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Recent Updates in OBG | Active Management of Third Stage of Labor, PPH, PIH, APLA & moreAdded:
Hi everyone. Are you surprised seeing me now that all the test and discussion videos are done? Oh, the world of revision is done and again we are looking at ma'am why so this is because even after recording the world of revision videos there are so many updates which have come in obs and these updates are extremely extremely important which are not only for your INIC exam but also for your need PG and FMG. So here I am compiling all the updates for all my mar links at one place in obseni and and just keeping fingers crossed that now before your exam there are no more updates right so a lot many updates which I have to give you like I have to give you updates on amtsl update on bph update on the management of utrine inversion update on pH management hypermesis gravidarum and diagnostic criteria of applaimemia screening induction of labor, sana press, ACOG screening of cancer cervix and update on post-menopausal bleeding the next step in management right so let's begin one by one so let's first talk about the update which has come in active management of third stage of labor see better earlier you read I have told you in the world of revision also and in the main videos also that there are four steps in active management of third stage of labor in which the first step is you have to give injection utrotonic after the delivery of immediately after the delivery of the baby. Number two step was delayed cord clamping. Number three was delivery of the placenta by controlled cotraction or by modified brand Andrew's technique.
And number four was intermittent assessment of uterrine tone. This is something which we have done in the main videos also and we have done in world of revision as well. Now when the latest ACOG guidelines have come, latest ACOG guidelines is now considering only three steps in active management of third stage of labor. Number one is you have to give injection neutonic definitely immediately after the delivery of the baby. Number two delayed cord clamping and number three delivery of the placenta by controlled cord traction. So this step over here which is intermittent assessment of utrine tone has now been shifted to fourth stage of labor. It is not a part of active management of third stage of labor. Now this has been shifted to fourth stage of labor. So it is still done but it is now a part of fourth stage of labor. So now suppose if you get a question that all of the following are steps in active management of third stage of labor except what are you going to answer.
Please you have to remember the answer in the sequence in which I am telling you now if the best answer will be if you have any of these three in the options. If you have early cord clamping in the op option or if you have mechanical compression in the option or if you have balloon temponard in the option then that becomes your best answers. You have to choose any one of these three if it is given. Uh be rest assured it will not happen that two of them are present or three of them are present. No only any one of these would be present if present at all and if it is present then that has to be your best answer. So if a question comes that what which of the following is not a step in active management of third stage of labor best answer has to be early c clamping or mechanical compression or balloon temponad. Now suppose if any of these is not given then you have to choose the second best answer and the second best answer is utrine massage.
Remember utrine massage earlier was a part of active management of third stage of labor but later on it was shifted to treatment of pph. So it is used in the management of PPH. So if any of these three is not given then look for utrine massage. If utrine massage is given go mark that as the answer. But suppose if utrine massage is also not given then you are going to mark the answer as intermittent assessment of utrine tone.
So in this very sequence you have to mark the answers. The best answers is any one of the three early c clamping mechanical compression balloon tempon.
If that is not given look for utrine massage. If that is also not given then you are going to mark the answer as intermittent assessment of utrine tone.
Have I made myself clear to all of you?
Right. Now when we are talking about the utrotonic used for AMTSL till now in the world of revision and in the main notes I told you that the first drug which is recommended by WH and by ACOG alike is that we have to use oxytocin.
Right. But and if oxytocin is not available then you have to go for methylargometrin or you can use synometrin or you can use carbtocin misopro or and tranexymic acid plus minus in high-risk individuals we were giving trannexemic acid otherwise we were not giving trannymic acid now I'm sorry to say uh I just uh you know that was just a slip of tongue this is not AC updates this is who update so there are so many updates which are by WH there are so many by acco this particular ular update on AMTSL and PPH is by WH right.
So now WH says that whenever you are doing active management of third stage of labor you have to use any one of the following three drugs only. Now there are only three utrotonics which are recommended by WH. What are they? Number one oxytocin right? Number two is carbtocin and number three is misoprost.
So now who has said that you have to use only any one of these three drugs. You are not going to use methylerometrin right? You are not going to use syntotin. you are not going to use transexemic acid in active management of third stage of labor. So the drugs which are not used right for AMTSL as per the new recommendations. So as per the new recommendations you will not use methileometrin you will not use syntotrin beta and you will not use transexmic acid.
Please remember earlier also caroprost which is also called as hembate or doprost was not used and it was reserved for management of pps. Earlier also caroprost was not used in AMTSL. Now also carboprost is not used in AMTSL.
Caroprost is a very very good drug and it is reserved for management of BPH.
Only three drugs can be used and they are oxytocin, carbtocin and misoprost.
Now oxytocin is the first utrotonic which is recommended by WH for AMTSL.
The dose of oxytocin which is recommended by WHO for AMTSL is 10 international units. You can give it IM or you can give it as IV infusion where you have to give it slowly over 1 to 2 minutes. The preferred route is IV root.
If your patient has an intravenous access, if your patient has an intravenous line secured, then I prefer IM root or IV root over IM root. The prerequisite which says is that you are going to use oxytocin only and only if cold chain was maintained.
In other words, in your labor rooms, you have to keep oxytocin in the fridge. If oxytocin is kept in room temperature in labor room, you are not going to use oxytocin. Right? This kind of oxytocin is ineffective. And if this is the case, then instead of using oxytocin, then you are going to use carbtocin.
Carbtocin is an oxytocin.
So it's a synthetic oxytocin right? So carbtocin that's a synthetic oxytocin.
It's a synthetic analog of oxytocin.
What is the dose of carbtocin? The dose of carbtocin is 100 micrograms and you can use it IM or IV. When do you prefer carbtocin? You prefer carbtocin if cold chain of oxytocin is not maintained.
So if cold chain of oxytocin is not maintained then it's better you use carbtocin and you don't use oxytocin.
When it comes to misoprost the dose which is recommended by wh management of amtsl is 400 or 600 micrograms. Root is oral root. Please remember for active management of third stage of labor who recommends oral root.
We all know that misoprost is available in tablet format and the side effect of misoprost. What is the side effect of misoprost? It leads to hyperothermia.
This is something which you already know and it is not contraindicated in amma patients but it is contraindicated in previous cesarian section patients.
Clear to all of you? So these are the only three uh oxytoconic drugs which are recommended by WH for AMTSL.
Right? Then the second step in AMTSL is delayed cord clamping. Everything about delayed cord clamping remains the same that you call it as delayed cord clamping when you clamp the cord within 1 to 3 minutes right after delivery. If the clamp is cord is clamped within 1 to 3 minutes after delivery then that is 1 to 3 minutes of delivery then that is called as delayed cord clamping. It is preferred. Why? Because the extra 80 ml of blood goes to the newborn and it is enough to prevent neonatal anemia.
Right? What are the steps which uh so this delayed cord clamping it is included in EMTTSL and it is also included in anemia muktarat program. I hope you remember that this is an important point in anemia muktarat program. Why have we included delayed cord clamping? Because it prevents neonatal anemia and delayed cord clamping is preferred in all cases.
Now when it comes to early cord clamping, early cord clamping means when you clamp the cord within 1 minute of delivery. So if you are clamping the cord between 1 to 3 minutes of delivery, that's delayed cord clamping. If you are clamping the cord within 1 minute of delivery, then that is early cord clamping. The only absolute indication which has been told by WH for early C clamping is if baby needs neonatal resuscitation.
If neonatal resuscitation is needed then only you have to do early cord clamping.
And in which condition is neonatal resuscitation required? It is required in birth asphixia. Right? So others are relative indications. You just have to keep them in mind. But if you have to mark a single best answer for uh indication for early cord clamping, that has to be neonatal resuscitation. For example, in case of birth asphixia.
Please remember early cord clamping is not included in AMTSL.
Right? So this point over here is important because it has been written again in WH guidelines.
Next is the third step. Third step in active management of third stage of labor is delivery of the placenta by controlction or modified brand and technique. And you know what do you do there? In that case, you are going to put your one hand onto the uterus and you are going to push it up and up uh up and backwards and you are going to p give attraction to the cord in downward and forward direction. So you have to push the uterus upwards and backwards and you have to give a traction to the cord in downward and forward direction. Right?
