Learn — Antenatal care & normal pregnancy

15 notes · 90 questions on the topic

Obstetric score (GPAL/TPAL)

The obstetric score is the shorthand that fixes a woman's reproductive history in one line: G (gravida) is the total number of pregnancies including the present one, P (para) the number carried beyond viability, A the abortions and L the living children. TPAL expands para into Term (37 weeks and over), Preterm (20 to 36+6 weeks), Abortions (under 20 weeks) and Living children, and it is written at the top of every case sheet because parity is what drives the risk of atonic haemorrhage, malpresentation and scar rupture.

Gravida counts pregnancies, not fetuses — the present pregnancy is included from the day it is diagnosed, and a twin pregnancy is one gravida.
Para counts pregnancies carried beyond the age of viability (20 completed weeks or 500 g in Indian practice), whether the baby was born alive or stillborn; a twin delivery is one para, not two.
TPAL: T = deliveries at 37 weeks and over, P = deliveries from 20 to 36+6 weeks, A = losses before 20 weeks, L = children alive now.
Ectopic and molar pregnancies add to gravida and are counted with abortions; they never add to para.
The Indian shorthand P3+2 means three viable deliveries and two abortions; L is written separately because the number of living children can be lower than para after a neonatal death.
Nullipara (never delivered beyond viability) is not the same as nulligravida (never pregnant) — a standard NORCET trap, as is counting the current pregnancy in P.
Grand multipara is para 5 or more: flag her for atonic postpartum haemorrhage, malpresentation and rupture of a scarred uterus. A primigravida is flagged instead for pre-eclampsia, prolonged labour and shoulder dystocia.

Calculation of EDD (Naegele rule)

Naegele's rule dates a pregnancy from the first day of the last menstrual period: EDD = LMP + 9 calendar months + 7 days. It assumes a regular 28-day cycle with ovulation on day 14, so it gives a 280-day (40-week) pregnancy counted from the LMP, which is about 266 days from conception.

EDD = LMP + 9 months + 7 days; the working form is LMP minus 3 months, plus 7 days, plus one year (LMP 1 January 2026 gives an EDD of 8 October 2026).
Gestation from the LMP is 280 days or 40 weeks. Term is 37+0 to 41+6 weeks, preterm is before 37+0 and post-term is 42+0 weeks and beyond.
For a cycle longer than 28 days add the extra days (a 35-day cycle adds 7); for a shorter cycle subtract them.
First-trimester ultrasound by crown–rump length (7 to 13+6 weeks) dates to within about 5 to 7 days and replaces the LMP whenever the two differ by more than 7 days.
Second-trimester biometry (BPD, HC, AC, FL) is accurate only to about 7 to 14 days, and after 22 weeks scan dating is unreliable — date early or not at all.
Naegele's rule fails after irregular cycles, recent hormonal contraception, lactational amenorrhoea and an uncertain LMP; those pregnancies are dated by scan.
Cross-checks: quickening at about 18 to 20 weeks in a primigravida and 16 to 18 weeks in a multigravida, and McDonald's rule — fundal height in centimetres roughly equals the gestation in weeks between 24 and 34 weeks.

Antenatal care

Antenatal care is the planned supervision of a pregnant woman from the diagnosis of pregnancy to the onset of labour — history, examination, investigation, supplementation, immunisation and counselling — so that deviations are found while they are still treatable and the birth is planned. WHO's 2016 model replaced the four-visit "focused ANC" package with 8 contacts, because fewer contacts were associated with higher perinatal mortality; India's MoHFW schedule still specifies a minimum of four visits plus the monthly PMSMA check.

