SM CMT 05213 Obstetrics and gynaecology II

UNITED REPUBLIC OF TANZANIA

Ministry of Health and Social Welfare

CMT 05213
Obstetrics and
Gynaecology II
NTA Level 5 Semester 2
Student Manual
August 2010

CMT 05213 Obstetrics and Gynaecology II NTA Level 5 Semester 2 Student Manual
ii
Copyright © Ministry of Health and Social Welfare – Tanzania 2010

iii
Table of Contents
Background and Acknowledgement........................................................................ iv
Introduction.............................................................................................................. ix
Abbreviations........................................................................................................... xi
Module Sessions
Session 1: Multiple Pregnancies................................................................................1
Session 2: Hypertensive Disorders in Pregnancy ......................................................5
Session 3: Operative Delivery .................................................................................13
Session 4: Emergency Obstetrics Care ....................................................................17
Session 5: Managing Patients with Abortions.........................................................21
Session 6: Ectopic Pregnancy ..................................................................................35
Session 7: Abnormalities of Menstruation...............................................................39
Session 8: Pelvic Inflammatory Disease (PID)........................................................43
Session 9: Infertility.................................................................................................47
Session 10: Uterine Fibroids (Myoma) and Ovarian Tumours ...............................53
Session 11: Cancer of the Cervix.............................................................................59
Session 12: Gynaecological Problems in Women Living with HIV.......................63
Session 13: Obstetric Fistula....................................................................................69
Session 14: Genital Prolapse....................................................................................73
Session 15: Postpartum Psychiatric Disorders.........................................................79
Session 16: Diabetes in Pregnancy ..........................................................................83

iv
Background and Acknowledgement
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.
In September 2009, MOHSW embarked on an innovative approach of developing the
standardised training materials through the Writer’s Workshop (WW) model. The model
included a series of three-week workshops in which pre-service tutors and content experts
developed training materials, guided by facilitators with expertise in instructional design and
curriculum development. The goals of WW were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials.
The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.
Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.
Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to

v
Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.
Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.
Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.
These participants are listed with our gratitude below:
Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC

vi
Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC
Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)

vii
Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro
Editorial Review Team
Dr. Kasanga G. Mkambu - Obstertric and Gynaecology specialist, Tanga Assistant Medical
Officers Training Centre (AMOTC)
Dr. Ronald Erasto Msangi - Principal, Bumbuli COTC
Mr. Sita M. Lusana - Tutor, Tanga Environmental Health Science Training Centre
Mr. Ignas Mwamsigala - Tutor (Entrepreneurship) RVTC Tanga
Mr. January Karungula - RN, Quality Improvement Advisor, Muhimbili National Hospital
Prof. Pauline Mella - Registered Nurse and Profesor, Hubert Kairuki Memorial University
Dr. Emmanuel A. Mnkeni – Medical Officer and Tutor, Kilosa COTC
Dr. Ronald E. Msangi - Principal, Bumbuli COTC
Mr. Dickson Mtalitinya - Pharmacist, Deputy Principal, St Luke Foundation, Kilimanjaro
School of Pharmacy
Dr. Janeth C. Njau - Paediatrician/Tutor, Kibaha COTC
Mr. Fidelis Mgohamwende - Labaratory Technologist, Programme Officer National Malaria
Control Programme (NMCP), MOHSW
Mr. Gasper P. Ngeleja - Computer Instructor, RVTC Tanga
Dr. Shubis M Kafuruki - Research Scientist, Ifakara Health Institute, Bagamoyo
Dr. Andrew Isack Lwali - Director, Tumbi Hospital
Librarians and Secretaries
Mr. Christom Aron Mwambungu - Librarian MUHAS
Ms. Juliana Rutta - Librarian MOHSW
Mr. Hussein Haruna - Librarian, MOHSW
Ms. Perpetua Yusufu - Secretary, MOHSW
Mrs. Martina G. Mturano -Secretary, MUHAS
Mrs. Mary F. Kawau - Secretary, MOHSW

viii
IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam

Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare

ix
Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
3.3.7. Manage gynecological emergencies: Induced abortions, Ectopic pregnancy, Acute
pelvic inflammatory diseases (PID), Pelvic abscess, Incomplete and septic abortion.
3.3.9. Provide postpartum care.
4.3.7. Utilize intervention strategies for prevention of mother to child transmission
(PMTCT) of HIV.
3.3.3 Manage or refer complicated Obstetric conditions (previous caesarean scar, multiple
Pregnancies, IUFD, anaemia in Pregnancy,Pregnancy Induced hypertension/pre-
eclampsia and eclampsia, malpresentation/malposition (breech, transverse lie),
presence of chronic disease with pregnancy e.g. diabetes, obstructed labour.
3.3.4 Manage or refer complicated gynaecological conditions (Missed abortion, Uterine
Myomas, ovarian tumours/cysts and vesico-vaginal fistula
Who is the Module For?
This module is intended for use primarily by students of CA and CO schools. The module’s
sessions give guidance on contents and activities of the session and provide information on
how students should follow the tutor when he/she teaches the module. It also provides
guidance and necessary information for students to read the materials on his/her own. The
sessions also include different activities which focus on increasing students’ knowledge,
skills and attitudes.
How is the Module Organized?
The module is divided into 16 sessions; each session is divided into several sections. The
following are the sections of each session:
• Session Title: The name of the session.
• Learning Objectives – Statements which indicate what the student is expected to have
learned at the end of the session.
• Session Content – All the session contents are divided into subtitles. This section
includes contents and activities with their instructions to be done during learning of the
contents.
• Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
• Evaluation – The last section of the session consists of short questions based on the
learning objectives to check if you understood the contents of the session. The tutor will
ask you as a class to respond to these questions; however if you read the session by
yourself try answering these questions to evaluate yourself if you understood the session.
• Handouts – Additional information which can be used in the classroom while the tutor is
teaching or later for your further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the students to study material on their own and to reference after the session. Sometimes,
a handout will have questions or an exercise for students to answer.

x
How Should the Module be Used?
Students are expected to use the module in the classroom and clinical settings and during self
study. The contents of the modules are the basis for learning Obstetrics and Gynaecology II.
Students are therefore advised to learn all the sessions including all relevant handouts and
worksheets during class hours, clinical hours and self study time. Tutors are there to provide
guidance and to respond to all difficulty encountered by students. One module will be
assigned to 5 students and it is the responsibility of the tutor to do this assignment for easy
use and accessibility of the student manuals to students.

xi
Abbreviations
AMTSL Active Management of third Stage of Labour
APH Antepartum haemorrhage
ARM- Artificial Rupture of Membrane
BP Blood Pressure
BV Bacterial Vaginosis
CET Cervical excitation test
CCT Controlled Cord Traction
CVA Cerebral Vascular Accident
C/S Caesarian Section
DES Diethylstilbestrol
DM Diabetes Mellitus
DUB Dysfunctional Uterine Bleeding
EmOC Emergency Obstetric Care
FBG Fasting Blood Glucose
FH Fundal Height
FIGO International Federation of Obstetrician and Gynaenocologist
GA Gestation Age
GnRH Gonadotropin Releasing Hormone
HBV Hepatitis B Virus
HELLP Haemolytic Eleveted Liver enzymes Low Platelet count
HPV Human Papilloma Virus
HRT Hormonal Replacement Therapy
HSG Hysterosalpingography
HSV Herpes Simplex Virus
ICSI Intracytoplasmic Sperm Injection
IM Intra-Muscular
IPT Intermittent Preventive Treatment
IUCD Intrauterine Contraceptive Device
IUFD Intra Uterine Fetal Death
IUGR Intra Uterine Growth Restrictions/Retardation
IUI Intrauterine artificial insemination
IV Intravenous
IVF In Vitro Fertilization
LCVE Low Cavity Vacuum Extraction
LSCS lower segment caesarean section
MTCT Mother to Child Transmission
MVA Manual Vacuum Aspiration
NNRTIs Non Nucleoside Reverse Transcriptase Inhibitors
OPD Outpatient Department
PCOS Polycystic Ovarian Syndrome
PEP Post Exposure Prophylaxis
PI Protease Inhibitor
PID Pelvic Inflammatory Disease
PIH Pregnancy-Induced Hypertension
PMTCT Prevention from Mother To Child Transmission

xii
PPH Postpartum Haemorrhage
PPROM Preterm pre-labour rupture of membranes
PR Pulse Rate
PROM Premature ruptures of membranes
PV Bleeding Per Vaginum
RR Respiration Rate
RTI Respiratory tract infection
RBG Random Blood Glucose level
RVF Rectal Vagina Fistula
UPT Urine for Pregnancy Test
Hb Hemoglobin
USS Ultrasound
SP Sulfadoxine/pyrimethamine
STD/STI Sexually Transmitted Diseases/Infections
SVD Spontaneous Vaginal Delivery
TB Tuberculosis
TORCHES Toxoplasmosis, Rubella, Cytomegalovirus, Herpes and Syphillis
VIA Visual inspection with acetic acid
VILLI Visual Inspection with Lugols Iodine
VVF Vescico Vagina Fistula