This is what is called as controlled cotraction or modified brand Andrew's technique. So, WHO says that it should be done only if a trained birth attendant is available.
Right? So, it has to be done only by a trained birth attendant. Right? So, if a trained birth attendant is not there, right? Then control should not be done.
Then it is the preferred method of placental delivery during cesarian section. Obviously cesarian section will be done by a gynecologist right or by a surgeon. So yes during cesarian section this is the preferred method of placental delivery. Clear? So these are the three steps which are now included in AMTSL.
Remember that intermittent assessment of utrine tone is now a part of fourth stage of labor. We still do intermittent assessment but we don't count it in third stage of labor active management.
We count it as a part of fourth stage of labor. What is fourth stage of labor?
Fourth stage of labor is that period after delivery where you are observing the patient for 1 to two hours. So when you observe the patient by period 1 to 2 hours after delivery where you are going to observe the patient for any kind of complication that is the fourth stage of labor. Now there are updates which are there on PPH very very important updates which you should be doing and number one update is on definition of PPH. Now till now in the world of revision also and in the main notes also I told you that PPH is if blood loss is more than equal to 500 ml. So if it is more than equal to 500 ml after vaginal delivery and or more than equal to 1,000 ml after cesarian section right and then uh ACOG came up with the definition ACOG said nothing like vaginal delivery or nothing like cesarian section if blood loss is more than equal to 1,000 ml after vaginal delivery or after cesarian section we are going to call it as PPH.
Now every time I've told you that WH and ACOG they never agreed to there they never agree with each other. Now when ACOG said that we are not going to take care whether it is vaginal delivery or whether it is cesarian section if blood loss is more than equal to 1,000 ml it should be called as PPH. Now WH was not agreeing with what ACOG said. So now what did WH say? WH now gave a new definition.
We are also now not going to take into consideration whether it is vaginal delivery or cesarian section. We will also give one definition for both of them. And the definition which has been given by WH for both of them is if blood loss is more than equal to 500 ml after vaginal delivery or after cesarian section. Not only this, who also said that you have to objectively see how much blood loss is happening and if blood loss is more than equal to 300 ml and if there is any one of the following. So either blood loss has to be more than equal to 500 ml to be called as PPH or blood loss has to be more than equal to 300 ml with any one of the following. And what is that?
Anyone of the following. Number one, systolic BP less than 100 mm of mercury.
So you know this is a sign of shock, right? Number two, diastolic BP less than 60 mm of mercury.
Pulse rate more than equal to 100 per minute or shock index more than one. So if any of these signs of shock are present, what are these signs of shock?
Systolic BP less than 100 mm of mercury less than equal to 100 mm of mercury.
Diastolic BP less than 60 mm of mercury.
Pulse rate more than 100 beats per minute and a shock index more than one.
So either your patient should have blood loss more than equal to 500 ml or she should have blood loss more than equal to 300 ml with any one of the following.
Whichever amongst these occurs earlier, I'm going to say my patient has gone into PPH. So I hope it you've understood the definition of PPH. Now the definition of PPH is blood loss more than equal to 500 ml be it vaginal delivery or be it cesarian section or blood loss more than equal to 300 ml with any one of these four signs. Right now now comes management of PPH. In the management of PPH again nothing has changed as far as the initial management of PPH is concerned. When I did initial management of PPH I told you that the first step is maternal resuscitation and in maternal resuscitation I told you that you have to put two large B IV canulas that is canula number 14 or canula number 16 right and you have to uh you know start IV fluids you have to arrange for blood. Then I told you simultaneously you have to do a massage of the uterus right and initially the massage which you are doing is a uterine massage and once you are confirmed that it is atonic PPH you are going to do a bmanual massage. In bmananual massage you press the uterus you take your hand inside the uterus and the other hand is behind the uterus. So one is inside the uterus vaginally the other one is behind the uterus per abdominally and you massage the uterus. And the third thing which you do is you give her oxytocin and tranexemic acid. So this step had to be done together. Maternal resuscitation number one. Number two you had to give a banual utrine massage. Right? Uh once the diagnosis of atonic PPH was confirmed and you also had to do go for oxytocin plus triexmic acid. Now instead of saying all this separately, now these things have been consolidated in a bundle which is called as motive bundle.
Right? So now who has given a name to this first step it has said that so that you don't forget that there are in total five things which you have to do together. It has clubbed all those five things and it has given it a name which is called as motive bundle. What is this motive bundle? This motive bundle is M for massage of the uterus.
Right? O for oxytocin in other words utrotonic drugs. T for transexymic acid.
IV for IV fluid and E for examination and escalation.
So you have to examine your patient and you have to escalate this motive bundle.
Right? Now when it comes to utrine massage, utrine massage has to be done per abdominally and it is recommended by WH.
Right? This uterine massage will help the uterus to contract also and it will also help you in making a diagnosis that whether you are dealing with traumatic PPH or atonic PPH because if the tone of the uterus is normal that means you are dealing with traumatic PPH and if tone of the uterus is decreased that means you are dealing with atonic PPH right?
So, WH says that yes, when your patient goes into PPH, you have to do a utrine massage. But this bimmanual massage is not recommended in motive bundle, right? Bimmanual massage was when your one hand was inside the uterus per abdominally uh was inside the uterus per vaginally and your other hand was behind the uterus per abdominally. Right? That was a bmanual massage. Bimmanual massage is not recommended in motive bundle. Per abdominal utrine massage is recommended.
I hope I've made myself clear to all of you. Right? Now, when it comes to tranexemic acid, you have to give tranexymic acid within 3 hours of delivery. Right? Within 3 hours you have to give it. Then only its effect will be the maximum. The IV fluid which you have to give are crystalloids. And when you are going to examine the patient, you have to examine the patient number one for the tone.
Number two for any retained product of the placenta, right? Or any membrane which has been retained. And number three, you also have to examine the patient for any tear which has happened vaginally. Yeah.
Cervitally, right? So you have to do this much of examination. Clear to all of you? So the first step is a combination of five steps which together come under this bundle which is called as the motive bundle. Right? Now what are the utrotonics which are recommended by WHO for management of PPH? Number one utrotonic recommended is oxytocin right as I told you you have to give 10 international units which you can have to give either IM or by IV infusion.
Number two you can give methylerometrometrin was not used for AMTSL but it can be used for PPH. Similarly number three syntotin which is a fixed dose combination of oxytocin and methylerometran. It was not used in amtsl but it can be used in management of pph. Number four is misoprost. Now when it comes to misoprost the dose of misoprost which you have to use for management of pph is 800 micrograms and you have to give it by sublingual root.
Right? For AMTSL the dose was 400 or 600 micrograms and you were giving it orally right. And number six drug which you can give is carboplast. Please remember that the carboplast dose which you have to give is still the same. It is 250 micrograms which you have to give. You are going to give it intramuscularly.
You can repeat it in every 15 to 90 minutes and you can give maximum eight doses which means maximum you can give 2 mg and you know that it is contraindicated in bronchial amma patients. If they ask you a question that there is a hypertensive female who is having PPH which drug is contraindicated beta then the best answer I've already told you is methile erometrin and if methile erometrin is not given in the options then the second best answer is carborrost.
Carboroprost is PGF2 alpha and it is also called as doprost or hebate. It is not doproone.
Right. Now the utrotonics which are not recommended for management of PPH.
Number one carbtocin. Carbtocin which I told you is a synthetic oxytocin. It is used for management of active management of third stage of labor but it is not used in the management of PPH.
Dinoroprost I told you is used for induction of labor and for the ripening of cervix. It is not used either in AMTSL nor it is used in PPH. Right? Then now comes the algorithm for management of PPH. Again I want all of you to just revise this algorithm with me and simultaneously I will tell you what are the changes which have come in the management of PPH. So number one step or the first step is the motive bundle right where I told you M was for massage, O was for oxytocin, T was for tranexymic acid, IV was for IV fluids and E was for examination. Now if it fails then you go to the second step and what is the second step? Second step is mechanical compression and this mechanical compression is done with the help of balloon temponard.
