Update to the manual "Managing Complications in Pregnancy and ...

Update to the manual "Managing Complications in Pregnancy and ...

WHOs Managing Complications in Pregnancy and Childbirth (MCPC): Whats New in the Second Edition? April 2018 Presentation Outline Dissemination of the 2nd edition MCPC MCPC background and overview of revision process Review of updates on: Respectful maternity care (RMC) for mother and newborn Pre-eclampsia/eclampsia (PE/E) Bleeding in early pregnancy and postpartum haemorrhage (PPH) Immediate newborn problems Prevention and management of infection in pregnancy and childbirth 2

Global Dissemination of MCPC Manual WHO printed 2,000 copies (English) in November 2017 Planning French translation; possibly Spanish Briefers English, French, Spanish and Portuguese Technical PPT (WHO/MCSP) Dissemination at country, regional and global 3 MCPC Background Reference manual for midwives and doctors working at district hospital level Uses symptom/sign-based, stepby-step approach (e.g., vaginal

bleeding in early pregnancy) Section 1: Clinical principles Section 2: Symptoms Section 3: Procedures First edition published in 2000 (reprinted 2007) 4 MCPC Revision Process User survey conducted in 2015 to solicit stakeholder feedback to inform revisions Core team of WHO, partners and external experts prioritized 18 chapters for revision WHO and MCSP members assigned as technical co-leads for each chapter targeted for revision Revisions had to be consistent with previously updated WHO guidelines and recommendations WHO Guideline Review Committee (GRC) requirement: two expert external reviewers for each revised chapter Every revision tracked in master list of 2nd edition MCPC changes 5

18 MCPC Chapters Prioritized for Revision Chapter Category Clinical Principles (Section 1) First Edition Chapters Revised Symptom s

(Section 2) Procedur es (Section 3) Emotional and psychological support Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles

Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing Prelabour rupture of membranes Immediate newborn conditions or problems Induction and augmentation of labour Manual removal of placenta Repair of vaginal and perineal tears 6 Revisions Related to Respectful Maternity Care (RMC) for Mothers and Newborns Photo by Kate Holt, Liberia 7 18 Updated MCPC Priority Chapters Chapter Category

Clinical Principles (Section 1) First Edition Chapters Revised Symptom s (Section 2) Procedur es

(Section Emotional and psychological support Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing

Prelabour rupture of membranes Immediate newborn conditions or problems Induction and augmentation of labour Manual removal of placenta Repair of vaginal and perineal tears 8 Respectful Maternity Care (RMC) for Mothers and Newborns RMC is recognized as a universal right of all women and newborns and an essential component of quality care. The MCPC updates reflect this importance. Emotional and Psychological Support chapter offers guidance on meeting womens and families emotional and psychosocial needs in emergencies, emphasizing the

importance of clear, honest communication and empathy. 9 Respectful Maternity Care: Basic Care Principles To reinforce RMC as a key element of quality care, many updated chapters refer readers to the care principles outlined in revised General Care Principles chapter: Where feasible, ensure that the woman has a companion of her choice with her. Provide information to the womanand any accompanying family members the woman would like to be involved in decisionmakingabout the care to be provided and what to expect. Obtain Informed consent for all procedures, including diagnostic and treatment

10 Revisions Related to PreEclampsia and Eclampsia (PE/E) Revised chapter reflects WHO 2011 Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia 11 18 Updated MCPC Priority Chapters Chapter Category Clinical Principles (Section 1) Symptoms (Section 2) Procedures (Section 3) First Edition Chapters Revised Emotional and psychological support

Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing Prelabour rupture of membranes Immediate newborn conditions or problems Induction and augmentation of labour Manual removal of placenta Repair of vaginal and perineal tears 12 PE/E: Key Areas of Revision Revised classification framework for hypertensive disorders of pregnancy, including PE/E

