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imitation of treatment, patient should be monitored regularly. However, if there is flaring
of infection in the form of spreading facial cellulitis then patient should be hospitalized
and shifted to systemic IV antibiotics. If patient is having recurrent furunculosis, then the
patient must be investigated for diabetes mellitus.
Patient education
 Do not fidget with the furuncle as this lies in the dangerous area of the face and cause
serious complications.
 Complete antibiotic therapy to avoid risk of developing antimicrobial resistance
References
1. Disease of external nose and nasal vestibule. In diseases of ear nose and throat, PL Dhingra’s 2 nd edition.
ACUTE TONSILLITIS
The common cause is viral infection due toadenovirus and Epstein-Barr virus. Secondary


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ACUTE TONSILLITIS
The common cause is viral infection due toadenovirus and Epstein-Barr virus. Secondary
bacterial infection due to Group Aβ haemolytic S treptococci,H aemophilus influenza,
Staphylococcusalso occurs.
Salient features
Pharmacologicaltreatment
• Tab. paracetamol 500 mg 3-4 times a day for5 days (children 10 kg/dose) or Tab.
ibuprofen 400 mg-600 mg 3 times a day for 5 days (children 10 mg/kg/dose.)
• Cap.amoxicillin 500mgTDS for 5 days. Or Tab. erythromycin 500mgQID for 5-7
CHRONIC TONSILLITIS
Chronic inflammation of tonsil starts asan acute inflammation. Minute abscesses get walled
by chronic inflammation.It can be chronic parenchymatous or hypertrophic type tonsillitis.


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ENT Diseases
167
 Tonsils are uniformly enlarged and congested.Chronic follicular tonsillitis shows beads of
white discharge on surface of tonsil.Tonsils are small and inflamed, occur in adults,
anterior pillars are congested inchronic fibrotic tonsillitis
Symp toms
 Repeated attacks of sore throat with little remission between attacks
 Odynophagia, fever,cough and irritation in throat. Halitosis–foul breath. Thick speech,
difficulty in breathing, swallowing and snoring
Signs
 Hypertrophied tonsils, congestionof anterior pillar, enlarged non-tender jugulodigastric
nodes
 Extrusion of purulent discharge on pressure over the tonsil with a tongue depressor– Irwin
Moore’s sign
 Bilateral parotid swelling,pain over gland, ear pain
 Low -grade fever, arthralgia, malaise,headache


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Moore’s sign
 Bilateral parotid swelling,pain over gland, ear pain
 Low -grade fever, arthralgia, malaise,headache
 Pain, swelling, tenderness,indurationsof gland.Erythema of skin and oral mucosa, fever.
Salient features
Pharmacological treatment
 Cap. amoxicillin 500mgTDS / tab. azithromycin 500mgOD for 5-7 days
 Tab. paracetamol 500mgTDS for 5 days
 Bed rest
 Surgery– tonsillectomy for  recurrent episodes of tonsillitis
ACUTE PAROTITIS
Known as mumps, caused by paramyxovirus. It usually affects children less than 15 years.
the incubation period–2-3 weeks.
Salient features
Non -pharmacological treatment
 Supportive measures-bed rest, adequate hydration, antipyretics
 Prevention– Measles Mumps Rubella (MMR) vaccine
BACTERIAL PAROTITIS


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 Supportive measures-bed rest, adequate hydration, antipyretics
 Prevention– Measles Mumps Rubella (MMR) vaccine
BACTERIAL PAROTITIS
Mechanical blockage of salivary duct or due to stasis of salivary secretions coupled with
secondary infection results in bacterial parotitis. It is prevalent in debilitated patients.
Retrograde migration of intra-oral bacteria contributes to development of acute bacterial
parotitis. Sialolithiasis is the cause of acute parotitis in non-debilitated patients.
Salient features


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ENT Diseases
168
Investigations
 Leucocytosis
 Milking of gland for purulent discharge through the duct for culture and sensitivity
 Palpation and X-ray for stone
Non -pharmacological treatment
 Adequate hydration, goodoral hygiene
 Warm compression and repeated massage of the gland. Stone in the distal duct–
expressed manually or removed after enlarging the duct orifice with a small incision.
Failure indicates an abscess, which is confirmed by CT scan or USG.
Pharmacological treatment
 Cap. amoxicillin 500mg thrice a day /Tab. amoxicillin with clavulanic acid 625 mg (in
adult)TDS for 7 days.