Write mechanical compression or balloon tempard with the help of bakery balloon catheter.
Right?
Okay.
Now if that also fails then you go to the third step. What is the third step?
You are going to shift your patient to OT and you are going to do a leprotomy.
I am going to take out the uterus and I am going to apply stitches on the uterus like this which is called as the blink suture.
All of you know that suppose your roommate falls and she has bleeding from her forehead. First you try to press it and that is why we did mechanical compression with the help of battery balloon catheter. But if the bleeding doesn't stop from forehead what do you do? you take your patient to emergency so that the stitches can be applied.
Same thing I'm doing over here. I'm taking my patient to OT and I am applying stitches onto the uterus which is called as being suture. But please understand for leprotomy you have to wait for the anesthetist you have to wait for uh the consultant to arrive you have to you know do arrangements for leprotomy. Now, WH says that while you are doing arrangements for leprotomy, there are certain temporary methods which can be applied to decrease the blood loss and there are three temporary methods which are recommended by WH which can be done while you are waiting to do leprotomy. All right. So these are temporary methods. What are these temporary methods? Number one by manual compression. So do you see that WH has removed bmananual compression from the management of PPH and it has brought it to temporary management of PPH right? So whenever I have to temporarily close the blood loss I can go for a bimmanual compression or I can go for external iota compression or I can use military non-neumatic anti-shock garment. So this is a military non-neumatic anti-shock garment. The method which is not recommended by WH that is utrine packing.
So this is a method which is not recommended by WH. So first step was motive bundle. If it fails then you go to b then you go to the mechanical compression or balloon temponad. If that fails then you go for beg sutures. Now if this also fails then what do you do?
Then the next step is you have to go for stepwise devascularization surgery.
stepwise devascularization surgery.
Right? And in stepwise devascularization surgery the arteries which are liated the first artery to be liated is utrine artery because the major blood supply to the uterus is via utrine artery. And if bleeding does not stop then the second artery which you have to liate is the utrovarian anasttomotic branch.
Right? Now if still bleeding does not stop. Right? So if bleeding does not stop now at this point of time it becomes very very important for us that patient has been bleeding for so long let me see the vitals of the patient if vitals of my patient are stable then I'm going to go to the next step which is liation of anterior division of internal iliac artery we all know that utrine artery is a branch of the anterior division of internal iliac artery. So if the vitals of my patient are stable, I'm going to go for liation of anterior division of internal iliac artery. But if vitals of my patient are not stable, I will immediately go to subtotal hyerectomy.
Right here also if lation of internal iliac artery fails then you have to go for subtotal hyctomy. Please remember this is the protocol for management PPH.
Now some updates on the on the definition of hypermesis gravidarum and the diagnostic criteria for appla. Now till now I had told you that hypermesis gravidarum is excessive nausea and vomiting which happens and that leads to weight loss or if it leads to ketoora that is what is hyperemmesis gravidarum because we know that nausea and vomiting is a common symptom in pregnancy. So to differentiate the normal morning sickness which is happening or the nausea and vomiting of pregnancy which is happening from hyperemmesis graidorum we said that if there is excessive nausea and vomiting leading to weight loss or leading to keonora that was called as hypermesis graidorum. Now ACOG has very specifically said that let us give a proper definition of hypermesis gravidarum and the proper definition of hyperemmesis gravidarum which acco has given is that if there is excessive nausea and vomiting with any one of the following number one persistent vomiting. How do you define persistent vomiting? If vomiting is happening more than three times in a day then that is what is called as persistent vomiting or if it is leading to weight loss more than equal to 5% of pre-reg weight or total of weight loss more than equal to 3 kgs. So number one if your patient is having excessive nausea and vomiting with persistent vomiting. Persistent vomiting means if the vomiting is happening more than equal to three times in a day or if there is excessive nausea and vomiting such that it is leading to weight loss in pregnancy instead of weight getting gained weight is losing in pregnancy and how much weight loss more than equal to 5% weight loss or if in kgs if I have to tell then it has to be more than equal to 3 kg of weight loss or number three if it is leading to keonoria or number four if it is leading to dehydration or electrolyte imbalance.
Right?
Now if with excessive nausea and vomiting any one of these things is present any one of these then you call it as hypermesis graviderum. Next thing which they said that any female who's coming to me with nausea and vomiting I should be doing a scoring system and the name of the scoring system is puke score.
Puke you all know it's P K the English word puke for vomiting. So they have given P U as the puke scoring system.
Now if score is less than equal to seven that means your patient is having mild nausea and vomiting that is the morning sickness which your patient is having and you know that whenever a female comes to you with morning sickness. What is the first line of management? First line of management is always diet modification where you tell the female that she should not be having any spicy food. She should avoid having um you know fatty food. She should avoid having a lot of food at one time. Right? Now if diet modification is helpful, it's good.
But suppose diet modification is unable to control her vomiting. Then the drug which you have to give is a combination of pyoxin plus doxyamine.
So ACOG has specifically said that this combination is better than pyrooxin alone right. So if it is if the score is less than seven you just need to treat it like morning sickness. Now if score is between 7 to 12 that means this is moderate kind of vomiting which your patient is having. In this case the first line drug which you have to give is H1 antagonist right and if that is not helpful then the second line drug which you give is metagoprooide.
Metacloropramide I have to be little careful about the extra pyramidal side effects. Right now if score is more than equal to 13 that's severe vomiting and that is typical hypermesis gravidarum and in this case you have to admit the patient you have to give her IV fluids because you are going to put her NPO and you are going to give IV on densetron right so this is how you have to manage hypermesis gravidarum or vomiting in pregnancy based on puke score. Puke score less than seven that means that's the normal morning sickness which is happening. First you have to advise diet modification and if that doesn't work you have to go for pyroin plus doxyavine. If score is 7 to 12 that means moderate vomiting you have to give H1 antagonist and you can also give her metagomide right then if score is more than equal to 13 then you have to go for NPO you have to admit her you have to give her IV fluids and you have to give her IV on Cetron I hope I'm clear with hypermesis gravidarum right then now appla in appla we have a new criteria which has come up. But before I tell you the new criteria, I want all of you to revise the overview of AppLa with me. What happens in Appla? I told you in APLA there are three types of antibodies which can be present, right? And what are these antibodies? They are anti-lupus and so it is lupus anti-coagulant antibbody.
So it's lupus anti-coagulant that's the first antibbody which can be present or it can be anticardiolippin antibbody or anti-b2 glyoprotein antibbody. Now although the name is anti-coagulant but what do these antibodies do? These antibodies they bring about thrombosis.
Thrombosis can happen in any artery or any vein. And why do I teach you uh appla? Because it leads to placental thrombosis. Right? Now, because it leads to placental thrombosis, what is going to happen? If there is placental thrombosis, the blood flow to the fetus will decrease. So, I can say that there will be utroplacental insufficiency.
Right? There can be IUGR and you know that three things which come in the same spectrum are PIH, utplacental insufficiency, IUGR. So because there is placental thrombosis, this placental thrombosis can lead to utplacental insufficiency which can lead to IUGR which can lead to PIH also. Right? All these things can lead to pre-term labor.
Number two, this is if blood flow to the fetus is decreased. Suppose the blood flow to the fetus is absolutely stopped.
If blood flow to the fetus is absolutely stopped, it is going to lead to fetal loss.
Now this fetal loss can happen at less than 10 weeks or it can happen at more than 10 weeks.