WHO 2016: 8 contacts — one before 12 weeks, then at 20, 26, 30, 34, 36, 38 and 40 weeks. The Indian minimum is 4 visits: booking within 12 weeks, then 14–26 weeks, 28–34 weeks and 36 weeks to term.
Booking investigations: haemoglobin, blood group and Rh typing, urine for albumin and sugar, blood sugar (75 g test), VDRL, HIV, HBsAg and a dating ultrasound; repeat Hb at 26–28 and 36 weeks.
IFA: one red tablet (60 mg elemental iron + 500 µg folic acid) daily from the second trimester for 180 days in pregnancy and 180 days postpartum; folic acid 400 µg alone is started preconceptionally and continued through the first trimester to prevent neural tube defects.
Calcium 500 mg twice a day (1 g/day) from 14 weeks until 6 months postpartum — given at least 2 hours apart from the iron tablet, because calcium blocks iron absorption.
Td: two doses 4 weeks apart (Td-1 at the first contact, Td-2 four weeks later); a single booster if she was fully immunised within the last 3 years. Albendazole 400 mg once after the first trimester in hookworm-endemic areas.
Expected weight gain is about 10 kg (9–11 kg); fundal height matches the gestation in centimetres from 24 weeks; the fetal heart is audible on Doppler from 10–12 weeks and on a fetoscope from about 20 weeks; fetal movements are counted daily from 28 weeks (10 movements in 12 hours, or the "count to ten" rule).
Every contact screens for the three conditions behind most maternal deaths — anaemia, hypertensive disease and diabetes — and for the danger signs; PMSMA gives a free specialist check-up on the 9th of every month in the second and third trimesters.
Birth preparedness: place of delivery, transport, a blood donor, saved money, JSY/JSSK entitlements, and a written plan for what to do if a danger sign appears at night.

Anaemia in pregnancy

Anaemia in pregnancy is a haemoglobin below 11 g/dL at any time in pregnancy (WHO allows 10.5 g/dL in the second trimester, when haemodilution is greatest) and below 10 g/dL in the puerperium. It is graded mild 10–10.9, moderate 7–9.9 and severe below 7 g/dL, with WHO calling under 4 g/dL very severe; NFHS-5 (2019–21) found just over half of Indian pregnant women anaemic, so it is the commonest medical disorder of pregnancy in India.

Cut-offs: under 11 g/dL in the first and third trimesters, under 10.5 g/dL in the second, under 10 g/dL postpartum. Grades: mild 10–10.9, moderate 7–9.9, severe under 7 and very severe under 4 g/dL.
Iron deficiency causes most of it — a microcytic hypochromic picture with MCV under 80 fL, MCH under 27 pg, serum ferritin under 30 µg/L, low serum iron and a raised total iron-binding capacity; folate and B12 deficiency give a macrocytic picture, and haemoglobinopathies must be excluded when iron does not work.
Oral treatment for mild and moderate anaemia up to 30 weeks: two IFA red tablets a day (120 mg elemental iron + 1000 µg folic acid) for 3 months, then one tablet a day for another 3 months and through 180 days postpartum. Take it on an empty stomach with a source of vitamin C, never with tea, coffee, milk or the calcium tablet.
Intravenous iron sucrose (100–200 mg per sitting on alternate days) or a single-dose ferric carboxymaltose is used for intolerance, non-compliance, or moderate anaemia found after 30 weeks. The total dose is calculated as 2.4 × weight in kg × (target Hb − actual Hb) + 500 mg for stores, and it raises the haemoglobin by roughly 1 g/dL a week.
Packed red cells — never whole blood — are reserved for haemoglobin under 7 g/dL near term, under 5 g/dL at any gestation, or any anaemia with cardiac failure, sepsis or active bleeding; transfuse slowly, one unit at a time, with furosemide cover and a strict watch for circulatory overload.
Screening is at booking, 26–28 weeks and 36 weeks, and Anemia Mukt Bharat adds a digital haemoglobinometer test at every contact — the programme rule is test and treat, not treat blindly.
Maternal risks: pre-eclampsia, preterm labour, cardiac failure in labour, poor tolerance of even normal blood loss, postpartum haemorrhage and puerperal sepsis. Fetal risks: growth restriction, low birth weight, prematurity, stillbirth and poor iron stores in infancy.
Treat the causes, not only the number: deworm with albendazole 400 mg after the first trimester, treat malaria in endemic areas, and look for hookworm, haemorrhoids and repeated closely-spaced pregnancies.

Anemia Mukt Bharat Program

Anemia Mukt Bharat is the MoHFW strategy launched in 2018 to cut anaemia across the whole life cycle; since its operational guidelines of 29 June 2026 (16th CCHFW) it is Anemia Mukt Bharat Abhiyaan, built as a 7×7×7 grid — seven beneficiary groups, seven interventions and seven institutional mechanisms, up from the 6×6×6 of 2018 (whose headline target was a fall in prevalence of 3 percentage points a year). Its operating rule is saturation testing with digital invasive haemoglobinometers and treatment by category of anaemia — the T4 approach of Test, Treat, Talk and Track — rather than blind supplementation.