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169
 A gradually enlarging painless nodule. Very rarely a largeupper lid chalazion may press
on the cornea, induce astigmatism and cause blurred vision.A ‘marginal’ chalazion is
similar except that it involves a gland of Zeis and is therefore located not in the tarsal
plate but on the anterior lid margin.
 Patientswith meibomian gland disease or rosacea are at increased risk of chalazion
formation which may be multiple and/or recurrent.
 Acute pain and tenderness over inflamed Zeis gland,seen as a localised painful and
hard swelling seen near the lid margin.The lid margin is red and oedematous.
 An abscess may form which points near the base of the lash.The pain subsides after
evacuation of the pus.
Chapter 11
EYE DISEASES
STYE (EXTERNAL HORDEOLUM)


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evacuation of the pus.
Chapter 11
EYE DISEASES
STYE (EXTERNAL HORDEOLUM)
Stye is an acute suppurative inflammation of glands of Zeisdue tostaphylococciinfection
and is common in young adults and debilitated persons.
Salient features
Non -pharmacologicaltreatment
 Dry hot fomentation applied frequently in early stage is useful.
Pharmacologicaltreatment
 Evacuation of the pus by pulling the involved lash or incising the abscess.
 Antibiotic eye drops and ointment-to control and prevent spread of infection
(fluoroquinolones e.g.m oxifloxacin 0.5% eye drops4 to 6 hourlyuntil infection subsides)
 Systemic antibiotics (e.g. Tab.amoxicillin withclavulanic acid 625 mg TDSfor 5 days)
 For  pain andinflammatione.g. Tab.ibuprofen 400 mg TDS till inflammation subsides.
Patient education


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 For  pain andinflammatione.g. Tab.ibuprofen 400 mg TDS till inflammation subsides.
Patient education
 Maintain ocular hygiene to prevent recurrence.
CHALAZION
A chalazion (meibomian cyst) is a chronic, sterile, granulomatous inflammatory lesion
caused by retained sebaceous secretion leaking from the meibomian or other sebaceous
glands into adjacent stroma. A chalazion secondarily infected is referred as an internal
hordeolum.
Salient features


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Eye Diseases
170
 Common symptoms include itching, foreign body sensation, watering of eyes. It can also
present as pharyngoconjunctival fever and acute haemorrhagic conjunctivitis.
 Frequently a history of recent upper respiratorytract infection or contact with a patient. It
often starts in one eye and involves the fellow eye a few days later.
 On examination, inferior palpebral conjunctival follicles and pinpoint subconjunctival
haemorrhages are observed.The common organism responsible isAdenovirus.
 Conjunctival cultures/swabs are not needed unless the discharge is excessive or the
condition becomes chronic.
Non -pharmacologicaltreatment
 Treatment may not be required because at least a third of chalazia resolve spontaneously


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condition becomes chronic.
Non -pharmacologicaltreatment
 Treatment may not be required because at least a third of chalazia resolve spontaneously
and an internal hordeolummay discharge and disappear. Persistent lesions may be treated
as follows:
 Dry hot fomentation applied frequently in early stage is useful.
Pharmacologicaltreatment
 Steroid injectioninto the lesion is preferable if close to the lacrimal punctum becauseof the
risk of surgical damage.
- Between 0.2 and 2m lof 5mg/mL triamcinolone diacetate aqueous suspension diluted with
lidocaine (or equivalent) to a concentration of 5mg/mL is injected through the
conjunctiva into the tissue around the lesion with a 30-gauge needle.
- The success rate following one injection is about 80%. In unresponsive cases a second