Right? So now till now the criteria which we were using was the Sydney criteria or we were using modified sapros criteria. And what did Sydney criteria or modified SAPro criteria said? It said that there has to be a lab criteria and there has to be a clinical criteria. one lab criteria and one clinical criteria to make a diagnosis of appla lab criteria it said that if any of these three antibodies are present on two occasions 12 weeks apart right so any of these three antibodies lupus anti-coagulant anticariolippin antibodies or anti-beta 2 glyoprotein antibbody on two occasion 12 weeks apart. And what was the clinical criteria? Clinical criteria, any one of these four criterias. And what were the four criterias? Number one, thrombosis in any artery or anyway, right? Number one criteria. Number two, pre-term labor which is happening because of utroplacental insufficiency of PIH. And this pre-term labor should happen at less than 34 weeks. So any pre-term labor which is happening at less than 34 weeks which is happening due to utroplacental insufficiency or PIH that was the second criteria. Third criteria was if there is one or more than one fetal loss which happens at more than equal to 10 weeks. Right? So I'm not writing two over here because otherwise you will confuse. Two pre-term labors are required. Right? So first criteria is thrombosis in any artery or vein.
Second criteria is one episode of pre-term labor which is happening due to PIH or utplacental insufficiency. Third criteria is fetal loss more than equal to 1 happening at beyond 10 weeks or fetal loss more than equal to three happening at less than 10 weeks. So these were the four clinical criterias.
What were the four clinical criterias?
Number one, episode of arterial or venus thrombosis. Right? one or more episode number two one or more episode of pre-term labor which is happening due to utroplacental insufficiency or PIH number three one or more than one fetal loss which is happening beyond 10 weeks of pregnancy and number four three or more than three fetal losses which are happening at less than 10 weeks of pregnancy now so now what changed change has come. The change which has come is number one they are saying that instead of 10 weeks now it should be 15 weeks.
That means now the new criteria which is called as ACR criteria or the ULAR criteria American college of rheumatology your European college of rheumatology right so European criteria so whether it is the ACR criteria or the ULAR criteria both of them say that now if your patient is having three or more than three fetal losses which are happening at less than 15 weeks.
One or more than one fetal loss which is happening at more than equal to 16 weeks instead of pre-term labor. So now they are not saying it should be pre-term labor. Now they are saying that your patient should have severe utroplacental insufficiency or severe PIH happening at less than 34 weeks. So instead of pre-term labor now they are saying that your patient should have severe utroplacental insufficiency or severe PIH which is happening at less than 34 weeks. It can be or either of them or it can be both of them together.
Right? Then fetal loss three fetal losses happening at less than 15 weeks.
Now it's not less than 10 weeks or more than equal to one fetal loss which is happening beyond 16 weeks. Have you understood the new criteria? So let's deep dive into it. So the Sydney criteria or the modified sapro criteria.
What was the criteria? More than equal to one episode of arterial or venus thrombosis. more than equal to one episode of preterm labor which was happening due to utroplacental insufficiency or PIH more than equal to three fetal losses which was happening at less than 10 weeks and more than equal to one fetal loss which was happening at more than equal to 10 weeks right plus lab criteria lab criteria if any one of the three antibodies is present on two occasions 12 weeks apart so Sydney criteria said that you needed one clinical criteria plus you needed did one lab criteria.
Similarly, ACR or Uler criteria says you need one clinical criteria and you need one lab criteria. Lab criteria is still the same. Now, what change has come in the U clinical criteria? Number one criteria is the number one criteria is three or more than three fetal losses happening at less than 15 weeks. Number two is more than equal to one fetal loss happening at 16 weeks or more than 16 weeks.
Number three, severe preeacclampsia happening between 16 to 34 weeks or severe UPI happening between 16 to 34 weeks. And number four is severe preeacclampsia between 16 to 34 weeks and severe utroplasental insufficiency between 16 to 34 weeks. Right? So either of these criteria any one criteria is required along with lab criteria to say that your patient is having appla right now coming to updates on PIH extremely extremely important updates right I hope till now all the updates are clear to all of you please remember ACR and Ular criteria probably I have also given in your world of revision notes Now till now we were talking about PIH and we said that there are two terms. One is chronic hypertension in pregnancy and the other one is your PIH. What was chronic hypertension beta? Chronic hypertension was if a hypertensive female conceives, right?
And if a hypertensive female conceives, her BP will be increased from day one of pregnancy. In other words, the increase in BP will be seen before 20 weeks of pregnancy.
Right?
Then BP does not come back to normal by 12 weeks of delivery. So the criteria for till now we were saying chronic hypertension means that a hypertensive female has conceived right her BP is increased. And how do you define increased BP? BP more than equal to 140 by 90 on two occasions 4 hours apart.
Right? And this increase in BP should happen from day one of pregnancy. In other words, the increase in BP is happening before 20 weeks of pregnancy and BP does not come back to normal by 12 weeks of delivery. In case of chronic hypertension, there was no proteinora and no signs of end organ damage. When it comes to PIH, PIH means that a normal tensive female has conceived. But because of some problem in the placenta about which I have told you in detail in your main videos as well as in your revision videos, I told you that the increase in BP will be seen after 20 weeks.
So this female was absolutely normotensive. Her BP is increasing because of placental problem. And what was that placental problem? That placental problem was AB that was not proper vascular remodeling. Right? So incomplete trophoblastic invasion or incomplete vascular remodeling. Right? So because of that incomplete trophoblastic invasion her BP increases but the increase in BP is seen after 20 weeks of pregnancy. And once the placenta is out, BP comes back to normal within 12 weeks of delivery. This is something which I had done with you in your main videos also and revision videos also.
Now the first change which has come is that now they say that the BP should come back to normal within 6 weeks of delivery. This 12 has been changed to six.
So in chronic hypertension BP does not come back to normal by 6 weeks of delivery. Whereas in PIH that is pregnancy induced hypertension BP comes back to normal by 6 weeks of delivery.
It is not 12 weeks of delivery. That's the first change which has come in PIH.
Second change you know that PIH is of two varieties in turn. One is preeacclampsia, one is gestational hypertension. What is preeacclampsia and what is gestational hypertension? In both of them, the increase in BP is seen after 20 weeks.
Right? And BP comes back to normal within 6 weeks of delivery.
That is a common point for both of them.
In both preeacclampsia and pia uh gestational hypertension this is going to happen. What is the difference? The difference is in case of preeacclampsia proteinora is present or signs of end organ damage are present. Whereas in case of gestational hypertension neither do you get proteinora nor do you get signs of end organ damage. That is why any female whose BP is increased, you have to check for proteinora. And for proteinora, what was the screening test?
The proteinora screening test was dipstick.
Urine dipstick. Now in urine dipstick, the guidelines now are saying these are foxy guidelines.
These are our national guidelines. And wherever we have our national guidelines, we have to follow them.
Right? So urine dipstick more than equal to + one. Right? So protein ora is if urine dipstick is more than equal to + one. Then you knew that if screening test is positive, you have to go for a diagnostic test. And diagnostic test till now was 24 hours urine protein excretion. And I told you that if urine protein excretion is more than equal to 0.3 g in 24 hours then that was what was called as proteinora. That was a diagnostic test. But for this diagnostic test I had to collect a urine sample for 24 hours and then I had to send it for the protein estimation. Now Foxy says that at many places this might not be possible that you tell the patient to collect protein your urine sample for 24 hours. That is why now the recommended diagnostic test by Foxy is not 24 hours urine protein sample. Now it is urine protein is to creatinine ratio or urine albumin is to creatinine ratio. Urine protein is to creatinine ratio is called as abnormal if it is more than equal to 30 mg per mill mole and urine albamin is to creatinine ratio is called as abnormal if it is more than equal to 8 mg per mill mole. Have you understood better? So this is now what is the recommended diagnostic test instead of 24-hour urine protein sample. Clear?
Now next was mild versus severe preeacclampsia. Now in mild preeacclampsia uh and severe preeacclampsia also the definition has changed. Now the definition for mild preeacclampsia mild preeacclampsia can also be called as preeacclampsia without severe features.
Now for mild preeacclampsia the definition is BP less than equal to 140 by 90. Right? So BP has less than equal to 140 by 90. Plus there should be no premonetary symptoms.
No premonetary symptoms and plus no abnormal lab investigations.
All three should be present only if all these three things are present then you call it as mild preeacclampsia. So Foxy is saying that you just don't need the BP criteria.
Foxy has said that BP should be more sorry I'm really sorry but I here BP should be more than equal to 14090 but less than 160 by 110. So BP more than equal to 14090 but less than 160 by 110.