Prevention of PE/E Calcium supplementation Low-dose aspirin Use of systolic blood pressure (SBP) in diagnosis and management of PE/E Use of laboratory findings for PE/E diagnosis and management Use of antihypertensive medication for management of hypertension (HTN), including acute severe systolic HTN Anticonvulsant therapy for severe PE/E Timing of delivery in women with severe PE and eclampsia Postpartum monitoring Specialized postpartum care and follow-up 13 Revised Classification Framework for pertensive Disorders in Pregnancy, including P Chronic hypertension (elevation of BP < 20 weeks gestation or persisting > 12 weeks postpartum) Gestational hypertension (onset of HTN in pregnancy without pre-eclampsia) (Mild) pre-eclampsia

Severe pre-eclampsia Eclampsia Chronic hypertension with superimposed preeclampsia 14 PE/E Prevention Calcium supplementation (in areas with low dietary intake) 1.52.0 g elemental calcium/day All women, but particularly those at high risk for PE* Low-dose (75 mg) acetylsalicylic acid (aspirin) Initiated at 1220 weeks of gestation for *Risk Factors for risk Developing women at high for PE* PE/E: Previous severe PE/E, diabetes, chronic hypertension, obesity, renal disease,

autoimmune disease and multiple pregnancies 15 Clinical Criteria for Diagnosis of Hypertension in Pregnancy Systolic blood pressure (SBP) > 140 mm Hg and/or diastolic blood pressure (DBP) > 90 mm Hg (two consecutive readings 4 hours or more apart) Severe SBP > 160 and/or DBP > 110 mm Hg 16 PE: Diagnosis, Monitoring and Timing of Childbirth 17 Severe PE: Diagnosis and Timing of Childbirth 18

Anticonvulsive Treatment for PE/E Magnesium sulfate anticonvulsant of choice Diazepam removed as a treatment option for PE/E 19 Magnesium Sulfate Regimens for Severe PE/E Rout Loading dose Maintenance dose e Intramuscular (IM) Regimen IV (IV and IM) (IM) Give 4 g of 20% MgSO4 Give 5 g of 50% MgSO4 and IM solution IV over 5 solution with 1 mL of 2%

minutes. lidocaine in the same Follow promptly with 10 syringe by deep IM g of 50% MgSO4 injection into alternate solution IM: Give 5 g in buttocks every 4 hours. Continue treatment for each buttock as a deep IM injection with 1 mL of 24 hours after birth or 2% lidocaine in the same the last convulsion, syringe. whichever occurs last. Intravenous (IV) Regimen (New in 2nd Edition) Give 4 g of 20% MgSO4 Give intravenous IV solution IV over 5 minutes infusion 1g/ hr. If convulsions recur after Continue treatment for 15 minutes, give 2 g of 24 hours after childbirth

50% MgSO4 solution IV or the last convulsion, over five minutes. whichever occurs last. 20 Antihypertensive Treatment of Stable Elevated Blood Pressure in Pregnancy Antihypertensive Option Alpha methyldopa Nifedipine (immediate release capsules) Labetalol*

Dosing 250 mg every 6-8 hours Maximum dose 2000 mg/24 hours 10-20 mg every 12 hours Maximum dose 120 mg/24 hours 200 mg every 6-12 hrs Maximum dose 1200 mg/24 hours *Note: Women with CHF, hypovolemic shock, or asthma should not receive labetalol. 21 Treatment of Acute Severe Hypertension in Pregnancy: SBP > 160 mm Hg and/or DBP > 110 mm Hg Antihypertensiv e options Dosing

Hydralazine Intravenous treatment: Administer 5 mg IV, slowly (risk of maternal hypotension; closely monitor blood pressure). Repeat every five minutes until the blood pressure goal has been achieved. Repeat hourly as needed or give 12.5 mg IM every two hours as needed. The maximum dose is 20 mg per 24 hours. Labetalol Oral treatment: Administer 200 mg. Repeat dose after one hour until the treatment goal is achieved.

The maximum dose is 1200 mg in 24 hours. Intravenous treatment: Administer 10 mg IV. If response is inadequate after 10 minutes, administer 20 mg IV. The dose can be doubled to 40 mg and then 80 mg with 10-minute intervals between each increased dose until blood pressure goal is lowered below threshold. The maximum total dose is 300 mg; then switch to oral treatment. Nifedipine (immediaterelease capsule) Oral treatment: Administer 510 mg orally. Repeat dose after 30 minutes if response is inadequate, until optimal blood pressure is reached.