The seven beneficiary groups: children 6–59 months, children 5–9 years, adolescents 10–19 years, women of reproductive age (20–49 years), pregnant women, lactating mothers and — added in 2026 — low-birth-weight babies of 0–6 months.
Children 6–59 months get 1 mL of IFA syrup (20 mg elemental iron + 100 µg folic acid) twice a week, given by the anganwadi worker with a dispenser bottle.
Children 5–9 years get the pink IFA tablet (45 mg elemental iron + 400 µg folic acid) once a week, supervised in school.
Adolescents 10–19 years, boys and girls, get the blue IFA tablet (60 mg elemental iron + 500 µg folic acid) once a week under the Weekly Iron and Folic Acid Supplementation programme, in school or through the ASHA for those out of school.
Women of reproductive age get the red IFA tablet (60 mg elemental iron + 500 µg folic acid) once a week when they are neither pregnant nor lactating, and the same red tablet daily for 180 days in pregnancy and 180 days postpartum. The programme has three tablet colours only — pink, blue and red — and no white tablet.
The seven interventions (2026): prophylactic IFA supplementation; testing of anaemia; therapeutic management of anaemia; deworming and delayed cord clamping; Jan Bhagidari, a communication strategy against the normalised perception of anaemia and for IFA compliance; addressing non-nutritional causes such as malaria, fluorosis and haemoglobinopathies; and the new 'Eating Right' — locally available iron-rich foods and a diverse diet. The 2018 list had six: testing and treatment as one, a year-round behaviour-change campaign, and mandatory IFA fortification of foods in government programmes.
Deworming: albendazole 400 mg twice a year on National Deworming Day (10 February and 10 August) for everyone from 1 to 19 years, with a half tablet (200 mg) at 12–23 months; pregnant women are dewormed once, after the first trimester.
The seven institutional mechanisms (2026): intra-ministerial coordination, the National Centre of Excellence and Advanced Research on Anaemia, the National AMB Abhiyaan Unit, a strengthened supply chain and logistics, convergence with other ministries, the AMB Abhiyaan Portal, and the new digital framework for monitoring through the T4 approach, fed by the JANANI (pregnant and lactating women), RBSK (schoolchildren) and U-WIN (vaccination) portals; NFHS-5 (2019–21), still the latest national anaemia figure, found more than half of pregnant women anaemic; NFHS-6 (2023–24) does not report anaemia, and MoHFW will take future anaemia prevalence from an ICMR survey that tests venous blood.

Ectopic pregnancy management

An ectopic pregnancy is implantation of the blastocyst anywhere outside the uterine cavity; about 95% are tubal, and within the tube the ampulla is the commonest site, followed by the isthmus, fimbria and interstitium. It is the leading cause of first-trimester maternal death because a ruptured tube bleeds into the peritoneal cavity, where the loss is concealed until she collapses.

Classic triad: 6–8 weeks of amenorrhoea, unilateral lower abdominal pain and scanty dark vaginal bleeding — the bleeding is less than a period because it is decidual, not placental.
Risk factors: a previous ectopic (the strongest), pelvic inflammatory disease and tubal damage, tubal or pelvic surgery including sterilisation, an IUCD in situ, progestogen-only contraception, assisted reproduction, endometriosis and smoking.
Rupture: sudden severe pain, syncope, shoulder-tip pain (Kehr's sign, from blood irritating the diaphragm), abdominal distension with guarding, extreme cervical excitation, fullness in the pouch of Douglas, and shock out of proportion to any visible bleeding.
Diagnosis: serum β-hCG with transvaginal ultrasound. An empty uterus with β-hCG above the discriminatory zone of 1500–2000 mIU/mL is an ectopic until proved otherwise; in a normal early pregnancy β-hCG rises by at least 63% in 48 hours, so a plateau or a slow rise points to an ectopic.
Methotrexate 50 mg/m² IM as a single dose suits a haemodynamically stable woman with β-hCG under 5000 mIU/mL, a mass under 3.5–4 cm, no fetal cardiac activity, no significant free fluid and reliable follow-up; check β-hCG on days 4 and 7 and repeat the dose if the fall is under 15%. She avoids alcohol, folic acid and NSAIDs, and does not conceive for 3 months.
Surgery: laparoscopic salpingectomy for a ruptured tube or a damaged tube with a healthy other side; salpingostomy when the contralateral tube is absent or diseased, with follow-up β-hCG for persistent trophoblast; laparotomy when she is in shock.
Expectant management is only for a stable woman with minimal symptoms, a small mass and a falling β-hCG under about 1000–1500 mIU/mL.
Give anti-D within 72 hours to Rh-negative women — 50 µg before 12 weeks and 300 µg at or after 12 weeks — and counsel that the risk of another ectopic is about 10%.

