Inevitable Abortion

Guidelines

-Check Hb. Send blood for grouping and cross matching if the bleeding is severe.

-Consider blood transfusion if patient is in shock.

-Get ultrasonography done, if clinical diagnosis is in doubt..

-Perform uterine curettage urgently in the 1st trimester, without waiting for the products to be expelled out with oxytocin drip infusion.

-In the 2nd trimester abortion (spontaneous/induced)-await abortion of fetus.

-Wait for 30 min for placental expulsion after fetal expulsion only if there is no bleeding. If there is vaginal bleeding, remove the placenta and perform blunt curettage urgently.

-Obtain blood group Rh typing, VDRL and urinalysis report within 24 hours.

If Rh negative, follow respective policy.

Treatment Orders

-Nil by mouth

-Shave/ clip hair and prepare private parts

-TPR 1/2 hourly

-Sterile vulval pad

-Save all pads

-Watch for vaginal bleeding

-Consent for curettage

-IV 500 ml RL + 10 units Oxytocin

-Inj TT 0.5 ml IM

-Antibiotic

-Inj. PGF 2 a - 250 m g IM as required.

-Inj. Anti D 50 m g IM within 72 hours Ä of 1 st trimester abortion/300 m g IM within 72 hours Ä of 2 nd trimester abortion in a non-sensitized Rh –ve gravida with a Rh +ve partner.

Inform if**

• P >120/min
• Vaginal bleeding is present.

Ä Preferably within the first 24 hours.  

Missed Abortion

Guidelines

-Get Hb, blood group, VDRL, urinalysis, pelvic ultrasonography done.

-Perform bleeding time and clot observation test.

-Ultrasonography

-Obtain coagulation profile as applicable

-Check uterine size:

• 1st trimester- urgent evacuation if bleeding vaginally, otherwise electively.
• 2nd trimester-follow unit policy.

Treatment Orders

-Shave/ clip hair and prepare private parts

-Sterile vulval pad

-Watch for vaginal bleeding

-Inj TT 0.5 ml IM

-Antibiotic (see antibiotic policy)

-Consent for dilatation and suction evacuation/curettage.

Sudden Postpartum Collapse

Guidelines

-Check the cause and follow specific protocol

Causes

-Massive PPH

-Acute puerperal uterine invasion

-Eclampsia

Embolism

-Amniotic fluid embolism

-Pulmonary embolism

-Air embolism

Causes related to anesthesia

-Anesthesia toxicity

-Mendelson’s syndrome

Cardiac causes

-Heart failure (acute pulmonary

edema)

-Arrhythmias

-Acute myocardial infarction

-Cardiac arrest

Intracranial hemorrhage

-Spontaneous subarachnoid hemorrhage

-Preeclampsia - associated

intracerebral hemorrhage

Endocrine

-Hypoglycemia

Miscellaneous

-Septic shock

-Anaphylactic shock

-Acute adrenocortical insufficiency

-Adverse drug reaction .

-Send blood for grouping cross match. Send Hb, BUN, serum electrolytes, random blood sugar, ABG, baseline DIC profile.

-Inform lecturer on duty.

-Identify cause and follow appropriate protocol

Treatment Orders

-Left lateral position

- Head low

-IV access with 18 #- cannula. Central venous line.

- Foley catheter.

-Monitor TPR/BP / ABG

-Give nasal moist O 2

-Consider endotracheal intubation /mechanical ventilation.

-Maintain I/O chart

-25% glucose 50 ml IV,

-IV 500 ml RL/ Blood/ FFP as required

-Dopamine /Dobutamine drip as per advise by

emergency medical resident

-If PPH- (follow guidelines for PPH)

-If hemoperitonium – (exploratory laprotomy)

-If eclampsia – (follow guidelines for eclampsia)

-If acute pulmonary edema , cardiac failure , embolism, septic shock – (follow appropriate protocol)

-If cardiac arrest - (follow CPCR protocol)

Indications For Central Venous Access

-Severe anemic woman aborting or in labour who needs blood transfusion

-Heart disease

-Hemorrhagic shock

-Severe antepartum hemorrhage

-Severe postpartum hemorrhage

-Coagulopathies

-Sudden collapse

-Ruptured ectopic pregnancy

-Severe PIH/ eclampsia

-Any gravida with persistent reduced urine output despite fluid challenge/diuretic  

Sexual Assault (Rape)

-To be seen by registrar and shown to lecturer on call

Strictly follow Sexual Assault Evidence KitProtocol kept in lecturer’s duty room.

