Antenatal Screen

The antenatal screen includes the following tests:

1. CBC
2. Sickling
3. Blood Group
4. FBS
5. MSU
6. HVS
7. MTCT (HIV, HTLV 1&2, Hep B, VDRL) [within the last 6 months or one per trimester]
8. If 28 - 32 Weeks review if patient has had O’sullivan
9. Recent US

Common Gynecological Diagnosis

Incomplete vs Complete vs Missed Abortion

All forms of abortion should have the following labs done:

1. CBC
2. Blood Group
Orders:
1. Abx (Cefuroxime 500 mg PO BD x7/7 and Flagyl 500 mg PO TDS x7/7) unless it’s a
missed abortion (which is sterile).
2. Monitor PV losses
3. Panadol PRN pain

Special considerations:
Incomplete Abortion

Diagnosis confirmed by the presence of Product of Conception (POC) on the vaginal

examination.

Please note: If no POC seen - US is not enough to confirm the diagnosis, if the patient does not
have a previous US showing an initial viable intrauterine pregnancy. Thus, take a beta HCG and
indicate the time, as well as Progesterone. A 48hr repeat of beta HCG will ascertain the
diagnosis as with an abortion, the beta HCG will trend downwards.

Missed Abortion

OS closed, no POC. Unless a previous US, once again beta HCG, progesterone and time. Also
PT, PTT and INR! These patients tend to have unfavourable cervix and often need PG to ripen
the cervix to make them suitable for D+C
Abnormal Uterine Bleed

Labs:
R/o hormonal abnormality: LH, FSH, estradiol, testosterone, prolactin, beta hCG, RBS/FBS
(think PCOS), progesterone, PT, PTT, INR

Orders: Monitor PV bleed

Vomiting in pregnancy r/o hyperemesis gravidum

Orders:
Nursing: daily urine dipstick (to assess for ketones)
Diet: dry, low fat (NPO until the next morning/ consultant review)
Investigations: CBC, U/E/Cr +/- missing antenatal screen. MSU, HVS (infections can cause
vomiting)
Meds: ranitidine 50mg IV TDS
Gravol 50mg IM tds 30mins - 1 HR before meals, when settled switch to Gravel PO n Gravol IM
vomit

PPROM

Q4hrly temperature and pulse charting

Labs: CBC and ESR (q48-72 hrs)
Medication: Cefuroxime and Flagyl PO

Writing the orders for a patient for Total Abdominal Hysterectomy (TAH):
1. Please keep NPO from midnight
2. Please commence 1lDS q8hrly at 6am
3. Please give douche and enema at 9pm
4. Please repeat douche at 6am
5. Please shave suprapubic region
6. Please catheterize patient

Obstetric Case Presentations

GDM

Diagnosis made by abnormal O’sullivan followed by an abnormal glucose tolerance test.

Values for Glucose Tolerance (retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827530/):
 FBS < 92mg/dl
1hr glucose < 180mg/dl
2hr glucose < 153 mg/dl

Plan: If no previous treatment -> 1st place patient on a diet.

Diet calculated by height (measure height on ward).

Step 1 -> calculate the ideal weight for the patient based on their height

For every 5 ft = 100lbs

Multiply every inch by 5lbs
E.g. 5ft 5” = (100 + (5x5))lbs
Next Convert lbs to kg by dividing by 2.2
Finally to determine the calories per kg - multiply x 35
NB in other settings the constant chosen is based on the assessment of the patient’s weight that
is:
Underweight x 45
Overweight x25
Normal weight x 35
In grenada, multiply by 35 for all admission and round to give either 1800 kcal or 2000 kcal diet

Orders: diet - based on calculation

Daily fingerstick (NB. if the patient is placed on insulin pre-meal fingerstick is indicated)
Daily urine dipstick
Glucose profile in 48 hrs after commencement of diet/ insulin

If diet fails, the next step MIGHT be insulin. In pregnancy NPH is the insulin of choice.

Step 1: Calculate insulin requirement

Insulin requirement is 0.7 to 1.2 units/kg - based on ideal weight (45.4 + 2.3x(height in
inches-60). In Grenada 0.7 is used for all patients.

For example, a 60kg woman requires 60 x 0.7 = 42 units

Step 2: divide the required insulin in ratios 2/3rd am & 1/3rd pm

Thus, 42 units is divided 28 units in the morning and 14 units in the evening

In pregnancy NPH is given with soluble insulin. For the morning dose, you then further divide
the insulin into ⅔ and ⅓
Thus, 28 units in the morning = 18 units NPH and 10 units soluble insulin
On the other hand, for the evening dose it is divided in halves
So the evening dose = 7 units NPH and 7 units soluble insulin

Hypertension in Pregnancy

Diagnosis made < 20 weeks - Chronic Hypertension

Diagnosis made >20 weeks - Pregnancy induced hypertension

Bloods:

Baseline Preeclampsia screen (to be repeated every 3 days in antenatal):

CBC, U/E/Cr, LFT, AST, LDH, Uric acid (prognostic factor of fetal outcome), PT, PTT, INR
If Total Protein/ Albumin is low then 24 hr urine should be collected to assess proteinuria and
protein/creatinine ratio
U/E/CR (venous sample) should be taken during the collection of the 24hr urine

Orders:
1. Q8hrly vitals; q4 hr BP charting
2. Daily urine dipstick
3. Hydralazine PRN SBP >/= 160 mmHg or DBP >/= 110 mmHg (Note interns are the one
to administer Hydralazine - draw up the 1ml 20mg in 9 ml distilled water - administered
desired amount over a slow push) For example, because of the dilution to administer
5mg Hydralazine, give 2.5mg of the solution. Warn patient that headache is side effect.
4. Await senior review prior to commencing antihypertensive -
First line Aldomet.
Second line pregnant patients/ Third line postnatal - Hydralazine PO
Second line post natal Nifedipine

Note: Patient needs daily reflexes assessment.

Complication of pre-eclampsia - Glomerular Endotheliosis thus urine output should be

monitored

Post date patients

These patients are admitted for induction.

Labs: Cbc and crossmatch

Investigation: Obst USS (if none within the past week?)
Medication: IFA T PO OD; monitor for signs of labour and allow to progress