\nMajority of these women can achieve optimal glycaemia with modest \nchanges in diet and exercise.\nConsider insulin and /or metformin treatment if suboptimal glycaemia \npersists despite diet and exercise modifications. The choice of these \ntreatments will depend on physician and patient preferences. \nIdeally the  insulin regimen should be adjusted to achieve targets: in most \ncases with moderate to severe hyperglycaemia three doses of short acting \npre prandial insulin combined with a single dose of basal insulin at bed \ntime is required. However, twice daily dose of pre mixed 30:70 insulin \nhas high patient compliance with adequate control of blood sugar in most \ncases. If blood sugar is not controlled by this twice daily regimen, adding \nmetformin or soluble insulin to cover lunch is an alternative.",
  "However, twice daily dose of pre mixed 30:70 insulin \nhas high patient compliance with adequate control of blood sugar in most \ncases. If blood sugar is not controlled by this twice daily regimen, adding \nmetformin or soluble insulin to cover lunch is an alternative.\n\n--- Page 92 ---\nNational Guideline for Maternal Care - Volume I\n74\nACE inhibitors, statins and ARBs are contraindicated during pregnancy\n4.2.\t Monitoring of glycaemic control\nSelf-monitoring of blood glucose (SMBG) with close liaison with the \ndiabetic team is recommended for those who are able to afford a glucometer \nand test strips. (However, in view of variable quality of glucometers women \nmust be advised to crosscheck the values occasionally with estimations \nmade by a reliable laboratory. \nFor women who cannot afford the cost of SMBG, monitoring with regular \n6 point blood glucose monitoring should be offered. \nThe frequency of such monitoring should be decided by the overall \nglyceamic control, presence or absence of fetal macrosomia and the period \nof gestation;: with at least four weekly  reviews  in pregnancy two weekly \nreviews  in late pregnancy\nSchedule ultrasound measurement of AC at 28, 32 and 36 weeks. If AC > \n90 centile at any stage, consider insulin therapy to target 2 hour PPBS to \nbe less than 100mg/dl but avoiding hypoglycaemia.\nIf crossing centiles or AC <10 centile, do AFI and request obstetrician \nreview.\nInsulin requirements change throughout the pregnancy. If requirements \nare falling (or maternal hypoglycaemia occurs frequently) request early \nobstetrician review for fetal assessment.\nHbA1c is not a reliable indicator of glycaemic control in the second \nand third trimesters. \n5.\t\nDelivery and intra natal care\n6.1. Timing of delivery\nFor women with pre-pregnancy diabetes or who receive insulin therapy, \nschedule obstetrician review at 36-37 weeks for planning their delivery at \n38-39 weeks.",
  "5.\t\nDelivery and intra natal care\n6.1. Timing of delivery\nFor women with pre-pregnancy diabetes or who receive insulin therapy, \nschedule obstetrician review at 36-37 weeks for planning their delivery at \n38-39 weeks.\n\n--- Page 93 ---\nNational Guideline for Maternal Care - Volume I\n75\nFor women on diet control and/or women having optimal glycaemic \ncontrol and, carrying a normally grown baby, there is insufficient evidence \nto suggest the best time for delivery. \nDiabetes alone is not an indication for a caesarean section.\nThe obstetrician should make the decision after discussing with the \nwoman.\nDelivery should be arranged in the day time, when all supports are more \neasily available.\n5.2. Labour care\nSecond tier obstetric on-call (SHO/Registrar) should be informed of any \nwoman with diabetes at  the onset of labour. He/she should be present \nfor the delivery. It is recommended to involve the medical team in the \nmanagement of difficult cases.\nInform on-call neonatal team of any planned/ imminent delivery of a \ndiabetic mother.\nDuring labour and birth, capillary blood glucose should be monitored \n1-2 hourly in women with diabetes and maintained at between 4 and 7 \nmmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the \npartogram. \nHartmann’s/ normal saline or Insulin-dextrose – potassium (GIK) \ninfusion should be started if the values are lower or higher respectively.\n6.\t\nPost natal care\n6.1a. Neonatal care\nHandover care of newborn, to neonatal team.\nEnsure delivery-to-abdomen and initiate breastfeeding as early as possible \n(within first ½ to 1 hour) unless specific concerns prevent such action.\nTake all suitable ENC measures to avoid hypothermia.",
  "Hartmann’s/ normal saline or Insulin-dextrose – potassium (GIK) \ninfusion should be started if the values are lower or higher respectively.\n6.\t\nPost natal care\n6.1a. Neonatal care\nHandover care of newborn, to neonatal team.\nEnsure delivery-to-abdomen and initiate breastfeeding as early as possible \n(within first ½ to 1 hour) unless specific concerns prevent such action.\nTake all suitable ENC measures to avoid hypothermia.\n\n--- Page 94 ---\nNational Guideline for Maternal Care - Volume I\n76\nBlood glucose testing should be carried out routinely in babies of women \nwith diabetes at 2–4 hours after birth. The mother must be informed about \nthis antenatally to avoid unnecessary distress.\nNeonatal blood glucose values below 36 mg/dl (2 mMol/L) should trigger \naction. \n \nBlood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and \nhypomagnesaemia should be carried out for babies with clinical signs.\n6.1b. Immediate post partum care \nIt is recommended that the mother be tested for RBS within 4 hours of \ndelivery. The decision to manage maternal diabetes with insulin or oral \nmedication should be made within the first 48 hours after delivery and \nprior to discharge from hospital.\nIf the mother received insulin in the antenatal period, it is recommended \nthat the dose needs adjustments to pre pregnant doses in those with type \n2 diabetes mellitus or be maintained on diet alone in those with GDM. \nThis decision should be based on her post partum blood glucose value. If \nFBG exceed 126mg/dl or RBS exceeds 200mg/dl, insulin in a lower dose \n(usually half of the antenatal dose) or metformin would be required. This \ndecision is best left to the managing physician who should be responsible \nfor the woman’s long term care. \n6.2. At hospital discharge\nInform MOH and area public health midwife (PHM) through woman’s \npregnancy record.\nFor women with pre- gestational diabetes, prescribe suitable hypoglycaemic \nagent, restart statins, schedule follow up clinic date at the medical clinic.\nFor women who developed GDM, give a date or make arrangements to \nscreen for DM at 6 weeks postpartum. \nDiscuss and help to decide on the suitable contraceptive method.",
  "At hospital discharge\nInform MOH and area public health midwife (PHM) through woman’s \npregnancy record.\nFor women with pre- gestational diabetes, prescribe suitable hypoglycaemic \nagent, restart statins, schedule follow up clinic date at the medical clinic.\nFor women who developed GDM, give a date or make arrangements to \nscreen for DM at 6 weeks postpartum. \nDiscuss and help to decide on the suitable contraceptive method.\n\n--- Page 95 ---\nNational Guideline for Maternal Care - Volume I\n77\n6.3. Late Postnatal care and follow up\nAt 6 -8 weeks postpartum, all women with GDM are screened for diabetes \nmellitus. The test of screening is ideally the 75g OGTT.  FBS is an alternative \nif resources are limited. Women whose fasting venous plasma glucose is \nabove 100 mg/dl (5.5 mMol/L) must be referred for further evaluation. \nWomen who have been diagnosed with GDM and are screen-negative at \nthe 6 week review should receive lifestyle advice and screening for diabetes \nmellitus annually with at least a FBS. The importance of maintaining a \nnormal BMI and the contribution of breastfeeding to weight loss must be \nemphasized.\n7.\t\nFamily Planning\n8.1 All reliable methods of family planning can be used as \nappropriate for the needs    of the individual woman with \ndiabetes.\n8.2  For women with BMI >25kg/m2, DMPA is best avoided.\n8.3 Women with type 2 diabetes should be advised to complete \ntheir family within  5-10 years   of diagnosis of diabetes in view \nof possible development of complications.\nReferences (need to add the sections taken from NIROGI guide)\n1. \nNICE, clinical guideline 63 Diabetes in pregnancy: management \nof diabetes and its complications from pre-conception to the \npostnatal period. 2008, National Institute for Health and \nClinical Excellence.\n2. \nSeshiah V., Das AK.,BalajiV et al., Gestational Diabetes Mellitus \n- Guidelines. Journal of the Association of Physicians of India. \n2006. 54: 622- 628\n3. \nIADPSGCP, International Association of Diabetes and \nPregnancy Study Groups Recommendations on the Diagnosis \nand Classification of Hyperglycemia in Pregnancy. Diabetes \nCare, 2010. 33(3): p. 676-682.\n4. \nKuhl C. Insulin Secretion and insulin resistance inpregnancy \nand GDM. Implications for diagnosis andmanagement. \nDiabetes 1991;40(December (Suppl. 2)):18–24.",
  "Diabetes 1991;40(December (Suppl. 2)):18–24.\n\n--- Page 96 ---\nNational Guideline for Maternal Care - Volume I\n78\n5. \nGough WW, Shack MJ, Bennett PH, Burch TA, Miller \nM.Evaluation of glucose in the Pima Indians by longitudinal \nstudies. Diabetes 1970;19(Suppl. 1):388.\n6. \nPettitt DJ, Bennett PH, Hanson RL, Narayan KM, KnowlerWC. \nComparison of World Health Organization and National \nDiabetes Data Group procedures to detect abnormalities \nof glucose tolerance during pregnancy. Diabetes Care \n1994;17(November (11)):1264–8.\n7. \nHaeckel R.,  Brinck U, Colic D. et al.,  Comparability of Blood \nGlucose Concentrations Measured in Different Sample Systems \nfor Detecting Glucose Intolerance. Clinical Chemistry 2002. 48: \n(6); 936-939.\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume I\n79\nManagement of \nPostparum Haemorrhage\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume I\n80",
  "Clinical Chemistry 2002. 48: \n(6); 936-939.\n\n--- Page 97 ---\nNational Guideline for Maternal Care - Volume I\n79\nManagement of \nPostparum Haemorrhage\n\n--- Page 98 ---\nNational Guideline for Maternal Care - Volume I\n80\n\n--- Page 99 ---\nNational Guideline for Maternal Care - Volume I\n81\nGuideline on Managementof Primary post Partum \nHaemorrhage\n1.\t\nIntroduction\nThe aim of this guideline is to provide evidence based recommendations \nin the management of primary post partum haemorrhage (PPH). This is \nthe commonest direct cause of maternal death globally and in Sri Lanka. \nThe objective of this guideline is to ensure anticipation, prevention, early \ndetection and timely and appropriate management of PPH. \n2. \t\nDefinition\nFor the purpose of this guideline PPH is defined as blood loss of 500 ml or \nmore from the genital tract within 24 hours of the birth of a baby. Blood \nloss of over 1000 ml is defined as major PPH. \nIrrespective of blood loss, the appearance of cardiovascular instability (i.e. \ntachycardia and hypotension) signifies major obstetric hemorrhage.\n• Since blood volume differs between persons, blood loss must \nbe individualized. \n \nIn general, blood volume = body weight in Kg÷12 (e.g. in a 60 \nkg woman 60/12 = 5 litres)\n• The loss of 40% or more of the blood volume is life threatening \nand will be defined as a massive obstetric hemorrhage e.g. \n2400 ml in a 60 Kg woman.\n3.\t\nPrevention of Post Partum Haemorrhage\nActive management of the third stage of labour is the cornerstone \nof prevention of primary PPH. For details please refer guideline on \nmanagement of third stage of labor.\nAnemia in pregnancy should be corrected during antenatal period.",
  "2400 ml in a 60 Kg woman.\n3.\t\nPrevention of Post Partum Haemorrhage\nActive management of the third stage of labour is the cornerstone \nof prevention of primary PPH. For details please refer guideline on \nmanagement of third stage of labor.\nAnemia in pregnancy should be corrected during antenatal period.\n\n--- Page 100 ---\nNational Guideline for Maternal Care - Volume I\n82\n4.\t\nPrediction of Post Partum Haemorrhage\nPPH occurs most often in women without risk factors. Therefore the \nblood group of every woman who goes into labor must be known.\nHowever, there are known risk factors associated with PPH, as listed in \nBox 1. Such women should be advised to deliver in a specialist obstetric \nunit under extra vigilance. Out of these, abruptio placentae and placenta \npraevia have a particularly higher risk.\nBox 1\nRisk Factors for PPH\nRisks existing prior to labour\nGrand multiparity\nPrevious PPH \nFibroids complicating pregnancy\nAnaemia complicating pregnancy\nPre-existing haemorrhagic conditions \nTreatment with anticoagulants \nObesity \nPre-eclampsia/gestational hypertension\nUterine over distension e.g. multiple pregnancy, etc.\nLarge baby (>4 kg)\nChorio-amnionitis\nDengue infection\nAny woman with risk factors should have intravenous access established \nwith either a 16 or 14-gauge cannula and a sample of blood taken and \npreserved.",
  "Out of these, abruptio placentae and placenta \npraevia have a particularly higher risk.\nBox 1\nRisk Factors for PPH\nRisks existing prior to labour\nGrand multiparity\nPrevious PPH \nFibroids complicating pregnancy\nAnaemia complicating pregnancy\nPre-existing haemorrhagic conditions \nTreatment with anticoagulants \nObesity \nPre-eclampsia/gestational hypertension\nUterine over distension e.g. multiple pregnancy, etc.\nLarge baby (>4 kg)\nChorio-amnionitis\nDengue infection\nAny woman with risk factors should have intravenous access established \nwith either a 16 or 14-gauge cannula and a sample of blood taken and \npreserved.\n\n--- Page 101 ---\nNational Guideline for Maternal Care - Volume I\n83\n5.\t\nManagement of Primary Pph\nIn Sri Lanka, the usual practice has been to commence treatment when \nthere is continuing bleeding despite uterine massage irrespective of the \namount of blood lost. It is recommended that this practice be continued. \nIt is good practice to estimate and record blood loss in all deliveries.\n5.1 General measures\n• \nCall for help.\n• \nMaintain a calm atmosphere.\n• \nKeep the mother (and labor companion/family) informed and \nreassure the mother regularly.\n• \nAssess, monitor and record: general condition, estimated \nblood loss, pulse, blood pressure and respiratory rate (every 15 \nminutes)\n• \nInsert a Foley catheter and monitor urine output hourly. \n• \nCommence an ongoing chronological record of patient’s \ncondition and interventions. It is recommended that one \nmember of staff is delegated specifically for this task and to \ncoordinate with other relevant disciplines.\n• \nEnsure there is intravenous access with two wide (14 – 16 G) \nbore cannulae. \n• \nSend blood for cross matching and baseline full blood count. \nIn cases of massive haemorrahge, other investigations such as \nclotting profile will be needed.\n• \nStart Ringer’s lactate (Hartmann’s) solution.\n• \nIdentify the cause of bleeding. \n• \nKeep the woman warm.\n• \nPay attention to the temperature of labor room, operating \ntheatre, intravenous fluids, blood, blood products and \nfluids used for lavage. Hypothermia is known to promote \ncoagulopathy.\n• \nWhere available, the early involvement of the anesthetic team, \neven while the patient is still in the labor room is recommended.",
  "• \nKeep the woman warm.\n• \nPay attention to the temperature of labor room, operating \ntheatre, intravenous fluids, blood, blood products and \nfluids used for lavage. Hypothermia is known to promote \ncoagulopathy.\n• \nWhere available, the early involvement of the anesthetic team, \neven while the patient is still in the labor room is recommended.\n\n--- Page 102 ---\nNational Guideline for Maternal Care - Volume I\n84\n• \nGive oxygen via a face mask at a minimum rate of 8L/minute \n(where suitable masks are available, oxygen must be given at a \nrate of10-15L/min).\n• \nIf deterioration of the patient is greater than expected for the \nvisible blood loss, internal hemorrhage is the probable cause. \n• \nCheck for completeness of the placenta. If incomplete or in \ndoubt consider exploration of the uterus under anesthesia.\n• \nThe Consultant must be informed in the situations listed in \nBox 2.\nBox 2. Situations in which the Consultant must be informed\n1. Blood loss of >1000 ml\n2. Pulse rate of >100/minute\n3. Systolic blood pressure <100 mm Hg\n4. Drop of systolic blood pressure by 30 mmHg\n5. Increase of pulse rate by >30 beats/minute \n6. Increasing fundal height  \n7. Deterioration of the patient out of proportion to the overt \nblood loss.\n5.2\t Specific measures\n5.2.1 Establish a cause for the bleeding \nPalpate the uterine fundus.\nA poorly contracted uterus usually indicates atonic PPH, which is the \ncommonest cause. However, the possibility of concomitant genital tract \ntrauma needs to be considered. \nIf the uterus is well contracted, the genital tract must be inspected for \ntrauma with adequate exposure, in good light.",
  "However, the possibility of concomitant genital tract \ntrauma needs to be considered. \nIf the uterus is well contracted, the genital tract must be inspected for \ntrauma with adequate exposure, in good light.\n\n--- Page 103 ---\nNational Guideline for Maternal Care - Volume I\n85\n5.2.2. Management of atonic haemorrhage\n• \nStart uterine massage by ‘rubbing up the fundus’.\n• \nClear the cervical canal and vagina of blood clots by vaginal \nexamination.\n• \nAdminister either ergometrine maleate 0.5 mg slow IV or \nmethyl ergometrine 0.2 mg slow IV or oxytocin 5 IU IV and \nstart an infusion of 40 IU in 500 ml of Hartmann’s solution at \n125 ml per hour via an infusion pump.\n• \nStart bimanual compression of uterus.\n• \nIf the bleeding fails to abate completely in 5- 10 minutes \nadminister/repeat ergometrine 0.5mg IV.\n• \nIf the bleeding fails to abate completely in a further 10 minutes \nadminister misoprostol 800µg per rectally or sublingually.\n• \nIf the bleeding fails to abate completely in a further 10 minutes \nproceed to uterine balloon tamponade and inform the \nConsultant. At the same time, administer tranexamic acid 1 \ng by slow IV over 10 minutes. This dose may be repeated after \n30 minutes if necessary and later if bleeding recommences. \nFor details of the method of balloon tamponade please refer \nappendix 1.  \n• \nBalloon tamponade is an important step in managing patients \nwho continue to bleed despite medical measures. It should \nalways be considered before resorting to surgical measures. \n• \nIf the institution does not have personnel trained in the use \nof balloon tamponade, the woman must be transferred to a \nhigher institution, at the point where the administration of \nergometrine and oxytocin infusion has failed to stop bleeding. \n• \nTemporizing measures such as manual aortic compression and \nsand bags to compress the uterus are recommended while the \npatient is in transit.\n• \n Inform the receiving institution.\n• \nAfter the balloon is inserted and the vagina packed (to keep \nthe balloon in the uterus), the woman’s vital parameters and \nthe level of the fundus must be monitored carefully. Where \nthese indicate the woman is continuing to bleed, she should",