-Admit patient.

-Do not send patient for bath till Dr. permits.

-Documentation points:

• Check PC (police constable) no.
• Note name and relationship of the informant.
• Note name and relationship of the person who brought the patient.
• Note date and time
• Note the marital status of the patient. Take detailed history with specific note of use of contraception and the date of last act of sexual coitus with husband, if any.
• Record on paper the actual incident, noting the following:
• Location- place, date, time of assault.
• Victim stripped of her underclothes.
• Bath taken by victim after the incident.
• Clothes worn at the time of incident

discarded, washed or preserved.

• Passed urine/stool after the incident or not.
• H/O Injury on any other part of the body.
• Was the assaulter a known or unknown person?
• H/o vaginal bleeding after the incident.
• Any other significant past medical/surgical history.

-Examination findings:

-Take written consent from the victim if major/ parent or guardian if minor in presence of and documented by a witness.

-Record

• General condition of patient- state of consciousness, co-operation, orientation in time and space.
• State of clothes including undergarments, especially if she is in the same clothes in which she was assaulted.
• Look for stains of blood, seminal fluid, dirt?
• Pulse, blood pressure.  

• Signs of injury on her person, like abrasion, hematoma, laceration, nail scratches, bites, blood stains on body especially around legs/ vagina etc. Serious injuries should be promptly attended to.
• Note dentition
• Height/weight
• Nails- look for tissue under nails. Collect nail clippings as evidence to be sent.
• Tanner’s stage of development: for breasts and pubic hair.
• Comb pubic hair to collect all loose hair for evidence- to be sent.
• Identification marks of the patient: two.
• Systemic Examination: RS/CVS/CNS/PA examination findings.
• Local examination: Condition of:

• External Genitalia
• Pubic hair if present- matted/ not matted
• Labia majora and minora
• Clitoris

Hymen (evidence of recent rupture)

• Posterior commissure
• Fossa navicularis
• Vagina
• Perineum

• Collect dry and wet swabs from introitus before speculum/vaginal examination.
• Snip off (cut with scissors) a sample of pubic hair for forensic examination.
• PS: do PS without use of antiseptic/saline solution. Take a dry and a wet swab from posterior fornix.
• PV: possible or not, if possible then possible with use of one finger or two fingers. Also note the discomfort experienced due to the PV examination.
• PR

-Samples to be sent to Central Forensic Laboratory, Kalina

Sexual Assault Evidence Kit has 6 colour coded forms. All have to be duly filled and either kept in hospital, given to patient, police or kept inside the kit as per the instructions on the form. Use the various containers and bags for collecting samples as specified.

- Bag 1:

-Patients clothes and undergarments worn at the time of the incident, if available and not washed

-Bag 2: Body evidence

- Oral swabs

-Blood stains on body

-Foreign material on body

-Seminal stains on body

-Other stains

-Head hair combing

-Scalp hair

-Nail scrapings of both hands separately

-Nail clippings of both hands separately

-Blood for grouping in citrate vial

-Blood for alcohol levels/drugs, double oxalate

-Bag 3:

-Genital and anal evidence

-Cut the matted pubic hair

-Combed pubic hair in another test tube

-Vulval swabs

-Dry and Wet swabs from introitus, anterior, two lateral and posterior fornices

-Anal swab

-Vaginal smear

Investigations in hospital laboratory:

• X-ray left wrist, elbow and shoulder for bone age in minors or suspected minors.
• CBC, VDRL, HIV, urinalysis, blood in fluoride bulb for detection of alcohol.

-Impression:

-Alleged case of sexual assault- attempted rape

-Awaiting results of investigations suggestive of sexual rape.

-Form II (Viscera form) - available in all wards or to be brought from MRO- fill in duplicate.

-Description of articles to be filled in this form.

-All samples with this form duly filled should be sent to the MRO for sealing of the tubes- during the daytime ‡.