But along with that two more things should be there. There should be no premonitory symptoms and there should be no abnormal lab investigation. Have you understood this? Now you will ask me ma'am what is the premonetary symptoms and what are the abnormal lab investigations? Just now I'll tell you.
Now severe preeacclampsia definition has also changed. Severe preeacclampsia is if BP is more than equal to 160 by 110.
either this or if BP is more than equal to 14090 but less than 160 by 110 then either your patient is having pre-monetary symptoms or abnormal lab finding then also they will be counted as severe preeacclampsia even if BP is less than 160 by 110 but your patient has premonetary symptoms or your patient has abnormal lab findings still you are going to call her as a case of severe preeacclampsia but all this have been included in guidelines now but questions on all these have been coming since one or two years if you remember in your u you know test and discussion also I have given you a question where you have to see the lab findings and you have to tell which lab finding tells you that your patient has severe preeacclampsia right So the questions were coming from a very very long time now. So let's see the premonetary symptoms.
Premonetary symptoms you are six premonetary symptoms. How are you going to remember them? Two symptoms related to head and neck. Two symptoms related to GI and two symptoms related to weight and edma. Okay. Two symptoms related to head and neck. two symptoms related to GI and two symptoms related to your uh weight gain and at bump. What are the two symptoms related to head and neck?
Number one, severe headache and number two visual disturbances. Right? Two symptoms related to GI so right upper quadrant pain and vomiting. Two symptoms related to weight gain and edma. So if there is severe edma, excessive weight gain. So what are the pre-monetary symptoms? Premoniary symptoms are six symptoms. Two symptoms related to head and neck. The two symptoms related to head and neck are severe headache, visual disturbances. Two symptoms related to GI. The two symptoms related to GI are right upper quadrant pain and vomiting. And two symptoms related to weight gain and edma. So excessive weight gain, severe edma. So these any of these symptoms and if patients BP is even more than 14090 but it is less than 160 by 110 still you are going to say that your patient has severe preeacclampsia if any one of these is present.
Similarly, if any one of these abnormal lab findings are present and what are the abnormal lab findings?
Abnormal lab findings are number one liver enzymes raised to two times the normal value, number two platelet count less than one lakh, number three serum creatinine raised, right? And number four abnormal coagulation profile. So you all know that these were signs of end organ damage. Liver enzymes raised to two times the normal value was sign of end organ damage. Platelet count less than one lakh was sign of end organ damage. Serum creatinine raised to more than 1.1 was sign of end organ damage.
And then we have abnormal coagulation profile. So if any one of these is present and if your patient's BP is more than 14090 but less than 160 by 110 you are going to call your patient as a case of severe pre-exclamia clear to all of you? Okay now now two new definitions have come up by Foxy.
One of them is white coat hypertension and the other one is mast hypertension.
Both of them are exactly two opposite conditions. White coat hypertension as you know that some of the patients when they enter into a hospital or when they see a doctor wearing a white coat their BP automatically increases and that is what is white coat hypertension. White coat hypertension is if BP of your patient in hospital is more than equal to 140 90 but at home in ambulatory settings it is less than 135 by 85 and exact opposite is m hypertension. ME hypertension is if your patient's BP in hospital is less than 140 90 but in ambulatory settings at home it is more than 135 by 85 then that is m hypertension. Okay. So now Foxy in its new guidelines it has said that in all pregnant females you have you can do any one of the two scoring systems and these two scoring systems which Foxy has recommended are the HDP gestosis score.
What is HDP? HDP stands for hypertensive disorders of pregnancy. So one scoring system which it has given is the HDP gesttosis score and the second one which it has given is the multimodal scoring.
Now this scoring system has to be done in all pregnant females in order to see whether they have high chances of developing PIH or not. Right? So first of all it has to be done in all pregnant females. Right? And at what time are you going to do it? Just now I'll tell you.
So let's talk about each one of these scores individually and separately. So first score is the HDP gestosis score.
As I told you HDP stands for hypertensive disorders of pregnancy. Now HDP gestosis scoring system. It is based on high risk factors. So what it is doing is it is classifying all the high-risk factors and it is putting it in a list like this. Right? So on a sheet of paper we have all the risk factors whether the age is less than 35 or a sorry age is more than 35 or age is less than 19 years whether it's a twin pregnancy whether she has PCOS right whether she has gestational diabetes whether she's a case of chronic hypertension whether she has previous history of PIH all the risk factors they are put in one place right and then all these risk factors are categorized into three categories to some of the risk risk factors we give a score of one right to some of the risk factors we give a score of two and to some of these risk factors we give a score of three.
So this entire table or chart is provided to the healthare worker. Now whenever a pregnant female comes to her the healthare worker will keep on asking these questions and whatever is present she will put a tick in front of them and ultimately once the questionnaire is over she's going to calculate that what is the total score as I said some of the risk factors are given a score of one some are given a score of two and some are given a score of three now if the total score comes out to be more than equal to three then you say that the patient has high risk of developing PIH.
So have you understood what we are doing in HDP gtosis score? In HDPsis score we are not doing any investigation. In HDPsis score based on risk factors we are telling whether a female has high chances of developing PIH in this pregnancy or not. And all the risk factors are divided into three categories. Some to some risk factors we are giving a score of one to some we are giving a score of two and to some we are giving a score of three right no investigation is needed. It can be done by the health care workers also. This is very very simple. Right? It has to be done at the first antiatal visit and then it has to be repeated in every visit till your patient is 32 weeks of pregnancy. Right? Now as I said that we are gynecologist beta. We are not astrologers that we will be very happy in predicting that my patient is going to have PIH. I am going to be happy when I predict my patient is going to have PIH and also I prevent her from having PIH. So in order to prevent her from having PIH uh if your patient's total score comes out more than equal to three you have to give her aspirin. And how much dose of aspirin you have to give?
You have to give her 75 mg per day. When you are going to start, when you are going to stop, all that I'll tell you.
But have you understood this much? So in HDPsis score, no investigations. You have to based on risk factors, you have to calculate the total score. And if total score is coming more than equal to three, you say that your patient has high risk for having PIH and you give her 75 mg of aspirin. I hope I I have made myself very clear over here right now. If my this point is clear to all of you, then I hope you remember in main videos and in revision videos I have told you that uh in all pregnant females if these five category of females come to you all hypertensive mothers can die.
This was the pneumonic which I told you that in these five categories of patients you have to give lowd do aspirin. Did I tell you this? I hope you remember this pneumonic in in world of revision also I've told you this and in main videos also I have told you this that there are five categories of females in whom you have to give aspirin. Now I just want you to upgrade this pneumonic and upgrade this pneumonic to all two hypertensive mothers can die. So instead of all hypertensive mothers now I'm asking you to remember all two hypertensive mothers can die. Now again a over here stands for appla.
A also stands for if you have done a rt that is if you have done IVF with the donor egg.
Right? So a in your original pneumonic was for appla. Now I'm saying please remember that a is for appla as well as for your art. A RT that is IVF with donor egg. T over here is for thrombopilia.
So if your patient has inherited or acquired thrombophilia, hypertensive is if she has chronic hypertension.
Mothers, please remember M in the original pneumonic was multifetal pregnancy. In this pneummonic M over here is if your patient has a mental disorder.
Right? K original also was kidney disease. Here also it is kidney disease.
D original was gestational diabetes.
Here also it is gestational diabetes.
Now you will ask me that ma'am you are telling the pneumonic but what is this pneumonic for? This pneumonic is for all those conditions where you have to give a score of three. Now understand I am saying if total score is more than equal to three you have to give aspirin and these are those risk factors where you have to give a score of three. This means that these conditions if present and if any other risk factor is present or not present hardly matters. If these conditions are present, you have to give aspirin because individually each of these condition has is given a score of three. Right? So what are those conditions which are given a score of three all two hypertensive mothers can die where A stands for appla syndrome. A also stands for art that is IVF which is done with donor egg. With the donor egg is very very important. And if IVF is not done with donor egg, it is not given a score of three. Right? Then T stands for thrombophilia, H stands for chronic hypertension, M stands for mental disorder, K stands for kidney disease.