  "• \nTemporizing measures such as manual aortic compression and \nsand bags to compress the uterus are recommended while the \npatient is in transit.\n• \n Inform the receiving institution.\n• \nAfter the balloon is inserted and the vagina packed (to keep \nthe balloon in the uterus), the woman’s vital parameters and \nthe level of the fundus must be monitored carefully. Where \nthese indicate the woman is continuing to bleed, she should\n\n--- Page 104 ---\nNational Guideline for Maternal Care - Volume I\n86\nbe moved to the theatre, since the situation would indicate the \nneed for a laparotomy. \n• \nShe should be shifted to the theatre without delay in this \nsituation. \n• \nPrior to laparotomy the woman must be examined under \nanesthesia for tears in the genital tract. \n• \nIn case laparotomy is needed it is best to keep the patient in \nthe modified Lloyd Davis position so that observations for \nbleeding could be done with minimum inconvenience and \ndelay.\n• \nThe surgical measures would depend on the woman’s condition. \n“Too little too late” is the main contributor to mortality in \nPPH. Surgical measures include brace (compression) sutures \n(see appendix 2), uterine de-vascularization (See appendix \n3), haemostatic mattress sutures to bleeding sinusoids, box \nsutures to include the bleeding lower segment in placenta \nprevia, internal iliac ligation and hysterectomy. \n• \nThe “sandwich technique” involves inserting a balloon \ntamponade after the application of brace sutures.\n• \nIt is important that hysterectomy is resorted to sooner than \nlater.\n• \nHypothermia is a particular risk in the theatre environment. \nMeasures must be taken to minimize the loss of heat from the \nwoman. \n5.2.3 Management of traumatic PPH\n• \nExclude high vaginal and cervical tears before suturing \nepisiotomy.\n• \nWhen the apex of the tear or episiotomy is not visible, apply a \nsuture at the highest visible point, pull downwards and apply \ncontinuous sutures at progressively higher points until the \napex is reached. \n• \nExamine for paravaginal and broad ligament haematomata \nwith a combined per vaginal and per rectal examination. \n• \nThe management should be individualized according to the \nsituation.",
  "• \nExamine for paravaginal and broad ligament haematomata \nwith a combined per vaginal and per rectal examination. \n• \nThe management should be individualized according to the \nsituation.\n\n--- Page 105 ---\nNational Guideline for Maternal Care - Volume I\n87\n• \nParavaginal hematomas of more than 5 cm diameter will \nusually require surgical evacuation. A bleeding point is usually \npresent and must be looked for. In cases where it is difficult to \ncontrol bleeding, a Foley catheter with its balloon inflated may \nbe left in the cavity. Packing of the vagina may also be useful. \n• \nCervical tears must be identified by systematic inspection of \nthe cervix using Green-Armytage forceps and sutured. \n• \nIn case of multiple tears with venous oozing, it may be better to \ninsert a balloon catheter into the vagina or to pack the vagina \nwith moistened vaginal packs than to try to suture all the tears. \n5.2.4 Rupture of the uterus\n• \nRupture of the uterus must be suspected when the general \ncondition is deteriorating out of proportion to the visible \nblood loss and there is continuing bleeding in the presence of a \ncontracted uterus.\n• \nThis is particularly so in a woman with a scarred uterus.\n• \nImmediate involvement of a Consultant and surgical \nintervention are important in this situation.\n5.2.5 Coagulopathy causing PPH\n• \nThis could be due to coagulopathy following death in utero, \nabruptio placentae, severe preeclampsia, HELLP syndrome, \nsepsis, amniotic fluid embolism, acute fatty liver, pulmonary \nimmune thrombocytopenia, Von Willebrand’s disease etc. \n• \nIt could also be due to suboptimal management of the PPH. \n• \nEarly involvement of a haematologist or transfusion medicine \nspecialist will be important in this situation. Where available, \nthromboelastometry would be useful in this situation. \n6.\t\nResuscitation and Fluid management\n \nPPH up to 1000 ml\n• \nCommence a crystalloid infusion of 2-3 times the estimated \nblood loss.",
  "Where available, \nthromboelastometry would be useful in this situation. \n6.\t\nResuscitation and Fluid management\n \nPPH up to 1000 ml\n• \nCommence a crystalloid infusion of 2-3 times the estimated \nblood loss.\n\n--- Page 106 ---\nNational Guideline for Maternal Care - Volume I\n88\nPPH of more than 1000 ml\n• \nPPH of over 1000 ml should be managed in consultation with \nother relevant specialists e.g. anesthesiologists, hematologists, \ntransfusion specialists etc. \n• \nAssess airway, breathing and circulation.\n• \nGive oxygen via face mask. \n• \nKeep the woman warm and flat.\n• \nTransfuse warmed blood as soon as possible.\n• \nUntil blood is available, warm crystalloids (up to 2 litres) \nand colloids (up to 1-2 litres) may be transfused as rapidly as \nrequired, up to a maximum of 3.5 litres in total.\n• \nDepending on urgency, group-specific blood may be given \nuntil cross-matched blood is available.\n• \nIf group-specific blood is not available, O Rhesus D negative \nblood could be given.\n• \nBlood transfusion should be individualized according to the \nsituation. When available, involve blood transfusion specialist/\nHaematologist. Where three or more units of blood are being \ntransfused, an equal number of packs of fresh frozen plasma \nmust also be transfused. If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.",
  "If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.\n\n--- Page 107 ---\nNational Guideline for Maternal Care - Volume I\n89\n8.\t\nRisk Management\n• \nIt is good practice to conduct a case review with the members \nof the team involved in the management and other staff as soon \nas possible after the event.\n \n \nThe spirit of such a meeting should be one of lessons learnt rather \nthan of apportioning blame.",
  "If available, thromboelastometry will \nenable factor-specific replacement. \n• \nDue consideration must be given to keeping transport facilities \navailable to obtain blood and blood products from another \ninstitution.\n7.\t\nDebriefing\n• \nIt is possible that a major PPH could result in significant \npsychological morbidity.\n• \nThis could be minimized by timely debriefing of the patient \nand her family, preferably by the Consultant.\n• \nThis should be done immediately after the event, before \ndischarge and at the postnatal visit or at any time as requested \nby her or the family.\n\n--- Page 107 ---\nNational Guideline for Maternal Care - Volume I\n89\n8.\t\nRisk Management\n• \nIt is good practice to conduct a case review with the members \nof the team involved in the management and other staff as soon \nas possible after the event.\n \n \nThe spirit of such a meeting should be one of lessons learnt rather \nthan of apportioning blame.\n\n--- Page 108 ---\nNational Guideline for Maternal Care - Volume I\n90\nAppendix 1\nInsertion of a ‘condom catheter’\nThis may be performed as an independent procedure or following \ninspection of the cervix and upper vagina for trauma.\nTherefore, whenever it is planned to inspect the cervix, or where there is \nan indication that medical therapy may fail to bring the bleeding under \ncontrol, keep the materials needed for insertion of a condom catheter \nready.\n1. Explain to the mother the need to insert a condom catheter \nand explain the procedure briefly. Be reassuring.\n2. Wear a pair of sterile gloves.\n3. The required items are:\n• \nSize 20 – 22 (or largest available) Foley catheter, \n• \nA condom, \n• \nSterile  No. 0 or 1 suture, \n• \nA bottle of warmed saline,\n• \nIntravenous infusion set released from the pack \n• \nArrange these items on a sterile towel laid on a side trolley.\n4. Take the Foley catheter out of the packing.\n5. Unfold the condom over the end of the Foley catheter to about \ntwo thirds of its length. Hand tie it to the catheter firmly, using \nseveral rounds of sterile suture at a point about 2 cm distal to \nthe open end of the condom. \n6. Have an assistant connect the infusion set to the bottle of \nwarmed normal saline suspended 4-6 feet above the patient.\n7. Connect the other end to the catheter, run saline into the \ncondom to make sure the system is water tight by holding the \ncatheter tip upwards.\n8. Afterwards, empty the balloon of the saline and leave it on the \nsterile trolley, ready for insertion.\n9. Wash the condom with either warm saline or 5% povidone \niodine lotion.",
  "Afterwards, empty the balloon of the saline and leave it on the \nsterile trolley, ready for insertion.\n9. Wash the condom with either warm saline or 5% povidone \niodine lotion.\n\n--- Page 109 ---\nNational Guideline for Maternal Care - Volume I\n91\n10. Place the woman either in the dorsal or lithotomy position and \nexpose the cervix by using one or two Sim’s speculae.\n11. Grasp the anterior lip of the cervix with a sponge holder.\n12. Now insert the entire condom catheter system into the uterus. \nYou may keep the condom catheter between the index and \nmiddle fingers and introduce it like exploring the uterus (or \ndoing a pelvic examination). \n13. Reconnect the catheter to a giving set and start filling the \ncondom with warmed saline.\n14. Keep watching the cervix for the balloon to bulge out of it and \nstop filling it any further for now. You may notice cessation of \nbleeding from the uterine cavity. \n15. At this point pack the vagina with a moist vaginal pack (Two \ninch ribbon gauze pack or a gauze towel) around the catheter \nin a circumferential manner. \n16. Continue filling till the gravity aided filling stops. Usually 400 \n– 500 ml is needed.\n17. Proximal end of the catheter is folded and a tight tie placed on \nit to prevent backflow.\n18.  Insert a size 12 Foley catheter to the bladder.\n19. Mark the level of the fundus on the abdomen with a marker \npen. Start a pulse and blood pressure chart.\n20. Give tranexamic acid 1 G slow i.v. and repeat after 8 hours.\n21. Keep pack and the condom catheter for 12 – 18 hours.\n22. Consider appropriate antibiotic prophylaxis.\n23. If there is no vaginal bleeding and vital signs are stable, plan to \nremove the catheter at a convenient time, after 12 hours.\n24. Release half the instilled volume of saline. Do not remove the \npack at this stage.\n25. Observe for bleeding through the pack.\n26. 30 minutes later remove the vaginal pack, without removing \nthe condom catheter.\n27. If there is no further bleeding for another 30 minutes, release \nthe total volume of instilled saline and remove the condom \ncatheter gently.",
  "30 minutes later remove the vaginal pack, without removing \nthe condom catheter.\n27. If there is no further bleeding for another 30 minutes, release \nthe total volume of instilled saline and remove the condom \ncatheter gently.\n\n--- Page 110 ---\nNational Guideline for Maternal Care - Volume I\n92\nAppendix 2\nBrace sutures, the best known of which is the modified B-Lynch sutures \nare very useful in the presence of a bleeding atonic uterus.\nThe uterus is exteriorized.  An absorbable No. 2 suture (or highest gauge \navailable) on a curved ‘hand-needle’ is passed anteroposteriorly through \nthe uterus above the reflection of the bladder about 2 cm medial to the \nlateral edge. \nThe process is repeated on the contralateral side. The sutures are tied \ntightly over the fundus, with an assistant manually squeezing the uterus. \nAdditional sutures may be applied medially.\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume I\n93",
  "The sutures are tied \ntightly over the fundus, with an assistant manually squeezing the uterus. \nAdditional sutures may be applied medially.\n\n--- Page 111 ---\nNational Guideline for Maternal Care - Volume I\n93\n\n--- Page 112 ---\nNational Guideline for Maternal Care - Volume I\n94\nAppendix 3\nSteps of uterine de-vascularization technique\n \n(Adapted from: Salah A. AbdRabbo.Stepwise uterine devascularization: \nA novel technique for management of uncontrollable postpartum \nhemorrhage with preservation of the uterus AJOG 1994 Volume 171 \nNumber 3)\nStep 1: Bilateral uterine vessel ligation\nIn this step the uterine arteries are ligated at the level where they run along \nthe uterine border beside the upper part of the lower uterine segment (Fig. \n1 Note: Steps I and II in the diagram constitute step 1 in our description. \nWe recommend that both sides are done in one step.).\nFig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3 \n(lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine \nsegment.",
  "We recommend that both sides are done in one step.).\nFig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3 \n(lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine \nsegment.\n\n--- Page 113 ---\nNational Guideline for Maternal Care - Volume I\n95\nWith the surgeon on the right side of the patient, the uterus is grasped and \nelevated to the contralateral side. A large needle (48 mm or greater) with \nnumber 1 absorbable suture is passed through the avascular area of the \nleft broad ligament from anterior to posterior and then brought forward, \nguided by the four fingers of the left hand, through the myometrium from \nposterior to anterior 2 cm medial to the left uterine vessels, and the suture \nis tied.\nThis process is repeated on the contralateral side.\nIn these two steps there is no need for bladder mobilization, because the \nsutures were not placed low. Also, there is no need for a peritoneal incision \nin cases having vaginal deliveries; however, in cases having caesarean \nsection the suture should be placed below the level of the transverse \nuterine incision, under the reflected peritoneal flap.\nStep 2: Low bilateral uterine vessel ligation\nThis step is reserved only for cases having continued lower uterine segment \nhaemorrhage diagnosed at caesarean section and not controlled by step 1.\nIn this step the bladder is reflected downwards and lower bilateral uterine \nvessel ligation is performed at the lower part of the lower uterine segment, \n3 to 5 cm below the upper ligatures, with the same technique in step 1. At \nthis level the uterine artery is ligated after its cervicovaginal branch turns \nabruptly upward to extend along the uterine margin. This ligature would \nobliterate most of the branches of the uterine artery to the lower uterine \nsegment and a branch of considerable size that extends to the upper \nportion of the cervix. It is important to include a significant amount of \nmyometrium to avoid damage to the uterine vessels and to obliterate some \nof the intramyometrial ascending arterial branches of the cervicovaginal \nartery (Fig. 1).",
  "It is important to include a significant amount of \nmyometrium to avoid damage to the uterine vessels and to obliterate some \nof the intramyometrial ascending arterial branches of the cervicovaginal \nartery (Fig. 1).\n\n--- Page 114 ---\nNational Guideline for Maternal Care - Volume I\n96\nStep 3: Ligation of uterine/ovarian arterial anastomosis\nThis step is indicated in continued uterine bleeding in spite of performing \nstep 1.The uterus is grasped and pulled to the contralateral side by the \nleft hand, and a large needle with a number 1 absorbable suture is passed \nthrough the avascular area in the broad ligament from anterior to posterior, \nat the level of the ovarian ligament. The needle is then passed anteriorly 2 \ncm medial to the edge of the uterine wall, to include the uterine muscle. \nThe suture is tied anteriorly.\n\n--- Page 115 ---\nNational Guideline for Maternal Care - Volume I\n97\n\n--- Page 116 ---\nNational Guideline for Maternal Care - Volume I\n98",
  "--- Page 1 ---\nSLCOG \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nPlease cite this paper as: De Silva PHP et al, on behalf of Sri Lanka College of Obstetricians and \nGynaecologists. Hypertensive disorders of pregnancy \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n  \nSri Lanka College of Obstetricians and Gynaecologists                       \nHypertensive disorders of pregnancy \nGuideline No: 02 \nMarch 2022 \nSri Lanka Journal of Obstetrics and Gynaecology",
  "--- Page 1 ---\nSLCOG \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nPlease cite this paper as: De Silva PHP et al, on behalf of Sri Lanka College of Obstetricians and \nGynaecologists. Hypertensive disorders of pregnancy \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n  \nSri Lanka College of Obstetricians and Gynaecologists                       \nHypertensive disorders of pregnancy \nGuideline No: 02 \nMarch 2022 \nSri Lanka Journal of Obstetrics and Gynaecology\n\n--- Page 2 ---\n65\nVol. 44, No. 1, March 2022\nSLCOG Guideline\nHypertensive disorders of pregnancy\nP H P De Silvaa, S Lanerolleb, S H Dodampahalac, R Silvad, C Mathotae on behalf of the Sri Lanka\nCollege of Obstetricians and Gynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2022; 44: 65-73\nSLCOG Guideline\nBackground\nHypertensive disorders of pregnancy (HDP) as a\ngroup, is one of the leading causes of both maternal\nand foetal perinatal mortality/morbidity and resultant\nlong term-disability. It accounts for approximately 14%\nof all maternal deaths globally1.\nHypertensive disorders of pregnancy broadly define a\ngroup of conditions closely associated with high blood\npressure, proteinuria and/or seizures during pregnancy.\nEclampsia is usually a consequence of pre-eclampsia\nconsisting of central nervous system seizures which\noften leave the patient unconscious. If untreated, it\ncan subsequently lead to death.\nThe serious consequences of such pre-eclampsia and\neclampsia are associated with vasospasm, pathologic\nvascular lesions in multiple organ systems, increased\nplatelet activation and subsequent activation of the\ncoagulation cascade in the microvasculature2.\nIn Sri Lanka, hypertensive disease has remained among\nthe top five causes of maternal mortality for the last\ntwo decades3. While it has trended down in its\nsignificance as one of the top causes of maternal\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v44i1.8046\nmortality, there is an inconsistent downward trend.\nMaternal hypertensive disease has reached the level of\nthe top second cause of maternal mortality as recently\nas 2009 followed by a clearly observed down-trend\nuntil 2019, finally posting a fourth-highest cause of\nmaternal mortality in Sri Lanka3.\nPreeclampsia complicates an approximate 2-8% of\npregnancies world-wide. Even in resource-high\ncountries, there has been an observed increase in the\nmaternal deaths that can be attributed to hypertensive\ndisorders2.\nHypertensive disease is one of the causes that could\nbe significantly modified to decrease its negative impact\non maternal and neonatal health. This guideline is\ndeveloped to aid in the dissemination of information\nwith this objective in mind.\nPathophysiology\nDuring an average pregnancy blood pressure generally\nfalls by a detectable level in the first trimester and\nusually reaches a lowest level in the second trimester.\nIt then rises back up to preconception pressure levels\nat term gestation.\na Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nb Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka\nc Professor in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology,\nUniversity of Colombo, Sri Lanka\nd Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\ne Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka",