The maximum total dose is 30 mg in the acute treatment setting.a Alpha methyldopa Oral treatment: Administer 750 mg orally. Repeat dose after three hours until blood pressure goal is achieved. 22 New Section on Postpartum Care for Women with PE/E Counsel regarding increased lifetime risk of cardiovascular disease (CVD) Assess and address risk factors for CVD (e.g., smoking, obesity, chronic hypertension, lack of physical activity, hyperlipidaemia) before discharge Link to follow-up and ongoing care for monitoring of blood pressure and CVD risk factors

Counsel regarding risk of PE/E with future pregnancies, importance of preventing unwanted pregnancy, and importance of early ANC enrolment in future pregnancies Provide effective, appropriate family 23 Revisions Related to Obstetric Haemorrhage: Bleeding in Early Pregnancy and Postpartum Haemorrhage (PPH) 24 18 Updated MCPC Priority Chapters Chapter Category Clinical Principles (Section 1) Symptoms (Section 2)

Procedures (Section 3) First Edition Chapters Revised Emotional and psychological support Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing Prelabour rupture of membranes Immediate newborn conditions or problem Induction and augmentation of labour Manual removal of placenta Repair of vaginal and perineal tears

25 Bleeding in Early Pregnancy Updates to differential diagnosis and management of threatened, inevitable and incomplete abortion, ectopic pregnancy, and molar pregnancy Updated guidance on management of inevitable and incomplete abortion, including surgical, medical and expectant management options; new table summarizing medical management drugs and protocol Updated section on management of abortionrelated infection/sepsis: clindamycin and ampicillin as first-line drugs; gentamycin and ampicillin as second-line drugs; both regimens without metronidazole Updated guidance on postabortion counselling 26 Definition and Classification of Postpartum Haemorrhage (PPH) Definition PPH is commonly defined as blood loss in excess of 500 mL Severe PPH is

defined as blood loss of 1000 mL or more or change in vital signs with any blood loss Classification of PPH Increased vaginal bleeding within the first 24 hours after childbirth is primary PPH Increased vaginal bleeding following the first 24 hours after childbirth is secondary PPH (delayed PPH) 27 Active Management of Third Stage of Labour (AMTSL) The main component of active management of the third stage of labour is immediate

postpartum uterotonic medication. Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side effects and can be used in all women. If oxytocin, if not available give: Oral misoprostol 600 mcg; or Ergometrine (0.2mg IM) or methylergometrine; or Fixed drug combination of oxytocin and ergometrine. Placenta may be allowed to deliver 28 physiologically (controlled cord traction is Postpartum Monitoring of Uterine Tone for Early Recognition of Uterine Atony Regular postpartum assessment of uterine tone is recommended for all women. Sustained uterine massage is not recommended for PPH prevention in women who have received a uterotonic. 29

Atonic Uterus The following subsections are new: Uterine Massage and Medicines Bimanual Uterine Compression External Aortic Compression Intrauterine Balloon Tamponade Surgical Interventions in the Treatment of PPH Uterine Compression Suture (Blynch) 30 Use of Medicines in Management of PPH Dose and route* Oxytocin IV: infuse 20 units in 1 L at fastest flow rate possible IM: 10 units Continuing dose*

Precautions and Maximum dose contraindicati ons IV: infuse 20 units in 1 Not more than 3 L Do not give as an L fluids at 40 drops per of intravenous IV bolus minute fluids containing oxytocin Ergometrine/ IM or IV Repeat 0.2 mg IM; methylergomet (slowly): 0.2 after 15 minutes rine mg If required, give 0.2mg IM or IV (slowly) every four hours

Five doses (total 1.0 mg) High blood pressure, pre-eclampsia, heart disease, retained placenta 15-methyl prostaglandin F2 alpha 0.25 mg every 15 minutes Eight doses (total 2 mg) Asthma Do not give IV Repeat 200800 mcg