And D stands for gestational diabetes.
So if these risk factors are present, it means I have to give aspirin. How much aspirin? 75 mg per day. So this was the HDPs scoring.
Then comes the second scoring system.
Second scoring system is multimodal scoring. As the name suggests multimodal, it's multimodality screening. Now in multimodality screening, there are four things which you have to do. Number one, maternal characteristic which in other words means risk factors. Number two, you have to check her mean arterial pressure.
Number three, you have to check serum placental growth factor. And number four you have to do utrine artery doppler. So these are four things which come under multimodal screening. What are the four things which are coming under multimodal screening? Number one maternal characteristics. Number two mean arterial pressure. Number three serum placental growth factor and number four utrine artery doppler. Now you are going to put some pressure on your brains and you are going to tell me that in a patient of PIH what happens to placental growth factor?
What happens? Does in a patient of PIH does placental growth factor decrease or increase? Placental growth factor decreases. Vascular endtheal growth factor, placental growth factor and nitric oxide decrease. Whereas SLT1, serum and doglin, thromboxin A2 they are the ones which are going to increase right now. What about utrine artery doppler? Please remember multimodal screening is done between 11 to 14 weeks. Now you all know that in utrine artery Doppler for uh screening purposes right we look for diastolic notch right I have told you that you have to see the diastolic notch right now in patients of PIH in those patients in those pregnant females who are going to develop PIH there is a diastolic notch which persists. Normally also in uterrine artery doppler there is a diastolic notch right but in usually this diastolic notch it disappears around 22 weeks of pregnancy. If this diastolic notch is persisting beyond 24 weeks of pregnancy right it means that in future your patient is going to have PIH in this pregnancy. But then please understand that this diastolic notch in a in a female who doesn't have to develop PIH will disappear around 22 to 24 weeks. Whereas multimodile screening I'm doing between 11 to 14 weeks of 11 to 14 weeks may if you say that in the uterrine artery doppler I'm going to look for a diastolic notch between every pregnant female diastolic notch will be present right. So what am I going to see between 11 to 14 weeks in utrine artery doppler? In between 11 to 14 weeks you have to look for pulsatality index.
Please remember that higher is the pulsatality index lesser is the blood flow.
Higher is the pulsatality index lesser is the blood flow in that vessel. Now just put your concepts together and you'll get all the answers. You remember I told you why is PIH happening in PIH pathophysiology. I told you that in between the vi the the spiral arteries open. Normally in during pregnancy the lining of the spiral arteries is replaced by cytorophoblast and that is why these convulated narrow vessels which have very high resistance they get converted into lowresistance vessels.
But in patients of PI this is not happening right and if this is not happening the blood supply or the blood coming to the interval space decreases right. So blood in the interval space is decreasing because blood in the spiral artery is less. Why is blood in the spiral artery less? because of high resistance and spiral artery is nothing but a branch of utrine artery. So if I ask you in a patient of PIH how how is the blood flow in the utrine artery? How much is the blood flow in the utrine artery? You will say that utrine artery has very high resistance in a patient of PIH. So blood flow in utrine artery is decreased.
So if blood flow is in utrine artery is decreased in a patient of PIH what happens to pulsatitality index pulsatality index is increased. So between 11 to 14 weeks if you see that the pulsatality index of utrine artery is high right it indicates that your patient is going to have pi clear to all of you? Yes. Okay. So these are the four parameters I have to check.
Now if your patient is coming as a high risk as per multimodality screening, multimodality screening has to be done between 11 to 14 weeks and if your patient is becoming high risk as per multimodality screening again you have to give her aspirin. But the dose of aspirin which you have to give her now is 150 mg per day.
So aspirin has to be given to all high-risk patients. Now the dose depends upon whether she's high risk based on gestosis score or whether she's high risk based on multimodality screening.
If she's high risk based on gestosis score the dose is 75 mg per day. And if she is high risk based on multimodality screening then the dose is 150 mg per day. So dose of aspirin varies depending upon the scoring system. Based on gestosis score the dose is 75 mg per day. And if she's high risk based on multimodality screening then the dose is 150 mg per day. What is the best time to start aspirin? As soon as possible. Right? And maximum till now we were saying that you can start by 16 weeks. This was the older guideline. Now they say you can start maximum by 20 weeks. Right? And you have to stop it by 36 weeks of pregnancy. The Foxy guidelines say that yes, aspirin is the best method to prevent PIH. But in all patients who have high chances of having PIH, you just don't have to give them aspirin, you also have to give them calcium. The dose of calcium which is recommended by Foxy is 1.5 to 2 g per day. And it says that you also have to give them vitamin D that is 1,000 to 2,000 international units per day. Now although the evidence that vitamin D supplementation is helpful in patients of PIH is lacking right. It is not documented but still Foxy is saying that in a patient who has high risk for PIH you have to give her aspirin, you have to give her calcium and you have to give her vitamin D. Out of these three drugs, evidence-based treatment is aspirin.
When it comes to calcium, calcium definitely has evidence of preventing PIH in a patient who has decreased calcium levels.
So if your patient has decreased calcium levels, definitely when you give her calcium, it prevents PIH. But this evidence is lacking that the page females calcium levels are normal and still if you are giving her calcium, it can prevent PIH. But still these are the three drugs which are recommended by Foxy for prevention of PIH.
I hope I have made myself clear. Okay.
From prevention of PIH, let's talk about management of PIH and management of severe preeacclampsia and eclamsia may one drug which is very very important right to prevent to prevent convulsions and to treat convulsions is magnesium sulfate.
Right? Everything about magnesium sulfate remains the same. You know what is precharge regime. In precharge regime you have to give the loading dose and you have to give maintenance dose.
Right? How much was the loading dose beta which you were giving? You were giving you were giving IM plus IV loading dose. The IM loading dose which you were giving was 10 g 50% which you were giving 5 g in alternate but you were giving IV loading dose which was 4 g 20%. And how much was the maintenance dose? maintenance dose which you were giving was only IM and that was 5 g 50% which had to be repeated after every 4 hours until when were you repeating it? You were repeating it till 24 hours after delivery or till 24 hours hours after the last seizure whichever happened earlier. Right? So nothing has changed over here. Then I told you that when you have to give the maintenance dose, when you are giving the loading dose, you don't have to think about renal function, you don't have to think about anything, right? But when you are giving maintenance dose, because magnesium has a very narrow therapeutic range that is why before giving maintenance doses, there are three things which you had to check. What were the three things you had to check? Number one, urine output.
Number two, knee-jerk. Number three, respiratory rate. How much urine output did I tell you? In four 4 hours the urine output should be more than equal to 100 ml or per hour it should be more than equal to 30 ml. Right? Then how knee should be present and respiratory uh rate should be more than 12 breaths per minute. If all these three criteria are fulfilled then only you give the maintenance dose.
Right? If any criteria is not fulfilled then you don't give maintenance dose right then you wait for next 4 hours and after 4 hours you are going to go again and you are going to check these things right now the first change which has come over here the first change which has come is in respiratory rate till now we were saying that respiratory rate should be more than equal to 12 breaths per minute then you have to give the maintenance dose. Now the Foxy guidelines say that it has to be more than equal to 16 breaths per minute.
That's the first change which has come.
Secondly, secondly if you remember I told you that urine oligura always I have told you olig ura is not a sign of magnesium sulfate toxicity.
Right? This is one line which I have made you write whether it is your main notes or your world of revision notes.
Everywhere I have made you write this that ura is not a sign of magnesium sulfate toxicity then why am I checking urine output? I am checking urine output because magnesium is excreted by the kidneys. So if my patient is having olig ura then the excretion of magnesium sulfate will be less and there will be high chances of magnesium sulfate toxicity. So oolle ura predicts that your patient is going to have magnesium sulfate toxicity. It is not a sign of toxicity. So now now be very very attentive and listen to me. Suppose you get a question and there's a high chance that these questions may come. Suppose you get a question that a resident had gone to give the maintenance dose and in maintenance dose when they had gone to give kneejerk was present right.