Session 1: Multiple Pregnancies 1
Session 1: Multiple Pregnancies
Learning Objectives
By the end of this session, students are expected to be able to:
• Define multiple pregnancies, monozygotic and dizygotic twinning
• Describe the prevalence and types of multiple pregnancies
• Describe clinical features and diagnosis of multiple pregnancies
• Describe the complications of multiple pregnancies
• Describe the management of multiple pregnancies
Definition of Terms
• Multiple pregnancies are a term used to describe the presence of two or more foetuses in
utero.
• Monozygotic Twining: Multiple pregnancies developing from a single fertilized ovum
which divides into two or more zygotes.
• Dizygotic Twinning: Multiple pregnancies developing from fertilization of two separate
ova.
Prevalence and Types of Multiple Pregnancies
• Multiple pregnancy rates vary worldwide.
• Monozygotic twinning
o Instance is relatively constant
o Frequency: approximately one set per 250 births
o Independent of race, heredity, age, and parity
• Dizygotic twinning
o Rates vary by age, parity, ethnic group and use of assisted reproduction/fertility drugs
o As a determinant of twinning, the genotype is familial.
o Incidences increase with maternal age and parity
Clinical Features and Diagnosis of Multiple Pregnancies
Clinical Features
• Excessive symptoms of early pregnancy
• Exaggerated foetal movements
• Family history of multiple pregnancy
• Fast increase of Fundal Height (FH) than the Gestational Age (GA)
• Multiple foetal parts
o Very difficult in case of one twin overlying the other, in obese women, or
polyhydramnios and early pregnancy
• Foetal heart beats may be heard at various parts with different rates
• Confirmed with ultrasound
Differentials of Large Uterus for Gestational Age
• Inaccurate menstrual history
• Polyhydramnios
• Hydatidiform mole

• Uterine myomas
• Closely attached adnexal mass
• Macrosomia/hydrocephaly
Complications of Multiple Pregnancies
• Multiple pregnancies can result in various pregnancy-related complications.
o Exaggerated symptoms of pregnancy
o Increased risk of spontaneous abortion
o Increased risk of anaemia
o Pre-term delivery
ƒ Pre-term birth = 66.0%
o Hypertension
ƒ Pre-eclampsia is five times more likely in twin pregnancies
o Antepartum haemorrhage
o Postpartum haemorrhage
o Polyhydramnios
o Malpresentations and malpositions
o Locked twins
ƒ A form of malpresentation in which a breech twin and a vertex twin become
locked at the chin during labor and attempted delivery.
o Prolonged labour
o Intrauterine growth restrictions
o Twin-Twin transfusion syndrome
o Congenital malformations like conjoined twins
ƒ The conjoined twins could be craniopagus, thoracopagus, ischiopagus, pyopagus
o Cord accidents
Management of Multiple Pregnancies
Antenatal Care
• The management is the same as for singleton pregnancy, but a woman with a multiple
pregnancy requires more visits towards term and possible admission close to term if she is
far from hospital
• Screen for hypertension and gestational diabetes, as these conditions occur more
frequently in twin pregnancies.
• Supplements: Iron and folate should be given routinely
• Weight gain should be monitored closely to ensure adequate nutrition
• Routine serial ultrasound (in each trimester) to rule out congenital malformations,
development of acute polyhydromnion and twin to twin transfusion syndrome
Mode of Delivery
• Depends on presentation of the first twin and the presence of other obstetric
complications
• If the first twin is cephalic, vaginal delivery is indicated, but caution should be exercised
when the second twin is breech.
• If the first twin is non-cephalic in prime gravida elective caesarean section is indicated
• For multiparous women, vaginal delivery can be attempted
• Regardless of the type of presentation, twin pregnancy with other obstetrics complications
(e.g. one previous scar, pre-eclampsia, etc.) consider elective caesarean section at term.

Management of Labour
• Pregnant women with twins should be referred to hospital for delivery at term.
Delivery of the First Twin
• Spontaneous onset of labour is common
• Labour is monitored similarly as in singleton pregnancies
• Delivery of the first twin is also similar as in singleton pregnancies
Delivery of the Second Twin
• Should be delivered within 30 minutes after the first twin
• Assess the lie and presentation of the foetus
o Correct the presentation if possible
o Delivering the second twin in breech position may be complicated if the second twin
is larger than the first or if the cervix has contracted and is no longer fully dilated
o Foetal distress of the second twin can occur if the cord prolapses.
• Establish contractions in case they are inadequate
o May use oxytocin if necessary
• Monitor labour – maternal and foetal parameters
• Assist delivery, as in a singleton delivery
• Third stage of labour
o Active management of third stage of labour – to prevent post-partum haemorrhage
(PPH)
Key Points
• Multiple pregnancies account for about 1.5% of all pregnancies.
• Perinatal mortality in multiple pregnancies is about six times higher than in singletons,
primarily due to spontaneous preterm births.
• Both serious maternal and foetal complications and minor discomforts are increased in
multiple gestations.
Evaluation
• Explain the different between monozygotic and dizygotic twinning.
• What are the differentials of large uterus for gestational age?
• What are the complications of multiple pregnancies?
References
• Baker, P. Monga, A. (2006). Obstetrics by Ten Teachers (18th Ed.). London: Hodder
Arnold.
• Fraser, D.M., Cooper, M.A. (2003). Myles’ Textbook for Midwives. (14th
Ed.). London:
Churchill Livingstone.
• Hanretty, K.P. (2003). Obstetrics Illustrated (6th
Ed.). London: Churchill Livingstone.
• Oats, J., Abraham, S. (2005) Llewellyn-Jones Fundamentals of Obstetrics and
Gynaecology. (8th
Ed.). Edinburgh: Mosby.
• Parisaei, M., Shailendra, A., Dutta, R., Broadbent, J.A. (2008). Crash Course: Obstetrics
and Gynaecology. (2nd Ed.) Mosby.

Session 2: Hypertensive Disorders in Pregnancy 5
Session 2: Hypertensive Disorders in Pregnancy
Learning Objectives
• Define the terms pre-eclampsia and eclampsia
• Identify risk factors for pre-eclampsia and eclampsia
• Classify pre-eclampsia based on clinical features
• Describe management of a woman with pre-eclampsia and eclampsia
• Describe complications of pre-eclampsia and eclampsia
Classification of Hypertensive Disorders in Pregnancy
• Hypertensive disorders in pregnancies are grouped into four classifications:
o Pregnancy-Induced Hypertension (PIH): Transient elevation of blood pressure
during pregnancy which occurs in the third trimester and is not associated with
proteinuria. Resolves spontaneously within 12 weeks post delivery.
o Chronic hypertension antedates pregnancy or elevated Blood Pressure (BP) detected
before 20 weeks of gestation age. Proteinuria is rare.
o Chronic hypertension with superimposed PIH or Pre-eclampsia
ƒ Pregnancy worsens the pre-existing hypertension
Pre-Eclampsia
• Raised blood pressure in pregnancy, when BP 140/90 mmHg with the presence of
protein in urine more than 300mg in a 24 hour urine collection and oedema or proteinuria
of 0.3 grams or greater in a 24 hour urine specimen or persistent 1+ (30mg/dL on
dipstick)
o The diagnosis requires two such abnormal BP measurements, recorded at least six
hours apart
Imminent Eclampsia
• Elevation of BP (in pregnant women) above 160/110mmHg accompanied by blurring of
vision, vomiting, epigastric pain and severe and persistent headache.
Eclampsia
• Convulsions occurring in a woman with established pre-eclampsia in the absence of any
other neurological or metabolic cause.
• Note that eclampsia may occur without warning signs of imminent eclampsia.
Risk Factors for Pre-Eclampsia and Eclampsia
• There are several risk factors for pre-eclampsia and eclampsia in pregnant women
o Primigravida
ƒ 85% of pre-eclampsia occur in primigravidas
o Increased placental tissue for gestational age
ƒ Resulting from Hydatiform moles, twin pregnancies, etc.
o Family history of pre-eclampsia
o Pre-existing hypertension
o Renal diseases
o Diabetes mellitus

o Rhesus isoimmunization
o Obesity
o Extreme maternal age
Classification of Pre-Eclampsia
• Classification of pre-eclampsia is based on severity and clinical features.
Mild–Moderate Pre-Eclampsia
• May be asymptomatic
• BP is raised but is below 160/110 mmHg
• Protein in urine is 1+ or less, less than 5 grams in a 24 hour urine collection
• No symptoms of imminent eclampsia
Severe Pre-Eclampsia
• Severe pre-eclampsia involves at least one of the following:
o Symptoms of imminent eclampsia
ƒ Severe persistent headache, visual disturbances, epigastric and right upper
abdominal pain
o BP is above 160/110 mmHg
o Protein in urine is 3+ or above
o Hyperreflexia
o Respiratory distress (pulmonary oedema)
o Oligohydramnion
o Intra-Uterine Growth Restrictions/Retardation (IUGR)
o Oliguria
o Acute renal failure (Oliguria with less than 500mL per 24 hours)
o HELLP syndrome, especially with thrombocytopaenia
ƒ Haemolytic Elevated Liver enzymes Low Platelet count (HELLP)
o Persistent maternal headache or visual disturbance
o Pulmonary oedema or cyanosis
o Concerning abdominal pain
o Impaired liver function test findings
o Thrombocytopenia
Management of Pre-Eclampsia and Eclampsia
Mild–Moderate Pre-Eclampsia before 37 Weeks of Gestation Age
• Manage as outpatient if patient is compliant and can be followed closely
• Provide antihypertensives: Aldomet, etc.
• Rest at home
• Monitor foetal well-being
o Foetal movements, ultrasound (USS), etc.
• Deliver at term
• Patients presenting with pre-eclampsia prior to 34 weeks of gestational age (GA) should
be given a course of steroids.
• Note: Patients with severe pre-eclampsia and severe eclampsia should be managed in the
hospital by a doctor