  "Even in resource-high\ncountries, there has been an observed increase in the\nmaternal deaths that can be attributed to hypertensive\ndisorders2.\nHypertensive disease is one of the causes that could\nbe significantly modified to decrease its negative impact\non maternal and neonatal health. This guideline is\ndeveloped to aid in the dissemination of information\nwith this objective in mind.\nPathophysiology\nDuring an average pregnancy blood pressure generally\nfalls by a detectable level in the first trimester and\nusually reaches a lowest level in the second trimester.\nIt then rises back up to preconception pressure levels\nat term gestation.\na Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\nb Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka\nc Professor in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology,\nUniversity of Colombo, Sri Lanka\nd Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\ne Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n\n--- Page 3 ---\n66\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nHypertensive disorders of pregnancy are classified\nby SLCOG as\n1. Preeclampsia – Pregnancy specific disorder with\nHypertension cured following the delivery of the\nconceptus.\n2. Chronic hypertension  –  Hypertension pre-existing\nthe pregnancy due to various causes.\n3. Preeclampsia – Superimposed on chronic\nhypertension.\n4. Hypertension discovered for the first-time during\npregnancy without clinical criteria necessary for\nthe diagnosis of preeclampsia – May or may not\ndisappear after delivery.\n5. Supra-physiological hypertension – Exaggerated\nphysiological response in the latter part of the\npregnancy in the presence of multiple pregnancies\nwithout other symptoms or signs of preeclampsia.\nHypertension is defined in pregnancy as systolic blood\npressure greater than or equal to 140mmhg or a diastolic\nblood pressure of greater than or equal to 90mmHg or\nmore, or both, on two occasions at least 4 hours apart\nafter 20th weeks of gestation, in seated or left lateral\nposition with at least ten minutes rest before the\nmeasurement was taken.\nIn a woman with a previously normal blood pressure,\nhypertension is considered to be severe when the\nsystolic level reaches 160mmHg or the diastolic level\nreaches 110mmHg with a mean arterial pressure of\nmore than 130mmHg even on one occasion.\nPreeclampsia is defined as hypertension found for\nthe first time during current pregnancy with significant\nproteinuria (300mg per 24 hours or urine Protein/\nCreatinine ratio of 30 mg/mmol or more)7. If urine\nalbumin to creatinine ratio is considered an alternative\nfor the diagnosis of significant proteinuria, the cut-off\nvalue of 8mg /mmol is taken as the value for con-\nsideration7.\nIt is not essential to have significant proteinuria for the\ndiagnosis of preeclampsia (although it is the most\ncommonly used supportive evidence for preeclampsia\nin the presence of significant hypertension).  However,\nthe absence of significant proteinuria, other parameters\nas given below with preeclampsia-specific organ\ninvolvement could use for the diagnosis of Preec-\nlampsia. They are;\n•\nPlatelet count (Less than 100 × 109 /l )\n•\nLiver profile (Elevation of liver transaminases twice\nthe normal value)\n•\nRenal insufficiency (creatinine more than 1.1 mg/\ndl or doubling of serum creatinine concentration\nobserved in the absence of other renal disease)\n•\nExaggerated neurological reflexes\n•\nPulmonary oedema\n•\nFoetal indicators: Such as growth retardation,\nreduction in liquor volume, CTG and doppler\nwaveform-abnormalities are allowed to be used for\nthe diagnosis of preeclampsia7.\nIt is the clinical experience that after making the\ndiagnosis of preeclampsia without proteinuria, most if\nnot all patients subsequently develop proteinuria during\nthe time taken for management of such pregnancies.\nLonger the time given, more developed the proteinuria.\nIn a case of preeclampsia, the aim is to control blood\npressure values at about 140/90mmHg as further\nreduction has not shown to improve maternal or foetal\noutcome in preeclampsia.\nAs in any medical condition, identifying risk categories\nfor development of preeclampsia and taking actions to\nprevent the onset or worsening of the disease is of\ngreat importance.\nThe major risk factors for preeclampsia are;\n1. Preeclampsia in first pregnancy\n2. Pre-existing renal disease\n3. Autoimmune conditions such as APLS and SLE\n4. Diabetes mellitus\n5. Pre-existing hypertension\nAny of the above factors are considered to be major\nindicators for the risk. Therefore, instituting antiplatelet\ntherapy in the form of 75-150mg of aspirin is\nrecommended8.\nUndermentioned factors are considered lesser risk\nfactors for occurrence of preeclampsia.\nIn the presence of more than one such condition, it is\nadvisable to start antiplatelet treatment in the form of\n75-150 mg of aspirin from early second trimester until\nthe birth of the baby.",
  "Pre-existing hypertension\nAny of the above factors are considered to be major\nindicators for the risk. Therefore, instituting antiplatelet\ntherapy in the form of 75-150mg of aspirin is\nrecommended8.\nUndermentioned factors are considered lesser risk\nfactors for occurrence of preeclampsia.\nIn the presence of more than one such condition, it is\nadvisable to start antiplatelet treatment in the form of\n75-150 mg of aspirin from early second trimester until\nthe birth of the baby.\n\n--- Page 4 ---\n67\nVol. 44, No. 1, March 2022\nSLCOG Guideline\n1. First pregnancy age 35 years old\n2. Pregnancy with an interval more than 10 years\n3. BMI more than 35 kg/m2 or more at first visit\n4. Family history of preeclampsia\n5. Multiple pregnancies\nIt is said that prophylactic aspirin therapy for above\nrisk categories are preventive of preterm preeclampsia\nwhen aspirin is started between 12 and 20 weeks of\ngestation optimally before 16 weeks of gestation but it\nhas not shown to reduce term-preeclampsia6,7. Although\nthere is some evidence for early calcium supple-\nmentation in pregnancy with a favorable effect on\npreeclampsia, there are no accepted guidance for such\nby other recognized colleges and bodies6,7.\nIt is recommended that achieving better control of pre-\nexisting hypertension prior to planned pregnancy is\nbeneficial. This has proven value in literature7. There\nare no recommendations for salt restriction to prevent\npreeclampsia or hypertension in pregnancy6.\nControl of blood pressure before\npregnancy\nIt is recommended that any woman contemplating\npregnancy, if possible, to have a preconception-health\ncheck, including the measurement of blood pressure.\nThis is more important when the maternal age is\nadvanced (more than 35 years), history of renal disease,\nrelevant medical disorders or with family history of\nearly onset hypertensive disorders. If hypertension is\nobserved, taking steps to control it is recommended\nas well as looking for any underlying pathology.\nIf essential hypertension or anything else is diagnosed,\nmanagement should be aimed at controlling the blood\npressure to equal to less than 140/90, using anti-\nhypertensives considered safe in pregnancy. Any\nwoman with the possibility of being pregnant planned\nor otherwise, should avoid ACE Inhibitors or AR\nBlockers.\nIf a woman gets pregnant while on ACE inhibitors or\nARBs, take steps to stop such medications immediately\nand offer suitable alternatives. Hydrochlorothiazide is\nnot recommended for this category of women as it\nhas shown increased risk of congenital abnormalities\nand complications of the neonate when the drug is\nused in pregnancy.\nAs in any case of medically important high blood\npressure management, weight management, exercise,\nmodification of life-style leading to a stress-free life-\nstyle with sufficient rest, is advocated in hypertension\nin pregnancy.\nWhen drug therapy is considered, the following drugs\nare proven for their efficacy and for their safety profile\nfor the foetus. There are two categories of drugs. First\nused for long term control of blood pressure and the\nsecond group of drugs are used for rapidly lowering\nof blood pressure.\nElevations of both systolic and diastolic blood pressures\nare associated with negative maternal and foetal\noutcomes1.\nControl of blood pressure during\nPregnancy\nOnce blood pressure elevation is diagnosed during\npregnancy be it pre-existing hypertension or preec-\nlampsia, the drugs used are not different. However,\nsubcategories of safe medications, if taken by the\npatient prior to the pregnancy, need not change if that\nis safe in pregnancy (eg. metoprolol, verapamil, sotalol,\ncarvedilol etc.)\nTwo types of medications are used for treatment of\nHypertension in pregnancy:\n1. Long-term control of blood pressure\n2. Rapid lowering of blood pressure.\nDrugs used for long term control of blood\npressure\nTaking the availability, cost and side effects of the drugs\navailable in Sri Lanka, the drug of choice for control\nof blood pressure in pregnancy is oral nifedipine slow\nrelease tablets followed by methyldopa and labetalol6.\nRegarding pharmacotherapy for rapidly lowering of\nblood pressure in preeclampsia, use of hydralazine IV\nand labetalol IV or oral nifedipine is discussed in our\nprevious guidance10.\nLabetalol IV is very scarce in Sri Lanka. However, it is\nto be considered the drug of choice in the absence of\ncontraindications, for use in the presence of tachy-\ncardia as a manifestation of preeclampsia. IV hydra-\nlazine could make the condition of tachycardia worse.",
  "However, it is\nto be considered the drug of choice in the absence of\ncontraindications, for use in the presence of tachy-\ncardia as a manifestation of preeclampsia. IV hydra-\nlazine could make the condition of tachycardia worse.\n\n--- Page 5 ---\n68\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nNifedipine used in rapidly controlling blood pressure\nis quick-release nifedipine which is not commonly\navailable in Sri Lanka.\nDrug – Mechanism\nDose\nContraindications\nNotes\nof action\nMethyldopa –\n250-750 mg\nDepression\nSlow onset of action\nCentrally acting\nthree times a day\nover 24 hours\ndry mouth\nsedation\ndepression\nblurred vision\nWithdrawal: rebound\nhypertension\nLabetolol – Beta blocker\n100-400 mg\nAsthma\nBradycardia\nwith mild alpha\nevery 8 hours\nChronic airways\nBronchospasm\nvasodilator effect\nlimitation (COPD)\nHeadache\nNausea\nScalp tingling\n (labetolol oly)\nwhich usually resolves\nwithin 24 hours\nNifedipine – Calcium\n20-60 mg\nAortic stenosis\nSevere headache in first\nchannel antagonist\nslow release\n24 hours\ntwice a day\nFlushing\nTachycardia\nPeripheral oedema\nConstipation\nHydralazine – Vasodilator\n25-50 mg\nFlushing\nevery 8 hours\nHeadache\nNausea\nLupus-like syndrome\nCochrane review on all three drugs recently showed\nno difference between the efficacy12,13.\nTable 1. Outline of drugs commonly used in control of hypertension14",
  "IV hydra-\nlazine could make the condition of tachycardia worse.\n\n--- Page 5 ---\n68\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nNifedipine used in rapidly controlling blood pressure\nis quick-release nifedipine which is not commonly\navailable in Sri Lanka.\nDrug – Mechanism\nDose\nContraindications\nNotes\nof action\nMethyldopa –\n250-750 mg\nDepression\nSlow onset of action\nCentrally acting\nthree times a day\nover 24 hours\ndry mouth\nsedation\ndepression\nblurred vision\nWithdrawal: rebound\nhypertension\nLabetolol – Beta blocker\n100-400 mg\nAsthma\nBradycardia\nwith mild alpha\nevery 8 hours\nChronic airways\nBronchospasm\nvasodilator effect\nlimitation (COPD)\nHeadache\nNausea\nScalp tingling\n (labetolol oly)\nwhich usually resolves\nwithin 24 hours\nNifedipine – Calcium\n20-60 mg\nAortic stenosis\nSevere headache in first\nchannel antagonist\nslow release\n24 hours\ntwice a day\nFlushing\nTachycardia\nPeripheral oedema\nConstipation\nHydralazine – Vasodilator\n25-50 mg\nFlushing\nevery 8 hours\nHeadache\nNausea\nLupus-like syndrome\nCochrane review on all three drugs recently showed\nno difference between the efficacy12,13.\nTable 1. Outline of drugs commonly used in control of hypertension14\n\n--- Page 6 ---\n69\nVol. 44, No. 1, March 2022\nSLCOG Guideline\nManagement of hypertension detected for\nthe first time in pregnancy\nMild to moderate hypertension\nIt is advised to check blood pressure in seated or left\nlateral position with an appropriate blood pressure cuff,\nwith an accurate mechanical or mercury sphyg-\nmomanometer, four hours apart for the confirmation\nof the diagnosis.\nOnce the diagnosis is confirmed of hypertension, basic\npreeclampsia screening should be carried on.\nThis includes\n• Urine Full Report\n• Urine Culture and Antibiotic Sensitivity Test\n• Urine Protein Quantification\n• Full Blood Count\n• Blood Picture\n• Serum Creatinine\n• Liver Profile\n• PT/INR is indicated only when other investigations\nare showing liver involvement\nUric acid is not usually tested. Though some suggest\npredictive value of uric acid level interpreted in relation\nto the gestation to correlate better with adverse\nevents14,15.\nIt is mandatory to check for foetal wellbeing with\nultrasound scanning with emphasis on foetal biophysical\nprofile, foetal doppler parameters and growth para-\nmeters. Further monitoring of foetus with a cardio-\ntocographic tracing is essential. These would give an\nassessment of possible foetal effects of preeclampsia.\nIn some cases foetal effects maybe the most significant\nfinding other than the presence of hypertension.\nAim of management is to achieve maximum possible\nmaturity of the foetus with no reasonable threat to the\nmother and the foetus. When the gestation is less than\n34 weeks, the opinion is that it is unlikely to be\nfavourable for achieving vaginal delivery though there\nare no contraindications for vaginal delivery because\nof the condition preeclampsia per se.\nIn the presence of hypertension, be it preeclampsia or\nnot, delivery should be aimed at the completion of the\n37th week of pregnancy. From the first time of detection\nof hypertension, until completion of 37 weeks of\ngestation, all patient’s clinical characteristics need to\nbe considered in deciding the time of delivery. This\nincludes available infrastructure facilities of neonatal\ncare, availability of the theater and available manpower\nresources.\nIn the absence of proteinuria and derangement of other\nabove mentioned laboratory parameters identified as\nindicators of preeclampsia before the 35th week of\npregnancy, prediction of onset of preeclampsia can\nbe done using PlGF (Placental Growth Factor) alone\nor in comparison with soluble fms-like tyrosine kinase\n(sFlt-1). These blood tests are widely available for\nuse in developed countries. Results from PELICAN\nstudy (Table 2) show a cut off value of 100 picogram/\nml for PlGF as a high sensitivity test for women heading\nfor preeclampsia which needs delivery within 14 days\nof the test.\nThe negative result would give confidence for\noutpatient management of women with hypertension\nwith pregnancy. As these tests are not available in Sri\nLanka, SLCOG Guidance Committee suggests\noutpatient management with no less than 14 days\nreview appointments for women with hypertension in\npregnancy in the absence of any other maternal, foetal,\nbiochemical or ultrasound scan derangement of\nsignificance. The blood pressure control also need to\nbe at a level for the satisfaction of the obstetrician\nconcerned.\nThough the 2019 NICE guideline gives an aim of\nkeeping control of blood pressure 135/85 mmHg, there\nis controversy about the control need for mild to\nmoderate hypertension in pregnancies even with\npreeclampsia. Treatment of blood pressure has not been\nshown to have prevented preeclampsia or perinatal\noutcomes. But the evidence shows reduction of\ndevelopment of severe blood pressure among treated\nwomen with mild blood pressure. Approximately 10\nwomen need to be put on antihypertensive therapy to\nprevent one episode of severe hypertension11.\nHowever, uncontrolled spikes of blood pressure in\nuntreated pregnancies may prompt action for delivery.\nTherefore, achieving blood pressure control by\npharmaco-therapeutic means would facilitate prolon-\ngation of the pregnancy to achieve greater maturity of\nthe foetus.",
  "But the evidence shows reduction of\ndevelopment of severe blood pressure among treated\nwomen with mild blood pressure. Approximately 10\nwomen need to be put on antihypertensive therapy to\nprevent one episode of severe hypertension11.\nHowever, uncontrolled spikes of blood pressure in\nuntreated pregnancies may prompt action for delivery.\nTherefore, achieving blood pressure control by\npharmaco-therapeutic means would facilitate prolon-\ngation of the pregnancy to achieve greater maturity of\nthe foetus.\n\n--- Page 7 ---\n70\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nCochrane review of treatment has shown the possibility\nof clinically relevant reduction in preeclampsia related\nfoetal or neonatal death particularly early pregnancy\nloss with treatment of mild to moderate hypertension\nin pregnancy. Antihypertensive therapy does not prevent\npreeclampsia (RR 0.99; 95% CI-0.84-1.18) or the\nassociated adverse perinatal outcomes, but it decreases\nby half the incidence of development of severe\nhypertension among women with mild hypertension\n(RR 0.52; 95% CI-0.41 - 0.64)11.\nThe focus of control, if antihypertensives are started,\nis aimed at achieving blood pressure targets bet-\nween140-160 /90-100 mmHg, taking local practice and\nexistence of hypertension predating pregnancy into\nconsideration11. SLCOG recommends aiming to keep\nblood pressure at or below 150/100 mmHg.\nMonitoring\nIn the absence of any investigative derangement of\nbiochemical or foetal parameters, deviations of only\nthe blood pressure which is judged to be controlled by\nthe obstetrician. Repetition of full assessment of the\npatient inclusive of biochemistry and foetus is\nrecommended in intervals not less than 14 days apart\nuntil the time of delivery.\nIn the presence of biochemical markers for systemic\ninvolvement, the patient is recommended for in-ward\npatient care. When a patient is admitted to a ward for\npreeclampsia, an obstetrician needs to review the patient\nat least 72 hours apart. Repetition of frequency of\nbiochemistry depends on the available clinical data on\nthe patient. Progression of the disease as indicated by\ninvestigative deterioration is to be considered important\nfor more action: eg: Observed drop in platelet count\neven though the total count is over 100, mm9/L or\nrising liver enzymes.\nHowever, once significant proteinuria is observed,\nincreasing the amount of protein is not indicative of\noutcome of preeclampsia.\nWhen the delivery decision is taken, the appropriate\nmode of delivery would be decided by;\n•\nThe clinical picture\n•\nPeriod of gestation\n•\nPlatelet count\n•\nLiver involvement.\nPatients with significant liver involvement or a drop in\nplatelet count less than 70 × 109/L6, should be delivered\npreferably in the presence of the specialist team.\nTable 2. PELICAN 2013 study results: Triage PlGF (Placental Growth Factor) test accuracy for\npredicting preeclampsia needing delivery within 14 days for women presenting between\n20 weeks and 34 weeks plus 6 days gestation7\nTest cut-off\nSensitivity\nSpecificity\nPPV\nNPV\n(95% CI)\n(95% CI)\n(95% CI)\n(95% CI)\n<100pg/ml\n0.96\n.56\n.44\n.98\n(0.89 to 0.99)\n(0.46 - 0.63)\n(0.36 to 0.52)\n(0.93 to 1.00)\n>/= 100pg/ml\n0.96\n.56\n.43\n.98\n(0.89 to 0.99)\n(0.49 to 0.63)\n(0.36 to 0.51)\n(0.93 to 1.00)\n<fifth percentile\n.96\n0.56\n0.43\n.98\n(0.89 to 0.99)\n(0.48 to 0.61)\n(0.36 to 0.51)\n(0.93 to 1.00)\n<12 pg/ml\n0.63\n0.90\n0.70\n0.87\n(0.51 to 0.74)\n(0.85 to 0.94)\n(0.57 to 0.80)\n(0.82 to 0.91)",