Chorionic villi sampling

Chorionic villus sampling takes a sample of placental (chorionic) villi — tissue of fetal origin — for karyotyping, DNA analysis and enzyme assays, either transabdominally or transcervically under continuous ultrasound guidance. It is done between 10 and 13+6 weeks, and that early answer is its whole purpose: a first-trimester diagnosis allows a safer, earlier and more private termination than one made after amniocentesis.

Timing is 10 to 13+6 weeks. It is never done before 10 weeks, because earlier sampling has been linked to limb-reduction defects and oromandibular hypogenesis.
Routes: transabdominal with an 18–20 G needle (the preferred route) or transcervical with a catheter; 10–20 mg of villi is aspirated under continuous ultrasound guidance after skin preparation and local anaesthesia.
Procedure-related fetal loss is about 0.5–1% above background — higher than amniocentesis, and that is the price paid for the earlier result.
Results: a direct preparation of cytotrophoblast gives a karyotype in 24–48 hours and long-term culture in 1–2 weeks, much faster than amniocentesis; QF-PCR gives the common trisomies within a day.
Indications: maternal age 35 years and above, a previous child with aneuploidy, a parent carrying a balanced translocation, both parents carrying a single-gene disorder (thalassaemia, sickle cell disease, haemophilia, Duchenne muscular dystrophy), and a high-risk first-trimester combined screen or NIPT.
It cannot detect neural tube defects — there is no amniotic fluid, so no alpha-fetoprotein or acetylcholinesterase; those need the 18–20 week anomaly scan or amniocentesis.
Confined placental mosaicism occurs in 1–2% and can give a result that does not reflect the fetus, so an abnormal or ambiguous result is confirmed by amniocentesis.
Rh-negative women get anti-D 50 µg within 72 hours because sampling is a sensitising event; the procedure is deferred in active cervical or vaginal infection and avoided in women already alloimmunised. In India, prenatal diagnostic procedures may be done only at a centre registered under the PC&PNDT Act 1994, for the permitted indications, and the sex of the fetus is never disclosed.

Amniocentesis

Amniocentesis is the ultrasound-guided transabdominal aspiration of amniotic fluid, which carries desquamated fetal cells and fetal biochemistry, for karyotype, DNA, enzyme and biochemical studies. Genetic amniocentesis is done at 15–20 weeks and never before 15, because earlier sampling causes talipes and respiratory morbidity; late amniocentesis assesses lung maturity or bilirubin in Rh disease, and therapeutic amniocentesis drains severe polyhydramnios.

Genetic amniocentesis at 15–20 weeks: 15–20 mL of fluid through a 20–22 G spinal needle under continuous ultrasound guidance, avoiding the placenta and the fetus, with the first 1–2 mL discarded to avoid maternal cell contamination.
Procedure-related fetal loss is about 0.1–0.3% above background — lower than chorionic villus sampling. Culture takes 2–3 weeks; FISH or QF-PCR reports the common trisomies in 24–48 hours.
Amniotic fluid alpha-fetoprotein and acetylcholinesterase are raised in open neural tube defects and low in Down syndrome — the test that CVS cannot offer.
Fetal lung maturity: a lecithin–sphingomyelin ratio of 2 or more, or the presence of phosphatidylglycerol; the L/S ratio is falsely reassuring in a diabetic mother.
In Rh alloimmunisation, ΔOD450 on the Liley or Queenan chart grades the severity of haemolysis, although middle cerebral artery peak systolic velocity on Doppler has largely replaced it.
Rh-negative unsensitised women are given anti-D 300 µg within 72 hours, since amniocentesis after 12 weeks is a sensitising event; the bladder is emptied first and the fetal heart is checked before and after.
Complications: leaking liquor (usually seals within 48 hours), chorioamnionitis, fetomaternal haemorrhage, needle injury to the fetus, and talipes if done before 15 weeks.