Management of Severe Pre-Eclampsia
• Urgently refer the patient to the hospital for further management and planned delivery.
• Provide the general measures
• Control BP with Aldomet, Hydralazine; Consider labetolol
o Beta blockers should not be used for asthmatics or for patients with congestive heart
failure
• Prevent fits/convulsions with prophylaxis using Magnesium sulphate
Management of Eclampsia
• Urgently refer the patient to the hospital for further management
• Before referring this patient, provide the general measures
• Keep airway clear
• Control convulsions
• Control BP
• Control fluid balance
Management in the Hospital
• Control convulsions with IV Magnesium sulphate
• Control BP with IV Hydralazine
• Basic investigations will include; urine for proteins, FBC, renal and liver function tests,
Obstetrics USS:
o Deliver the mother
• Mode of delivery
o Preferably vaginally
o Caesarean Section (C/S) is indicated in case of repetitive convulsions, uncontrolled
hypertension, foetal distress or in the presence of any other obstetric indication
o Second Stage: Assist with vacuum extraction; if there is a delay, perform C/S
o Third Stage: Active management
o Post-Delivery:
ƒ Continue observation for at least 48 hours post-delivery
ƒ Record and monitor input/output chart
ƒ Keep the patient in hospital until BP stabilizes
ƒ Continue with and Magnesium for at least 24 hours post-delivery, and Aldoment
orally until BP is back to normal.
Refer to Handout 2.1: Management of Pre-Eclampsia and Eclampsia
Complications of Pre-Eclampsia
• Pre-eclampsia can produce complications in many different systems.
• Cardiovascular System
o Haematological changes – HELLP syndrome may lead to disseminated intravascular
coagulopathy.
• Kidneys
o Acute renal failure (oliguria or anuria)

• Brain
o Cerebral oedema
o Infarction, cerebral haemorrhage
o Blindness, possibly due to retinal artery vasospasms and retinal detachment
o Fever from 39ºC and above (considered a grave sign).
o Coma – may be a result of Cerebral Vascular Accident (CVA)
• Respiratory
o Pulmonary oedema and cyanosis
• Reduced utero-placental perfusion
o May be due to increased vasospasms and perfusion and acute artherosis
o Oligohydramnion
• Foetal complications
o Intrauterine growth restriction, foetal distress, intrauterine foetal death
Key Points
• Severe pre-eclampsia and eclampsia are dangerous medical conditions, requiring referral
to the hospital level.
• Manage minor hypertensive problems during pregnancy to prevent progression into
eclampsia.
• In severe cases, control convulsion and BP, maintain fluid balance, deliver the mother at
whatever gestation age, and keep records.
Evaluation
• What are the clinical features of imminent eclampsia?
• How would you manage a patient with eclampsia?
References
Arnold.
• MOHSW. (2005). Advanced Life Saving Skills Trainee Manual. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• MOHSW. (2008). Emergency Obstetric Care: Job Aid. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• WHO. (2005). Managing Complications in Pregnancy and Childbirth: A Guide for
Midwives and Doctors. Geneva: World Health Organization.

Mild–Moderate Pre-Eclampsia
• Manage as outpatient
• Antihypertensive: Aldomet, etc
• Do not prescribe diuretics. Patients with pre-eclampsia have reduced intravascular
volume.
• Rest at home
• Advise the patient to take a normal diet, and drink plenty of fluid
• Foetal movement monitoring
• See the patient every two weeks up to 32 weeks, and then weekly up to 36 weeks
• Plan delivery at 37–38 weeks
• At every visit :
o Ask if they have experienced symptoms of severe pre-eclampsia
o Monitor BP
o Check for oedema, proteinuria, weight
o Monitor foetal growth and wellbeing
• Strongly advise patient to deliver baby in a hospital
• Indications for hospitalization:
o A bad obstetric history
o Evidence of poor foetal growth
o Gestation age of 37 weeks or more
o When bed rest at home is not possible
o Staying far from the hospital
• Investigations/Clinical Work-Up
o Blood Slide for malaria parasites
o Urine analysis: proteinuria, cells, glucose
o Full blood picture: platelets, haematocrit
o Uric acid level
o Serum creatinine and blood urea
o Transaminases and prothrombin time
o Ultrasound Scan (USS): foetal wellbeing, amniotic fluid volume, foetal size
• Follow management steps for eclampsia (below)
• Note: Patients with severe pre-eclampsia and severe eclampsia should be managed in the
hospital by a doctor.
Eclampsia
• Before referring this patient, provide the general measures.
o Keep the airway by inserting an airway, clear by suction of secretion
o Give oxygen if the patient has difficulty in breathing
o Give the loading dose of MgSO4 4g (i.e. 20mls of 20% solution) + 200mls NS or
sterile water IV over five minutes.
Handout 2.1: Management of Pre-Eclampsia and Eclampsia

o Follow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M
with 1ml of 2% lignocaine in the same syringe
• Control BP
o Insert urethral catheter
• Urgently refer the patient to the hospital for further management
Management in the Hospital
• Control BP
• Antibiotics
• Investigations
• Deliver the mother
Intramuscular Regimen
• Loading dose
o Give MgSO4 4g (i.e. 20mls of 20% solution) + 200mls NS or sterile water IV over
five minutes
o Follow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep IM
with 1ml of 2% lignocaine in the same syringe
• Maintenance dose
o MgSO4 5g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2%, every four hours in
alternate buttocks.
o Note: Intramuscular (IM) injections are painful and are complicated by local abscess
formation in 0.5% of cases. The intravenous (IV) route is therefore preferred
Intravenous Regimen
• Loading dose
o MgSO4 4g (i.e. 20mls of 20% solution) + 200mls NS IV over five minutes
• Maintenance dose
o MgSO4 4g (i.e. 20ml of 20% solution) in 500ml NS every four hours for 24 hrs after
the last fit
Recurrent Fits (any Regimen)
• Therapeutic dose may not have been reached
• Give 2g (i.e. 10ml of 20% solution) IV over five minutes
Treatment Duration
• Continue for 24 hours after delivery or last convulsion, whichever occurs first
Magnesium Toxicity
• Causes loss of deep tendon reflexes, followed by respiratory depression and ultimately
respiratory arrest.
• Thus, before repeating MgSO4, ensure that:
o RR ≥ 16/min
o Patellar reflexes are present

o Urinary output is at least 30ml per hour over four hours
o Otherwise withhold or delay MgSO4
o Keep antidote ready
o In case of respiratory arrest: Assist ventilation and administer calcium gluconate.
BP Control
• Keep systolic BP between 140 -160 mm Hg and diastolic BP between 90 -110 mm Hg
• Why these levels: Avoid potential reduction in either uteroplacental blood flow or
cerebral perfusion pressure.
Drugs
• Anti Hypertensives (HPTs): Hydralazine, nifedipine, or labetalol
• Diuretics are not used except in the presence of pulmonary oedema
Deliver the Mother
• Delivery should be within six to eight hours after of onset of fits
• Vaginal delivery is the safest mode of delivery
• Assessment
o Note and consider the contraindications to Spontaneous Vaginal Delivery (SVD) e.g.
Malpresentation, big baby, cephalopelvic disproportion (CPD)
o Bishop score if the cervix is favourable - induce labour, otherwise prepare for
caesarean section.
• Second Stage: Assist with vacuum extraction
• Third Stage: Active management. If there is a delay, perform caesarean section.
• Post-Delivery: Continue observation for at least 48 hours post-delivery, record and
monitor input/output chart, keep the patient in hospital until BP stabilizes, continue with
Aldoment PO until BP back to normal.

Session 3: Operative Delivery 13
Session 3: Operative Delivery
Learning Objectives
• Define operative delivery
• List the types of operative delivery
• List indications of each operative delivery
• List the common complications
Operative Delivery
• Operative Delivery: An alternative method of delivery that is used when the mother is
unable to give birth normally and needs surgical intervention.
Types of Operative Delivery
• Caesarean delivery
o Transverse Lower Segment Caesarean Section (LSCS)
o Classical caesarean section
o Caesarean hysterectomy
• Operative vaginal delivery
o Vacuum
o Destructive delivery of a dead foetus.
ƒ Includes the following: Craniotomy (dead fetus, 2/5 or less of their head must be
above the brim. If it is higher than this, Caesarean section is usually safer. Head
must be impacted. Maternal cervix must be at least 7 cm dilated, and preferably
fully dilated. Uterus must be unruptured, and not in imminent danger of rupturing)
Baby is dead and is lying transversely, cervix is 8 cm or more dilated, and
maternal uterus is not ruptured.
Indications and Complications for Operative Delivery
Indications for Caesarean Section
• Faults with birth canal
o Cephalo pelvic disproportion
o Pelvic tumours
o Previous scars, caesarean section, perinearaphy, Vesico-Vaginal Fistula (VVF) and
Rectal Vaginal Fistula (RVF) repair
o Cervical/vaginal stenosis
• Foetal malpresentation and lie
o Breech
o Brow
o Face - mental posterior
o Cord presentation/prolapse
o Transverse lie
• Abnormalities of labour
o Obstructed labour
o Antepartum Haemorrhage (APH)
o Foetal distress

o Eclampisia
o Placenta praevia
Preparation of the Patient for Caesarean Section
• Obtain informed consent from the patient
• Take blood for haemoglobin and blood grouping
• IV line for input of fluids
• Catheter to monitor urine output
Complications of Caesarean Section
• Bleeding, intra-operative or post-operative
• Pain
• Wound infection
• Anaesthetic agents exposure
• Late ambulation post delivery
• Increased risk of thromboemblism
• Surgical complications: injury to bowel, bladder, etc.
Trial of Scar (Vaginal Delivery after C/S)
• Providing a pregnant woman with an opportunity to deliver vaginally, when she has a
previous caesarean scar/history of C/S
• Close monitoring of labour should be done using partograph
Indications for Trial of Scar
• Indication for the previous caesarean section should be non-recurrent
• Healing of the uterine scar was without sepsis
• The previous caesarean should be more than two years prior to this delivery
• Must be single previous scar
• The foetus must be in cephalic presentation
• Singleton pregnancy
• Adequate pelvis
• Facilities for emergency caesarean must available
Management of a Patient for Trial of Scar
• During trial of scar, the labour progress should be closely monitored by:
o Scar tenderness
o Pulse rate
o PV bleeding (Bleeding per vaginum)
o Foetal heart rate
Low Cavity Vacuum Extraction (LCVE)
• Indications for vacuum delivery
o Delayed second stage
o Foetal distress in second stage
o Maternal conditions: requiring short second stage
ƒ Severe anaemia
ƒ Heart failure
ƒ Maternal distress

