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Management of Common Obstetrics

& Gynae Emergencies
At Primary Health Care Level
(2nd Edition)

Primary Health Care Department

Woman & Child Health
DGHS Muscat
Feb. 2022
 Management of diabetic ketoacidosis (DKA) in pregnancy

(Treat as non-pregnant state)

Symptoms Signs
Diagnosis
Polydipsia Dehydration
Polyuria Tachycardia
Nausea & Hypotension
vomiting Hyperventilation
Abdominal pain RBS ≥14 mmol/l Acidotic breathing
Muscle cramps
Disorientation
Drowsiness
(rarely coma )
Ketone bodies in the urine

Positive Negative

Treat for DKA with insulin* and hydration Treat as simple hyperglycemia

1. I.V Fluid **: 2. Fetal assessment 3. Patient assessment

0.9% Normal saline Fetal movements / heart sound -Take detailed history and
drug complaince
1 st hour: 1000 ml -2 nd hour: 500ml Treat quickly and effectively
3 rd hour: 500ml -Modify underlying
Baby recovers with mother
diabetic treatment
Followed by 500 ml over four hours

4. Escort :
Escort the patient to the
nearest Hospital if DKA
*Insulin:
Give 0.1units/kg of regular
insulin subcutaneously in
symptomatic DKA
** IV fluid:
Use caution in patients with
heart failure.

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Management of Hypoglycemia in Pregnancy with Diabetes

Blood glucose <3.3 mmol/l

Conscious Unconscious or unable to take orally

Give oral carbohydrates,

1. Do the ABC
(1/2 cup of juice, one slice
2. Insert an I.V line
of bread, biscuits , or 1
teaspoon of honey)

recheck of blood glucose after I.V access cannot be

I.V access established
10 -15 minute established

Normal Low Glucagon 1 mg IM 50 ml of 50%

till I.V access can glucose IV
be established.
*Prevent recurrence; the Start 10% dextrose start 10%
patient should consume a dextrose infusion
infusion 80 -100
snack or meal.
ml/hr 80 -100 ml/hr
*Adjust the treatment
regimen

*Avoid critical tasks such as

driving Above Treatment should be repeated
Stabilize and escort
*Self monitor of blood
10-15 minute recheck of blood sugar
glucose
If still low

Establish an intravenous access

Start with 5% or 10% dextrose

infusion 80-100 ml/hr

Primary Health Care Department - Woman & ChildPrimary

Health Health
/ DGHSCare Department...etc
Muscat Feb. 2022
 Management of hypertension in pregnancy-1

Chronic hypertension in pregnancy

(Gestational age <20 weeks) with high BP (BP ≥140/≥90mmhg or Hypertensive before pregnancy

Determine the severity of hypertension

Mild HTN : BP (140 -149/90 – 99 mmHg)

Moderate HTN : BP (150-159 /100 –109 mmHg)
Severe HTN : BP ≥ (160 /110 mmHg)

Do baseline investigations (if not done for the last 3 months)

Chronic HTN on medication Chronic HTN not on medication

or diagnosed at booking

Change to safe drugs in pregnancy i.e. Stop ACE Initiate anti-hypertensive therapy if persistent diastolic
inhibitors and ARBs within 2 days and offer alternatives. BP of 95 to 99 mmHg, systolic BP ≥150 mmHg, or signs
of hypertensive target-organ damage.
Prescribe 75-150 mg of Aspirin daily from
12 week till 34 wks. Prescribe 75-150 mg of Aspirin daily from 12 week till 34 wks
Rule out secondary hypertension

The target control Aim: BP < 150/100 mmHg (Don’t lower BP to less than 130 /80 mmHg)

Mild -Moderate HTN: Refer with early Severe HTN: Stabilize &Escort as
appointment. Refer EMERGENCY.

-Instruct woman to report any symptoms suggestive of preeclampsia,decreased

fetal movement vaginal bleeding and signs of preterm labour
( Follow the algorithum of preeclampsia )

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Management of hypertension in pregnancy-2

Gestational HTN
Pregnant (Gestational age ≥20) with high BP
(BP ≥140/≥90mmhg) 2 readings 4 hour apart
No Proteinuria or new signs of end-organ dysfunction

Assess fetal well-being

Signs & symptoms
Preeclampsia
(Algorithm 3) Features of severe disease° of severe disease°
Yes
* headaches
No * blurred vision
* flashing lights
Determine the severity of hypertension * difficult breathing
* severe abdominal pain
* convulsion

Mild HTN : BP (140 -149/90 – 99 mmHg)

Moderate HTN : BP (150-159 /100 –109 mmHg)
Severe HTN : BP ≥ (160 /110 mmHg)

Treatment

Mild HTN: Moderate HTN: Severe HTN:

Do not start treatment Give oral Labetalol 200mg Give oral Labetalol 200 mg
Test for proteinuria & Check BP (1st line, caution with asthma) Check bp every 5 minutes
twice weekly. or Methyldopa 500mg for 15 minutes
Instruct woman to report if any or Nifedipine SR 20 mg. Oral Labetalol 200 mg can be
decreased fetal movement , Aim :to keep BP below repeated in 20-30 minutes
vaginal bleeding and signs of (maximum dose 800mg)
150/100 mmHg
preterm labour

Escort as emergency to hospital.