Antepartum haemorrhage — placenta previa and abruptio

Antepartum haemorrhage is bleeding from the genital tract after 20 weeks of gestation and before the birth of the baby. Placenta praevia — a placenta implanted wholly or partly in the lower uterine segment — and abruptio placentae — premature separation of a normally situated placenta — account for most cases; the rest are local causes such as cervical lesions, and the rare vasa praevia, in which the blood lost is fetal and the fetus exsanguinates within minutes.

Praevia: painless, causeless and recurrent bright red bleeding; a soft, non-tender, relaxed uterus; a high or malpresenting presenting part; a normal fetal heart, and a maternal condition that matches the visible blood loss.
Abruption: continuous abdominal pain with dark bleeding that may be wholly or partly concealed; a tense, tender, woody uterus that does not relax between contractions; a uterus larger than dates; fetal distress or fetal death, and shock out of proportion to the visible loss.
Never perform a digital vaginal examination in bleeding after 20 weeks until ultrasound has excluded praevia — a gentle speculum examination to inspect the cervix is permitted once the woman is stable.
Praevia is graded I to IV (I low-lying, II marginal reaching the os, III partially covering, IV completely covering). Transvaginal ultrasound is safe and more accurate than the transabdominal route; a placental edge within 2 cm of the internal os means caesarean delivery.
Risk factors — praevia: previous caesarean or curettage, multiparity, multiple pregnancy, advanced maternal age and smoking. Abruption: hypertensive disease (the commonest), trauma, sudden decompression of polyhydramnios, previous abruption, smoking and cocaine, thrombophilia and a short cord.
Resuscitation comes before diagnosis: two wide-bore cannulae, full blood count and coagulation screen, cross-match at least 2 units, a urinary catheter for hourly output, continuous fetal monitoring, and anti-D with a Kleihauer test for Rh-negative women.
Delivery: immediate caesarean for maternal instability, fetal distress or a term pregnancy. Between 24 and 34 weeks with a stable mother, a stable fetus and bleeding that has stopped, manage expectantly (McAfee–Johnson regimen) with corticosteroids for lung maturity. In an abruption with a dead fetus and a stable mother, vaginal delivery after amniotomy is reasonable.
Complications of abruption: disseminated intravascular coagulation from consumption of fibrinogen, acute kidney injury, Couvelaire uterus (blood infiltrating the myometrium), postpartum haemorrhage from atony, and Sheehan syndrome after prolonged shock.

Placenta accreta types

Placenta accreta spectrum is abnormal adherence of the placenta to the uterine wall because the decidua basalis is deficient, usually over a caesarean scar, so the placenta will not separate after the birth. It is graded by depth of invasion — accreta (villi reach the myometrium), increta (villi invade into the myometrium) and percreta (villi pass through the serosa and may involve the bladder or bowel) — and it is now the commonest reason for peripartum hysterectomy.

Accreta accounts for roughly 75–80% of the spectrum, increta about 15%, percreta about 5% — accreta is the commonest and percreta the most dangerous.
The dominant risk factor is a previous caesarean scar with an anterior placenta praevia sitting on it; risk rises steeply with the number of caesareans. Other risks are curettage, myomectomy, Asherman syndrome, endometrial ablation, advanced maternal age and assisted reproduction.
Antenatal diagnosis is the single thing that improves outcome: colour Doppler ultrasound showing loss of the clear retroplacental zone, placental lacunae, bridging vessels and interruption of the bladder wall, with MRI reserved for a posterior placenta or suspected percreta.
Plan delivery at 34 to 36+6 weeks after corticosteroids, in a centre with a blood bank, interventional radiology and urology, by caesarean hysterectomy with the placenta left in situ — the uterine incision is made away from the placenta and no attempt is made to remove it.
Attempted manual removal is what converts accreta into catastrophic haemorrhage; anticipate a loss of several litres and arrange cell salvage, a massive transfusion protocol, and internal iliac balloon occlusion or ligation where available.
Conservative, uterus-preserving management — leaving the placenta in place, with or without methotrexate — is only for selected, stable, fully counselled women and carries a high risk of secondary haemorrhage, sepsis and delayed hysterectomy.
An undiagnosed accreta presents as a placenta that will not separate after delivery, with torrential bleeding the moment traction is applied.