• Prerequisites for vacuum delivery
o Full dilatation of cervix
o Good uterine contractions
o Adequate pelvis
o Normal size of the baby
o Cephalic presentation
o Descent 3/5 or more
o No caput
o No severe moulding
o Avoiding a vaginal operative delivery for a foetus whose mother is HIV positive is
advisable if possible to minimize trauma to the foetal scalp which may increase
maternal foetal HIV exposure.
• Basic rules
o Delivery should be completed within 15 minutes
o Head should descend with each pull
o The cup should be applied no more than three times
• Contraindications of LCVE
o Breech presentation
o Face presentation
o Prematurity
o Any contraindications for Spontaneous Vaginal Delivery (SVD)
ƒ For example, two previous scars, APH, previous perineal repair
• Common Complications of Low Cavity Vacuum Extraction (LCVE)
o Maternal:
ƒ Trauma to the genital tract
o Foetal:
ƒ Oedema and necrosis of the scalp
ƒ Cephalhaematoma (subperiosteal bleed)
ƒ Intracranial haemorrhage (more common in premature babies)
Key Points
• Decision for any operative management should be made in a timely fashion to try to
ensure good outcomes.
• Indications for caesarean section include faults with the birth canal, malpresentation and
lie, and abnormalities of labour.
Evaluation
• List the common complications of operative deliveries.
• Describe the indications for trial of scar delivery.
References
• Baker, P. Monga, A. (2006). Obstetrics by Ten Teachers (18th
ed.). London: Hodder
Arnold.
• DeCherney, A.H. Nathan, L. (2002). Current Obstetrics and Gynaecology (9th
ed.).
McGraw Hill.
• Oats, J., Abraham, S. (2005). Llewellyn-Jones Fundamentals of Obstetrics and
Gynaecology. (8th
ed.). Edinburgh: Mosby.
and Gynaecology. (2nd
ed.) Mosby.

Session 4: Emergency Obstetrics Care 17
Session 4: Emergency Obstetrics Care
Learning Objectives
• Define emergency obstetrical care
• List the obstetric emergency conditions
• Describe types of emergency obstetrical care
• Explain the immediate resuscitative measures to be performed to pregnant women with
obstetric complication
• Describe the format for writing a patient referral letter
• Explain the essential components needed for providing EmOC
• List the relevant equipment and supplies for EmOC
Obstetric Emergencies
• Emergency Obstetric Care (EmOC): A set of minimal health care elements that should
be made available to all women with obstetric complications.
• Obstetric conditions which need emergency attention include:
o Obstetric haemorrhage at any stage of pregnancy, including:
ƒ Antepartum Haemorrhage (APH)
ƒ Postpartum Haemorrhage (PPH)
ƒ Unsafe abortion
o Pregnancy-induced Hypertension (PIH) in imminent eclampsia and pre-eclampsia
o Obstructed labour
o Rupture of uterus
o Sepsis
o Very severe anaemia
o Severe malaria
Types of EmOC
Basic Emergency Obstetric Care
• The elements of basic emergency obstetrics care include:
o Administration of IV antibiotics
o Administration of parental sedatives
o Administration of parental oxytocics (Oxytocin-like drugs) or other uterotonics
(agents used to induce contraction or greater tonicity of the uterus) that may be
available
o Performing manual removal of retained placenta and products of conception
o Performing assisted delivery by vacuum extractor
Comprehensive Emergency Obstetric Care
• Comprehensive Emergency Obstetric care includes all of the elements of Basic EmOC
(see above), as well as:
o Performing surgery (Caesarean section or Laparatomy for Ectopic pregnancy)
o Administration of blood transfusion
o Provision of emergency obstetric anaesthesia

Immediate Resuscitative Measures
• In any case of obstetric emergency, the service provider should be able to provide
immediate care in emergency obstetrics before referral.
• The service provider should use the problem-solving method to identify the client’s
problem:
o Ask and listen, look and feel, identify problem and take appropriate action
o Resuscitate the woman by:
ƒ Initiating treatment
ƒ Set IV fluid (if necessary)
ƒ Give initial dose of antibiotics (if necessary)
ƒ Give sedative and analgesic where needed
ƒ Pass indwelling catheter where indicated
ƒ Check all vital signs
ƒ Check blood grouping
ƒ Refer the woman with an escort of a skilled service provider
Format for Writing a Referral Letter to a Higher Level
• A proper well-laid referral system is an essential component in the provision of
emergency obstetric care.
• When faced with an emergency, the healthcare provider should know exactly where to
refer. Mechanisms should be put in place to ensure prompt referral.
• The following pieces of important information should be included in the referral letter:
o Patient’s identity (name, sex, age, address)
o Patient’s history
o Findings on examination
o Laboratory findings
o Treatment (management) given
o Reasons for referral
o Name and signature of the referring officer
Essential Components Needed for Providing EmOC
Physical Setting
• Waiting area with adequate and comfortable sitting space
• Rooms that offer privacy
• Clean floors, walls and working surfaces
• Good ventilation, source of light, and drinking water
• Waste disposal facility
• Space for processing equipment
• Toilet facilities for staff and patients
• Signs indicating available services for smooth client flow
Personnel
• Skilled service providers with behaviours/attitudes that encourage utilization of
healthcare services
• Allocation of providers according to job and tasks
• Up-to-date knowledge and information, through on-the-job training
• Available and use the guidelines and standards for care
• Motivated staff

Time Management
• Set time for client/provider interaction based on client needs
• Avoid routines that may inconvenience some clients
• Try not to fix dates for specific services without considering clients’ convenience
• Avoid long waiting times
EmOC Equipment
• Basic EmOC equipment to be made available as per facility
• Maintain inventory of all equipments
• Keep and use ledger book
• Store equipment appropriately
Teaching Aids
• Know which visual aids are available and their use
• Use them according to the manufacturer’s instructions
• Keep them safe
Emergency Obstetric Supplies and Equipment
• Ensure supplies for emergencies are easily accessible to all service providers
• Ensure adequate stock levels of supplies
• Follow storage guidelines
• Do not use expired or damaged items
Client Records
• Record all relevant information, as per standard forms and registers
• Use files
• Ensure privacy and confidentiality
Relevant Equipments and Supplies for EmOC
Equipment for EmOC
• Blood pressure machine with stethoscope in good working condition
• Baby and adult weighing scales in good working condition
• Foetal stethoscope
• Boiler (sterilizer)
• Autoclave
• Delivery set
• Suturing set (materials)
• Kidney, dishes, gallipots, dressing forceps, sponge forceps
• Clinical thermometer
• Light source
• Syringes and needles
• Cannula
o 16, 18, 20 and 22 gauge
• Urethral catheters (Foleys and Nelaton)
• Ventilator bag and mask for neonates and adults (Ambu bag)
• Mouth gag
• Sterile surgical gloves

• Clean gloves
• Partograph forms
• Infant warmer
• Long sleeved gloves (sterile)
• Giving sets (infusion sets)
Supplies
• Oxytocic drugs: - Oxytocin, Ergometrine, Misoprostol tablets
• Intravenous solutions
o Ringers Lactate
o Normal Saline
o Dextrose 5% for IV Quinine
• Antibiotics
• Anticonvulsants
• Antihypertensives
• Analgesics
• Magnesium sulfate 6-g loading dose followed by a continuous infusion at a rate of 2 g per
hour (Only in referral places)
• Local anesthetic drugs
• Manual vacuum aspirator (eg. Ipas, or other device)
• Vacuum extractor (eg. Kiwi vacuum)
Key Points
• Most maternal deaths result from obstetric emergencies, some of which are unpredictable.
• All deliveries should be attended by a skilled service provider.
• All skilled service providers must be competent at providing life-saving skills in all
obstetric emergencies.
• All serious patients should be accompanied by a service provider when referred to a
higher level of service.
• Health centres that recieve referred patients should provide feedback to the referring
centres. This will help the healthcare provider to know what happened to the client and
what type of subsequent/follow-up care is needed.
Evaluation
• What are the key components of basic EmOC?
• Outline the obstetric conditions that need emergency attention.
• Describe the important pieces of information that should be included in a referral letter.
• Which equipment and supplies are required to provide EmOC?
References
• Fraser, D.M., Cooper, M.A. (2003). Myles’ Textbook for Midwives. (14th
Ed.). London:
Churchill Livingstone.
• MOHSW (2005). Advanced Life Saving Skills. Dar es Salaam, Vol 1. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare.
• MOHSW (2005). Basic Life Saving Skills. Dar es Salaam, Vol 2. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare.
• WHO. (2000) Integrated Management of Pregnancy and Childbirth: A Guide for
Midwives and Doctors. Geneva: World Health Organization.