  "Progression of the disease as indicated by\ninvestigative deterioration is to be considered important\nfor more action: eg: Observed drop in platelet count\neven though the total count is over 100, mm9/L or\nrising liver enzymes.\nHowever, once significant proteinuria is observed,\nincreasing the amount of protein is not indicative of\noutcome of preeclampsia.\nWhen the delivery decision is taken, the appropriate\nmode of delivery would be decided by;\n•\nThe clinical picture\n•\nPeriod of gestation\n•\nPlatelet count\n•\nLiver involvement.\nPatients with significant liver involvement or a drop in\nplatelet count less than 70 × 109/L6, should be delivered\npreferably in the presence of the specialist team.\nTable 2. PELICAN 2013 study results: Triage PlGF (Placental Growth Factor) test accuracy for\npredicting preeclampsia needing delivery within 14 days for women presenting between\n20 weeks and 34 weeks plus 6 days gestation7\nTest cut-off\nSensitivity\nSpecificity\nPPV\nNPV\n(95% CI)\n(95% CI)\n(95% CI)\n(95% CI)\n<100pg/ml\n0.96\n.56\n.44\n.98\n(0.89 to 0.99)\n(0.46 - 0.63)\n(0.36 to 0.52)\n(0.93 to 1.00)\n>/= 100pg/ml\n0.96\n.56\n.43\n.98\n(0.89 to 0.99)\n(0.49 to 0.63)\n(0.36 to 0.51)\n(0.93 to 1.00)\n<fifth percentile\n.96\n0.56\n0.43\n.98\n(0.89 to 0.99)\n(0.48 to 0.61)\n(0.36 to 0.51)\n(0.93 to 1.00)\n<12 pg/ml\n0.63\n0.90\n0.70\n0.87\n(0.51 to 0.74)\n(0.85 to 0.94)\n(0.57 to 0.80)\n(0.82 to 0.91)\n\n--- Page 8 ---\n71\nVol. 44, No. 1, March 2022\nSLCOG Guideline\nNICE guidance does not recommend planned early\nbirth before 37th week to a woman with chronic\nhypertension whose blood pressure is less than 160/\n110 mmHg with or without antihypertensive treatment\nunless there are other medical indicators.\nIf planned birth before completion of 37th is necessary\na course of corticosteroids and magnesium sulfate is\nto be used if indicated.\nSevere hypertension\nSevere Hypertension is considered to be present when\nthe blood pressure recorded is more than 160/110\nmmHg or a Mean Arterial Pressure of more than 130\nmmHg is detected in pregnancy. This could be due to\nany one of the above mentioned (1) - (4) hypertensive\ndisorders of pregnancy. Eclampsia (or occurrence of\nseizures) is a common complication of severe\nhypertension though the relationship is not linear.\nIf eclampsia is present the SLCOG in keeping up with\nall available international guidance, recommends\ndelivery as early as possible before 24 hours of\noccurrence of the first fit. For an ongoing convulsion,\nuse of anticonvulsant agents such as IV magnesium\nsulfate is recommended.\nAny woman who is being treated for severe hyper-\ntension whose birth is planned within the next 24 hours,\nconsideration should be given for medication of\nintravenous magnesium sulfate. Following symptoms\nare recommended as points to consider magnesium\nsulfate treatment\n•\nSevere headache\n•\nVisual disturbance\n•\nNausea and vomiting\n•\nEpigastric pain\n•\nOliguria\n•\nDeterioration of laboratory parameters\n(NICE 2010, amended 2019)\nSLCOG recommends the use of collaborative\neclampsia trial for administration of magnesium\nsulfate7.\n•\nA loading dose of 4g should be given intravenously\nover 5 to 15 minutes, followed by an infusion of\n1g/hour maintained for 24 hours. If the woman\nhas had an eclamptic fit, the infusion should be\ncontinued for 24 hours after the last fit.\n•\nRecurrent fits should be treated with a further dose\nof 2-4 g given intravenously over 5 to 15 minutes\n[NICE 2010, amended 2019].\n•\nDo not use diazepam, phenytoin or other anti-\nconvulsants as an alternative to magnesium sulfate\nin women with eclampsia [2010, amended 2019].\nAntihypertensive treatment is aimed at rapidly lowering\nblood pressure to a safer level. SLCOG recommends\nbringing down blood pressure to 150/100 or less with\nthe use of medication recommended for rapidly\nlowering blood pressure. They are IV hydralazine, IV\nlabetalol, oral nifedipine quick-release. Medication\nregimen is indicated in our previous guidance10.\nIt is recommended to use a crystalloid load of 500ml\nprior to or concomitantly when drugs are used for\nrapidly lowering of blood pressure. This is very\nimportant especially in managing patients with oliguria\nbut is not confined to the management of oliguria.\nIn women managed for preeclampsia with severe\nhypertension, decision of delivery should be considered\nwhen the foetal maturity is 35 weeks or more. But\nbefore 34 weeks +6 days if blood pressure control is\nachieved and laboratory parameters are favorable with\ndue consideration of infrastructure and manpower and\ncontinuing pregnancy until 35 weeks is recommended\nwith close scrutiny of the patient every 24 hours.\nMode of delivery when decided should be done on the\nclinical criteria, available infrastructure and monitoring\nfacilities in consultation with the mother’s wish.\nIt is important that appropriate critical care provision\nis the duty of the head of the institution when requested\nby the in-charge obstetrician.\nSLCOG supports the clinical criteria for choice of\ncritical care, as given in Table 4 of NICE guideline,\nJune 25: 2019 (7), given below.",
  "This is very\nimportant especially in managing patients with oliguria\nbut is not confined to the management of oliguria.\nIn women managed for preeclampsia with severe\nhypertension, decision of delivery should be considered\nwhen the foetal maturity is 35 weeks or more. But\nbefore 34 weeks +6 days if blood pressure control is\nachieved and laboratory parameters are favorable with\ndue consideration of infrastructure and manpower and\ncontinuing pregnancy until 35 weeks is recommended\nwith close scrutiny of the patient every 24 hours.\nMode of delivery when decided should be done on the\nclinical criteria, available infrastructure and monitoring\nfacilities in consultation with the mother’s wish.\nIt is important that appropriate critical care provision\nis the duty of the head of the institution when requested\nby the in-charge obstetrician.\nSLCOG supports the clinical criteria for choice of\ncritical care, as given in Table 4 of NICE guideline,\nJune 25: 2019 (7), given below.\n\n--- Page 9 ---\n72\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nCare of woman after delivery\nContinue monitoring of clinical parameters with the\nsame vigilance in the first 48 hours following delivery\nof a patient who has been delivered. Medications used\nin pregnancy can be continued.\nIt is preferable the case is that of a preeclampsia urine\nalbumin to be negative before discharge from the\nhospital. In patients with proteinuria persisting,\ndischarge from the hospital for care in the community\nshould be done by the consultant/specialist in charge\nof the care.\nDrugs used in hypertension are excreted through breast\nmilk, though no harmful effects are observed,\nmanufacturers do not commit themselves on lactation.\nAs preeclampsia settles down after delivery, by six\nweeks postpartum most medication can be tapered off\nand stopped with the individual assessment of patients.\nProviding appropriate contraceptive advice is\nrecommended.\nIn Sri Lanka consideration should be for offering a\npermanent method of contraception to women who\nhave completed their family or had experienced\nrecurrent severe hypertension in pregnancy if cesarean\ndelivery was contemplated as the mode of delivery.\nThe patients who had preeclampsia who were found\nto have no hypertension or proteinuria at 6 to 8 weeks\npostpartum could be reassured about their renal status\nas the absolute risk for End Stage Kidney disease is\nvery low.\nThey can be assured that no further follow up on renal\ncomponent or hypertension is necessary if they are in\nthe normal range at 6 to 8 weeks. Hypertension\npersisting after 6-8 weeks from delivery should be\nreferred for a medical specialists care.\nPreeclampsia is a state where SLCOG recommends\nuse of postoperative thromboprophylaxis with\nenoxaparin when operative delivery was the mode of\ndelivery.\nReferences\n1.\nLowe SA, Brown MA, Dekker GA, Gatt S,\nMcLintock CK, McMahon LP, et al. Guidelines\nfor the management of hypertensive disorders of\npregnancy 2008, Austr N S J Obstet Gynaecol\n2009; 49(3): 242-6 (Epub 2009/07/02).\n2.\nAbouZahr C, Guidotti R. Hypertensive disorders\nof pregnancy. In: Murray, CJL and Lopez, AD,\neds,. Health dimensions of sex and reproduction:\nLevel 3 care\nSevere pre-eclampsia and needing ventilation\nLevel 2 care\nStep-down from level 3 or severe pre-eclampsia with\nany of the following complications:\n• Eclampsia\n• HELLP syndrome\n• Haemorrhage\n• Hyperkalemia\n• Severe oliguria\n• Coagulation support\n• Intravenous antihypertensive treatment\n• Initial stabilization of severe hypertension\n• Evidence of cardiac failure\n• Abnormal neurology\nLevel 1 care\nPre-eclampsia with hypertension\nOngoing conservative antenatal management of severe\npreterm hypertension\nStep-down treatment after birth\nClinical criteria for choice of critical care level",
  "In: Murray, CJL and Lopez, AD,\neds,. Health dimensions of sex and reproduction:\nLevel 3 care\nSevere pre-eclampsia and needing ventilation\nLevel 2 care\nStep-down from level 3 or severe pre-eclampsia with\nany of the following complications:\n• Eclampsia\n• HELLP syndrome\n• Haemorrhage\n• Hyperkalemia\n• Severe oliguria\n• Coagulation support\n• Intravenous antihypertensive treatment\n• Initial stabilization of severe hypertension\n• Evidence of cardiac failure\n• Abnormal neurology\nLevel 1 care\nPre-eclampsia with hypertension\nOngoing conservative antenatal management of severe\npreterm hypertension\nStep-down treatment after birth\nClinical criteria for choice of critical care level\n\n--- Page 10 ---\n73\nVol. 44, No. 1, March 2022\nSLCOG Guideline\nthe global burden of sexually transmitted diseases,\nmaternal conditions, perinatal disorders, and\ncongenital anomalies. WHO 1998.\n3.\nFamily Health Bureau, Ministry of Health Sri Lanka,\n2020 National statistics, <https://fhb.health.gov.lk/\nindex.php/en/statistics> Date accessed 03/03/2022\n4.\nFamily Health Bureau, Ministry of Health Sri Lanka,\n2019 Report, <http://www.fhb.health.gov.lk/\nindex.php/si/resources/annual-report> Date\naccessed 3/32022\n5.\nBrown MA, Lindheimer MD, de Swiet M, Assche\nAV, Moutquin J-M. The classification and diagnosis\nof the hypertensive disorders of pregnancy:\nstatement from the international society for the\nstudy of hypertension in pregnancy (ISSHP).\nHypertens Pregnancy 2001; 20 (1): ix-xiv\n6.\nGestational Hypertension and Preeclampsia. Acog\nPractice Bulletin Number 202. American College\nof Obstetricians and Gynecologists. Obstet\nGynecol 2019; 133: No.1\n7.\nNice.org.uk. June 25, 2019. Overview | Hyper-\ntension in pregnancy: diagnosis and management |\nGuidance | NICE. [online] Available at: <https://\nwww.nice.org.uk/guidance/ng133> [Accessed 22\nMarch 2022]\n8.\nRolnik DL, Wright D, Poon LC, O’Gorman N,\nSyngelaki A, de Paco Matallana C, et al. Aspirin\nversus placebo in pregnancies at high risk for\npreterm preeclampsia. N Engl J Med 2017; 377:\n613-22.\n9.\nHofmeyr GJ, Lawrie TA, Atallah AN, Duley L,\nTorloni MR. Calcium supplementation during\npregnancy for preventing hypertensive disorders\nand related problems.  Cochrane Database of\nSystemic Reviews 2014, Issue 6. Art. No.:\nCD001059. (Systematic Review and Meta-\nAnalysis)\n10. Senadheera D, Jayasundara DMSC, Jayawardane,\nIA, Ratnasiri UDP, 2021. Management of\nhypertensive disease in pregnancy. Sri Lanka\nJournal of Obstetrics and Gynaecology 2021;\n43(4): 383-94. DOI: http://doi.org/10.4038/\nsljog.v43i4.8033\n11. Lowe S, Bowyer L, Lust K, McMahon L, Morton\nM, North R, Paech M, Said J. 2014. The SOMANZ\nGuideline for the Management of Hypertensive\nDisorders of Pregnancy. [online] Somanz.org.\nAvailable at: <https://www.somanz.org/documents/\nHTPregnancyGuidelineJuly2014.pdf> [Accessed\n18 March 2022].\n12. Duley L, MEher S, Jones L. Drugs for treatment\nof very high blood pressure during pregnancy.\nCochrane-Database of Systemic Reviews 2013,\nIssue 7.  Art. No.: CD001449. (Systemic Review\nand Meta-Analysis)\n13. Emergent therapy for acute-onset, severe\nhypertension during pregnancy and the postpartum\nperiod. Committee Opinion No. 692. American\nCollege of Obstetricians and Gynecologists,\nMonster Gynecol 2017: 129: e90-5. (Level III)\n14. Koopmans CM, van Pampus MG, Groen H,\nAarnoudse JG, van den Berg PP, Mol BW.\nAccuracy of serum uric acid as a predictive test\nfor maternal complications in pre-eclampsia:\nbivariate meta-analysis and decision analysis,\nEuropean Journal of Obstetrics, Gynecology &\nReproductive Biology 2009; 146(1): 8-14.\n15. Lind T, Godfrey KA, Otun H, Philips PR. Changes\nin serum uric acid concentrations during normal\npregnancy. British Journal of Obstetrics &\nGynaecology 1984; 91 (2): 128-32.\n16. Abalos E, Duley L, Steyn DW, Henderson-Smart\nDJ.  Antihypertensive drug therapy for mild to\nmoderate hypertension during pregnancy.\nCochrane Database of Systematic Reviews 2007\n(1): CD002252.",
  "--- Page 1 ---\nCheck \npartner’s blood \nManagement Rhesus Negative Mother \n \n \n \n \n \n \n \n \n \n \n \n Initial procedure is determined by past clinical history. Usually performed at least 4-8 weeks earlier than the previous \npoint of Significant morbidity  \n \n \n \n \n \n \n \n \n \n \n \n \n1ST  \nTRIMESTER \n \n \n \n20 WEEKS \n \n \n24 WEEKS \n  \no No potentially sensitizing events \no Threatened miscarriage before \n12 weeks \n \n                   \n                                      \nPOST   \nPARTUM               \nIdentification of Rh-negative mother \nNon-sensitized mother \nA titre of >1:4 \n \n \n \n \n \n2ND \nTRIMESTER \n    \n         28WEEKS\nBefore 20 \nweeks Anti-\nD Ig-250 IU \nAfter 20 \nweeks Anti-\nD Ig-500 IU \nEarly pregnancy \ncomplications \no Suspected \ntermination \no Ectopic \npregnancy \no Spontaneous \nmiscarriage \no Threatened \nmiscarriage- \nAfter 12 weeks \nPotentially \nsensitizing events \no Antepartum \nHaemorrhage \no External cephalic \nversion \no Closed abdominal \ninjury \no Intrauterine death \no Invasive perinatal \ndiagnosis \nCheck unexpected  antibody levels at \nbooking visit, 28,32 and 36 weeks of POA \nLABOUR \n \n \n \n \nROUTINE \nCARE \nAnti-D Ig-\n500 IU \n \nTEST FOR \nFMH \nAnti-D Ig-500 \nIU \n28weeks \nAnti-D Ig-500 \nIU \n32weeks \nRoutine blood test \nPost Partum management \nCord blood for, \no 2ml (Plain bottle)-Grouping & Rh. \no 2ml (EDTA bottle)-Fetal Hb. \no 2ml (Plain bottle)-Serum bilirubin \no 2ml (Plain bottle)-Direct Coomb’s test. \no 2ml (EDTA bottle)-Reticulocyte count \nFMH test in (Kleihauer acid elution test), \nTraumatic delivery-LSCS \nManual removal of placenta. \nStillbirth/IUD. \nAbdominal trauma in 3rd trimester. \nTwin pregnancy (At delivery) \nUnexplained Hydrops Fetalis \n>4ml Red \ncells \nAdditional anti-D Ig The dose to be \nadministered should assume that 500iu \nof anti-D Ig IV will                   \nsuppress immunization by 8-10 ml of \nfetal RBC \nAnti-D Ig \nrecommended \nbecause of \nsilent FMH \n3RD \nTRIMESTER \nAlready \nsensitized \ndue to \nprevious \nevent\nSensitized \nmother \n            \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n     \nIAT titer \n≤1:32 \nIAT titer \n>1:32/ \nAlbumin titer      \n>1:16 \nFirst sensitized \npregnancy. \n(Previously \naffected \npregnancy) \nRh negative \nRh positive \nCheck \npartners \nblood \nIAT titer \n≥1:64\nRepeat \nantibody \ntiters every \n2-4 weeks \nAmniocent\nesis every \n2-3 weeks \nNo Further \nInvestigations \nSri Lanka College of Obstetrics and \nGynaecology \nHealth sector development Project \nGuidelines- Management Rhesus Negative \nMother \nNo risk\nAt risk\nInvestigation\nDocumenattion Mandatory \nInitial procedure is \ndetermined by \npast clinical \nhistory. Usually \nperformed at least \n4-8 weeks earlier \nthan the previous \npoint of \nSignificant \nmorbidity\nFMH-Feto-Maternal \nTransfusion \nIAT-Indirect Antibody \nTest",
  "--- Page 1 ---\n269\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nPostnatal care during hospital stay\nD L W Dasanayakea  on behalf of Sri Lanka College of Obstetricians and Gynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2021; 43:  269-276\n1.  Scope and background\nThe purpose of this guideline is to describe the routine\nessential postnatal care during hospital stay and provide\ncurrently available best evidence to health care\nprofessionals to provide optimal care for postnatal\nmothers and newborns. This guideline also recom-\nmends management options depending on the\nresources available in the local setting. The guideline\nexplains the postnatal care except management of\npsychological wellbeing as it is separately addressed\nby another guideline.\nImmediate postpartum period is critical phase of the\nlife for both mother and infant, setting the stage for an\nongoing process of optimizing health and well-being.\nFirst 24 hours of delivery where both mother and baby\nwithin the facility will provide excellent opportunity\nfor health professionals to initiate essential postnatal\ncare for them and continue thereafter.\n2.  Summary of key recommendations\n2.1  Immediate postpartum monitoring\nModified Obstetric Early Warning System\n(MOEWS) should be used to monitor vital para-\nmeters to recognize early abnormalities of postnatal\nwomen.\nMonitoring with MOEWS chart should be continued\nfor two hours for vaginal delivery and four hours\nfor caesarean delivery.\na Consultant Obstetrician and Gynaecologist, Mahamodara Teaching Hospital, Galle\nSLCOG Guideline\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\n2.2  Pain management\nA stepwise approach using multi-model combination\nof agents should be prescribed.\nAcetaminophen (Paracetamol) should be prescribed for\nperineal discomfort and pain following uncomplicated\nvaginal delivery.\nNon-Steroidal Ante-Inflammatory Drugs (NSAID’s)\nsuch as diclofenac and ibuprofen with acetaminophen\nare relatively safe during postpartum period and should\nbe prescribed for postnatal women with more severe\npain.\nWhen, a multimodal approach to analgesia using\nNSAID’s and acetaminophen given simultaneously on\na set schedule is insufficient, a milder opioid (codeine)\nshould be considered especially for caesarean delivery\nfor enhanced recovery.\nWhen caesarean delivery is conducted following general\nanaesthesia or when intrathecal long acting opioids are\nnot used for spinal anaesthesia, Transversus Abdominis\nPlane field block (TAP block) should be considered as\nit provides excellent postoperative pain control and\nimproves postoperative analgesia.\nStronger opioid analgesics (morphine, diamorphine and\npethidine) are best reserved for women with inadequate\npain control with sufficient doses of multimodal\napproach.\nDrowsiness from opioids use can be interfered with\nmaternal activities and breast feeding.\nDOI: http://doi.org/10.4038/sljog.v43i3.8021",