Refer as emergency to hospital

Refer as urgent to High risk Obstetrics

Primary Health Care Department - Woman & ChildPrimary

Health Health
/ DGHSCare Department...etc
Muscat Feb. 2022
 Management of hypertension in pregnancy-3

Pre-eclampsia and preeclampsia

superimposed on chronic hyperte nsion

Signs & symptoms Pregnant (Gestational age ≥20) with high BP (BP
of severe disease ° ≥140/≥90mmhg) 2 readings 4 hour apart.
headaches proteinuria or new signs of end-organ dysfunction
blurred vision No convulsions
flashing lights NB: If systolic BP ≥ 160 mmHg or diastolic ≥ 110 mmHg
difficult breathing confirmation within minutes is sufficient
severe abdominal pain
convulsion

Determine
The severity of hypertension
Features of severe preeclampsia

Mild Moderate Severe

If severe HTN ( systolic BP ≥
If BP 140-149 / 90-99 mmHg If BP 150-159 / 100-109 mmHg
160mmHg or diastolic ≥
110mmHg).
OR
There are symptoms or signs of
Give stat oral Labetalol 200 mg. severe preeclampsia.
Aim BP: <150/100

Don’t treat

• Give Labetalol IV if blood pressure > 160/110 20 mg slow

IV over 5 min recheck BP every 5 min over 20 min if not
controlled give 40mg, 40 mg, 80 mg at 10 minutes intervals
up to 180 mg
• Give Hydralazine 5mg IVslowly over 3-4 minutes, if IV not
possible gives IM.
• Give magnesium sulphate 4gm loading dose (Prepare 8 ml of
50% magnesium sulphate solution + 12 ml of normal saline).
To be given slowly IV over 15-20 minutes.

Stabilize and escort the patient to

secondary / tertiary hospital

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Management of hypertension in pregnancy-4

Eclampsia
• Diastolic pressure ≥ 90 mmHg (after 20 weeks of gestation)
• Proteinuria Yes
• generalized tonic-clonic seizures

ABC Prevent maternal hypoxia and trauma

Maintain airway.
Aspirate the mouth and throat as necessary.
Protect the woman from injury but do not actively restrain her.
Initiate an IV line Position the woman on her left side to reduce risk of aspiration
of secretions, vomit and blood.
Give oxygen at 4 - 6 L per minute.

1. Control blood pressure 2. Control convulsions

Magnesium sulphate available

NO
No Yes

Give Labetalol IV if blood pressure Give Diazepam: Magnesium sulphate 4gm loading dose
> 160/110 20 mg slow IV over 5 min (Prepare 8 ml of 50% magnesium
If convulsions occur in early
recheck BP every 5 min over 20 min pregnancy or magnesium sulphate solution + 12 ml of normal
sulphate is not available. saline). To be given slowly IV over 20
if not controlled give 40mg, 40 mg,
minutes using syringe driver at rate
80 mg at 10 minutes intervals up to Loading dose 10 mg IV slowly
of 60 ml /h
over 2 minutes.
180 mg Monitor signs of respiratory
If convulsions recur,
repeat 10 mg. depression
Antidote calcium gluconate 1g (10 ml
of 10% solution) IV slowly till
respiration is stabilized.
Escort as an emergency after resuscitation (If not in labour) If unable to give IV, give 10 g of
magnesium sulphate IM divided into
NB:
2 doses; give 5 g (10 ml of 50%
-If in labour, expedite delivery if possible
solution) IM deep in upper outer
- Do not give ergometrine after delivery
quadrant of each buttock with 1 ml of
- Monitor vital signs (pulse, blood pressure, and respiration),
2% lignocaine in the same syringe.
- Monitor reflexes and fetal heart rate hourly.