Session 5: Managing Patients with Abortions 21
Session 5: Managing Patients with Abortions
Learning Objectives
By the end of the session, students are expected to be able to:
• Define abortion
• Describe different types of abortion
• Identify causes of abortion
• List different types of abortion complications
• Describe management of different types of abortion
• Demonstrate skills to perform manual vacuum aspiration
• Provide post-abortion education and counselling
Definition of Abortion
• Abortion: The termination of pregnancy before 28 completed weeks of gestation or 1000
gm foetus.
• Note: The World Health Organization (WHO) definition is 22 weeks of gestation or 500
gm foetus. This definition is applicable in the developed world.
Types of Abortions
• Spontaneous Abortion
o Also known as ‘miscarriage’
o Refers to the spontaneous loss of a foetus prior to 28 weeks of gestation (see previous
definition)
o Does not refer to medical/surgical abortions (using pills/drugs, or surgical
intervention)
o There are many types of spontaneous abortion, including threatened, inevitable,
incomplete, complete, and missed
• Threatened Abortion
o Vaginal bleeding before 20 weeks of pregnancy with a closed cervix
o Normally bleeding is slight and the foetus is viable
• Inevitable Abortion
o A stage of abortion process when it is not possible for the pregnancy to continue
o Presents with massive bleeding
o Often, the foetus is not viable
• Incomplete Abortion
o A type of abortion where some products of conception have partially been expelled
from the uterine cavity
o Usually involves heavy bleeding
o It is common to get secondary bacterial infection
o There is persistent abdominal pain, continuous bleeding and open cervix
• Complete Abortion
o All the products of conception have been completely expelled.
o Normally bleeding is minimal
o No abdominal pain
• Missed Abortion
o This implies that the pregnancy has been retained following death of the foetus

o No bleeding
o Loss of signs of pregnancy
• Septic abortion
o Abortion that is complicated by infection
o It is common complication of incomplete abortion
• Habitual Abortions
o Occurrence of three or more consecutive abortions
o Usually at similar gestation age
• Induced Abortion (Unsafe or Criminal)
o Intentional termination of pregnancy with medical or surgical methods
ƒ Pregnancy may be terminated using drugs/medicines, surgical intervention, or
other intervention using other non-surgical implements, herbs or plants, traditional
methods, etc.
o It is illegal in Tanzania
Causes and Complications of Abortion
• Foetal Causes
o Chromosomal abnormalities
ƒ This is the most common cause of abortion in the first trimester 70%
ƒ Abnormalities can be due to the number or structure of chromosomes (Aneuploidy
or Euploidy respectively)
ƒ Malformation of trophoblast
• Maternal Causes
o Infections
ƒ Such as TORCHES (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes and
Syphilis), HIV and AIDS, and/or Malaria
o Other medical conditions (e.g. diabetes mellitus and hypertension)
• Uterine Abnormalities
o Uterine fibroids
o Cervical incompetence
o Congenital defects of the uterus
• Idiopathic
o Cause not known
Complications of Abortions
• Early
o Haemorrhage, which may lead to shock
o Sepsis
• Late
o Pelvic Inflammatory Disease, which may lead to infertility
o Chronic pelvic pain
o Emotional disturbance
Management of Abortion
Threatened Abortion
• Confirm foetal viability with ultrasound
• Advise the woman to have adequate bed rest at home
• Advise the woman to avoid strenuous activities

• Give appointment to come to antenatal clinic regularly
• Advise a woman to come immediately if:
o Bleeding becomes heavy
o She experiences offensive discharge
o She has severe abdominal pain
Inevitable Abortion
• Resuscitate with intravenous fluids
o Ringer’s lactate or Normal saline, 3 litres
• If pregnancy is advanced (18 weeks), augment the process of abortion by administering
oxytocin 20 IU in 500 ml Ringer’s lactate.
o In general, Misoprostol (a prostaglandin E1 analog) is better but not readily available.
• If after induction some products of conception remain in the uterus, manage as you would
an incomplete abortion.
• If all products of conception have been expelled, manage as complete abortion
Incomplete Abortion
• Incomplete abortion is an obstetric emergency.
o Resuscitate with intravenous fluids
ƒ Ringer’s lactate or normal saline, 3 litres
o Perform evacuation of the uterus to remove retained products of conception
o Perform manual vacuum aspiration (MVA) if pregnancy is less than 12 weeks
o After the evacuation, administer oxytocin, ergometrine, or misoprostol as follows:
ƒ Oxytocin 10 IU stat, OR
ƒ Ergometrine 0.5 mg stat OR
ƒ Misoprostol 600 mcg stat
o Observe for four to six hours
o Give ferrous sulphate and folic acid for six weeks
o Give Amoxycillin and Metronidazole for five days
o Counsel for family planning and provide contraceptives
Activity: Demonstration
Instructions
A Manual Vacuum Aspiration (MVA) kit will be passed around the classroom for you to see
before starting the demonstration.
Refer to Handout 5.1: Manual Vacuum Aspiration Procedure
The MVA procedure will be demonstrated in front of the class. Make sure that you can see
what the tutor is doing. Follow along with the demonstration according to the handout.
Complete Abortion
• If the patient is stable:
o Give oral Amoxycillin and Metronidazole for five days
o Give ferrous sulphate and folic acid for six weeks
o Counsel for family planning and provide contraceptives
• If patient is in shock:

ƒ Ringer’s lactate or Normal saline, 3 litres
o Take blood for grouping and cross match, transfuse if necessary
o Give Amoxycillin and Metronidazole for five days
Missed Abortion
• Missed abortion is not an emergency
• Manage in hospital where bleeding indices and blood transfusion can be done
• If the pregnancy is less than 12 weeks, do dilatation and curettage (DC)
• Antibiotics: Amoxycillin and Flagyl
Septic Abortion
• Dispensary and health centre management
o Resuscitate with intravenous fluids-
ƒ Ringer’s lactate or normal saline, 3 litres
o Obtain blood for haemoglobin, grouping and cross-matching if possible
o Give broad-spectrum antibiotics: Ampicillin 1g IV PLUS Metronidazole
o 500mg IV PLUS Gentamicin 80mg IM stat
o Refer patient to hospital with potential blood donors
• Hospital management
ƒ Ringer’s lactate or normal saline, 3 Litres.
o Monitor input and output
o Obtain blood for Haemoglobin, grouping and cross-matching
o Give antibiotics:
ƒ Ampicillin 1g IV stat followed by 500mg every six hours, PLUS Gentamicin
80mg IM every 12 hours, PLUS metronidazole 500mg IV every eight hours;
ƒ Then change to Amoxicillin 500 mg and Metronidazole 400mg by mouth every
eight hours and Gentamicin 80mg IM 12 hourly for five days
o If no response (persisting fever, high pulse, tender abdomen) with the above
antibiotics within three days, change to Cephalosporins such as Ceftriaxone 1g once a
day for five days
o Evacuate the uterus with sharp wide curette after initiating antibiotics and the patient
is stable
o Give Ferrous Sulphate 200mg every eight hours, PLUS 5mg Folic Acid once a day
for six weeks
o Counsel for family planning and provide contraceptives on discharge
o Presence of generalized peritonitis or pelvic abscess requires urgent laparotomy
Post-Abortion Education and Counselling
• Teach the woman about the complications of abortions, e.g. persistent bleeding, foul
smelling vaginal discharge
• Counsel and offer family planning options; allow woman to select method of her choice
• Counsel for HIV
• Discuss about future sex and fertility
• Give appointment date for follow-up/review

Key Points
• Abortion complications account for 19% of all maternal deaths in Tanzania.
• Incomplete abortion is an obstetric emergency, and therefore it should be managed
without delay.
• Comprehensive post-abortion care is the cornerstone in the prevention of maternal death.
Evaluation
• What is the difference between inevitable abortion and incomplete abortion?
• List at least three causes and complications of abortions.
• What are the three key elements in the management of incomplete abortion?
References
Arnold.
Ed.).
McGraw Hill.
• Klein, S., Miller, S., Thomson, F. (2009) A Book for Midwives. Berkeley, California:
Hesperian Foundation.
Gynaecology. (8th
• MOHSW. (2005). Advanced LSS Trainee Manual. Dar es Salaam, Tanzania: Ministry of
Health and Social Welfare.

Handout 5.1: Manual Vacuum Aspiration Procedure
Preparation of Equipment and Materials
• Wash your hands with soap and water for several minutes let your hands dry in the air.
• Put clean plastic gloves on your hands.
• Reassemble, lubricate and check the vacuum of the aspirator
• Place the valve liner in position inside the valve by aligning the internal ridges. Close the
valve until it snaps in place.
• Snap the cap onto the end of the valve. Push the cylinder straight into the base of the
valve without twisting.
• Place the plunger O-ring in the groove at the end of the plunger and lubricate it by
spreading one drop of lubricant around the O-ring with a fingertip. Silicone or another
non-petroleum-based lubricant can be used.
• Squeeze the plunger arms and insert the plunger fully into the cylinder. Move the plunger
in and out to lubricate the cylinder.
• Insert the tabs of the collar stop into the holes in the cylinder. Check the vacuum by
pushing the buttons and pulling the plunger until the arms lock.
• Leave in this position for two to three minutes, and then release the buttons. A rush of air
indicates that the aspirator maintained the vacuum.
• If no rush of air is heard, remove the plunger. Check the plunger O-ring and instrument
for foreign particles and cracks.
• If the aspirator still loses vacuum, it should be discarded.
Figure 1: Equipment and Materials Needed
Source: Klein, Miller Thomson, 2009
Preparation of the Patient
• Help the woman to be comfortable
• Tell the woman what you will be doing. Answer any questions that she has.
• You should find a private place to do the MVA where others are not watching, and be
sure to keep everything about her care confidential.