Leopold manoeuvres

Leopold's manoeuvres are the four systematic abdominal palpations that establish the fetal lie, presentation, position, attitude and engagement in late pregnancy and in labour. They are performed with the bladder empty and the woman supine with her knees slightly flexed; the examiner faces her head for the first three grips and her feet for the fourth.

First grip (fundal): both hands palpate the fundus — a hard, round, ballotable mass there is the head, meaning a breech presentation; a soft, broad, irregular mass is the breech, meaning a cephalic presentation.
Second grip (lateral or umbilical): steady one side of the uterus and palpate the other — the back is a smooth, firm, continuous resistance and the limbs are small, knobbly and shifting. The back tells you where to listen for the fetal heart.
Third grip (Pawlik's): grasp the lower pole between the thumb and fingers just above the symphysis to confirm the presenting part and whether it is still mobile; it is uncomfortable, so it is done gently and last of the head grips.
Fourth grip (pelvic): facing the woman's feet, walk both hands down the sides of the lower pole — fingers that converge mean the head is not engaged, fingers that diverge mean it is engaged. This grip also shows attitude: a cephalic prominence felt on the side opposite the back means a well-flexed head.
Engagement is recorded in fifths palpable per abdomen: 5/5 is entirely above the brim and 2/5 or less means the biparietal diameter has passed the brim, that is, the head is engaged.
Palpate from about 28 weeks, reliably from 32–36 weeks; earlier the parts are too small and the lie still changes. Auscultate the fetal heart over the back after the second grip — below the umbilicus in a cephalic presentation and at or above it in a breech.
Document lie (longitudinal, transverse or oblique), presentation (cephalic, breech or shoulder), position (LOA, ROA, LOP and so on), attitude (flexed or deflexed) and engagement in fifths.
A transverse or oblique lie at or after 37 weeks, or a head that is not engaged in a labouring primigravida, is abnormal and needs obstetric review — both carry the risk of cord prolapse and obstructed labour.

Diabetes in pregnancy (GDM)

Gestational diabetes mellitus is any degree of glucose intolerance with onset or first recognition during pregnancy, caused by the anti-insulin hormones of the placenta — human placental lactogen, cortisol, progesterone and prolactin — unmasking a limited insulin reserve. India screens every pregnant woman because prevalence is high and most Indian women with gestational diabetes have none of the classical risk factors.

MoHFW/DIPSI single-step test: 75 g of oral glucose given irrespective of the last meal, with a plasma glucose measured at 2 hours — 140 mg/dL or more is gestational diabetes and 200 mg/dL or more is overt diabetes. It is done at the first antenatal contact and repeated at 24–28 weeks if the first test was normal.
Targets on treatment: fasting under 95 mg/dL, one hour after a meal under 140 mg/dL and two hours after a meal under 120 mg/dL.
First-line treatment is medical nutrition therapy — about 25–35 kcal/kg of ideal body weight split into three meals and three snacks, complex carbohydrates, no gap longer than 8 hours without food — plus 30 minutes of walking after meals. Two weeks of this controls most women.
If targets are not met, start insulin: human regular insulin before meals with NPH at bedtime. Insulin does not cross the placenta and remains the drug of choice; metformin is accepted in Indian guidance when insulin is refused or unaffordable, and glyburide is second line.
The insulin requirement rises through pregnancy, peaks at about 32–36 weeks and falls abruptly once the placenta is delivered — halve or stop the dose immediately after birth and recheck the glucose.
Fetal and neonatal risks: macrosomia and shoulder dystocia, polyhydramnios, unexplained late stillbirth, respiratory distress syndrome, and neonatal hypoglycaemia, hypocalcaemia, polycythaemia and jaundice. Congenital malformations, including caudal regression, belong to pre-gestational diabetes, not to gestational diabetes.
Delivery: aim for 38–39 weeks when control is good; consider elective caesarean when the estimated fetal weight is 4 kg or more because of the shoulder dystocia risk. In labour, check capillary glucose hourly and keep it between 70 and 110 mg/dL, with an insulin–dextrose infusion if needed.
Newborn care: check the baby's blood glucose within the first hour and before feeds, feed early and often, keep the baby warm and with the mother, and treat a value below 40 mg/dL.
Postpartum: repeat a 75 g oral glucose tolerance test at 6 weeks and then every 1–3 years — up to half of women with gestational diabetes develop type 2 diabetes within 5–10 years, and breastfeeding with weight loss reduces that risk.