  "Summary of key recommendations\n2.1  Immediate postpartum monitoring\nModified Obstetric Early Warning System\n(MOEWS) should be used to monitor vital para-\nmeters to recognize early abnormalities of postnatal\nwomen.\nMonitoring with MOEWS chart should be continued\nfor two hours for vaginal delivery and four hours\nfor caesarean delivery.\na Consultant Obstetrician and Gynaecologist, Mahamodara Teaching Hospital, Galle\nSLCOG Guideline\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\n2.2  Pain management\nA stepwise approach using multi-model combination\nof agents should be prescribed.\nAcetaminophen (Paracetamol) should be prescribed for\nperineal discomfort and pain following uncomplicated\nvaginal delivery.\nNon-Steroidal Ante-Inflammatory Drugs (NSAID’s)\nsuch as diclofenac and ibuprofen with acetaminophen\nare relatively safe during postpartum period and should\nbe prescribed for postnatal women with more severe\npain.\nWhen, a multimodal approach to analgesia using\nNSAID’s and acetaminophen given simultaneously on\na set schedule is insufficient, a milder opioid (codeine)\nshould be considered especially for caesarean delivery\nfor enhanced recovery.\nWhen caesarean delivery is conducted following general\nanaesthesia or when intrathecal long acting opioids are\nnot used for spinal anaesthesia, Transversus Abdominis\nPlane field block (TAP block) should be considered as\nit provides excellent postoperative pain control and\nimproves postoperative analgesia.\nStronger opioid analgesics (morphine, diamorphine and\npethidine) are best reserved for women with inadequate\npain control with sufficient doses of multimodal\napproach.\nDrowsiness from opioids use can be interfered with\nmaternal activities and breast feeding.\nDOI: http://doi.org/10.4038/sljog.v43i3.8021\n\n--- Page 2 ---\n270\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n2.3  Perineal/surgical wound care\nFor the uncomplicated vaginal delivery, cold packs\ncould be applied for 10 to 20 minutes as it helps to\nimprove pain and edema at the episiotomy site.\nPostnatal women should change perineal pad frequently\n(4 to 6 hours) and have shower at least daily to keep\nthe perineum clean.\nVaginal douching is not recommended in the early\npueperium.\nThe vulva should be cleaned from anterior to posterior\nand not vice versa, to prevent the possibility of fecal\ncontamination of traumatized area.\nIf a woman has painful defecation or constipation,\nlaxatives should be prescribed for easy bowel motion.\nRoutine antibiotics are not recommended for first and\nsecond degree perineal tears or episiotomy.\nHealth professionals should follow a standard protocol\nfor management of Obstetric Anal Sphincter Injuries\nfor the additional recommended care.\nA visual assessment of the perineum and vaginal\nexamination should be carried out in all postnatal women\nprior to discharge to assess healing, breakdown and\npresence of foreign bodies.\nStandard dressings should be removed 24 hours after\nthe caesarean delivery and thereafter consider applying\na soft dressing.\nAssement of wound should be done for signs of\ninfection, separation or dehiscence.\nThe woman should be encouraged to wear loose,\ncomfortable clothes and cotton underwear.\nGentle cleaning and drying the wound should be carried\nout daily.\nRemoval of sutures or clips should be arranged in 5 to\n7 days of caesarean delivery.\n2.4  Postpartum bladder care\nEvery postnatal woman should be educated from the\nlabour ward to empty the bladder every 4 to 6 hours\nand,t he time and volume of first void following delivery\nmust be recorded in the maternal notes.\nTo ensure that normal bladder function resumes,\nwomen should be left no more than six hours following\ndelivery without voiding.\nIf the woman has not passed urine successfully by six\nhours following delivery, prompt action should be taken\nby the obstetric team.\nEffort to assist urination should be advised, such as\ntaking a warm bath or shower. If these measures are\nnot successful, prompt assessment of bladder volume\nand catheterization should be done.\nWhere the Post Voidal Residue (PVR) is >150 or the\nwomen is unable to void, an indwelling catheter should\nbe inserted for 24 hours.\nOffer removal of the urinary bladder catheter once a\nwoman is mobile after a regional anaesthetic for\ncaesarean birth, but no sooner than 12 hours.\n2.5 Care for the newborn baby\nAim for a full clinical examination around one hour\nafter birth, when the baby has had his/her first\nbreastfeeding. The baby should be checked again before\ndischarge.\nClean dry cord care is recommended for babies born\nin health facility.\nBathing should be delayed until 24 hours after birth. If\nit is not possible due to cultural reasons, bathing should\nbe delayed at least six hours.\nThe new born baby should be clothed with one or two\nlayers of cloth with hat/cap for ambient temperature.\nImmunization should be promoted as per the Expanded\nImmunization Programme.\n2.6  Postpartum contraception\nDiscussion on Postpartum Family Planning (PPFP)\nshould be initiated prior to discharge which should be\na continuum of antenatal contraception counselling.\nThe couple should be informed that they are at risk of\npregnancy as early as four weeks after delivery if the\nwoman is not exclusively breastfeeding.\nFor women with no other medical illnesses, there is\nno restriction for the use of the following methods",
  "The baby should be checked again before\ndischarge.\nClean dry cord care is recommended for babies born\nin health facility.\nBathing should be delayed until 24 hours after birth. If\nit is not possible due to cultural reasons, bathing should\nbe delayed at least six hours.\nThe new born baby should be clothed with one or two\nlayers of cloth with hat/cap for ambient temperature.\nImmunization should be promoted as per the Expanded\nImmunization Programme.\n2.6  Postpartum contraception\nDiscussion on Postpartum Family Planning (PPFP)\nshould be initiated prior to discharge which should be\na continuum of antenatal contraception counselling.\nThe couple should be informed that they are at risk of\npregnancy as early as four weeks after delivery if the\nwoman is not exclusively breastfeeding.\nFor women with no other medical illnesses, there is\nno restriction for the use of the following methods\n\n--- Page 3 ---\n271\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nduring the immediate postpartum period: Post-Partum\nIntra uterine Devices (PPIUD) and progestogen\nimplants.\nIf couple requests PPIUD, it should be offered to\nwomen within 48 hours of delivery.\nIf the couple wishes to have postpartum sterilization,\nit should be arranged within 48 hours after delivery.\nLactational Amenorrhoea (LAM) alone should not be\npromoted as a method of contraception due to its high\nfailure rate.\n2.7  Lactation management\nEvery effort should be taken to commence\nbreastfeeding within the first hour after delivery.\nSupport must be immediately available for new\nmothers to initiate breast feeding soon after birth.\nExtended support from trained staff should offer\ntraining of new mothers and then observe and monitor\nbreastfeeding during hospital stay.\nWomen and their newborn baby should stay in hospital\nfor at least 24 hours and should not be discharged\nearly until mother is confident about breast feeding.\n2.8  Nutrition and general health advice on\ndischarge\nNurse in charge of health education should talk to\nwomen, preferably arrange small group discussions.\nWomen should be advised to eat a greater amount and\nvariety of healthy foods, dairy products, oils, nuts,\nseeds, cereals, vegetables, to help her to be well and\nstrong.\nA liquid diet can be offered 2 hours after an uncom-\nplicated cesarean delivery. Women should be reassured\nthat she can eat any normal food.\nContinue iron, folic acid and calcium supplementation\nduring lactation.\nWomen should avoid sexual intercourse until perineal\nwound heals and she feels comfortable, preferably until\n4-6 weeks postpartum.\n3.  Introduction\nPostnatal period is a time of great change, physically,\nmentally and socially for mothers, infants and families.\nWhile many mothers transition through this time\nuneventfully, others find it overwhelming or develop\nsignificant health issues that may persist for weeks\nand months after giving birth. Postnatal care of the\nwoman and her newborn baby, is the weakest and the\nmost neglected component of reproductive health care.\nGlobal data shows that almost half of the post natal\nmaternal deaths occur within the first 24 hrs of child-\nbirth1 and one million of newborns died on the first\nday2,3. As the first day of the postpartum period carries\nthe highest risk of adverse outcomes for the woman\nand her baby, it is essential that comprehensive postnatal\ncare is initiated immediately after delivery and continued\nuntil the woman is discharged from hospital.\nEssential postnatal care which should be commenced\non the first postpartum day itself include: pain manage-\nment, perineal care, bladder care, care of the new born,\npostpartum contraception, lactation management and\nassessment of psychological wellbeing.\nThe World Health Organization (WHO) recognized\nthe importance of the postnatal management and has\nissued detailed, evidence-based recommendations for\npostnatal care4.\nIn Sri Lanka, almost all births take place in hospitals\nwith skill birth attendance5. Therefore, we have\nexcellent opportunity to commence comprehensive\ncare for postnatal mothers until they are discharged\nfrom the facility.\n4.  Recommendations and discussion\n4.1  Immediate postpartum monitoring\nModified Obstetric Early Warning System (MOEWS)\nshould be used to monitor vital parameters to recognize\nearly abnormalities of postnatal women.\nMonitoring with MOEWS chart should be continued\nfor two hours for vaginal delivery and four hours for\ncaesarean delivery.\nEarly Warning Scoring Systems are a simple, quick-\nto-use tool based on routine physiological observations.\nThe scoring of these observations can provide an\nindication of the overall status of the patient’s condition.\nPrompt action and urgent medical review when indi-",
  "Therefore, we have\nexcellent opportunity to commence comprehensive\ncare for postnatal mothers until they are discharged\nfrom the facility.\n4.  Recommendations and discussion\n4.1  Immediate postpartum monitoring\nModified Obstetric Early Warning System (MOEWS)\nshould be used to monitor vital parameters to recognize\nearly abnormalities of postnatal women.\nMonitoring with MOEWS chart should be continued\nfor two hours for vaginal delivery and four hours for\ncaesarean delivery.\nEarly Warning Scoring Systems are a simple, quick-\nto-use tool based on routine physiological observations.\nThe scoring of these observations can provide an\nindication of the overall status of the patient’s condition.\nPrompt action and urgent medical review when indi-\n\n--- Page 4 ---\n272\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\ncated, allow for appropriate management of women\nat risk of deterioration. The MEOWS tool has been\nspecifically adopted to reflect the physiological adap-\ntations of normal pregnancy and should therefore be\nused for pregnant, labouring and postnatal women.\nUse of MOEWS, which alerts care providers of poten-\ntial impending critical illnesses, is recommended to\nimprove maternal outcomes and safety6.\n4.2 Postpartum pain management\nA stepwise approach using multi-model combination\nof agents should be prescribed.\nAcetaminophen (Paracetamol) should be prescribed for\nperineal discomfort and pain following uncomplicated\nvaginal delivery.\nNon-Steroidal Ante-Inflammatory Drugs (NSAID’s)\nsuch as diclofenac and ibuprofen with acetaminophen\nare relatively safe during postpartum period and should\nbe prescribed for postnatal women with more severe\npain.\nWhen, a multimodal approach to analgesia using\nNSAID’s and acetaminophen given simultaneously on\na set schedule is insufficient, a milder opioid (codeine)\nshould be considered especially for caesarean delivery\nfor enhanced recovery.\nWhen caesarean delivery is conducted following general\nanaesthesia or when intrathecal long acting opioids are\nnot used for spinal anaesthesia, a Transversus\nAbdominis Plane field block (TAP block) should be\nconsidered as it provides excellent postoperative pain\ncontrol and improves postoperative analgesia.\nStronger opioid analgesics (morphine, diamorphine and\npethidine) are best reserved for women with inadequate\npain control with sufficient doses of multimodal\napproach.\nDrowsiness from opioids use can interfere with\nmaternal activities and breast feeding.\nPain has been documented as a major concern for most\nTAP block women following childbirth. Management\nof postpartum pain, however, is a relatively neglected\ndue to under estimation7. Inadequate pain relief could\nlead to interference with mobilization, breastfeeding,\nand newborn bonding by impeding mobility, can\nincrease the risk of postpartum complications8. Non-\npharmacological and pharmacological therapies are\noptions for pain management. It is also important to\nconsider safety of drug therapy due to concerns of\nsecretion through breast milk. Multimodal analgesia\nuses drugs that have different mechanism of action,\nwhich augments analgesic effect9 (Appendix no. 1). A\nCochrane review of local analgesia infiltration and\nabdominal nerve blocks found that they improved\npostoperative analgesia for cesarean delivery10.\nAcetaminophen and NSAIDs are relatively safe during\nbreast feeding11. However, opioids should be used\ncautiously as maternal and neonatal sedation12.\n4.3  Postpartum perineal /surgical wound care\nFor the uncomplicated vaginal delivery, cold packs\ncould be applied for 10 to 20 minutes as it helps to\nimprove pain and edema at the episiotomy site.\nPostnatal women should change perineal pad frequently\n(4 to 6 hours) and have shower at least daily to keep\nthe perineum clean.\nVaginal douching is not recommended in the early\npueperium.\nThe vulva should be cleaned from anterior to posterior\nand not vice versa, to prevent the possibility of fecal\ncontamination of traumatized area.\nIf a woman has painful defecation or constipation,\nlaxatives should be prescribed for easy bowel motion.\nRoutine antibiotics are not recommended for first and\nsecond degree perineal tears or episiotomy.\nHealth professionals should follow a standard protocol\nfor management of obstetric anal sphincter injuries for\nthe additional recommended care.\nA visual assessment of the perineum and vaginal\nexamination should be carried out in all postnatal women\nprior to discharge to assess healing, breakdown and\npresence of foreign bodies.\nStandard dressings should be removed 24 hours after\nthe caesarean delivery and thereafter consider applying\na soft dressing.\nAssessment of wound should be done for signs of\ninfection, separation or dehiscence.",
  "A\nCochrane review of local analgesia infiltration and\nabdominal nerve blocks found that they improved\npostoperative analgesia for cesarean delivery10.\nAcetaminophen and NSAIDs are relatively safe during\nbreast feeding11. However, opioids should be used\ncautiously as maternal and neonatal sedation12.\n4.3  Postpartum perineal /surgical wound care\nFor the uncomplicated vaginal delivery, cold packs\ncould be applied for 10 to 20 minutes as it helps to\nimprove pain and edema at the episiotomy site.\nPostnatal women should change perineal pad frequently\n(4 to 6 hours) and have shower at least daily to keep\nthe perineum clean.\nVaginal douching is not recommended in the early\npueperium.\nThe vulva should be cleaned from anterior to posterior\nand not vice versa, to prevent the possibility of fecal\ncontamination of traumatized area.\nIf a woman has painful defecation or constipation,\nlaxatives should be prescribed for easy bowel motion.\nRoutine antibiotics are not recommended for first and\nsecond degree perineal tears or episiotomy.\nHealth professionals should follow a standard protocol\nfor management of obstetric anal sphincter injuries for\nthe additional recommended care.\nA visual assessment of the perineum and vaginal\nexamination should be carried out in all postnatal women\nprior to discharge to assess healing, breakdown and\npresence of foreign bodies.\nStandard dressings should be removed 24 hours after\nthe caesarean delivery and thereafter consider applying\na soft dressing.\nAssessment of wound should be done for signs of\ninfection, separation or dehiscence.\n\n--- Page 5 ---\n273\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nThe woman should be encouraged to wear loose,\ncomfortable clothes and cotton underwear.\nGentle cleaning and drying the wound should be carried\nout daily.\nRemoval of sutures or clips should be arranged in 5 to\n7 days of caesarean delivery.\nPerineal damage can cause significant maternal\nmorbidity both immediate and long term8. Vast majority\nof perineal trauma is due to intentionally made episio-\ntomy to facilitate vaginal delivery. Episiotomy rates vary\nconsiderably in various countries according to individual\npractices and policies of staff and institutions. Overall\nrates of episiotomy in different countries range from\n8% to 99%13. In Sri Lanka, almost all primipara and\nmost of the multipara experience episiotomy. Edema\nand discomfort may result painful defecation and\ninterfere with mobilization. Although evidence is limited,\na meta-analysis found that cold pack applied for 10 to\n20 mins. improve perineal discomfort and edema14.\nLaxatives should be administered, in immediate\npostpartum period, if a women has painful defecation\nor constipation following perineal trauma, to aid easier\nbowel motion and early discharge from hospital15.\nRoutine perinel examination should be carried out by a\ndoctor before discharge to assess the perineum for\nsigns of infection and wound breakdowns16. NICE\nguideline on caesarean delivery recommends to remove\nstandard dressing in 8 to 24 hours but not advised for\nnegative pressure dressing unless risk of bleeding17.\n4.4  Postpartum bladder care\nEvery postnatal women should be educated from the\nlabour ward to empty the bladder every 4 to 6 hours\nand the time and volume of first void following delivery\nmust be recorded in the maternal notes.\nTo ensure that normal bladder function resumes,\nwomen should be left no more than six hours following\ndelivery without voiding.\nIf the woman has not passed urine successfully by six\nhours following delivery, prompt action should be taken\nby the obstetric team.\nEffort to assist urination should be advised, such as\ntaking a warm bath or shower. If these measures are\nnot successful, prompt assessment of bladder volume\nand catheterization should be done.\nWhere the Post Voidal Residue (PVR) is >150 or the\nwomen is unable to void, an indwelling catheter should\nbe inserted for 24 hours.\nOffer removal of the urinary bladder catheter once a\nwoman is mobile after a regional anaesthetic for\ncaesarean birth, but no sooner than 12 hours.\nA small number of women (0.4% to 4%) experience\nlong term bladder dysfunction following child birth18.\nThis can cause embarrassment and distress19. The\nbladder could be an unfortunate victim of child birth.\nA single episode of bladder over distention can lead to\nirreversible damage to detrusor muscles20. PVR and\ntotal urine volume are considered as significant finding\nwhen a woman is managed for acute urinary retention.\nShort while after delivery, retention of urine with\nbladder distention can be a frequent phenomenon due\nto child birth related denervation an ischemia of the\nbladder muscles. Urinary retention is most likely to\noccur in the first 8 to 12 hours following delivery\nbecause of its onset may be slow and asymptomatic21.\nEarly diagnosis, interventions and treatment are neces-\nsary to prevent permanent bladder damage. Simple\nmeasures such as education of women regarding\neffective voiding and frequency would prevent most\nof undiagnosed bladder distention. Even though it is\nrecommended by Enhance Recovery After Surgery\n(ERAS) society to remove urinary catheter immediately\nafter caesarean delivery, it is not practically possible in\nlocal setting.\n4.5  Care for the newborn baby\nAim for a full clinical examination around one hour\nafter birth, when the baby has had his/her first\nbreastfeeding. The baby should be checked again before\ndischarge.\nClean dry cord care is recommended for babies born\nin health facility.\nBathing should be delayed until 24 hours after birth. If\nit is not possible due to cultural reasons, bathing should\nbe delayed at least six hours.\nThe new born baby should be clothed one or two\nlayers of cloth with hat/cap for ambient temperature.\nImmunization should be promoted as per the Expanded\nImmunization Programme.",