Not more than 1600mcg IM: 0.25 mg Misoprostol Sublingual: (new in second 800 mcg edition) Tranexamic IV (slowly): 1 Repeat after 30 acid (new in g minutes if bleeding second edition) continues Not more than 10 mg per kg of body weight; three to four times daily History of

coagulopathy or active intravascular clotting, 31 Uterine Balloon Tamponade (UBT) If bleeding continues in spite of bimanual and aortic compression, insert uterine balloon tamponade Inflate to 300500 mL Administer Ampicillin 2 g IV (or cefazolin 1 g IV) before the procedure Keep in place for 624 hours and slowly deflate the balloon monitoring closely for bleeding If bleeding continues, consider surgical interventions Uterine balloon tamponade graphic added 32 33

Non-Pneumatic Anti-Shock Garment Newly included in MCPC as temporizing measure for PPH Guidance on application and removal 34 Surgical Interventions in Management of PPH Uterine compression suture (B-Lynch) If bleeding does not stop, further surgical intervention (subtotal or total hysterectomy) is required. World Health Organization, Managing Complications in Pregnancy and Childbirth.

Geneva: WHO, 2017; figure S-7. 35 Vaginal and Perineal Tears Single oral dose of prophylactic antibiotic (ampicillin 500 mg) should be administered before beginning repair of third and fourth degree tears (but not first and second degree tears). 36 Retained Placenta with Bleeding Manual removal of the placenta should be attempted after administration of a prophylactic antibiotic (single dose, ampicillin 2 gm IV or cefazolin1gm IV). 37 Care after PPH

Updated guidance on postpartum care, including: counselling on selfcare, nutrition, iron supplementation, postpartum family planning, warning signs/care-seeking 38 Revisions Related to Immediate Newborn Problems Photo by Karen Kasmauski, Nigeria 39 Immediate Newborn Conditions or Problems Chapter Category Clinical Principles (Section 1)

First Edition Chapters Revised Symptom s (Section 2) Procedur es (Section 3)

Emotional and psychological support Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing Prelabour rupture of membranes Immediate newborn conditions or problems Induction and augmentation of labour Manual removal of placenta

Repair of vaginal and perineal tears 40 Immediate Recognition and Management of Signs of Serious Illness in a Newborn Signs of serious illness in a newborn expanded in 2nd edition (e.g., lethargy, movement only when stimulated, hyperthermia in addition to hypothermia) Also updated initial antibiotic treatment and communication with family of newborn: Administer first dose of ampicillin (50 mg/kg body weight) and gentamycin (5 mg/kg body weight) IM for signs of serious illness; refer without delay. Inform mother and companion/family about 41 Management of Breathing Difficulty

Drying, additional stimulation, and ventilation (if needed) in first minute Suctioning only if amniotic fluid is meconium-stained or mouth/nose is full of secretions (no routine suctioning) Resuscitation illustrations added and revised (new graphic demonstrating correct fit of mask; use of size 0 for small infants < 2.5 kg) Added guidance on continuous positive airway pressure (CPAP) and safe use of oxygen in neonate (delivery method/nasal 42 New Section: Management of Asymptomatic Newborns Exposed to Infection Treat with prophylactic antibioticsampicillin and gentamycin IMfor at least 2 days while infection is ruled out. Key indications for prophylactic antibiotics: Preterm prelabour rupture of membranes Membranes ruptured > 18 hours before birth Mother is being treated with antibiotics for chorioamnionitis

Mother had fever greater than 38C before childbirth or during labour Amniotic fluid was foul-smelling or purulent Mother had Group B streptococcus colonization without adequate antibiotic therapy during labour43 Early Management of Low Birth Weight Newborns Low birthweight (LBW)/prematurity categories expanded to include: LBW (< 2500 gm), moderate to late preterm (3236 weeks plus 6 days) Very LBW (< 1500 gm) or very preterm (< 32 weeks) Addition of kangaroo mother care: early continuous and prolonged skin-to-skin and exclusive breastfeeding or feeding with breastmilk Transfer of very LBW or very preterm infants for specialized care Safe oxygen and antibiotic use in LBW infants44 Revisions Related to Prevention and Management of