Respiratory rate was more than 16 breaths per minute but urine output was decreased. The only problem which is happening is urine output rest everything is normal.
So you now Foxy says that we all know that the first sign of magnesium sulfate toxicity is absent kneejerk. So if kneejerk is present respiratory rate is normal it is not that uh this oligura should stop you from giving magnesium sulfate. So now what Foxy says that if other two criteria are normal and the only problem is oligura the first step which you have to do is you have to check the patency of the catheter.
It could be that your catheter is blocked. It could be that there is some kinking of catheter which has happened.
Once you have ruled out that the catheter is not blocked but your patient is definitely having oligura then instead of missing that dose of magnesium sulfate you have to reduce the dose by 50% and give in other words I will give 2.5 g 50% magnesium sulfate IM have you understood this change The change is that if your question is saying that kneejerk is present, respiratory rate is more than 16 but oligura is there. The first step which you have to do in this case is you have to check for the patency of the catheter. And second step which you have to do is if the catheter is patent then you have to give 50% of the maintenance dose that is 2.5 g of 50% magnesium sulfate. Clear to all of you? Okay.
Next important thing which the guidelines are saying suppose your patient's convulsions do not stop after the loading dose. You have given her loading dose. A patient of eclamsia came to you. You have given her the loading dose of magnesium sulfate but her convulsions are not stopping. Now what is the next step? If your patient's convulsions are not stopping after the loading dose, you have to repeat 50% of IV loading dose.
And what was the IV loading dose? IV loading dose was 4 g. So I have to give 2 g 20% IV magnesium sulfate. So if your patient's convulsions do not stop after giving the loading dose please give her 50% of the IV loading dose. Now if your patient still is having recurrent convulsions then the drug of choice is thiopentone sodium you will continue with magnesium sulfate and if with theopentone sodium also your patient's convulsions are not stopping then you can intubate your patient give a assisted ventilation muscle relaxant and you are going to add levy terracet.
So first step which you do whenever your patient's convulsions are not getting controlled with loading doses give her 50% of the IV dose if still she's having convulsions give a thopinone sodium and if still she's having convulsions then you will add leviteracetim have you understood this okay next change next change is till now I taught you this in your revision video notes also and in your main video notes that if your patient has mild PIH right in that case you may or you may not give her anti-hypertensives nice guidelines said that anti-hypertensive has to be given if BP is more than 150 by 100 and if it was severe PIH definitely anti-hypertensive had to be given now they have changed the guidelines they are saying whether it is mild or whether it is severe you have to give anti-hypertensive in case of mild PIH you have to give oral anti-hypertensive in case of severe PIH you will give initially IV anti-hypertensive right so now if now the guidelines are saying that I have to give an anti anti-hypertensive.
So they the guidelines very clearly tell us that if your patient has mild PIH and you have to give her oral anti-hypertensives out of these three anti-hypertensives you have to choose any one. What are the three anti-hypertensives which have been recommended? Number one oral lavital, number two oral nitapene and number three oral methile dopa. This table which I have taken for you is directly from the guidelines. I don't want you to remember the entire table but whatever I am highlighting you have to remember that. Now there is no drug of choice.
These are the three firstline drugs and you can choose any one of them. When it comes to label please remember that the starting dose is 100 to 200 mg oral and maximum you can take it up till 2400 mg per day. Right? So the maximum dose of oral labol is 2400 mg per day. Please remember labalol one very very important prerequisite is that the pulse rate of your patient should be more than 100 per minute. If your patient has bradicardia or if your patient has ama and this was a question in FMG exam. So if your patient has bradicardia, if your patient has am asma or if your patient has heart failure or diabetes, you are not going to give labelol because labalol in the neonate can lead to bradicardia and hypoglycemia.
So only if your patient's pulse rate is more than 100 and she does not have diabetes, she does not have asthma or she does not have heart failure, then only I'm going to choose labalol, oral labol in a to manage a patient of mild PIH. Now if my patient's pulse rate is less than 100 per minute, then I can go for oral nitopene.
Maximum dose of oral nitopine which you can give in a day is 120 mg per day. The condition in which nidopene is contraindicated is iotic stenosis.
And if your patient is having taking oral methile dopa then the maximum dose is 2250 mg per day. Please remember methile dopa is the safest anti-hypertensive.
It can cause depression and postural hypotension. So these are the uh oral anti-hypertensives which are recommended in mild PIH.
Now in patient of severe PIH in patient of severe PIH the anti-hypertensives which I can give are any one of the four anti-hypertensives number one you can give IVL number two you can give oral nephidopene number three you can give IV hydraazine or you can give IV nicardine very important is in your main notes and world of revision notes also I told you that you have to use any one of the three. What were the three which I told you? I told you nicidapene, I told you hydraysene and I told you uh labalol. The one drug which has been added now is nicardipene. So now you can give out of these four drugs you can give any one of the drugs to manage severe PIH. An important thing about labol ivabitol which you are going to remember is that oral labbital maximum dose was 2400 mg per day. But when it comes to ivabitol the maximum dose which you can give per day is 300 mg. Right? Now please remember nifidopene and nicadopene both of them are calcium channel blockers but both and both of them decrease BP but both of them are different drugs. Oral nidopene you can also use it in mild PIH but nicardipene can be used only in severe PIH right and whenever you are using nicardipene nicadopene has to be used IV whereas nicidopene has to be used oral now the dose of ivy nicadopene is very important because it's a newly added drug you have to begin with 1.5 mg per hour and maximum minimum you can take it up till 6 mg per hour right and whenever you are giving nicardopene you have to be very very careful about monitoring the BP of the patient so the new drug added is IV nicardopene the dose is 1.5 mg per hour starting dose and maximum dose is 6 mg per right so please remember nicotine has to be given orally and nicadopene has to be given IV in the management ment of severe PI.
Now then Foxy says that suppose your patient's BP is not getting controlled.
It's a refractory hypertension. Then two drugs which are recommended for managing refractory hypertension are nitroglycerine and sodium nitroide.
So these were all the updates which were related to PIH. very very important whether you are giving your inic neatp or FMG extremely extremely important update. Then the next set of update is related to thalismia screening. Now till now screening was not a universal screening in pregnant females but now it has been included in universal screening which means that every pregnant female has to be screened for thalismia and the screening has to be done in the first antiatal visit. Ideally it should be done before 8 weeks and ideally both the partners should be tested at the same time. What is the screening test which we are going to use? The screening test which has been recommended is HPLC that is high performance liquid chromatography. Ideally as I said both the partners should be screened together but just in case only the female was tested and she is coming out to be a carrier forthmia. In that case you have to check the partner also forth thalismia. And if both are coming out to be positive then you have to also check the fetus forthallmia by corionic vi sampling. And then if the fetus is also coming as a carrier. Now it is up to the parents. If the fetus is comes out to be as athaloscemia then it is up to the parents whether they want to keep the baby or they want to go for MTP. MTP for thalismia at le can be done at less than 24 weeks. If the patients want to get uh the MTP done after 24 weeks then they need permission of medical board. So please remember now in the first antiatal visit screening test you have to include thalismia screening also. Clear to all of you? Okay. Then what are the updates which have come in induction of labor? Now induction of labor may one thing which is not changed and thankfully it is not changed is bishop's score. Everything related to bishop score is same in induction of labor and again Foxy is saying that uh before you induce labor you have to do a bishop score and if score is coming as less than equal to five then you have to first ripen the cervix and then go for induction of labor and if score is more than equal to six you can directly go for induction of labor. Now in case of uh induction of labor the or for ripening of cervix the drug of choice earlier was dorroone right the cerviprim gel.