  "The baby should be checked again before\ndischarge.\nClean dry cord care is recommended for babies born\nin health facility.\nBathing should be delayed until 24 hours after birth. If\nit is not possible due to cultural reasons, bathing should\nbe delayed at least six hours.\nThe new born baby should be clothed one or two\nlayers of cloth with hat/cap for ambient temperature.\nImmunization should be promoted as per the Expanded\nImmunization Programme.\n\n--- Page 6 ---\n274\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nNewborn period refers to the first twenty-eight days\nof life. However first 24 hours of the life is the most\nchallenging time of human life, since babies are born\nto an entirely new surrounding. There are several\nphysiological adaptations occurring in this period in\nthe baby, which is essential for their survival. Family\nHealth Bureau has issued a comprehensive guideline\non new born care for detailed reference22.\n4.6  Postpartum contraception\nDiscussion on Postpartum Family Planning (PPFP)\nshould be initiated prior to discharge which should be\na continuum of antenatal contraception counselling.\nThe couple should be informed that they are at risk of\npregnancy as early as four weeks after delivery if the\nwoman is not exclusively breastfeeding.\nFor women with no other medical illnesses, there is\nno restriction for the use of the following methods\nduring the immediate postpartum period: Post-Partum\nIntra uterine Devices (PPIUD) and progestogen\nimplants.\nIf couple requests PPIUD, it should be offered to\nwomen within 48 hours of delivery.\nIf the couple wishes to have postpartum sterilization,\nit should be arranged within 48 hours after delivery.\nLactational Amenorrhoea (LAM) alone should not be\npromoted as a method of contraception due to its high\nfailure rate.\nFertility returns shortly after childbirth in non-breast\nfeeding women23. Non-use of PPFP would result in\nunplanned and unwanted pregnancies. Closely spaced\npregnancies leads to adverse maternal perinatal and\ninfant outcomes. PPFP enables women to achieve\nhealthy interval between births and potentially averting\n25-40% of maternal deaths and reducing child mortality\nby an estimated 10%24,25. The post-partum period\nrepresents the critical window of opportunity for\nwomen to receive family planning services. Discussion\non PPFP should be carried out antenatally and further\ndiscussions and the provision of PPFP should be\ninitiated soon after delivery. For women with no other\nmedical illnesses, there is no restrictions for the use of\nthe following methods in the immediate postpartum\nperiod: Post-Partum Intra uterine Devices (PPIUD),\nprogestogen implants and progestogen only pills26. The\nPPIUD enables women to leave the birth facility with\na safe and extremely affective, long acting, reversible\nmethod already in place. The main advantage of this\nmethod is convenient to mother due to timing of\ninsertion.\n4.7  Lactation management\nEvery effort should be taken to commence breast-\nfeeding within the first hour after delivery.\nSupport must be immediately available for new\nmothers to initiate breast feeding soon after birth.\nExtended support from trained staff should offer\ntraining of new mothers and then observe and monitor\nbreastfeeding during hospital stay.\nWomen and their newborn baby should stay in hospital\nfor at least 24 hours and should not be discharged\nearly until mother is confident about breast feeding.\nBreast feeding is considered as the single most effective\nlow cost intervention to reduce child morbidity and\nmortality worldwide27. Another effort for encouraging\nbreastfeeding practice is “Baby Friendly” hospitals.\nSupport must be available immediately for new\nmothers to initiate breastfeeding in maternity facilities.\nIt is important to integrate the WHO/UNICEF Ten Steps\nof Successful Breastfeeding (established in 1989) that\ndescribe what maternity facilities should do to enable\na successful start to breastfeeding. Improving access\nto skilled breastfeeding counseling and education, has\nbeen shown to result in a 90 percent increase in\nexclusive breastfeeding rates for infants up to five\nmonths of age28. Sri Lanka ranks first among 97\ncountries globally on breastfeeding rate according to a\nnew survey conducted by the World Breastfeeding\nTrends Initiative (WBTi) achieving first “Green” nation\nstatus in supporting breastfeeding women29.\n4.8 Nutrition and general health advice on\ndischarge\nNurse in charge of health education should talk to\nwomen, preferably arrange small group discussions.\nWomen should be advised to eat a greater amount and\nvariety of healthy foods, dairy products, oils, nuts,\nseeds, cereals, vegetables, to help her to be well and\nstrong.\nA liquid diet can be offered 2 hours after an uncom-\nplicated cesarean delivery.",
  "Improving access\nto skilled breastfeeding counseling and education, has\nbeen shown to result in a 90 percent increase in\nexclusive breastfeeding rates for infants up to five\nmonths of age28. Sri Lanka ranks first among 97\ncountries globally on breastfeeding rate according to a\nnew survey conducted by the World Breastfeeding\nTrends Initiative (WBTi) achieving first “Green” nation\nstatus in supporting breastfeeding women29.\n4.8 Nutrition and general health advice on\ndischarge\nNurse in charge of health education should talk to\nwomen, preferably arrange small group discussions.\nWomen should be advised to eat a greater amount and\nvariety of healthy foods, dairy products, oils, nuts,\nseeds, cereals, vegetables, to help her to be well and\nstrong.\nA liquid diet can be offered 2 hours after an uncom-\nplicated cesarean delivery.\n\n--- Page 7 ---\n275\nVol. 43, No. 3, September 2021\nSLCOG Guideline\nWomen should be reassured that she can eat any normal\nfood.\nContinue iron, folic acid and calcium supplementation\nduring lactation.\nWomen should avoid sexual intercourse until perineal\nwound heals and she feels comfortable, preferably until\n4-6 weeks postpartum.\nAs postnatal mothers have increased demand for\nnutrition due to rapid recovery of pregnancy related\nphysiological changes and breastfeeding, they need high\nquality food and greater amount for eating. There are\nnumerous myths and taboos in different cultures,\nexposing women to limited intake. Therefore, postnatal\neducation and counseling is important, should com-\nplement antenatal education and counseling and should\nbe implemented prior to discharge from the hospital.\nIdeally, postnatal education and counseling need to be\nindividualized and flexible, although there could be\nbarriers to do so30. The largest trial to study early\nfeeding, conventional feeding within 18 hours or early\nfeeding within 2 hours, demonstrated a reduction in\nthirst and hunger and improved maternal satisfaction,\nambulation, and infections31. A systematic review and\nmeta-analysis of 17 studies also supported these\nfindings32.\n5. Clinical governance\n5.1 Quality of care\nWith increasing numbers of births in health facilities,\nattention has shifted to the quality of care, as poor\nquality of care contributes to morbidity/mortality and\nmaternal unsatisfaction.  A hospital providing maternity\nservices should have the mission of every pregnant\nwoman and newborn receives high-quality care\nthroughout pregnancy, childbirth and the postnatal\nperiod. To accomplish the mission, standard quality\nassessment procedure should be implemented and\nmonitored in regular basis.\n5.2  Training\nThe maternity staff should be regularly trained with\nupdated knowledge and skills to provide comprehensive\npostnatal care. Communication and counseling\nworkshops should be arranged for health professionals\nfor better communication with postnatal women and\ntheir families.\n5.3  Incident reporting\nThe hospital should adopt effective way of incident\nreporting and feedback mechanism for adverse events.\nThe prompt investigation of particular incident and\nimplementation of recognized recommendations should\nbe carried out by the institutions.\nReferences\n1.\nEvery Newborn, An Executive Summary for The\nLancet’s Series. 2014.\n2. The Inter-agency Group for Child Mortality\nEstimation (UN IGME). Levels & Trends in Child\nMortality, Report 2014. United Nations Children’s\nFund.\n3.\nLawn JE et al. Every Newborn: Progress,\nPriorities, and Potential Beyond Survival. Lancet\n2014; 384: 189-205.\n4.\nWHO. WHO Recommendations on Postnatal Care\nof the Mother and Newborn. October 2013.\nGeneva: WHO.\n5.\nDepartment of Census and Statistics Sri Lanka.\nSri Lanka Demographic and Health Survey 2016.\nColombo, Sri Lanka http://www.statistics.gov.lk/\nResource/en/Health/DemographicAndHealth\nSurveyRep ort-2016-Contents. (Accessed 30.\n09.2020)\n6.\nSingh S, McGlennan A, England A, Simons R.A\nvalidation study of the CEMACH recommended\nmodified early obstetric warning system\n(MEOWS). Anaesthesia 2012(67): 12-18.\n7.\nGlazener CMA, Abdalla M, Stroud P, Naji S,\nTempleton A. Russell IT Postnatal morbidity.\nExtend, course, prevention and treatment. Br J\nObstet Gynaecol 1995; 102: 286-7.\n8.\nSleep J. Perineal care: a series of 5 randomized\ncontrol trials, In: Robinson S, Thomson A , Editors.\nMidwives Research and Child-birth. London :\nChapman and Holl. 1991: 199-251.\n9.\nLeung L. From ladder to platform: a new concept\nfor pain management. J Prim Health Care 2012; 4:\n254-8.\n10. Bamigboye AA, Hofmeyr GJ. Local anaesthetic\nwound infiltration and abdominal nerves block\nduring caesarean section for postoperative pain\nrelief. Cochrane Database Syst Rev 2009; 3:\nCD006954.",
  "Local anaesthetic\nwound infiltration and abdominal nerves block\nduring caesarean section for postoperative pain\nrelief. Cochrane Database Syst Rev 2009; 3:\nCD006954.\n\n--- Page 8 ---\n276\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n11. Spigset O, Hagg S. Analgesics and breast-feeding:\nsafety considerations. Paediatr Drugs 2000; 2:\n223-38.\n12. Fahey JO. Best practices in management of\npostpartum pain. J Perinat Neonatal Nurs 2017;\n31: 126-36.\n13. Renfew MT, Hannah W, Albert L, Floyed E.\nPractices that minimize trauma to the genital track\nin the child birth: A systematic review of the\nLiteratur. Birth 1998 ; 25: 143-60.\n14. East CE, Begg L, Henshall NE, Marchant PR,\nWallace K. Local cooling for relieving pain from\nperineal trauma sustained during childbirth.\nCochrane Database of Systematic Reviews 2012,\nIssue 5. Art. No.: CD006304.\n15. Harvey MA, Pierce M, Alter JE, Chou Q, Diamond\nP, Epp A, et al. Obstetrical anal sphincter injuries\n(OASIS): Prevention, recognition, and repair.\nClinical Practice Guideline No. 330. Journal of\nObstetrics and Gynaecology Canada 2015; 37(12):\n1131-48.\n16. Bick D. Postpartum management of the perineum.\nBritish Journal of Midwifery 2009; 17(9): 571-7.\n17. NICE clinical guideline on caesarean section, No.\n132, 2011.\n18. Ian N, Ramsay, Torbet TE. Incidence of abnormal\nvoiding parameters in the immediate postpartum\nperiod. Neurology and urodynamics 1993 (12):\n179-83.\n19. Lennard, F. To wee or not to wee: that is the\ndistention? Journal of the Association of Chartered\nPhysiotherapists in Women’s Health 2005; 96:\n41-6.\n20. Ching-Chung, L, et al. ‘Postpartum urinary\nretention: assessment of contributing factors and\nlong term clinical impact’ in Australian and New\nZealand Journal of Obstetric Gynaecology, 2002;\n42 (4): 367-70.\n21. Glavind, K. and BjØrk, j . Incidence and treatment\nof urinary retention postpartum. International\nUrogynaecology Journal, 2003; 14: 119-21.\nwww.springerlink.com.\n22. National Guidelines for Newborn Care, Family\nHealth Bureau, 2020.\n23. Jackson E, Glasier A. Return of ovulation and\nmenses in postpartum non lactating women: a\nsystematic review. Obstet Gynecol 2011; 117(3):\n657-62.\n24. Campbell MR, Graham WJ. Strategies for reducing\nmaternal mortality. Getting on with what works,\nLancet, 2006; 368(9543): 1284-99.\n25. Cleland J, et al. Family planning. The unfinished\nagenda, Lancet 2006; 368(9549): 1810-27.\n26. UK Medical Eligibility Criteria. 2016. https://\nwww.fsrh.org/standards-and-guidance/\ndocuments/ukmec-2016 (Accessed 30.09.2020)\n27. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker\nN, Horton S, et al. Maternal and Child Nutrition\nStudy Group. Evidence-based interventions for\nimprovement of maternal and child nutrition: what\ncan be done and at what cost? The lancet 2013;\n382(9890): 452.\n28. Sinha B, Chowdhury R, Sankar MJ, Martines J,\nTaneja S, Mazumder S, et al Interventions to\nimprove breastfeeding outcomes: A systematic\nreview and meta-analysis. ActaPaediatrica 2015;\n104: 114-34.\n29. World Breastfeeding Trends Initiative year 2019,\nhttps://www.worldbreastfeedingtrends.org/wbti-\ncountry-ranking.php (Accessed 30.09.2020)\n30. World Health Organisation. WHO Recom-\nmendations on Postnatal Care of the Mother and\nNewborn. 2013. WHO. Geneva Switzerland.\n31. Jalilian N, Ghadami MR. Randomized clinical trial\ncomparing postoperative outcomes of early versus\nlate oral feeding after cesarean section. J Obstet\nGynaecol Res 2014; 40: 1649-52.\n32. Hsu YY, Hung HY, Chang YI. Early oral intake and\ngastrointestinal function after cesarean delivery: a\nsystematic review and metaanalysis. Obstet\nGynecol 2013; 121: 1327.",
  "--- Page 1 ---\n Management of Puerperal sepsis \n                                                        \n \n                \n \n \nSri Lanka College of Obstetrics and Gynaecology \nHealth sector development Project \nGuidelines- Management of Puerperal sepsis \n \nFever/purulent vaginal \ndischarge/pelvic pain \nVery sick (high fever, altered \nconsciousness, rapid pulse-Assume \ncritically ill. \n \n \nImprovement in 24 hours \nYes \nNo \nContinue IV antibiotics for 3 days \nResolved completely \nYes \nDiscontinue IV \nDischarge the patient  \nOral antibiotics for 4-7 days \nCheck haemoglobin and treat anaemia  \nAdvice to return if following recurres \n• Fever  \n• Vaginal discharge \n• Pelvic pain  \nNo \nTransfer to specialist \nhospital \nƒ Physical examination & Ultrasound to \nrule out:  \nPelvic abscess \nPelvic thromboplebitis \nRetained products \nƒ Culture and sensitivity test for vaginal \ndischarge, Gram stain \nƒ   Renal,liver, coagulation profiles \nƒ Blood culture \nƒ Continue IV therapy \nAmoxycillin- clavulinic acid (Amoxyclav)-\n1.2g intravenous 8 hourly with or without \ngentamicin \nIf response is poor, \nImipenem 500 mg intravenous 8 hourly \nOr \nTicarcillin-clavulinic \nacid \n3.2 \ng \nintravenous 8 hourly.may be used in place \nof \nAmoxycillin- \nclavulinic \nacid \n(Amoxyclav).  \nƒ Review and change antibiotic based on \nsensitivity \nSpecialized Unit  \nMidwifery level \nPost partum visits \nNon specialist unit  \nAppropriate management of complications  \nƒ Retained placental fragments- Evacuate \nonly when the patient is stable. \nƒ Pelvic abscess, \nƒ Thromboplebitis, \n \nLow risk \nAt risk \nAlarming \nAssessment \nReferral \nAssume Puerperal sepsis \nAdmit immediately- \nIf possible accompany the patient \nAdmit \nimmediately \nƒ Assess-signs of shock, septicaemia, anaemia & treat accordingly \nƒ Abdominal examination for uterine size and tenderness \nƒ Check for uterine haemorrhage & control it  \nƒ Penicillin 2 million units IV/IM every 6 hours +gentamicin 80mg \nƒ Amoxycillin- clavulinic acid -1.2 g intravenous 8 hourly or 625mg oral 8 hourly/bd\nƒ (IV/IM every 8 hourly +metronidazole) 500mg every 8 hours orally. \nƒ IV fluids-I litre, 5% dextrose or N. saline rapidly followed by \nƒ 3000 mls every 24 hours. \nƒ Vital signs every 6 hours \n \nIf evidence of \nsepticaemia, \npresent attend to \nresuscitation and  \ntransfer \nimmediately \nNeeds an ultrasound to \nexclude retained products –\nPlacental segments as a cause \nof sepsis \nRefer to specialist unit for \nultrasound or further advice \nTransfer to specialist \nhospital \nIf very ill \n Septicaemic \n in shock \n in respiratory distress \nbleeding tendency \npresent  \nManage in ICU",
  "--- Page 1 ---\n335\nVol. 43, No. 4, December 2021\nSLCOG Guideline\nAssisted Vaginal Delivery\nD Senadheeraa, C Jayasundarab, I A Jayawardaneb on behalf of the Sri Lanka College of Obstetricians and\nGynaecologists\nSri Lanka Journal of Obstetrics and Gynaecology   2021; 43: 335-347\na Consultant Obstetrician and Gynaecologist, De Soysa Hospital for Women, Colombo, Sri Lanka\nb Consultant Obstetrician and Gynaecologist, De Soysa Hospital for Women, Senior Lecturer, University of Colombo,\nSri Lanka\nSLCOG Guideline\n1. Introduction, background and\nepidemiology\nManagement of second stage of labour frequently\nnecessitates assisted birth, to avoid a potentially\nhazardous second stage caesarean section. In the\nUnited Kingdom 10% to 15% of all women undergo\nassisted vaginal birth, even though rate is much lower\nin Sri Lanka1. Instrumental delivery when performed\ncorrectly by a trained clinician, results in satisfactory\nfeto-maternal outcomes2. However, clinician should be\naware that serious and rare complications, such as sub-\ngaleal and intracranial haemorrhage, skull fractures\nand spinal cord injury, can occur particularly in the\nuntrained hands as well as with repeated failed\nattempts3. Mastering the art of safe assisted delivery is\nan essential skill in the modern obstetrician’s armament.\n2. Purpose and scope\nThe aim of this guideline is to provide evidence-based\nrecommendations on the use of forceps and vacuum.\nThis guidance is intended not only for practicing\nspecialists, but also for trainee registrars, senior\nregistrars who are expected to develop competency in\nthe use of both vacuum and forceps for non-rotational\nbirth and at least one technique for rotational birth.\nRecommendations made in this document may serve\nfor all grades of medical staff involved in women’s\nhealth and labour management. The scope of this\nguideline includes indications, procedures, governance\nand follow up issues relating to assisted vaginal birth.\nCorrespondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.\nE-mail: slcogoffice@gmail.com\nDOI: http://doi.org/10.4038/sljog.v43i4.8029\n3. Identification and assessment of\nevidence\nSearch strategy: External guidelines, systemic reviews\nand Cochrane revives were searched assessing available\nevidence and the best practices.\n4. Summary of recommendations\nWhenever possible, strive to provide continuous\nsupport during labour, one to one care and the\nchoice of a labour companion. Available evidence\nsuggests this can reduce instrumental delivery\nrate and promote normal vaginal delivery.\nEpidural analgesia may increase the duration of\nactive second stage and the need for instru-\nmental vaginal birth.\nEncourage upright or lateral positions in second\nstage of labour (in women not on epidural\nanalgesia). This reduces the need for instru-\nmentation.\nAllow delayed pushing (passive second stage)\nin women with epidural analgesia. This may\nreduce the need for rotational and mid-pelvic\nassisted vaginal birth.\nDo not routinely discontinue epidural analgesia\nduring pushing as this increases the woman’s\npain with no evidence of a reduction in the\nincidence instrumental delivery.\nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.",