-These sealed tubes should be handed over to the police inspector/sub-inspector/constable whose name, ID no.; his police station address should be noted on the form and on the indoor paper.

-His signature for receiving the sealed articles should be taken on the form.

-One form goes with the police, second to the MRO with the indoor paper.

-Obtain on a plain paper with carbon copy

name and number of police station and police constable receiving the samples for forwarding to forensic laboratory.

-Also note the date and time when samples were handed over.

-Give emergency contraception and HIV prophylaxis

‡ - to be sent to mortuary for sealing when not in office hours.

Guidelines For Registering A Police Case

-A police case should be done for the following.

1. Suspected criminal abortion
2. Unknown patient
3. Sexual assault
4. Domestic violence

-Send case papers to casualty medical officer (CMO) - if police constable number is not written on paper.

-Instructions in residents’ manual may be referred to for any queries.

Ultrasonography In Labor

Rules

-Do’s

-Suspected ectopic pregnancy but coplopuncture is negative.

-Threatened abortion: for fetal cardiac activity.

-Malpresentations- some

-Suspected IUFD.

-Serious patients to be accompanied by RMO with resuscitation kit.

-Don’t send the patients with following diagnosis unless advised by lecturer

-Bleeding placenta previa

-Abruptio placentae

-Patient in shock

-Incomplete/inevitable abortion  

Anaphylactic Shock

-Stop administration of allergen

-Airway (consider intubation)

-Give 100% oxygen

-IV access: # 14 or 16 cannula

-IV fluid 500 ml RL

-Adrenaline 1-2 ml of 1:10000 solution IV (1 ml of 1:1000 solution diluted with 9 ml of normal saline gives 1: 10000 solution)

-Diphenhydramine 50 mg IV or IM

-Hydrocortisone 100 mg iv

-Aminophylline 6 mg/kg loading dose followed by IV 0.5-1.0 mg/kg/hour infusion

-Cimetidine 300 mg IV  

Universal Precautions

-3 Cardinal Principles

1. Protection
2. Disinfection
3. Waste Disposal

Protection

-Wash hands before examination or a procedure - minor or major with a soap solution containing 1% sodium hypochlorite in proportion of 3:1 provided in plastic soap dispensers.

-Perform all major/minor procedures after wearing gowns, masks, and surgical gloves.

-Consider wearing double pair of gloves.

-Change gloves after 1 hour, as continuous use may be detrimental. Total time a glove can be used is 3 hours.

-Wear protective glasses or eye-shields

-Guidelines for collection of blood samples

• Always use gloves- at least non-surgical gloves.
• Prevent blood spillage.
• Use disposable syringes and needles.
• Use 70% ethanol or isopropyl alcohol swabs to clean needle puncture sites. Use thick dressing pad or absorbent cotton below forearm, and place polydrape under this.
• Do not recap used needles.
• Tie all blood bulbs containing blood samples in plastic bag.
• Place used syringes and needles in a puncture resistant container containing disinfectant.
• Prevent overflow of sharps disposable containers, and send them for incineration when ¾ full.

-Contaminated linen to be disinfected before sending to laundry by immersing in 3% sodium hypochlorite solution.

-No need to wear gloves when giving injections other than IV injections.

Management of spills:

• Cover spills with paper towel/ blotting paper / newspaper.
• Pour on and around spill-1% sodium hypochlorite solution (giving 10,000 ppm of chlorine)
• Cover with paper for at least 10 minutes. Remove paper with gloved hands- discard in red bag.

-Proper disinfection and sterilization techniques to be followed for equipment, material or instruments which are used for non invasive procedures.

Immerse in disinfectant solution for at least 20 minutes, then wash with water and autoclave.

-All theatre personnel must use plastic aprons under the gown and use double gloves (surgical- ISI quality).

-Protective glasses and reflector masks should be used by personnel likely to get exposed to blood or fluid splashes.

-All menial staff in theatres and ICU's to use "sponge mops on long handles" dry or with detergent soap to clean the floors of household dust.

-All class 4 staff to wear plastic disposable gloves while cleaning patients.

-Aseptic precautions to be observed prior to urinary catheterizations, IV infusions.  