Pregnancy induced hypertension (PIH)

Pregnancy-induced hypertension is a blood pressure of 140/90 mmHg or more, recorded on two occasions at least 4 hours apart, after 20 weeks in a woman who was previously normotensive. It becomes pre-eclampsia when proteinuria (300 mg or more in 24 hours, a protein–creatinine ratio of 0.3 or more, or 1+ on dipstick) or an end-organ sign appears, and eclampsia when a woman with pre-eclampsia convulses.

Gestational hypertension is a blood pressure of 140/90 or more after 20 weeks with no proteinuria and no end-organ involvement; about a quarter of these women go on to develop pre-eclampsia.
Pre-eclampsia can be diagnosed without proteinuria if there is new thrombocytopenia (platelets under 100,000/µL), creatinine above 1.1 mg/dL, transaminases doubled, pulmonary oedema, or new headache or visual symptoms.
Severe features: blood pressure 160/110 or more, platelets under 100,000/µL, creatinine above 1.1 mg/dL, doubled transaminases with epigastric or right upper quadrant pain, pulmonary oedema, and persistent headache or visual disturbance.
Antihypertensives: labetalol (oral 100 mg twice daily; intravenous 20 mg, doubling every 10 minutes to a total of 300 mg), nifedipine 10 mg orally repeated after 20–30 minutes, or hydralazine 5 mg IV every 20 minutes. Aim for 130–150/80–100 mmHg — a sudden fall cuts placental perfusion. ACE inhibitors, angiotensin receptor blockers and atenolol are contraindicated in pregnancy.
Magnesium sulphate is the anticonvulsant of choice for eclampsia and for severe pre-eclampsia. Pritchard regimen: loading 14 g — 4 g IV slow + 10 g IM (5 g each buttock); maintenance 5 g IM every 4 h, alternating buttocks, continued for 24 hours after the last fit or after delivery. The Zuspan alternative is 4 g IV loading followed by 1–2 g per hour by infusion.
Before every maintenance dose check three things: the knee jerk is present, the respiratory rate is at least 12 per minute and the urine output is at least 30 mL per hour. Therapeutic magnesium is 4–7 mEq/L; the patellar reflex is lost at 8–10 mEq/L and respiration is depressed above 10 mEq/L. The antidote is calcium gluconate 1 g (10 mL of 10%) IV slowly over 3–10 min.
Eclampsia first aid: call for help, turn her to the left lateral position, protect the airway and give oxygen, never restrain her or force anything into her mouth, give magnesium sulphate, control the blood pressure, then plan delivery — fits may be antepartum, intrapartum or postpartum, and postpartum fits can occur up to 48 hours and occasionally 6 weeks after birth.
HELLP syndrome is Haemolysis (raised LDH, schistocytes on the film), Elevated Liver enzymes and Low Platelets; it can occur without severe hypertension and presents with malaise and epigastric pain.
Prevention in high-risk women: low-dose aspirin 75–150 mg at night started between 12 and 16 weeks and continued to 36 weeks, and calcium 1.5–2 g a day where dietary intake is low. Delivery remains the only cure.

Anti-D dose and indication

Anti-D immunoglobulin is human IgG directed against the RhD antigen, given to an RhD-negative woman who is not yet sensitised so that any fetal RhD-positive red cells in her circulation are destroyed before her immune system can recognise them. It prevents alloimmunisation and therefore haemolytic disease of the fetus and newborn in later pregnancies, and it is useless once she already has anti-D antibodies.