  "This reduces the need for instru-\nmentation.\nAllow delayed pushing (passive second stage)\nin women with epidural analgesia. This may\nreduce the need for rotational and mid-pelvic\nassisted vaginal birth.\nDo not routinely discontinue epidural analgesia\nduring pushing as this increases the woman’s\npain with no evidence of a reduction in the\nincidence instrumental delivery.\nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\n\n--- Page 2 ---\n336\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nOperators should appreciate that no indication\nforinstrumental delivery is absolute, and that\nprudent clinical judgment is required in each\nsituation.\nSuspected fetal bleeding disorders and pre-\ndisposition to fractures are relative contrain-\ndications for assisted vaginal birth.\nPresence of blood borne viral infection in a\nwoman is not an absolute contraindication for\nassisted vaginal birth.\nVacuum is not contraindicated following a fetal\nblood sampling or application of a fetal scalp\nelectrode.\nThere is a higher risk of sub-galeal haemorrhage\nand scalp trauma with vacuum extraction\ncompared to forceps at preterm gestation.\nVacuum is contraindicated below 32 weeks\nof gestation and should only be used with\nextreme caution between 32+0 and 36+0.\nSafe assisted vaginal birth requires not only\ntechnical expertise, but also careful assessment\nof each clinical situation, clear communication\nwith the woman and other healthcare personnel.\nUltrasound assessment of the fetal head position\nprior to assisted vaginal birth can be attempted\nwhere uncertainty exists following clinical\nexamination.\nRoutine use of abdominal or perineal ultrasound\nfor assessment of the station, flexion and\ndescent of the fetal head in the second stage is\nnot recom mended and is not a substitute for\nclinical examination.\nFor procedures in the labour room, verbal\nconsent should be obtained and documented in\nthe notes.\nWhen mid-pelvic or rotational birth is indicated,\nthe risks and benefits of assisted vaginal birth\nshould be compared with the risks and benefits\nof second stage caesarean section, for the given\ncircu-mstances and skills of the operator.\nPrior written consent is recommended for a trial\nof assisted vaginal birth in the operating theatre.\nOperators must achieve expertise in spon-\ntaneous vaginal birth prior to commencing\ntraining on assisted vaginal birth.\nNon-rotational low-pelvic and lift out assisted\nvaginal births have a low probability of failure,\nhence most procedures can be attempted safely\nin the labour room.\nAssisted vaginal births that have a higher risk\nof failure should be termed a trial of instru-\nmental delivery and is best attempted in an\noperation theater, where immediate CS can be\nresorted to.\nThe operator should choose the instrument most\nappropriate to the clinical circumstances and\ntheir level of skill.\nForceps and vacuum extraction are associated\nwith different benefits and risks.\nFailure to complete the birth with a single instru-\nment is more likely with vacuum extraction, but\nmaternal perineal trauma is more likely with\nforceps.\nSoft cup vacuum extractors have a higher rate\nof failure but a lower incidence of neonatal\nscalp trauma.\nRotational births should be performed by\nexperienced operators; the choice of instrument\ndepending on the clinical circumstances and\nexpertise of the individual.\nThe options include, Manual rotation followed\nby direct traction with forceps or vacuum,\nRotational vacuum extraction or Kielland’s\nrotational forceps.\nIt is recommended to complete vacuum-\nassisted birth with not more than three pulls to\nbring the fetal head on to the perineum.\n(Additional gentle pulls may be used only to ease\nthe head out of the perineum).\nIf there is minimal descent with the first pull of\na vacuum, consider if the application is sub-\noptimal, the fetal position has been incorrectly\ndiagnosed or if there is cephalopelvic dispro-\nportion.\nDiscontinue vacuum-assisted birth where there\nis no evidence of progressive descent with\nmoderate traction during each pull of a correctly\napplied instrument.\nDiscontinue vacuum-assisted birth if there have\nbeen two ‘pop-offs’ of the instrument.",
  "This reduces the need for instru-\nmentation.\nAllow delayed pushing (passive second stage)\nin women with epidural analgesia. This may\nreduce the need for rotational and mid-pelvic\nassisted vaginal birth.\nDo not routinely discontinue epidural analgesia\nduring pushing as this increases the woman’s\npain with no evidence of a reduction in the\nincidence instrumental delivery.\nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\n\n--- Page 2 ---\n336\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nOperators should appreciate that no indication\nforinstrumental delivery is absolute, and that\nprudent clinical judgment is required in each\nsituation.\nSuspected fetal bleeding disorders and pre-\ndisposition to fractures are relative contrain-\ndications for assisted vaginal birth.\nPresence of blood borne viral infection in a\nwoman is not an absolute contraindication for\nassisted vaginal birth.\nVacuum is not contraindicated following a fetal\nblood sampling or application of a fetal scalp\nelectrode.\nThere is a higher risk of sub-galeal haemorrhage\nand scalp trauma with vacuum extraction\ncompared to forceps at preterm gestation.\nVacuum is contraindicated below 32 weeks\nof gestation and should only be used with\nextreme caution between 32+0 and 36+0.\nSafe assisted vaginal birth requires not only\ntechnical expertise, but also careful assessment\nof each clinical situation, clear communication\nwith the woman and other healthcare personnel.\nUltrasound assessment of the fetal head position\nprior to assisted vaginal birth can be attempted\nwhere uncertainty exists following clinical\nexamination.\nRoutine use of abdominal or perineal ultrasound\nfor assessment of the station, flexion and\ndescent of the fetal head in the second stage is\nnot recom mended and is not a substitute for\nclinical examination.\nFor procedures in the labour room, verbal\nconsent should be obtained and documented in\nthe notes.\nWhen mid-pelvic or rotational birth is indicated,\nthe risks and benefits of assisted vaginal birth\nshould be compared with the risks and benefits\nof second stage caesarean section, for the given\ncircu-mstances and skills of the operator.\nPrior written consent is recommended for a trial\nof assisted vaginal birth in the operating theatre.\nOperators must achieve expertise in spon-\ntaneous vaginal birth prior to commencing\ntraining on assisted vaginal birth.\nNon-rotational low-pelvic and lift out assisted\nvaginal births have a low probability of failure,\nhence most procedures can be attempted safely\nin the labour room.\nAssisted vaginal births that have a higher risk\nof failure should be termed a trial of instru-\nmental delivery and is best attempted in an\noperation theater, where immediate CS can be\nresorted to.\nThe operator should choose the instrument most\nappropriate to the clinical circumstances and\ntheir level of skill.\nForceps and vacuum extraction are associated\nwith different benefits and risks.\nFailure to complete the birth with a single instru-\nment is more likely with vacuum extraction, but\nmaternal perineal trauma is more likely with\nforceps.\nSoft cup vacuum extractors have a higher rate\nof failure but a lower incidence of neonatal\nscalp trauma.\nRotational births should be performed by\nexperienced operators; the choice of instrument\ndepending on the clinical circumstances and\nexpertise of the individual.\nThe options include, Manual rotation followed\nby direct traction with forceps or vacuum,\nRotational vacuum extraction or Kielland’s\nrotational forceps.\nIt is recommended to complete vacuum-\nassisted birth with not more than three pulls to\nbring the fetal head on to the perineum.\n(Additional gentle pulls may be used only to ease\nthe head out of the perineum).\nIf there is minimal descent with the first pull of\na vacuum, consider if the application is sub-\noptimal, the fetal position has been incorrectly\ndiagnosed or if there is cephalopelvic dispro-\nportion.\nDiscontinue vacuum-assisted birth where there\nis no evidence of progressive descent with\nmoderate traction during each pull of a correctly\napplied instrument.\nDiscontinue vacuum-assisted birth if there have\nbeen two ‘pop-offs’ of the instrument.\n\n--- Page 3 ---\n337\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n5.  Avoiding assisted vaginal birth\nEvidence suggests, continuous one to one care and labour companionship can reduce the need for assisted\nvaginal birth4. Use of epidural analgesia may increase the need for instrumental delivery5. Adopting an upright or\nlateral position during second stage reduces the need for assisted vaginal delivery6. If on epidural it is not\nrecommended to routinely discontinue during second stage, as this will not reduce need of assisted vaginal\ndelivery but increases pain and distress to the woman7.\nThe use of sequential instruments is associated\nwith an increased risk of trauma to the infant\nas well as obstetric anal sphincter injury\n(OASI). Operator needs to balance the risks of\ncaesarean birth vs forceps following failed\nvacuum and may consider forceps extraction.\nAbandon forceps delivery when the forceps\ncannot be applied easily, the handles do not lock\nor if there is lack of progressive descent with\nmoderate traction and birth is not imminent\nfollowing three pulls with a correctly applied\ninstrument by an experienced operator.\nDiscontinue rotational forceps birth if rotation\nis not easily achieved with gentle pressure.\nIf there is minimal descent with the first pull of\ntheforceps, consider if the application is\nincorrect, the position has been incorrectly\ndiagnosed or there is cephalopelvic dispro-\nportion.\nThere is increased risk of fetal head impaction\nat caesarean birth following a failed instrumental\ndelivery and the operator should be prepared\nto disimpact the fetal head using recognized\nmaneuvers.\nMediolateral episiotomy should be discussed\nwith the woman and tailored to the circum-\nstances.\nWhen performing a mediolateral episiotomy, the\ncut should be at a 60-degree angle to the midline\nand initiated when the head is crowning the\nperineum.\nA single prophylactic dose of intravenous\namoxicillin and clavulanic acid should be\nconsidered following assisted vaginal birth as it\nsignificantly reduces confirmed or suspected\nmaternal infection compared to placebo.\nReassess women after assisted vaginal birth for\nvenous thromboembolism risk and the need for\nthromboprophylaxis.\nHighlight the risk of urinary retention and the\nimportance of bladder emptying in the\npostpartum period. Timing and volume of the\nfirst void urine should be monitored and docu-\nmented.\nA post void residual should be measured if\nurinary retention is suspected.\nFor women who had regional analgesia for a\ntrial in theatre, recommend indwelling catheter\nin situ following birth, to prevent covert urinary\nretention.\nReview women before hospital discharge with\na confirmatory vaginal examination. Discuss the\nindication for assisted vaginal birth, management\nof any complications and advice for future\nbirths.\nDocumentation for assisted vaginal birth should\ninclude information on the assessment, decision\nmaking and conduct of the procedure, a plan\nfor post natal care and information for subse-\nquent pregnancies – standardized proforma is\nrecommended.",
  "Timing and volume of the\nfirst void urine should be monitored and docu-\nmented.\nA post void residual should be measured if\nurinary retention is suspected.\nFor women who had regional analgesia for a\ntrial in theatre, recommend indwelling catheter\nin situ following birth, to prevent covert urinary\nretention.\nReview women before hospital discharge with\na confirmatory vaginal examination. Discuss the\nindication for assisted vaginal birth, management\nof any complications and advice for future\nbirths.\nDocumentation for assisted vaginal birth should\ninclude information on the assessment, decision\nmaking and conduct of the procedure, a plan\nfor post natal care and information for subse-\nquent pregnancies – standardized proforma is\nrecommended.\n\n--- Page 4 ---\n338\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n7.  The performing clinician should take\na relevant concise history and carry out\nsystematic examination to identify any\ncontraindications:\n•\nCheck obstetric, general, and medical history.\n•\nBirth weight of previous baby/babies and\nassessment of EFW in the index pregnancy.\n•\nAssessment of progress in the first stage (noting\nsecondary arrest).\n•\nAssessment of second stage of labour.\n•\nAssessment of frequency and strength of uterine\ncontractions and noting any contraindications\nfor the use of oxytocin infusion.\n7.1  Assessment of feto-maternal status\n•\nEvaluation of the physical and emotional state\nof the mother and her ability to participate\nactively in birth.\n•\nGive clear explanation and obtain informed\nconsent and document on her hospital notes.\n•\nReduce maternal discomfort by administering\nappropriate analgesia (Consider local or\nregional).\n•\nConfirm the bladder is empty. If on catheter,\nremove it or deflate the balloon.\n•\nNote colour of amniotic fluid for the presence\nof meconium or blood.\n•\nAssessment of fetal wellbeing.\n•\nAlways use aseptic techniques.\nFetal head is no more than one-\nfifth palpable per abdomen\nLeading point of the skull is at\nstation 0 or +1cm\nTwo subdivisions:\n1. Non-rotational ≤45°\n2. Rotational >45°\nFetal scalp visible without\nseparating the labia\nFetal skull has reached the perineum\nRotation does not exceed 45°\n6.  Classification of  instrumental delivery as outlet, low and mid cavity assisted birth\nin forceps delivery\nFetal skull is at station\n+2cm, but not on the\nperineum\nTwo subdivisions:\n1. Non-rotational ≤45°\n2. Rotational >45°\nOutlet\nLow\nMid\n7.2   Abdominal examination\n•\nEstimated fetal weight.\n•\nAssessment of engagement of the fetal head,\ndescent, the number of fifths palpable abdo-\nminally. The head should be ≤1/5 palpable per\nabdomen.\n•\nIdentification of the position of the fetal back\nand sinciput, (This examination is not always\npossible, but an attempt should be made).\n•\nExamination for distension of the lower uterine\nsegment or formation of a retraction ring\n(Bandl’s ring), indicating labour may have\nbecome obstructed.\n7.3  Vaginal examination\n•\nTo confirm full dilatation of the cervix and\nstation of the presenting part (should be at or\nbelow spines).\n•\nGrade the degree of moulding as mild, moderate,\nor severe.\n•\nNote the position, extent of de-flexion and\nasynclitism of fetal head. (see below)\n•\nEstimate the capacity of the pelvis relative to\nthe size of the baby. Special note of pubic arch\nand sacrospinous ligaments.\n•\nAccurate account of the findings should be\ndocumented. (Lack of appreciation of the\nsituation and delivery by wrong method in\nwrong place by inexperienced staff can cause\nincreased fetal and maternal morbidity.)",
  "Special note of pubic arch\nand sacrospinous ligaments.\n•\nAccurate account of the findings should be\ndocumented. (Lack of appreciation of the\nsituation and delivery by wrong method in\nwrong place by inexperienced staff can cause\nincreased fetal and maternal morbidity.)\n\n--- Page 5 ---\n339\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n5.\nBlood-stained urine.\n6.\nBleeding from the vagina.\nNote: Severe or increasing moulding of the head that\nfails to rotate descend despite of strong uterine\ncontractions is also a clinical finding suggestive of\nCPD/obstructed Labour.\n•\nIf a diagnosis of obstructed labour is made,\ndelivery should be undertaken immediately by\ncaesarean section.\n7.6  Estimation of the level of fetal head – Per\nAbdomen (P/A) and Vaginally (V/E) (This helps\nin assessment of progress at subsequent\nexamination and on decision regarding mode\nof delivery)\n1. P/A- 5/5 the fetal head is completely palpable above\nupper border of symphysis pubis.\nV/E-3 cm. digital examination at this stage is hardly\npossible.\n2. P/A- 4/5 the lower portion of the head is just below\nthe upper border of the symphysis pubis.\nV/E -2cm station (difficult examination of head).\n3. P/A -3/5 Occipitofrontal diameter of the head may\nbe palpable just above the upper border of the\nsymphysis pubis.\nV/E -1cm station.\n4. P/A- 2/5 the head is engaged. On one side, usually\nthe side of sinciput, the head may be easily palpable\nwhile on the other, the side of the occiput; it may\nnot be so easily palpable.\nV/E -0 cm station.\n5. P/A -1/5 the fetal head is engaged; the head, usually\nthe sinciput, may be just palpated with the fingers\non one side only.\nV/E  +1cm station.\n6. P/A 0/5 the head is deeply engaged; neither the\nocciput nor the sinciput are palpable abdominally.\nV/E +2cm.\n• If the station is at the level of ischial spines or\nhigher vaginally, instrumental delivery is\ncontra-indicated4,5.\nIf it is necessary to deliver the baby at this\nstage, either due to maternal or fetal distress,\nit should be by a caesarean section.\n7.4  Preparation of Staff\n•\nThe operator should have necessary knowledge,\nexperience, and skill.\n•\nConfirm the adequacy of facilities and availability\nof the theatre if a need arises.\n•\nBackup plan in case of failure.\n•\nInform senior staff.\n•\nConsider complications like shoulder dystocia,\nperineal trauma, and post-partum haemorrhage.\n•\nPresence of the Neonatal team.\n7.5  Recognition of obstructed labour/CPD\nCPD may be defined as the inability of the fetus to\npass safely through the birth canal for mechanical\nreasons. These mechanical reasons include, relative\nsizes of maternal pelvis and fetal presenting part, which\nmay vary, considerably in their three-dimensional sizes\nand shapes and in the degree to which the fetal head\nmay undergo compression without injury to the brain.\nCPD is either true disproportion, when even the smallest\ndiameters of the presenting part are too big to pass\nthrough the pelvis, or relative disproportion caused by\nlarger presenting diameters of the head that are\ncommonly associated with transverse and posterior\npositions of the occiput, which results from de-flexion\nand asynclitism of the head.\nThe distinction between the two types of disproportion\nmay be impossible to make  but should be attempted\nbecause correction of the malposition in the case of\nrelative disproportion, either by enhancing uterine\ncontractions with oxytocin or by manipulating the fetal\nhead with an instrument or manually, may allow safe\nvaginal delivery of the baby. Unfortunately, there is no\nreliable test that will diagnose CPD with certainty before\nthe onset of labour. It may be suspected if there is a\nhistory of previous difficult labours or from the\nfindings on clinical examination or when delay occurs\nin the late active phase of the first stage of labour or\npelvic (Decent) phase of the second stage.\n Signs of obstructed labour\n1.\nSignificant caput and moulding.\n2.\nTenderness and ‘ballooning’ of lower uterine\nsegment.\n3.\nFormation of uterine retraction ring.\n4.\nPresence of oedema of cervix and/or vulva.",