Infection in Pregnancy and Childbirth 45 18 Updated MCPC Priority Chapters Chapter Category Clinical Principles (Section 1) Symptoms (Section 2) Procedures (Section 3) First Edition Chapters Revised Emotional and psychological support Emergencies General care principles Antibiotic therapy Operative care principles Normal labour and childbirth Newborn care principles

Vaginal bleeding in early pregnancy Vaginal bleeding after childbirth Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness Fever during pregnancy and labour Fever after childbirth Difficulty in breathing Prelabour rupture of membranes Immediate newborn conditions or problems Induction and augmentation of labour Manual removal of placenta Repair of vaginal and perineal tears 46 Prevention and Management of Infection in Pregnancy and Childbirth Revisions incorporate: Antibiotic therapy (key principles) WHOs 2015 Global Recommendations for Prevention and Treatment of Maternal Peripartum Infections Updated summary tables of clinical presentation of common infections in pregnancy and after childbirth

Revised antibiotic treatment recommendations for several infections Updated section on management of malaria in pregnant women based on WHOs 2015 47 Prevention and Management of Infection in Pregnancy and Childbirth (cont.) Antibiotic therapy principles: Appropriate and inappropriate use of antibiotics for infection prevention and treatment Judicious use of antibiotics to reduce antimicrobial resistance (narrow spectrum antibiotic, correct dosing and duration) Monitoring local bacteria, antibiotic susceptibility and resistance patterns to inform antibiotic selection, where feasible Avoiding and managing antibiotic allergies, including anaphylaxis 48 When Prophylactic Antibiotics Are Not Recommended Prophylactic antibiotics are not

recommended under these conditions: Uncomplicated vaginal birth Operative vaginal birth Episiotomy First- or second-degree lacerations 49 Indications for Prophylactic Antibiotics Obstetrical procedure or condition Caesarean section (elective and emergency) Administer before the procedure, not after clamping and cutting the cord New recommendation for cleansing the vagina with povidone-iodine before a caesarean Manual removal of placenta Placement of uterine balloon

tamponade Repair of third and fourth degree lacerations Preterm prelabour rupture of membranes (PPROM) Recommended antibiotic(s) and dosage Single dose of antibiotics (ampicillin or first-generation cephalosporin): Ampicillin 2 g IV; OR Cefazolin 1 g IV Single dose of antibiotic: Ampicillin 500 mg Oral erythromycin 250 mg every 6 hours for 10 days (or until birth); or Ampicillin 2 g IV every 6 hours 50 Updated Timing of Pre-Procedure

Antibiotic Prophylaxis NEW Whenever possible, give prophylactic IV antibiotic 1560 minutes before start of procedure to achieve adequate blood levels of antibiotic at time of procedure. Obstetric procedures for which antibiotic prophylaxis is recommended: Elective and emergency caesarean (note: prophylaxis given before incision whenever possible); suturing of third and fourth degree tears; Manual removal of placenta; Placement of uterine balloon tamponade. 51 Differential Diagnosis of Fever during Pregnancy and Labour Typical signs and symptoms (in addition to fever, chills) Possible diagnoses Dysuria, frequency; flank pain

Cystitis; pyelonephritis Foul-smelling discharge, lower abdominal pain, uterine tenderness, maternal tachycardia, fetal tachycardia Septic abortion; amnionitis Headache, muscle/joint pain, anaemia, coma; sometimes convulsions, jaundice Uncomplicated malaria; severe malaria Cough with expectoration, chest pain; sometimes Pneumonia rapid/difficulty breathing, rhonchi/rales on pulmonary exam Dry cough, malaise, anorexia; sometimes Typhoid

confusion/stupor Malaise, anorexia, nausea, dark urine/pale stool, jaundice Hepatitis 52 Differential Diagnosis of Fever after Childbirth Typical signs and symptoms (in addition to Possible diagnoses fever, chills) Lower abdominal pain; purulent, foul-smelling lochia; uterine tenderness; persistent spiking fever/chills despite antibiotics Postpartum endometritis; pelvic abscess; peritonitis Breast pain and tenderness Mastitis; breast abscess Unusually tender wound Wound seroma, haematoma, cellulitis,