Standard dose 300 µg (1500 IU) intramuscularly, which covers a fetomaternal bleed of up to 30 mL of fetal whole blood (15 mL of fetal red cells); the mini-dose of 50 µg (250 IU) is sufficient for a sensitising event before 12 weeks.
Timing: within 72 hours of the sensitising event. If it has been missed, give it anyway — up to 10 days is still worthwhile and there may be partial protection up to 28 days.
Routine antenatal prophylaxis: a single 300 µg dose at 28 weeks, or a two-dose regimen at 28 and 34 weeks, given regardless of what happened earlier in the pregnancy.
Postnatal prophylaxis: 300 µg within 72 hours of delivery when the baby is RhD-positive — given even if the antenatal dose was already received, and repeated after every subsequent delivery.
Sensitising events before 12 weeks needing 50 µg: miscarriage with instrumentation, therapeutic abortion, ectopic pregnancy and chorionic villus sampling. A threatened miscarriage before 12 weeks with a viable fetus and settled bleeding does not need it.
Sensitising events at or after 12 weeks needing 300 µg: abortion or intrauterine death, amniocentesis and cordocentesis, external cephalic version, antepartum haemorrhage, abdominal trauma, and delivery of an RhD-positive baby.
Quantify a large bleed with the Kleihauer–Betke test or flow cytometry after abruption, abdominal trauma, twin delivery or manual removal of the placenta — every additional 30 mL of fetal whole blood needs another 300 µg.
Check the antibody screen (indirect Coombs test) first: a positive screen from existing anti-D means she is already sensitised and prophylaxis is pointless, and the pregnancy is then managed with middle cerebral artery Doppler and referral. Give it deep intramuscularly, usually into the deltoid, and record the batch number; a positive direct Coombs test on cord blood confirms an affected baby.

Pelvic inflammatory disease (PID)

Pelvic inflammatory disease is an ascending infection of the upper female genital tract — endometritis, salpingitis, oophoritis, tubo-ovarian abscess and pelvic peritonitis — usually caused by sexually transmitted organisms crossing the cervical barrier. It matters because the diagnosis is clinical and deliberately over-inclusive: a single episode leaves about one woman in eight infertile, so treating on suspicion costs far less than missing it.

Organisms: Neisseria gonorrhoeae and Chlamydia trachomatis are the classical causes, but most cases are polymicrobial with anaerobes, Gardnerella, enteric Gram-negative bacilli, streptococci and genital mycoplasmas. Genital tuberculosis is an important Indian cause of chronic PID and tubal infertility.
Minimum diagnostic criteria — treat empirically when a sexually active young woman has pelvic or lower abdominal pain with no other explanation plus any one of cervical motion tenderness, uterine tenderness or adnexal tenderness on bimanual examination.
Additional criteria that raise confidence: oral temperature above 38.3 °C, mucopurulent cervical discharge or cervical friability, abundant white cells on saline microscopy of vaginal fluid, a raised ESR or C-reactive protein, and a positive nucleic acid amplification test for gonorrhoea or chlamydia.
Outpatient regimen: ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 14 days, plus metronidazole 500 mg orally twice daily for 14 days.
Admit for intravenous therapy when there is a tubo-ovarian abscess, pregnancy, severe illness with high fever and vomiting, failure of oral treatment at 72 hours, a surgical emergency that cannot be excluded, or an inability to tolerate oral drugs; the inpatient regimen is cefoxitin, cefotetan or ceftriaxone with doxycycline, stepping down to oral doxycycline and metronidazole to complete 14 days.
Risk factors: age under 25, a new or multiple sexual partners, a previous episode, unprotected intercourse, and instrumentation of the uterus — IUD insertion, dilatation and curettage, MTP or hysterosalpingography; the IUD-related risk is confined to the first three weeks after insertion.
Sequelae rise with each episode: infertility in about 12% after one episode, 25% after two and 50% after three; a six- to ten-fold rise in ectopic pregnancy; chronic pelvic pain from adhesions; hydrosalpinx; and Fitz-Hugh–Curtis perihepatitis with right upper quadrant pain and violin-string adhesions.
Partner management is part of the treatment: every sexual partner of the preceding 60 days is treated for gonorrhoea and chlamydia, intercourse is avoided until both have finished, and the woman is retested for reinfection at 3 months.
Review at 72 hours is mandatory — substantial clinical improvement is expected by then, and its absence means reassessing for an abscess, a wrong diagnosis or non-adherence.

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