Performing the MVA Procedure
Step 1: Prepare and Check Instruments
• Make sure there is enough light on the woman’s genitals so you can see well. You may
need a helper to hold the light.
• Wash your hands with soap and water for several minutes
• Let your hands dry in the air
• Put clean plastic gloves on your hands
• Create a vacuum in the syringe:
o Close the valve by pushing the button inward and forward — the button will make a
‘click’ sound and will stay stuck in place until you open it again.
o Push the button inward and forward
o Hold the barrel of the syringe with one hand and pull the plunger back with the other
hand, until the arms of the plunger snap outward at the end of the syringe barrel.
o Check the arms of the plunger. They should both be out as far as they can go. With
the arms snapped in this position, you should not be able to push the plunger back into
the barrel.
o Position the plunger all the way inside the cylinder
o Push valve buttons down and forward until they lock
o Pull plunger back until arms snap outward and catch on cylinder base. This ‘charges’
the instrument
o Check vacuum by leaving the instrument in the ‘charged’ position for two to three
minutes, then release the buttons. A rush of air indicates that the aspirator maintained
a vacuum.
o If no rush of air is heard, remove the plunger. Check the plunger and instrument for
foreign particles and cracks. If the aspirator still loses vacuum, it should be discarded.
Figure 2: Preparing and Checking the MVA Syringe

Step 2: Prepare the Patient
• Ask the woman to empty her bladder
• Conduct a bimanual exam to confirm uterine size and position. See Figure 3.
• Insert speculum
Figure 3: Bimanual examination of uterus size and position
Source: Ipas, 2007. Source: Klein, Miller, Thomson, 2009.
Step 3: Perform Cervical Antiseptic Prep
• Clean cervical os with antiseptic. See Figure 5 for cleaning instructions.
• Follow No-Touch Technique: no instrument that enters the uterus can contact
contaminated surfaces before being inserted through the cervix.
Figure 4: Inserting a Speculum Figure 5: Cleaning of the Os of the Cervix
Step 4: Perform Para-Cervical Block
• Ask the woman to breathe deeply and relax. When she is ready, grasp the cervix with a
tenaculum or a ring forceps.
• Close the tenaculum and pull it a little to straighten the cervix. This can be very
uncomfortable for the woman, so be gentle and tell her what you are doing.

Figure 6: Grasping the Cervix with a Tenaculum or a Ring Forceps
• You will need a sterilized 22-gauge spinal needle (or a needle extender) and a local
anaesthetic with no epinephrine in it.
• 1% lidocaine is one example of a local anaesthetic to use.
• Before you give the injection, ask the woman if she has had this kind of anaesthetic
medicine before. Find out if she ever had a bad reaction to this medicine. If she has had a
bad reaction, do not give the injection.
• Use the tenaculum to move the cervix a little to the side until you can see the place where
the cervix (which is smooth) joins the vagina (which is rougher).
• Insert the needle about one centimetre under the skin, draw back on the syringe plunger to
ensure you have not entered a blood vessel, then inject 2 ml of medicine slowly as you
pull the needle out. Repeat on the other side of the cervix
• The medicine will take about three minutes to numb the cervix. The woman may still feel
cramping after the injection, but it will not hurt as much.
• Inject the medicine into these spots x x as shown in Figure 7.
Figure 7: Positions for Local Anaesthesia

Step 5: Dilate Cervix
• Use mechanical dilators or progressively larger cannula to dilate the cervix.
• Dilate the cervix to allow a cannula approximate to the uterine size to fit snugly through
the os. See Figure 8 for different sizes of cannula.
Figure 8: Different types of Cannula
Step 6: Insert Cannula
• While applying traction to the tenaculum, insert the cannula through the cervix, just past
the os and into the uterine cavity until it touches the fundus, and then withdraw it slightly.
• Do not insert the cannula forcefully
• As you insert a cannula, pay attention to the woman to make sure she is not in pain.
• Ask her to tell you if the procedure hurts. Sometimes the expression on a woman’s face
will tell you she is in pain even though she is not making any sounds.
• If the woman is in pain, slow down. Moving slowly will help prevent injuries.
• Ask the woman to take deep breaths to help her relax and to help her cervix open.
• Gently guide the cannula in until you feel it stop at the top of the womb. When you feel
the top of the womb, pull the cannula back just a little. If you need to, you can let go of
the tenaculum.
Figure 9: Inserting a Cannula

Step 7: Connecting an MVA Syringe to the Cannula
• Hold the syringe with one hand and the cannula with the other.
• Attach the syringe to the cannula by pulling the cannula slightly back onto the syringe.
• Make sure you do not push the cannula forward into the womb. Pushing too far will
injure the womb.
• Pinch the button on the syringe toward yourself to open the valve. The button will make a
clicking sound.
• Foamy and bubbly fluid and some blood and tissue from the pregnancy will flow from the
womb into the syringe.
• Some blood may also come out into the vagina
Figure 10: Connecting MVA Syringe to the Cannula
Step 8: Suction Uterine Contents
• Attach the cannula to the prepared aspirator
• Release the vacuum by pressing the buttons
• Evacuate the contents of the uterus by gently and slowly rotating the cannula and using a
gentle in-and-out motion.
• Keep moving and turning the syringe until the womb is empty
• Usually, the womb empties within five minutes.
• Do not pull the tip of the cannula out of the womb.
• If you pull the cannula tip out of the cervix, the vacuum will be broken.
• Even if you push the cannula back into the womb, it will not pull tissue anymore. The
MVA will not be complete.
• Do not push the cannula too far in or you could injure the womb
• These are the signs that the womb is empty:
o There is only pinkish foam in the cannula
o There is no more tissue in the cannula
o When you touch the cannula tip to the inside of the womb, it feels rough and gritty
o The womb tightens down and ‘grips’ the cannula
o When the womb is empty, take the syringe off the cannula. Empty the syringe into a
clear container, like a glass jar
o Now gently pull out the cannula, and then remove the tenaculum and take out the
speculum.

Figure 11: Suctioning the Uterine Contents
Source: Klein, Miller, Thomson, 2009.
Step 9: Inspect Tissue
• The MVA procedure is not complete until products of conception have been inspected
and confirmed.
• Empty the contents of the aspirator into a container
• Inspect tissue for products of conception by straining material or floating material in
water or vinegar and viewing with a light from beneath.
• If inspection is inconclusive, respiration may be necessary. If indicated, follow clinic
protocols to rule out ectopic pregnancy.
Step 10: Process Instruments
• As soon as the procedure is complete, immediately discard cannula and soak the aspirator
and adapters (if used) in an antiseptic to ease cleaning.
• Soak instruments immediately after use in antiseptic e.g. 0.5% chlorine or JIK 5%.
• Clean all aspirators and adapters thoroughly in warm water and detergent, not soap. Wear
gloves and face protection while cleaning.
• Disassemble the aspirator by pulling the cylinder out of the valve. Remove the cap by
pressing down the cap-release tabs with one hand and pulling off the cap with the other
hand.
• Aspirators should be stored in dry, covered containers or packages, protected from dust
and other contaminants.

Step 11: Basics of Infection Prevention
• Wash hands immediately before and after every patient contact.
• Consider all blood and body fluids from all patients to be potentially infectious.
• Use personal protective barriers (gloves, gowns, face protection, shoes) when contact
with blood or other body fluids is expected.
• Avoid skin punctures, especially when handling needles
• Use No-Touch Technique: the tip of the cannula, or the tip of any other instrument that
enters the uterus, should never touch non sterile surfaces (including the vaginal walls)
prior to insertion.

Session 6: Ectopic Pregnancy 35
Session 6: Ectopic Pregnancy
Learning Objectives
• Define ectopic pregnancy
• Explain risk factors of ectopic pregnancy
• Describe clinical features of ectopic pregnancy
• Describe management of ectopic pregnancy
Definition of Ectopic Pregnancy
• Ectopic Pregnancy: Any pregnancy where fertilised ovum gets implanted and develops
at a site other than normal uterine cavity, commonly in the fallopian tubes.
Sites of Ectopic Pregnancy
Activity: Small Group Work
Instructions
Refer to Worksheet 6.1: Labelling Exercise – Sites of Ectopic Pregnancy
In small groups, label all 10 sites of ectopic pregnancy. After 10 minutes, each group will be
asked to share their responses. Consider the following question for large group discussion:
• Of these sites, which do you think are the most frequent locations for ectopic pregnancies
to occur? Why?
• Ectopic pregnancies can occur in various places in a woman’s reproductive organs.
• The most common site is an ampullary tubal pregnancy. Roughly 85% of ectopic
pregnancies occur at this site.
Figure 1: Sites of Ectopic Pregnancy
Source: Monga, A. Baker, P. 2006