Disinfection

-Liberal use of a combination of 1% sodium hypochlorite with liquid soap (1:3 for hand washing).

-Following completion of the minor/ major procedures wash hands under running tap water with gloves on so as to remove and drain the contaminants

-Thereafter remove the gloves and place them in a large bowl containing bleaching power 1/4th teaspoon to 1 liter of water ( 1% solution).

-All biomedical non-sharp contaminated wastes linen like gowns, drapes, bed sheets, etc. to be immersed in a large plastic container (50litres/120litres) with lid, filled with 2-4% sodium hypochlorite (freshly prepared) for 1/2 an hour before being sent for washing.

-All small dressings like used gauze, cotton swabs to be collected in medium sized plastic buckets with black plastic bags (10-131/2 liters size ) filled with 2-4% sodium hypochlorite solution (freshly prepared) for 1/2 an hour before being sent for washing

-Alternative chemical agents for effective

sterilization/disinfection are:

Gluteraldehyde 1%,

Povidone iodine 2.5%,

Formaldehyde 5%.

-Heat sterilization by boiling for 20 minutes for instruments which could be boiled.

-Carbolise table each time after patient is shifted.

-Floor soiled with blood/ amniotic fluid should be cleaned with antiseptic/bleach solution immediately.

-Spillage should be covered with un-sterile gauge/lint soaked in hypochlorite solution for 10 minutes before being wiped out.

Waste Disposal

Safe handling and disposal of sharps

-Locate sharp disposal containers close to the point of use. Example: dressing trolley.

-Place used syringes and needles in a puncture resistant container containing disinfectant.

-All sharps like needles; syringes, scalpel blades, scalp veins, IV sets ,etc. should be put in special rigid non-penetrable plastic containers tightly capped- containing solution of 1% sodium hypochlorite having a prominent red label mark.

-NEVER place used sharps in other waste containers.

-Placenta should be collected in a separate bucket in a yellow plastic bag and sent for incineration.

-Household waste, dust, fruits, vegetable peels etc. to be collected in metal containers with black bags for disposal.  

Post Exposure Prophylaxis (PEP)

-To be followed if patient is HIV positive.

-On exposure to HIV infected blood/body fluids/ and contaminated sharps

Immediate:

-Needle stick/skin punctures/wound

-Wash thoroughly with soap and water and let blood flow freely.

-Splashes to nose, mouth, skin: wash thoroughly with water

-Eyes to be irrigated with clean water/saline.

-Apply iodoform/ tincture iodine on the exposed part except eyes.

Reporting:

-Immediately (as an emergency) to EMS/MICU medical registrar on call- to contact Professor/associate professor in charge of EMS /ART centre in medical department and follow their recommendations.

-Treatment must be initiated within 72 hours of exposure for it to be beneficial.

PEP Prophylaxis

-Need for it depends on nature of exposure to HIV (EC) and the HIV status (SC) of source.

-Nature of exposure defines the exposure code- EC

Exposure codes are 3 categories:

-EC1- Small volume (Few drops or short duration)

-EC2- 2 categories- Either

Large volume (several drops, major splash/longer duration of several minutes or more)

Or

Less severe - solid needle or superficial scratch

-EC 3- More severe (Large bore hollow needle, deep punctures, visible blood on device or needle used in patient’s artery or vein

HIV Status (SC)

-3 categories:

-SC 1 - Low titre exposure: (asymptomatic high CD4 count)  

-SC 2 - High titre exposure: (advanced AIDS, primary HIV infection, high viral load, low CD4 count)

-SC unknown - status unknown, source

unknown

-Intact skin- no PEP required.

-Mucous membrane/skin integrity compromised- EC1/EC2

-Percutaneous exposure- EC2/EC3

Testing: testing by 3 test kits- ELISA, rapid, simple

-Baseline HIV test- at time of exposure

-Repeat HIV test- 6 weeks following exposure

-2nd repeat HIV test- 12 weeks following exposure

Counseling

-Pretest : Refrain from donating blood, semen, organs, and tissues.

-Abstain from sexual intercourse or use latex condoms.

PEP Prophylaxis Recommendation

Surgical Antibiotic Prophylaxis

• Not to be given to lactating women

** To be given to lactating women