Primary Health Care Department - Woman & ChildPrimary

Health Health
/ DGHSCare Department...etc
Muscat Feb. 2022
 Managment of Chicken Pox in Pregnancy

No history of infection with significant Well documented history of

exposure infection before

Obtain varicella – Zoster IgG serology Reassure the woman

if available

Positive (immune) Negative (non-immune)

Reassure the woman Observe for sign and symptoms of varicella

(if any rash noticed report to health center immediately)

She develops chicken pox No infection developed

Reassure the woman

Severe disease Mild disease (skin lesions mainly)

Refer to Al Nahdha Start acyclovir within 24 hours of rash

hospital as emergency 800 mg five times per day for five days

Refer the women for detailed ultrasound and appropriate follow up

After 4 -6 weeks

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Chest Pain in Pregnancy and Recently Delivered Women

Cardiac Respiratory Others

Musculoskeletal Gasteroeintestinal
Angina
Costochondritis Pulmonary Embolisam GERD Anxiety
Acute coronary
Muscular pain syndrome Oesophageal rupture Panic attack
Rib fracture Aortic dissection Pneumonia Breast pain
Peptic ulcer
Acute pericarditis Pneumothorax Biliary disease
Hypertrophic pleurisy pancreatitis
obstructive
Cardiomyopathy

RED FLAGS
Chest pain requiring Take focus history
opiates Consider any risk factor
Chest pain radiating to Check vital signs,O2 saturation
arm, jaw or back > 15 min Do ECG ,CBC, x ray chest (if indicated)
Sudden onset of pain
Dyspneoa
Hypotension
Tachycardia Look for RED FLAGS

Primary Health Care Department - Woman & Child Health / DGHS Muscat
Known risk factor
DVT No
Yes

Escort to hospital after stabilisation Manage according to the clinical condition

Feb. 2022
 Vaginal bleeding in early pregnancy

Threatened abortion Ectopic pregnancy Incomplete/ Molar pregnancy

Missed abortion Complete abortion
Inevitable abortion

Light * bleeding Light * bleeding • Two or more of the • History of heavy • Heavy** bleeding • Heavy** bleeding
following signs: bleeding** but:
Closed cervix Closed cervix • Dilated cervix • Dilated cervix
- now decreasing, or
Abdominal pain • Uterus smaller than
Uterus Uterus not • Uterus larger than
corresponds to Fainting - no bleeding at present dates dates
corresponds to
Pale • Closed cervix
GA GA • Lower abdominal pain • Partial expulsion of
Foetal heart absent • Uterus smaller than dates products of conception
Very weak +Ve • Partial expulsion of
which resemble Grapes
(confirmed after two Pregnancy test • Light cramping/lower products of conception
weeks of scan ) abdominal pain
Gs ≥ 24 mm or No IUGS by Scan
CRL ≥ 7mm + no FH • History of expulsion of • Cramping /lower
activity products of conception abdominal pain

dates

Primary Health Care Department - Woman & Child Health / DGHS Muscat
Reassure Refer to hospital If no fever or severe Insert an IV line and Insert an IV line
If unstable Insert an IV line
Observe bleeding refer as emergency give fluids
and give fluids + Escort Give fluids rapidly
Follow up at health centre to hospital
If stable Refer as Refer as emergency
Scan after one week emergency to Refer as emergency
to hospital
Report Hospital SOS hospital to hospital

Feb. 2022
 Bleeding PV in later pregnancy (after 26 weeks of gestation)

Do NOT Perform Vaginal examination

Abruptio placenta Ruptured uterus Placenta previa

Rapid maternal pulse
Tense/tender uterus Abdominal distension/free fluid Relaxed uterus
Decreased/absent fetal Abnormal uterine contour Check fetal heart sound
movements Tender abdomen
Fetal distress or absent Easily palpable fetal parts
fetal heart sounds Absent fetal movements and
fetal heart sounds

Look for signs of shock

Primary Health Care Department - Woman & Child Health / DGHS Muscat
Yes No

Management of shock Insert IV line

Stabilize & e scort the patient to Give IV fluids
hospital Escort the patient to hospital

Feb. 2022
 Management of Anemia in Pregnancy

Moderate Anemia (7-9.9 gm/dL)

Severe Anemia (< 7 gm/dL)

Gestational age < 34 Gestational age > 34

Ferrous sulphate Refer urgently to Refer as an emergency at any

200 mg tablet TID + tertiary care stage of pregnancy
Folic acid 5mg OD

Yes No

Recheck every 4 weeks Improved

DECREASED FETAL MOVEMENTS

Fetal movements are less than 10 movements per 12 hours

History Examination:

• Check when last had food or fluids, • Check fetal heart rate
• Check maternal activity • Check Vitals
• Check for any significant risk factors Management • Check Movements by Scan if available

If < 28 weeks, or gave history of not taking food: • If ≥ 28 weeks and/or

- Advise her to take food and observe for movements for the next 1 hour. risk factors :
- Check for fetal heart sounds. Refer as emergency.
- If normal movements and normal FHS: reassure the women and provide kick chart.
- If no movements and/or abnormal FHS: refer to the hospital as emergency.