  "Unfortunately, there is no\nreliable test that will diagnose CPD with certainty before\nthe onset of labour. It may be suspected if there is a\nhistory of previous difficult labours or from the\nfindings on clinical examination or when delay occurs\nin the late active phase of the first stage of labour or\npelvic (Decent) phase of the second stage.\n Signs of obstructed labour\n1.\nSignificant caput and moulding.\n2.\nTenderness and ‘ballooning’ of lower uterine\nsegment.\n3.\nFormation of uterine retraction ring.\n4.\nPresence of oedema of cervix and/or vulva.\n\n--- Page 6 ---\n340\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\n7.7  Use of oxytocin for slow progress in second\nstage\nUse of oxytocin (especially in a nulliparous women)\nmay be better than premature instrumental delivery with\na high fetal head station for the treatment of delay in\nthe  second stage of labour6,7,8,9.\n•\nIn a nulliparous woman with inefficient\nuterine contractions, and with absence of\nsigns of fetal distress, contractions can be\nstimulated with oxytocin to achieve 4-5\ncontractions per 10 minutes.\n•\nHowever, in a multiparous woman,\ninefficient uterine action is less common and\ncaution is required before introducing\noxytocin to increase uterine contraction due\nto risk of hypertonic contractions and uterine\nrupture. Careful assessment should be made\nby an experienced clinician/consultant, to\nexclude disproportion before administering\noxytocin for delay in the first or second stages\nof labour.\n•\nOxytocin should not be routinely used in\nwomen with previous caesarean delivery.\nNeed should be discussed with on-call\nconsultant/Senior clinician before aug-\nmentation.\n{Rate of uterine rupture doubles with use of Syn-\ntocinon after previous C/S, compared to non-use of\nSyntocinon9,10,11. Earliest signs of uterine dehiscence/\nrupture can be fetal distress, abdominal pain (in the\nregion of scar), vaginal bleeding and blood-stained\nurine. If the pain ‘breaks through’ despite epidural\nanalgesia, scar dehiscence should be considered.}\n8.  Choice of instrument\nThe choice, judgement and the skill of the operator\ndictates the outcome rather than the instrument itself.\nFollowing factors needs to be considered in decision-\nmaking:\n•\nExperience of operator.\n•\nStation and position of head.\n•\nSize of the baby.\n•\nDegree of caput/moulding.\n•\nMaternal exhaustion – physical/mental.\nVentouse is more likely to fail in the presence of\nexcessive caput. The vacuum extraction causes less\nmaternal trauma but may increase the risk of cephal-\nhematoma, retinal haemorrhage and certain types of\nintra-cranial haemorrhage in the fetus compared to\nforceps delivery12. Maternal perineal trauma is more\nlikely with forceps but ability to complete delivery with\nsingle instrument is more likely with forceps.\nRegional analgesia is advisable for difficult forceps\ndelivery when done in theater, and a pudendal block\nwhen conducted in the labour room. Ventouse extrac-\ntion can be performed without regional analgesia.\nPerineal infiltration for episiotomy would suffice.\nHowever, operator should confirm adequacy of\nanalgesia with the woman prior to application of the\ninstruments.\n•\nApplication of rotational forceps needs training and\nexperience. If not adequately trained/experienced\non the technique,  manual rotation followed by non-\nrotational forceps/ vacuum or rotational vacuum\ndelivery or LSCS would be prudent.\n9.  Trial of instrumental delivery\nAdequate assessment of the case will generally resolve\nany doubts prior to attempting an instrumental delivery.\nOperator should first ensure adequate analgesia for\nexamination has been provided. If the operator is\nuncertain about the position of the fetal head, degree\nof engagement, instrument delivery should not be\nundertaken.\nWhen the operator is uncertain about the likelihood of\nsuccess or expect a difficult delivery a formal trial of\nventouse/forceps in the operating theater should be\nattempted where immediate resorting  into caesarean\nsection can be done. Failure in the labour room without\npreparation for immediate C/S), has shown to increase\nfetal morbidity and mortality13,14.\nVacuum and forceps birth has been associated with\nhigher incidence of episiotomy, pelvic floor tearing,\nlevator ani avulsion and obstetric anal sphincter injury\ncompared to spontaneous vaginal birth. Meticulous\nexamination for perineal or obstetric anal sphincter\ninjuries (OASIS) should be undertaken. Care should\nbe taken on the management decision and expert\nopinion should be sought when in doubt.",
  "Meticulous\nexamination for perineal or obstetric anal sphincter\ninjuries (OASIS) should be undertaken. Care should\nbe taken on the management decision and expert\nopinion should be sought when in doubt.\n\n--- Page 7 ---\n341\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n9.1  Probable indications for a trial in theatre\n• Head palpable abdominally 1/5 i.e., station  +1\n(mid cavity instrumental delivery). (If the station\nof the head is higher than this, instrumental\ndelivery is contra-indicated. Beware of the caput\nat the spines, whilst the actual head is much\nhigher.)\n• Severe caput/moulding\n• Non occipito-anterior (OA) positions such as  OP\nand OT positions.\n• Deflexed/Asynclitic head.\n• Protracted 1st stage of labour, prolonged 7-10cm\ninterval.\n• Fetal macrosomia/borderline CPD. (HC ≥95th\ncentile / EFW ≥4kg/ BMI above 30.)\n• Any condition, which may lead to failure of\ninstrumental delivery.\n10.  Vacuum extraction / ventouse delivery\nRigid/soft silicon cups can be used for OA positions\nand posterior cups should be used for non-OA positions.\nHand-held vacuum cup (kiwi omni cup) can be used\nfor both OA and non-OA positions.\n10.1  Indications for ventouse delivery\n•\nDelayed  second stage\n•\nFetal distress in the second stage with fetal\nhead below ‘0’ station (see above)\n•\nMaternal conditions requiring a short second\nstage (severe PET, cardiac disease)\n•\nDelivery of the 2nd twin (only if cephalic).\n10.2  Contraindications for ventouse delivery\n•\nFace/brow/breech presentation\n•\nMarked active bleeding from fetal blood\nsampling site or maternal immune thrombo-\ncytopenia in pregnancy.\n•\nVacuum is contraindicated below 32 weeks\nof gestation and should be used with extreme\ncaution between 32+0 and 36+0 and should\nbe discussed with consultant on-call).\n•\nFetal head per abdomen >1/5 palpable.\n•\nApparent CPD.\n•\nInexperience with the use of the equipment.\n10.3  Prerequisites of ventouse delivery\n•\nFull dilatation of cervix and ruptured\nmembranes.\n•\nCareful pelvic examination to assess adequacy\nof pelvis, with special attention to architecture\nof pelvis to assess sacral hollow, ischial spines\nand sub-pubic arch.\n•\nFully engaged head and any de-flexion of head\nidentified.\n•\nFull explanation of the procedure and verbal\nconsent of the woman, and need for her co-\noperation emphasized.\n•\nGood regular contractions should be present.\n(If they are less frequent, then Oxytocin\ninfusion should be set-up and caution needed\nin  multiparous women  and women with\nprevious section).\n10.4  Basic rules\n•\nThe delivery should be completed in no longer\nthan 15 minutes following application of the\ncup. (Fifteen minutes is given as the maximum\ntime allowed, but the average time from\ninsertion of the cup to delivery is normally\nsix minutes15,16).\n•\nThe head should be delivered with no more\nthan 3 synchronized pulls with maternal\nexpulsive force.\n•\nThe procedure is abandoned if there is no\ndescent after 2 pulls (actual head should\ndescend and not just the caput).\n•\nThe cup should be reapplied no more than\ntwice (discontinue after two pop-offs).\n•\nThe cup must be applied on flexion point. (Bird\net.al demonstrated  provided the cup is applied\ncorrectly over the flexion point and traction\ndirected along the pelvic axis, autorotation of\nfetal head would occur in >90% of the fetal\nOP and OT positions17.\n•\nAnterior placement of the cup (in relation to\nflexion point) will aggravate de-flexion, and\noff-center placement of the cup will cause\nasynclitism. Both the situations will increase\nfailure rate due to larger diameter of engage-\nment and increase the chance of fetal injury.\n•\nAfter checking the correct application and\nensuring that no maternal tissue is included in",
  "(Bird\net.al demonstrated  provided the cup is applied\ncorrectly over the flexion point and traction\ndirected along the pelvic axis, autorotation of\nfetal head would occur in >90% of the fetal\nOP and OT positions17.\n•\nAnterior placement of the cup (in relation to\nflexion point) will aggravate de-flexion, and\noff-center placement of the cup will cause\nasynclitism. Both the situations will increase\nfailure rate due to larger diameter of engage-\nment and increase the chance of fetal injury.\n•\nAfter checking the correct application and\nensuring that no maternal tissue is included in\n\n--- Page 8 ---\n342\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nthe cup, pressure is raised to 0.8kg/cm2 almost\nstraightaway. There is no advantage in\nstepwise increase in pressure.\n•\nTraction on the apparatus should coincide\nwith uterine contractions and maternal\nvoluntary effort. To avoid the cup detach-\nment, ‘finger thumb’ position of the other\nhand is used.\n•\nThe use of sequential instruments is associated\nwith an increased risk of trauma to the infant.\nHowever, the operator should assess the risk\nof performing a second stage caesarean\nsection with a deeply impacted fetal head\nversus a forceps delivery following a failed\nvacuum.\n•\nBeware of shoulder dystocia, after the ven-\ntouse delivery. The association is co-incidental\nrather than causal.\n10.5   Place of episiotomy for ventouse delivery\nEpisiotomy should be discussed with the woman prior\nto any instrumental delivery and formal consent\nobtained and documented. Episiotomy is not routinely\nrequired for ventouse delivery. Clinical judgement is\nadvised.\nEpisiotomy may be necessary in case of:\n•\nRigid perineum.\n•\nBig baby.\n•\nFetal distress to hasten the delivery.\nIf the perineum seems to be splitting an episiotomy is\noften performed to limit the damage18. Episiotomy\nshould be done under anesthesia. (Local block if\nregional anesthesia is not insitu). Episiotomy is always\ngiven medio-lateral (median, increases chance of 3rd /\n4th degree tear. Premature episiotomy should be avoided\nand should be given at the time of crowning. (In case\nthe instrument fails to deliver the baby and C/S is\nrequired).\n11.  Forceps delivery\n11.1   Indications\n•\nDelay in the 2nd stage of labour.\n•\nFetal distress in the second stage.\n•\nAfter coming head of breech delivery.\n•\nMaternal conditions requiring short second\nstage.\n•\nDelivery of the head at cesarean section.\n11.2  Choice of forceps over ventouse\n•\nAfter coming head in breech vaginal delivery.\n•\nFace presentation (Mento-anterior).\n•\nPre-term infants <36 weeks.\n•\nWomen under anesthesia and unable to\ngenerate substantial expulsion.\n•\nA heavily bleeding scalp sample site.\n•\nSignificant caput in OA positions, when\nventouse cup is likely to come off.\n11.3  Pre-requisites for forceps delivery\n•\nAppropriately experienced operator.\n•\nRupture of membranes.\n•\nFully dilated cervix.\n•\nClear knowledge of the position of the fetal\nhead (use of USS will be helpful if uncertain\nfindings).\n•\nClinically adequate pelvis.\n•\nFetal head engaged at station +1 or lower\n(1/5 or less palpable abdominally).\n•\nAdequate analgesia (regional/pudendal block).\n•\nEmpty bladder.\n•\nAn adequately informed and consented\n(verbal) patient.\n•\nAvailability of pediatric support.\n(The careful abdominal/pelvic examination for the fetal\nhead station, position and fetal size is carried out as in\nventouse protocol.)\n•\nIf episiotomy is given it should be\nmeticulously sutured. Vaginal and rectal\nexamination is mandatory after instrumental\ndelivery.\n•\nThe woman and her partner if available are\ndebriefed regarding the procedure.\n•\nAccurate, legible documentation of the\nprocedure should made. Postoperative care\nplan including prescription of antibiotics,\nanalgesia and thromboprophylaxis should be\ncarried out when needed.",
  "Vaginal and rectal\nexamination is mandatory after instrumental\ndelivery.\n•\nThe woman and her partner if available are\ndebriefed regarding the procedure.\n•\nAccurate, legible documentation of the\nprocedure should made. Postoperative care\nplan including prescription of antibiotics,\nanalgesia and thromboprophylaxis should be\ncarried out when needed.\n\n--- Page 9 ---\n343\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n11.4 Management of a failed attempted\nforceps delivery\n•\nIf the forceps cannot be applied easily, or if\nthe blades does not lock, or if there is  lack of\ndecent with moderate traction and maternal\npushing, it is prudent to abandon the forceps\ndelivery and resort to an emergency caesarean\nsection.\n•\nWhen attempting rotational forceps, the\nrotation should be achieved with ease and if\nnot should discontinue the procedure.\n•\nThe procedure should be abandoned and\nresorted to an emergency caesarean section\nif the birth is not imminent even after 3 pulls\nof a correctly applied instrument and a correct\ndirection in traction.\n•\nIf resorted to an emergency caesarean section\ndue to failed forceps, the obstetrician should\nbe aware that there is an increased risk of\nhead impaction and be ready to dis-impact\nthe head with known maneuvers.\n•\nThe neonatology team should be informed\nclearly about the failed forceps as there is\nincreased risk of neonatal morbidity following\ncaesarean section for failed forceps.\n12. Prophylactic antibiotics\n•\nFollowing instrumental vaginal birth, it is\nrecommended to give a single prophylactic\ndose of intravenous antibiotics to prevent\nmaternal infection.\n•\nAmoxicillin and clavulanic acid single dose can\nbe used for this purpose after confirming\nallergy status.\n13.  Postnatal care following instrumental\ndelivery\n•\nPostnatal care following instrumental vaginal\ndelivery requires the need to assess the\nrequirement of thromboprophylaxis to prevent\nthromboembolism, adequate pain relief,\nvoiding function, pelvic floor rehabilitation and\ndebriefing about the events in current birth\nand about future births.\n•\nFor pain relief NSAIDs and paracetamol\nadministered is adequate.\n•\nRoutine bladder emptying should be\nencouraged after instrumental vaginal birth to\nprevent urinary retention. It is prudent to\ndocument the timing and the volume of the\nfirst void urine following an instrumental\ndelivery.\n14. Postnatal psychological morbidity\n•\nDifficult childbirth can leave a traumatic\nexperience in women and ultimately result in\nfear of future childbirth. It will also impact\nquality of life with her partner and family,\nultimately leading to psychological morbidity.\n•\nShared decision making with the woman,\ngood communication, and continuous support\nduring and immediately after the childbirth\nhave the potential to reduce the psychological\nmorbidity following instrumental childbirth.\n•\nIt is best practice to discuss the indications\nfor the instrumental delivery, how the\ncomplications were managed and to advise\nregarding future births. This should ideally be\ndone by the obstetrician who attended the\nprocedure.\n•\nIt should be informed that there is a high\npossibility of a successful spontaneous vaginal\nbirth in the future pregnancies.\n15.  Clinical governance\n15.1  Proper documentation\na. Documentation should include detailed\ninformation on the assessment, decision making\nand conduct of the procedure, a plan for\npostnatal care and counselling for future\npregnancies.\nb. Use of a standard proforma for this purpose is\nrecommended and is best to be audited at\nregular intervals.\nc. Training the staff with using mannequins and\naccreditation of the trainees.\n15.2  Obtaining cord blood\nd. If facilities are available, cord blood be obtained\nin  instrumental delivery, and this should include\narterial as well as venous blood sampling. The",
  "If facilities are available, cord blood be obtained\nin  instrumental delivery, and this should include\narterial as well as venous blood sampling. The\n\n--- Page 10 ---\n344\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nPH and base deficit can be documented in the\npatient operative notes.\ne. Institutes may strive to provide obstetric care\nunits with required facilities to perform cord\nblood gases.\n15.3  Risk management\nAdverse outcomes, including failed instrumental\ndeliveries, major obstetric haemorrhage, fetal injuries,\nand morbidity, OASI, shoulder dystocia and associated\ncomplications should trigger risk management meeting\nwith unit consultant. Adequate steps can be taken to\nreduce these events in the future and to properly\nmanage such complications. Frequent audits should\nbe undertaken on these complication rates and trends.\nReferences\n1.\nNHS Maternity Statistics, England 2016-17\n[https://digital.nhs.uk/data-information/\npublications/statistical/nhs-maternity-statistics/\n2016-17].\n2.\nDemissie K, Rhoads GG, Smulian JC, Balasubra-\nmanian BA, Gandhi K, Joseph KS, et al. Operative\nvaginal delivery and neonatal and infant adverse\noutcomes: population based retrospective analysis.\nBMJ 2004; 329: 24-9.\n3.\nTowner D, Castro MA, Eby-Wilkens E, Gilbert\nWM. Effect of mode of delivery in nulliparaous\nwomen on neonatal intracranial injury. N Engl J\nMed 1999; 341: 1709-14.\n4.\nNHS Maternity Statistics, England 2016-17 [https:/\n/digital.nhs.uk/ data-and information /publications/\nstatistical/nhs-maternity-statistics/ 2016-17]. last\naccessed 04 February 2021.\n5.\nPhilpott RH. The recognition of cephalopelvic\ndisproportion. Clinics in Obstet Gynaecol 1982;\n9:  609-24.\n6.\nMurphy DJ, et al. Cohort study of operative\ndelivery in the second stage of labour and standard\nof obstetric care. BJOG 2003; 110: 610-15.\n7.\nKean LH, Baker PN, Edelstone DI. Best Practice\nin Labor Ward management, Scotland: Elsevier\nScience Limited, 2002.\n8.\nO’Connel MO, Hussain J, Maeclennan FA, Lindow\nSW. Factors associated with prolonged second\nstage of labour – a case-controlled study of 364\nnulliparous labours. J Obstet Gynaecol 2003; 23:\n255-7.\n9.\nPaterson CM, Saunders NG, Wadsworth J. The\ncharacteristics of the second stage of labour in\n25,069 singleton deliveries in the North West\nThames Health Region 1988. BJOG 1992; 99:\n377-80.\n10. Arulkumaran S, Ingemarsson I, Ratnam SS. Oxy-\ntocin augmentation in dysfunctional labour after\nprevious caesarean section. BJOG 1989; 96:\n939-41.\n11. Chelmow D, Laros RK. Maternal and Neonatal\nOutcomes After Oxytocin Augmentation in Patients\nUndergoing a Trial of Labour After Prior Cesarean\nDelivery. Obstet Gynecol 1992; 80: 966-71.\n12. Weerasekera DS, Premartane S. A randomised\nprospective trial of the obstetric forceps versus\nvacuum extraction using defined criteria. J Obstet\nGynaecol 2002; 22: 344-5.\n13. Miksovsky P, et al. CME Review Article: Obstetric\nvacuum extraction: state of the art in the new\nmillennium. Obstet Gynecol Survey 2001; 56: 736-\n51.\n14. Lowe B. Fear of failure: a place for trial of\ninstrumental delivery. BJOG 1987; 94: 60-6.\n15. Johanson R, Cox C, Grady K, Howell C. Managing\nobstetric emergencies and trauma, The  MOET\nCourse Manual. RCOG Press 2003.\n16. Johanson RB, et al. North Staffordshire/Wigan\nassisted delivery trial. BJOG 1989; 96: 537-44.\n17. Bird GC. The importance of flexion in vacuum\nextraction delivery. BJOG 1976; 83: 194-200.\n18. De Jonge ETM, Lindeque BG. A properly\nconducted trial of a ventouse can prevent\nunexpected failure of instrumental delivery. SAMJ\n1991; 70: 545-6.",
  "A properly\nconducted trial of a ventouse can prevent\nunexpected failure of instrumental delivery. SAMJ\n1991; 70: 545-6.\n\n--- Page 11 ---\n \n \n \n \nAnnexure 1 \n \n345 \nVol 43, No. 4, December 2021 \nSLCOG Guideline\n\n--- Page 12 ---\n \n \n \n \n \nAnnexure 1 (Continued) \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n             \n \n               \n \n \n \n \n346 \nSri Lanka Journal of Obstetrics and Gynaecology \n SLCOG Guideline\n\n--- Page 13 ---\n \n \n \n \nAnnexure 2 \n \n \n \n \n347 \nVol 43, No. 4, December 2021 \nSLCOG Guideline  \nPOSTPARTUM BLADDER CARE FOLLOWING \nINSTRUMENTAL DELIVERY",
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  "--- Page 55 ---\n39\n\n--- Page 56 ---\n40\n\n--- Page 57 ---\n41\n\n--- Page 58 ---\n42\n\n--- Page 59 ---\n43\n\n--- Page 60 ---\n44\n\n--- Page 61 ---\n45\n\n--- Page 62 ---\n46\n\n--- Page 63 ---\n47\n\n--- Page 64 ---\n48\n\n--- Page 65 ---\n49\n\n--- Page 66 ---\n50\n\n--- Page 67 ---\n51\n\n--- Page 68 ---\n52\n\n--- Page 69 ---\n53\n\n--- Page 70 ---\n54\n\n--- Page 71 ---\n55\n\n--- Page 72 ---\n56\n\n--- Page 73 ---\n57\n\n--- Page 74 ---\n58\n\n--- Page 75 ---\n59\n\n--- Page 76 ---\n60\n\n--- Page 77 ---\n61\n\n--- Page 78 ---\n62\n\n--- Page 79 ---\n63\n\n--- Page 80 ---\n64\n\n--- Page 81 ---\n65\n\n--- Page 82 ---\n66\n\n--- Page 83 ---\n67\n\n--- Page 84 ---\n68\n\n--- Page 85 ---\n69\n\n--- Page 86 ---\n70\n\n--- Page 87 ---\n71\n\n--- Page 88 ---\n72\n\n--- Page 89 ---\n73\n\n--- Page 90 ---\n74\n\n--- Page 91 ---\n75\n\n--- Page 92 ---\n76\n\n--- Page 93 ---\n77\n\n--- Page 94 ---\n78\n\n--- Page 95 ---\n79\n\n--- Page 96 ---\n80\n\n--- Page 97 ---\n81\n\n--- Page 98 ---\n82\n\n--- Page 99 ---\n83\n\n--- Page 100 ---\n84\n\n--- Page 101 ---\n85\n\n--- Page 102 ---\n86\n\n--- Page 103 ---\n87",
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