1. Fimbrial
2. Ampullary 85%
3. Isthmus 8%
4. Interstitial
5. Ovarian 2%
6. Cervical 2%
7. Cornual-Rudimentary horn 2%
8. Secondary abdominal 2%
9. Broad Ligament
10. Primary abdominal
Risk Factors of Ectopic Pregnancy
• History of pelvic inflammatory disease (PID)
• Past or present Intrauterine Contraceptive Device (IUCD) use
• Previous lower abdominal surgery
• Previous ectopic pregnancy
• Uterine or adnexal mass
• Endometriosis
• Assisted reproductive techniques
• Smoking
• Advanced maternal age
Clinical Features of Ectopic Pregnancy
• Intact ectopic pregnancy
o May be asymptomatic or may present with lower abdominal pain.
• Ruptured ectopic pregnancy
o May present in two variations, acute or subacute (slow leaking).
Acute Features
• Amenorrhea
• Abdominal pain that is generalized, often radiating to the shoulder
• Syncope (fainting attacks)
• Vaginal bleeding that is intermittent
• Pelvic mass
Physical Findings
• Pallor
• Unstable vital signs (shock); low BP, high PR ( 100 beats/minute), cold skin
• Abdominal swelling
• Guarding
• Rebound tenderness
• Cervical excitation test (Pain on moving the cervix) – positive
• Bulging posterior fornix
Sub-Acute Symptoms
• It is a salient feature of a slow or unruptured ectopic pregnancy
• Normally presents with history of lower abdominal pain with features of pregnancy

• Acute symptoms may develop when the gestation sac ruptures
• Investigation includes urine for pregnancy test (UPT), haemoglobin (Hb) and pelvic ultra
sound.
Management of Ectopic Pregnancy
• Resuscitate with intravenous fluids
o Ringer’s lactate or normal saline, 3 L. or more using a wide bore cannula
• Insert urethral catheter
• Obtain blood for blood grouping and cross match
• Refer for urgent laparotomy
Key Points
• Ectopic pregnancy is a life threatening gynaecological emergency which presents with
internal haemorrhage.
• Ectopic pregnancy is any pregnancy where fertilised ovum gets implanted and develops at
a site other than normal uterine cavity, commonly in the fallopian tubes.
• This condition needs urgent resuscitation with I.V. fluid before referral.
Evaluation
• Outline the predisposing factors for ectopic pregnancy.
• Outline the management of ectopic pregnancy.
References
Arnold.
Ed.).
McGraw Hill.
• MOHSW. (2005). Advanced LSS Trainee Manual. Dar es Salaam, Tanzania: Ministry of
Health and Social Welfare.
Gynaecology. (8th


Instructions
• This diagram shows 10 different sites where ectopic pregnancy may occur.
• Work in small groups to label each site with the correct name.

1. ________________________________
2. ________________________________
3. ________________________________
4. ________________________________
5. ________________________________
6. ________________________________
7. ________________________________
8. ________________________________
9. ________________________________
10. _______________________________
Worksheet 6.1: Labelling Exercise – Sites of Ectopic Pregnancy

Session 7: Abnormalities of Menstruation 39
Session 7: Abnormalities of Menstruation
Learning Objectives
• Define the terms amenorrhoea, dysfunctional uterine bleeding, dysmenorrhoea,
menorrhagia, and metrorrhagia
• Establish the causes of amenorrhoea, dysfunctional uterine bleeding, dysmenorrhoea,
Menorrhagia, and metrorrhagia
• Describe the management of amenorrhoea, dysfunctional uterine bleeding,
dysmenorrhoea, Menorrhagia, and metrorrhagia
Types of Menstrual Disorders
• Common menstrual disorders include Amenorrhoea, Dysfunctional Uterine Bleeding,
Dysmenorrhoea, Menorrhagia, and Metorrhagia.
• Amenorrhoea: Absence of menstrual period.
• Dysfunctional Uterine Bleeding: Abnormal uterine bleeding due to some disturbance of
the menstrual cycle, in the absence of organic condition such as tumour and infections.
• Dysmenorrhoea: Pain during menstruation.
• Menorrhagia: Heavy and prolonged menstrual bleeding.
• Metrorrhagia: Bleeding occurring in between menstrual periods (intramenstrual
bleeding).
Causes of Menstrual Disorders
Amenorrhoea
• Can be classified as primary, secondary or physiological.
• Primary Amenorrhoea: Failure of menarche to occur when expected, in relation to the
onset of pubertal development.
o In Tanzania one study reported the general age of menarche among school girls to be
14.3 +/- 1.1 years
o Usually if menarche does not start by the age 16 the girl should be evaluated for
amenorrhea
• Primary Amenorrhoea can be caused by:
o Constitutionally delayed puberty
o Delayed puberty due to endocrine abnormalities
o Genetic abnormalities such as Turner syndrome and gonadal dysgenesis (ovarian
failure due to the premature depletion of all oocytes and follicles)
o Uterine and vaginal anomalies, such as congenital absence of the uterus, vaginal
agenesis
o Anorexia nervosa, severe malnutrition
o Cryptomenorrhoea
o Obstruction, such as imperforate hymen or transverse septum
o Hypothalamic hypogonadism
o Pituitary disease

• Secondary Amenorrhoea: Absence of menstruation for three or more months in a
previously menstruating woman of child bearing age (reproductive age).
• Secondary Amenorrhoea can be caused by:
o Pregnancy
o Hypothalamus/Pituitary Conditions
ƒ Intrinsic, including defective hypothalamus feedback mechanism, pituitary
tumour, hyperprolactinaemia, pituitary adenoma
ƒ Extrinsic, including contraceptives, anorexia nervosa (low estrogen production,
resulting in ovarian insufficiency/gonadal dysgensis can cause elevated FSH,
which in turn leads to premature menopause/amenorrhoea
o Pseudopregnancy
o Anxiety/stress
o Ovarian condition such as premature menopause, polycystic ovary disease and
androgen-secreting tumours
o Other endocrine disorders including hypothyrodism and hyperadrenalism
o Local uterine causes/uterine disease
ƒ Uterine synechia caused by tuberculosis and endometrial fibrosis
o Systemic cause, which may result from prolonged wasting diseases
• Physiological Amenorrhoea
o Occurs in physiological situation where amenorrhoea is normal, including pregnancy,
lactation, menopause, and prior to the onset of puberty.
Dysfunctional Uterine Bleeding (DUB)
o Often results from anovulatory cycles. This causes the change in the
oestrogen/progesterone balance. It is common in after menarche and perimenopausal
women.
Dysmenorrhoea
• The causes can be described as primary or secondary
• Primary Dysmenorrhoea
o There is no underlying cause; it is ascribed to be due to prostaglandins release from
the endometrium.
• Secondary Dysmenorrhoea
o It occurs in the presence of identifiable organic or pathological cause.
o Common in older women and can be caused by endometriosis, adenomyosis, pelvic
inflammatory disease, intrauterine adhesion (Asherman’s syndrome), and cervical
stenosis
Menorrhagia
• The causes of menorrhagia include:
o Uterine tumours- Submucus myoma, endometrial polyps
o Malignant tumours
o Adenomyosis
o Endometrial hyperplasia
o Endocrine disorders – hypothyroidism, anovulatory bleeding
o Bleeding disorders

Metrorrhagia
• The common conditions that lead to metrorrhagia includes:
o Ovulatory bleeding – occurs in the midcycle as spotting
o Endometrial polyps and submucosal fibroids
o Endometrial carcinoma
o Exogenous administration of estrogen/hormonal contraceptive effects
o Endocrine disorders – hypothyroidism
o Cervical cancer
o Cervical/vaginal infection
Management of Menstrual Disorders
Amenorrhoea
• Principles of management of amenorrhea
o Identify and treat the cause
o Refer for further tests
o Attempts to restore ovulatory function by hormonal replacement therapy. Oestrogen
and progesterone are given to hypo-estrogenic amenorrheic women.
o Periodic progesterone should be taken by oestrogenic amenorrheic women.
o Many cases require frequent re-evaluation by gynaecologist
o To achieve pubertal development, conjugated oestrogen is used
Dysfunctional Uterine Bleeding (DUB)
• Treatment can be medical, surgical or combined methods
o The choice of approach depends on:
ƒ The cause
ƒ Severity of bleeding
ƒ Patient's fertility status
ƒ Need for contraception
ƒ Treatment options available at the care site
• In severe bleeding with hemodynamic instability:
o Establish airway, breathing and circulation
o IV lines for fluids
o Oxygen
o Refer the patient to the hospital
o Otherwise all patient with DUB should be referred
• For patients who are stable, primary treatment involves the use of combined oral
contraceptive pills or progesterone-only pills (e.g. primolut).
Dysmenorrhoea
• Treatment differs somewhat for primary and secondary dysmenorrhoea.
o Primary dysmenorrhoea:
ƒ Symptomatic approach
ƒ Oral contraceptive to inhibit ovulation
ƒ Analgesic
ƒ Antiprostaglandins to suppress release of prostaglandins.
o Secondary dysmenorrhoea
ƒ Treat the underlying cause
ƒ Analgesic
ƒ In case of endometriosis, hormonal therapy or surgery may be indicated

Menorrhagia
• Treat the underlying cause
Metrorrhagia
• Treat the underlying cause with either surgical or hormonal therapy
Key Points
• Menstrual disorders are common in women of child bearing age.
• A woman with uterine bleeding should not be ignored, as the condition may become life
threatening.
• Before starting treatment, it is important to take a proper history and conduct a physical
examination to obtain the correct diagnosis.
Evaluation
• Explain the main causes of menstrual disorders.
• Which measures should be taken to treat a woman with severe vaginal bleeding with
hemodynamic instability?
References
Arnold.
• Driessen, F. (1999). Obstetric Problems: A Practical Manual. Nairoby, Kenya; AMREF.
• Johnson, F. (2006). Lecture Notes Obstetrics and Gynaecology for Clinical Officers.
Gynaecology. (8th
• Rebacz, E. (2009) Age at menarche in schoolgirls from Tanzania in light of
socioeconomic and sociodemographic conditioning. Collegium Antropologicum.
Mar;33(1):23-9.