Now in its new updated guidelines the Foxy has said that if you are using dinrost there are two problems with dinrost. Number one, it is expensive and it has to be refrigerated, right? So now the drug of choice is misoprost. So now the question comes that misoprost was earlier also available. Why didn't Foxy or ACG earlier use uh misoprost as the first line drug? Why earlier the drug of choice was doproone and now the drug of choice is misoprost? This is because earlier beta when we were using misoprost we saw that there are very high chances of hyper stimulation right that is tachycist tachy leading to fetal distress. So that is why earlier the drug of choice was not misoprost and the dose which we were using was 50 micrograms of misoprost and the chances of hyper stimulation or chances of tachially were very high. Now what they said was let us reduce the dose of misoprost. When they reduced the dose of misoprost to 25 micrograms which has to be repeated every 3 to 4 hourly the chances of tachi cy decreased and the effectiveness was equivalent to that of dinoprostro and because misoprost is available in tablet form you don't have to refrigerate it. It is not expensive.
That is why now it has become the drug of choice for induction of labor also and for cervical ripening also. Now if your question is asking you drug of choice definitely it is misoprost. But if your question says that overall which is the best method for induction of labor? Best method for induction of labor is combination method.
And what is meant by this combination method? Combination method means that you are going to use tablet misoprost plus you are going to go for fo catheter.
You are going to put foley's catheter at the level of the internal loss. So you are going for mechanical induction of labor also and you are using a drug also. So best method for induction of labor as per the latest guidelines are combination method where I am going to use both fo catheter that is mechanical induction of labor as well as tablet misoprotol. Nevertheless if the question says drug of choice drug of choice remains misoprosttol. Please remember msoprosttol has been recommended as the drug of choice for induction of labor and cervical liping except in one condition. What is that one condition where misoprotol now is absolutely contraindicated?
So absolutely contraindicated in previous cesarian section patient right in previous cesarian section patient you don't use misoprost for induction of labor. So now the guidelines say that if you have a patient who has previous cesarian section and you have to induce labor in her best method is fles catheterization.
So you use a police catheter right or that is number one which is the best method and you can also use oxytocin but best is that you are going to use police catheter at the level of the internal O right then now one thing before I tell you the gy updates are management of utrine inversion In management of utrine inversion, I hope you remember that utrine inversion is an obstetrical emergency. Right? Your patient initially will go into neurogenic shock and later she will go into hemorrhagic shock. So you have to act very quickly. You have to call for help. Now utrine inversion patients go you have to divide them into two categories. One category is where you utrine inversion has occurred but the placenta is separated and the other category is where placenta is not separated.
Now if you are managing a case of uterrine inversion where placenta has separated you are going to obviously go for maternal resuscitation and after maternal resuscitation simultaneously you are going to attempt manual replacement of the uterus. This is something which you have done earlier also manual replacement of the uterus.
this manual replacement of the uterus which is called as Johnson's method right first time when you are going to do you are going to do it without a toolytic and if it fails then you are going to do it second time with a toolytic right and if it fails then you go for surgical management.
This is if the placenta is already removed. Right? Now if placenta is not removed then in that case you will go for maternal resuscitation right and you will do simultaneously manual replacement of the uterus.
Now in this case when you are doing manual replacement first time you are doing it with a toolytic if it fails second time you are going to use an anesthetic agent.
These two times when you tried you did not remove the placenta.
You did not try to remove the placenta.
So with the placenta attached I try to do manual replacement of the uterus first with the toollettic and second time under anesthetic agent. Now if this fails now till now I was telling you that you don't have to remove the placenta before you attempt manual replacement. Now the new guideline says that if these two attempts fail then third time you are going to try after removing the placenta.
Third time I will remove the placenta and I will try manual replacement and if it fails I will go for surgical management. Have you understood this?
This is the difference over here.
Earlier the guidelines said you don't have to remove the placenta. Now they say that if the manual replacement fails with the placenta attached, you have to attempt it after removing the placenta and if everything fails then you go for surgical management. Just for a quick revision purpose, tell me what was the surgical management of utrine inversion?
Which surgeries? Halton surgery or Huntington surgery? Very very good.
And which methods are outdated? Which what methods did I tell you? Spinelli surgery. That's outdated. And what did I tell you? O Sivance hydrostatic method that is contra that is obsolete. That is also not done. So the two s the two methods which are obsolete which are not done are spinelli surgery and oelivan's hydrostatic method. Is that clear to all of you? Have you understood the the management of utrine inversion right?
Please remember when you are doing manual replacement of the uterus what do you have to keep in mind? You have to keep in mind that the part which came out first and which part came out first?
Fundus. It has to be replaced the last.
Always the part which comes out first that was fundus has to be replaced the last. Clear? Okay. Now, now few things which have come up in gi which number one is a case of post-menopausal bleeding. I hope all of you remember so many times in the world of revision also and in main notes I've told you that when a female comes to me with post-menopausal bleeding what was my next step my next step was we did a TVS and on TVs if I had to measure the endometrial thickness if endometrial thickness was less than 4 mm then I gave transexmic acid And no endometrial biopsy was done.
Right? And if endometrial thickness was more than equal to 4 mm, then we did endometrial biopsy. This was the older recommendation. Now the new recommendation is that whenever a patient comes to you with complaint of postmenopausal bleeding, straight away you have to do TVS plus endometrial biopsy.
Right? Right away you have to go for TVS and endometrial biopsy. Endometrial biopsy is skipped only if all these four conditions are present.
In very rare patients in whom all these four conditions are present, you may skip endometrial biopsy. And what are the four conditions? Number one, it should be the first episode of bleeding.
Number two, there should be no risk for endometrial cancer. You all know obesity, diabetes, hypertension, PCOS, all of them are high risk for endometrial cancer. So if none of these is present, it is a first episode of bleeding, none of these things are present, endometrial thickness is less than 4 mm. I did TVS and I saw endometrial thickness is less than 4 mm and patient is reliable for followup.
Only if all these four conditions are present then I may skip endometrial biopsy. Otherwise in all patients of PMBB I have to do TVS plus endometrial biopsy. I told you what is the most common cause of PMB these days? The most common cause of PMB these days is a polip. Right? What is the second most common cause of PMB? It is endometrial atrophy. If someone asks you what is the most common cause of PMBB in India? Most common cause of PMBB in India is cancer cervix. Right? Then these are the two kits which I want you to identify. These are the self HPV testing kits.
Cell for HPV testing kit in which kit number? This instrument over here is a Deli self HPV testing kit and this is also a self HPV testing kit. Now you all know the ACOG recommendation for screening of cancer cervix. I hope you remember that. What did ACOG say? ACOG said that you have to begin the screening at 21 years and this 21 years pay you are going to do papsmear. This papsmear has to be done after every 3 years till your patient is 29 years of age. And then between 30 to 65 years, you had to do a core test.
And this core test had to be done every 5 yearly, right? Or you can if the patient is not getting a core test done you can do a pap which you have to do every 3 year. Now what has been added is now ACG says that even if a patient is not coming to you for CO test but she is doing self HPV testing even that is now being taken into consideration right so patient can go for self HPV testing which she has to do every 3 yearly right so by using These kits the ACOG is recommending self HPV testing as a part of the screening protocol for cancer cervix. Clear to all of you? Okay. Now look at these two images over here. Both of them are DMPA injection. This first image over here is the DMPA injection which is antra which was included in our national family planning program which has to be given intramuscularly. It is 150 mg and you have to repeat it after every 3 months. This second one over here is the newly added one which is subcutaneous dmpa. This subcutaneous DMPA is called as cyana press. Patient can self administer this injection and they can selfadminister this injection in thigh or in abdomen. The dose over here is 104 mg and again it has to be repeated after every 3 months. The rest everything about DMP and subcutaneous DMPA is the same. You know that DMPA acts by bringing about anovilation. Cyanopress also acts by bringing about anovation.
DMPA biggest drawback is that there is delayed return of ovelation. Here also the biggest drawback is there is delayed return of ovelation. So cyan press is nothing but subcutaneous DMPA which can be self administered by the patient. The dose of DMPA is 104 mg whereas in an uh in uh intramuscular variety that it was 150 mg. It was included in the national family planning program by the name of antra. This is now included by the name of sana press. So these were all the updates which have come in OBGY till now. But all of you are capable of not just getting your dream branch in neat PG. All of you are capable of getting your dream branch in IICT. As I always say, dream big, work hard, but stay humble. All the best to all my bachas. I know you are going to rock it. Just keep going and just believe in yourself. Take care.
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