or abscess Dysuria, frequency; flank pain Cystitis; acute pyelonephritis Spiking fever despite antibiotics, leg swelling, tenderness, Deep vein thrombosis redness Pleuritic chest pain, shortness of breath, tachypnea, Pre-eclampsia, hypoxia pneumonia Cough with expectoration, chest pain; sometimes Pneumonia rapid/difficulty breathing, rhonchi/rales on pulmonary exam Headache, muscle/joint pain, anaemia, coma; sometimes Uncomplicated malaria; convulsions, jaundice severe malaria Dry cough, malaise, anorexia; sometimes Typhoid 53 confusion/stupor Therapeutic Antibiotics for Selected Infections in Pregnant and Postpartum

Women Diagnosis New in second edition Comments Antibiotic options and dosing of either amoxicillin or nitrofurantoin remain the same, except: Avoid nitrofurantoin at term as it can cause neonatal haemolysis Do not use trimetoprim/ sulfamethoxazole due to interference with folic acid metabolism and increased risk of congenital malformations Antibiotic regimen IV Acute ampicillin PLUS gentamicin pyelonephri followed by oral amoxicillin tis remains the same

Added emphasis on prompt identification and treatment of pyelonephritis in pregnancy to prevent significant illness Importance of re-evaluating diagnosis and choice of Cystitis Amoxicillin 500 mg by mouth every 8 hours for 3 days; or nitrofurantoin 100 mg by mouth every 8 hours for 3 days Ampicillin 2 g intravenously (IV) every 6 hours PLUS gentamicin 5 mg IV per kg of body weight every 24 hours; amoxicillin 1 g orally every 8 hours to complete 14 days of treatment 54

Therapeutic Antibiotics for Specific Infections in Pregnant and Postpartum Women (cont.) Diagnosis Amnionitis New in second edition Postpartum endometrit is Antibiotic regimen IV ampicillin PLUS gentamicin remains the same If the woman gives birth vaginally, new guidance to continue treatment for at least 48 hours after the symptoms and signs of infection have subsided. Antibiotic regimen changed from

ampicillin, gentamicin and metronidazole to clindamycin and gentamicin for 2448 hours after complete resolution of clinical signs and symptoms (fever, uterine tenderness, purulent lochia, leukocytosis). Oral antibiotics are not necessary following IV antibiotics. Comments Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg IV per kg of body weight every 24 hours Clindamycin 600 mg IV every 8 hours PLUS gentamicin 5 mg IV per kg of body weight every 24 hours If clindamycin is not available: Ampicillin 2 g IV every 6

hours PLUS gentamicin 5 mg/ kg body weight IV every 24 hours When available, clindamycin (in combination with gentamycin) is more effective than ampicillin or a 55 penicillin antibiotic for the Therapeutic Antibiotics for Specific Infections in Pregnant and Postpartum Women (cont.) Diagno sis New in second edition Serious infection s of pelvic organs

Pelvic abscess, peritonit is Mastitis or breast abscess Antibiotic regimen narrowed to IV ampicillin PLUS gentamicin, with no metronidazole. Discontinue antibiotics 48 hours after complete resolution of clinical signs and symptoms. Antibiotic regimen remains the same: IV ampicillin PLUS gentamicin, PLUS metronidazole. Antibiotic regimen remains the

same: oral cloxacillin or erythromycin for 10 days. Comments Ampicillin 2 g IV every six hours PLUS gentamicin 5 mg IV per kg of body weight every 24 hours Ampicillin 2 g IV every six hours PLUS gentamicin 5 mg IV per kg body weight every 24 hours PLUS metronidazole 500 mg IV every eight hours Cloxacillin 500 mg by mouth every 6 hours or erythromycin 250 mg every 8 hours For abscess, surgical drainage is an option as 56