Session 8: Pelvic Inflammatory Disease (PID) 43
Session 8: Pelvic Inflammatory Disease (PID)
Learning Objectives
• Define pelvic inflammatory disease
• Describe the aetiology of pelvic inflammatory disease
• Outline the risk factors for pelvic inflammatory disease
• Describe the clinical features and course of pelvic inflammatory disease
• Describe the work up of a patient with pelvic inflammatory disease
• Describe the treatment of pelvic inflammatory disease
• Outline complications of pelvic inflammatory disease
• Describe the prevention of pelvic inflammatory disease
Definition of Terms and Aetiology of PID
• Pelvic Inflammatory Disease (PID): A general term that refers to infection of the uterus,
fallopian tubes, ovaries and parametrium, commonly classified as acute, sub-acute or
chronic PID.
• PID is mostly caused by Gonococci and Chlamydia; however, PID can also be caused by
other organisms including Staphylococcus, streptococcus, coliforms, clostridium
perfringens and mycoplasma.
• PID is most commonly spread through sexual intercourse
• PID-causing bacteria may also enter the body by other means, such as:
o After gynaecological procedures such as the insertion of an intrauterine contraceptive
device (IUCD)
o During childbirth
o Miscarriage
o Therapeutic or elective abortion
o Endometrial biopsy
Risk Factors and Clinical Features of PID
Risk Factors
• Sexually active age group
• Multiple sexual partners
• Past history of PID
• Insertion of an IUCD
• Immunodeficiency
• Excessive douching
Clinical Course of PID
• Incubation period varies depending on the causative organism, but generally ranges from
1-2 weeks
• There is an intense inflammatory reaction inside the lining layer of the cervical canal,
uterine cavity and fallopian tubes.
• Inside the fallopian tubes, acute suppurative salpingitis occurs
• The infection spreads to the ovaries to cause salpingo-oophoritis

• Accumulation of pus within the ovary and tubes leads to formation of abscess (tubo-
ovarian abscess) or pyosalpinx
• When the organisms disappear, pus undergoes proteolysis to form thin fluid and
hydrosalpinx results.
Clinical Features
• Acute PID
o Vaginal discharge with abnormal colour, consistency or odour
o Lower abdominal pain
o Fever and chills
o Irregular menstrual bleeding or spotting
o Increased menstrual cramping (dysmenorrhoea)
o Lack of appetite
o Nausea
o The patient may present with features of acute abdomen
o Pain with sexual intercourse
o Cervical motion tenderness (cervical excitation test)
• Chronic PID
o Lower back pain
o Fatigue
o Painful sexual intercourse
o Bleeding after sexual intercourse
o Cervical excitation test (CET) is commonly positive
Investigations of PID
Activity: Small Group Discussion
Instructions
In small groups discuss for about 10 minutes on the following question:
• What steps should a clinician take to investigate a suspected case of PID?
Be prepared to share your responses with the class.
Investigations
• Wet preparation or wet mount microscopic examination
• Culture and sensitivity for vaginal discharge and/or blood
• Laparoscopy if diagnosis unclear or concern for persistent infection, abscess not
improving with antibiotics
• Ultrasound scan of pelvic organs can be helpful in case of complicated PID
Differential Diagnosis of PID
• Acute appendicitis
• Diverticulitis
• Torsion of ovarian cyst
• Tubal pregnancy (ectopic pregnancy)
• Mesenteric vein thrombosis

Treatment of PID
Treatment
• Acute PID should be treated with IV antibiotics without waiting for laboratory results.
• Use broad spectrum antibiotics. Give:
o IM Ceftriaxone, plus doxycyline or gentamicin, plus clindamycine (if available)
• Analgesic
• In Outpatient Department (OPD), use combination of:
o Tabs metronidazole 400mg tds for two weeks
o Tabs doxyclline 100mg bid for two weeks
o Tabs cefixime
ƒ Note: Resistance to fluoroquinolones has been described in some settings limiting
their use. Can be used where no other option is available.
o Use ceftriaxone 250mg IM for PID
o Otherwise use lab results
• Treatment of sex partner(s)/contact(s) is essential
• The patient should use condoms throughout the period of medication
Complications and Prevention of PID
• PID infections can cause:
o Scarring and adhesions of the pelvic organs, possibly leading to infertility, ectopic
pregnancy and chronic pelvic pain
o Peritonitis
o Bacteremia and septicemia (with staphyloccoci and streptoccoci spp.)
o Pelvic abscess
• Prevention of PID includes:
o Safe sex
o Detection and treatment of Sexually Transmitted Diseases (STD) as early as possible
o Observe sterility when performing gynaecological procedures
o Personal hygiene
Key Points
• PID is one of the most common gynaecological conditions.
• Its complications can be devastating and life threatening, including sepsis, ectopic
pregnancy; infertility and chronic pelvic pain.
• Although consequences of PID can be severe, the condition is treatable and preventable.
Evaluation
• Describe the investigations for PID.
• List some clinical features of PID.
• Which strategies should be taken to prevent PID?
References
• Campbell, S. Lees, C. (2000). Obstetrics by Ten Teachers (17th
ed). London: Hodder
Arnold.
Ed.).
McGraw Hill.

Gynaecology. (8th
and Gynaecology. (2nd Ed.) Mosby.

Session 9: Infertility 47
Session 9: Infertility
Learning Objectives
• Define infertility
• Describe the prevalence of infertility
• Describe the causes of infertility
• Describe the management of infertility
Definition and Classification of Infertility
• Infertility: The inability of a couple to obtain a clinically recognizable pregnancy (failure
to conceive) after one year of regular unprotected sexual intercourse.
• Classification of Infertility: Infertility is classified as either Primary or Secondary.
o Primary infertility is applied to the couple who has never achieved pregnancy.
o Secondary infertility implies that at least one previous conception has taken place.
Prevalence of Infertility
• Infertility occurs in approximately 15% of couples at some time in their reproductive
lives.
• Of all couples attempting pregnancy with regular intercourse:
o 85% achieve conception within one year
o 80% of couples experiencing infertility for one year achieve conception by the end of
second year
• Fertility rates slowly decline after the age of 35 years because of decreasing reserve in the
ovaries (oocytes)
• For women in their late 30s and 40s, the ova are more likely to have chromosomal
abnormalities that may lead to increased risk of miscarriage and Down syndrome.
Causes of infertility
• The causes of infertility are best described based on sex. Males and females experience
infertility differently.
Activity: Small Group Discussion
Instructions
In small groups, discuss for 10 minutes on the following question:
‘What are the causes of male and female infertility?’ Brainstorm a list for males and another
list for females, and make a list in a notebook. Be prepared to share your responses.
Causes of Male Infertility
• Congenital anomalies
o Defects of the penis, testes (absence, agenesis, cryptochidism, etc)
• Surgical/trauma
o Testicles, epididymis, vas deferens (vasectomy and injuries), prostatectomy
• Infections
o STDs, mumps orchitis

Session 9: Infertility 48
• Impotence
• Gonadal failure (chromosomally normal and abnormal)
• Varicocele
• Certain medications
o Phenothiazines etc.
• Systemic diseases
o Diabetes mellitus (DM), Hypothyroidism and hyperthyroidism
• Immunologic
o Production of anti-sperm antibodies (relatively rare)
• Drug abuse
o Alcohol
ƒ Interferes with the synthesis of testosterone and sperm concentration
ƒ Alcoholism may delay a man's sexual response and may cause impotence
o Smoking
ƒ In experimental animals: nicotine blocks production of sperm
ƒ Decreases the size of testicles in men
• Environmental/occupation factors
o Exposure to heavy metals (Pb), pesticides
o Exposure to x-rays, radar or extreme thermal changes
o Long distance truck drivers: the scrotum naturally expands to reduce the temperature
of the testicles and prolonged sitting can impair this process
Causes of Female Infertility
• Ovarian
o Congenital anomalies of ovaries
ƒ Such as, Ovarian agenesis (rare)
o Adhesions may interfere with the ovaries
o Gonadal failure (chromosomally normal or abnormal)
o Hormonal imbalance leading to anovulation or oligoovulation (irregular ovulation)
o Ovarian aging
o Ovulatory disorders:
ƒ Polycystic Ovarian Syndrome
ƒ Hyperprolactinaemia
ƒ Hypothyroidism, idiopathic
• Tubal factors
o Blockage or impairment of the fallopian tubes.
ƒ Causes include PID, peritonitis, endometriosis, surgery, congenital anomalies
o DES (diethylstilbestrol) exposure
• Uterine factors:
o Note that the role of uterine factors in infertility is controversial; they are more
suspect in menstrual abnormalities or recurrent pregnancy loss.
o Malformed uterus
o Asherman’s syndrome (presence of adhesions and/ or fibrosis within the uterine
cavity due to scars.)
o Uterine polyps or fibroids
• Tumours
o Fibroids can prevent implantation of the embryo (but very rare)
• Cervical/Immunologic Factors (rare)
o Production of antibodies (in cervical mucus) against the male's sperm

SM CMT 05213 Obstetrics and gynaecology II

SM CMT 05213 Obstetrics and gynaecology II

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to SM CMT 05213 Obstetrics and gynaecology II

Similar to SM CMT 05213 Obstetrics and gynaecology II (20)

Recently uploaded

Recently uploaded (20)

SM CMT 05213 Obstetrics and gynaecology II