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Diagnosis & Management of Acute Pelvic Pain:

History, physical examination, and pregnancy test

Yes Suspect ectopic pregnancy

Pregnant
Refer as emergency to Hospital

No

RIF pain migrating from Yes Suspect appendicitis/bowel obstruction

peri-umbilical?
Refer as emergency to hospital
Acute Constipation &
Nausea /vomiting

No
Consider tubo -ovarian abscess, Refer as
Acute pelvic pain with high grade Yes emergency to hospital for I/V antibiotics
fever, vaginal discharge with tender
cervical motion, uterine or adenexial *Consider pelvic inflammatory disease
Swelling ,recent IUCD insertion Algorithm PID

No
Yes Refer as emergency to hospital to rule
Pelvic mass on examination out ovarian cyst, ovarian torsion,
with severe pelvic pain? degenerating uterine fibroid, or
endometriosis

No

Yes
Dysuria and white blood cells If urinary tract infection, request urine
on urinalysis/Frank hematuria culture and treat accordingly

If pyelonephritis & renal colic, refer to

hospital
No

Refer urgent to hospital

to evaluate other
diagnosis

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 ACUTE PELVIC INFLAMATORY DISEASE

Symptoms EXAMINATION Investigation

Should be predicted from symptoms
Lower abdominal pain which is typically Lower abdominal tenderness which is
and signs.
bilateral usually bilateral
ESR , C-reactive protein (not
Deep dyspareunia Adnexal tenderness on bimanual vaginal
specific)
Abnormal vaginal bleeding, including post examination
High vaginal swab (HVS) for
coital, inter-menstrual and menorrhagia Cervical motion tenderness on bimanual
culture and microscopy (absence of
Abnormal vaginal or cervical discharge which vaginal examination
high WBC in the vaginal discharge
is often purulent Fever (>38°C)
has high negative predictive value
but its presence has low positive
predictive value)
Endocervical swab for chlamydia
and gonorrhoea (if Available)

Treatment
Urgent referral to tertiary hospital because as early starting treatment as risk of complications is less
(Future complications include infertility, adhesions, chronic pelvic pain)
Severe cases with (high fever or with pelvic abscess) to be treated with parenteral antibiotics at Hospital

Primary Health Care Department - Woman & Child Health / DGHS Muscat
Those patients with mild disease or suspected ,can be started on empirical treatment which
include the following : Ceftriaxone 500 mg IM (Diluted in 1% Plain Lignocaine)
Tab doxycycline 100 mg BID for 14 days
Metronidazole 400 mg BID for 14 days

Feb. 2022
 EMERGENCY CONTRACEPTIVE PILLS (ECPS)

Unprotected sex

Presentation within 5 days

Yes No

Reassure
Do pregnancy test proper birth spacing plan
If missed period do
Urine pregnancy test

If negative

1-Give antiemetic:
(Metoclopramide 10 mg orally) 30 minutes
before taking the medication.

2-GIVE ECPs :
Explain possible side effects:
A. 4 COC tablets to be taken as soon as 1: Change in bleeding patterns
possible followed by 4 more tablets 2: Nausea, abdominal pain, fatigue,
after12 hours of the initial dose. Headache, breast tenderness,
dizziness, vomiting.
OR

B. POP Levonorgestrel pills: 1.5 mg in a

single dose. OR
Noregestrel pills: 3 mg in a single dose.

Important
Offer suitable birth spacing plan as
ECPs does not offer any future
protection

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022
 Painful vulvar lumps

Symptoms Symptoms
Symptoms
Few days history of Vulvar History of trauma to the
Vulvar pain for few pain , vulvar lump, fever, +/- vulva at any age group
days , vulvar lump, discharge Signs
fever, +/- discharge Any age but more common
Reproductive age in Obese patients, diabetic, Painful lump anywhere in vulva
group immune suppressed

Signs Signs

Lump in the lower ½ of Lump anywhere in vulva (other than

vulva, tender, ± cellulites Bartholin), tender, ± signs of
and indurations cellulites and induration
Vulvar hematoma

Bartholin abscess Vulvar abscess Analgesia for pain

Gather as much information from
history as possible
If suspicion of abuse fill
notification form
If hematoma >3 cm, associated
wounds, with active bleeding, cut
Oral NSAID Oral NSAID
wounds or difficulty voiding Refer
Emergency referral to Emergency referral to
as Emergency to Hospital .
hospital. hospital.

Contributors (task force from PHC- DGHS-Muscat)

Dr Faiza Al Fadhil, Sr. Consultant, Family Medicine

Dr Ahdab Abdul Hafiz, specialist OBG
Dr Nabila Al Wahaibi. Sr. Consultant, Family Medicine
Dr Naama Al Rawahi , Consultant, Family Medicine

Reviewers :
Dr Faiza Al Fadhil.
Dr Ahdab Abdelhafiz

Primary Health Care Department - Woman & Child Health / DGHS Muscat Feb. 2022