If Infection Suspected as Cause of Shock UPDATED ANTIBIOTIC TREATMENT RECOMMENDATION Collect appropriate samples (blood, urine, pus) for microbial culture, if facilities available, before starting antibiotics. Give combination of two antibiotics to cover aerobic + anaerobic infections, and continue until fever-free for 48 hours: AMPICILLIN 2 g IV q 6 hours; PLUS GENTAMICIN 5 mg/kg body weight IV q 24 hours Metronidazole no longer recommended as third line antibiotic for treatment of shock in 2nd edition MCPC 57 Postabortion Infection First-line regimen Clindamycin 600 mg IV every 68 hours PLUS Gentamicin 5 mg/kg body weight IV every 24 hours Second-line regimen (if clindamycin not available)

Ampicillin 2 g IV every 6 hours PLUS Gentamicin 5 mg/kg body weight IV every 24 hours 58 Severe Malaria: Antimalarial Treatment NEW TREATMENT GUIDELINES Give parenteral treatment to pregnant women with severe malaria as soon as possible. Mortality for untreated severe malaria (especially cerebral) approaches 100%. With prompt, effective treatment and supportive care, mortality falls to 1020%. Parenteral artesunate is treatment of choice for severe malaria in all trimesters ARTESUNATE Begin with IV or IM route for at least 24 hours and until woman can tolerate oral medication; then complete oral treatment. If artesunate not available, give IM artemether (or IV quinine if artemether not available) Loading Dose: Give Artesunate 2.4 mg/kg body weight IV every 12 hours for at least 24 hours and until woman can tolerate oral medication. Maintenance Dosing:

Artesunate 1.2 mg/kg body weight IV single bolus once daily beginning on second day of treatment. Continue maintenance dosing until woman is conscious and able to swallow oral 59 medication. Then give oral artesunate 2 mg/kg body weight once daily for a total of 7 days of Syphilis in Pregnancy Syphilis in pregnancy can lead to adverse perinatal outcomes including: Early fetal loss, stillbirth, neonatal death, prematurity, low birth weight, and evidence of syphilis in neonate To prevent maternal-to-child transmission: Screen all pregnant women and partners at first antenatal care visit (preferably before 16 weeks) and again in late pregnancy. Treat as indicated. If not screened during pregnancy, screen women during labour or immediately postpartum, before discharge. 60 Syphilis in Pregnancy

UPDATED RECOMMENDATIONS Treatment of baby exposed to syphilis in utero: If mother has positive serologic test or signs of syphilis treat her baby regardless of whether mother was treated previously or whether baby has signs of syphilis: Give baby 37.5 mg/kg body weight (50 000 units/kg) of benzathine benzylpenicillin in a single IM dose. Treatment of mother with positive serologic test for syphilis: If mother was not treated previously, was treated inadequately, or her treatment is unknown: Give mother + partner(s) benzathine benzylpenicillin 1.8 g IM as two injections at separate sites. Refer mother + partner(s) for follow-up at STI clinic. Inform mother about importance of treatment for her, her newborn, and her partner(s). Schedule follow up in 4 weeks to examine baby for growth and signs of congenital syphilis. Report syhpilis infection to authorities, if required. 61 World Health Organization [2018] Some rights reserved. This work is available under the Creative Commons AttributionNonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence,

you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services Suggested citation. World Health Organization, Managing Complications in Pregnancy and Childbirth. Geneva:, Switzerland:;WHO, 2017; Licence: CC BY-NC-SA 3.0 IGO. All reasonable precautions have been taken by WHO, MCSP and USAID to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WHO be liable for damages arising from its use. The contents do not necessarily reflect the views of WHO, MCSP, USAID, or the United States government. This resource is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. For further information on the WHO guidelines, please contact [email protected] or [email protected] 62 Thank You! The Second edition MCPC and a corresponding brief on key highlights can be found at the link below: http://www.who.int/maternal_child_adolesc

ent/documents/managing-complications-pr egnancy-childbirth/en / Requests for further information on this PowerPoint should be addressed to MCSP Communications, e-mail: [email protected] 63

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