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- The success rate following one injection is about 80%. In unresponsive cases a second
injection can be given 2 weeks later.
 Cap. doxycycline (100 mg BD for 7 days)may be required as prophylaxis in patients with
recurrent chalazia, particularly if associated with acne rosacea.
 Incision and curettage, in case of large chalazia, if present for more than 3– 4 months or
if cosmetically unacceptable.
Patient education
 Recurrence mayoccur;common causes are uncorrected refractive error, blepharitis and
diabetes.
VIRAL CONJUNCTIVITIS
Salientfeatures
Non -pharmacologicaltreatment
Self-limiting condition that typically gets worse for the first 4 to 7 days after onset and may
not resolve for 2 to 3 weeks or longer if there is corneal involvement. It is highly contagious,


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not resolve for 2 to 3 weeks or longer if there is corneal involvement. It is highly contagious,
usually for 10 to 12 days from onset as long as the eyes are red (when not on steroids).
 Use dark goggles and avoid close contact with other persons for two weeks.
 Restrict work and school for patients with significant exposureto others.
 Frequent handwashing and cool compresses several times per day.


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Eye Diseases
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 The patient present with marked itching and watery discharge. History of allergy is
usually present.
 On examination, conjunctival papillae and edema over eyelids is seen.
Pharmacologicaltreatment
 Preservative-free artificial tears (carboxy methyl cellulose 0.5% eye drops) four to eight
times per day for 1 to 3 weeks. Use single-use vials to limittip contamination and spread
of disease.
 Antihistamine (e.g., epinastine 0.05% BD) if itching is severe. Anti-inflammatory drops
likeketorolac 0.5% may also be used if needed.
 If a membrane / pseudomembraneare present, use a steroid in form of drops withor
without ointment (e.g.loteprednol 0.5% QID,flurometholone 0.1% ointment QID or
dexamethasone 0.3% ointment QID). Steroid treatment is maintained depending upon the


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dexamethasone 0.3% ointment QID). Steroid treatment is maintained depending upon the
response and then slowly tapered.
 Routine / unsupervised use of topical antibiotics or steroids should be discouraged.
Patient education
 Patients should avoid touching their eyes, shaking hands, sharing handkerchiefs, towels
with family members.
 Patient’s drops or ointment must not be used by other members of the family.
ALLERGIC CONJUNCT IVITIS
It occurs as a result of hypersensitivity reaction due exposure toallergicsubstances.
Salientfeatures
Non -pharmacologicaltreatment
 Cool compresses several times per day and avoid offending agents.
Pharmacological treatment
 Topical anti-inflammatory and anti-histaminic drops, depending on the severity


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Pharmacological treatment
 Topical anti-inflammatory and anti-histaminic drops, depending on the severity
(olopatadine 0.1% OD/BD,nedocromil 2% TDS, or ketotifen 0.025%BD, ketorolac
0.5% QID).
 In severe cases, mild topical steroid (e.g.,loteprednol 0.2% orfluorometholone 0.1%,
QID for 1 to 2 weeks)may have to be added. Steroids are gradually tapered as patient
responds to medications.
 Preservative free artificial tears four to eight times per day.
 Investigate for offending agents and avoidance of the same.
 Oral antihistamine (e.g.,diphenhydramine 25 mg TDS/QID. or cetrizine/
levocetrizine/m ontelukast/loratadine 10 mg OD) can be helpful in severe cases and in
cases with associated systemic allergy.


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Eye Diseases
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VERNAL / ATOPIC CONJUNCTIVITIS
Vernal keratoconjunctivitis (VKC) is a recurrent bilateral disorder in which both IgE- and
cell-mediated immune mechanisms play important roles. It primarily affects boys and onset is
generally from about the age of 5 years onwards (mean age 7 years).
Salient features
Treatment
 Treat as for allergic conjunctivitis.
 Mast cell stabilizer (e.g.sodium chromoglycate QID) or a dual action mast cell stabilizer
and antihistamine (e.g.,olopatadine 0.1% OD/BD) orketotifen 0.025%, orazelastine
0.05% for 2 to 3 weeks, prophylactically, before the season starts).
 If a shield ulcer is present, add topical steroid (e.g.,loteprednol 0.5% orflurometholone
0.1%, prednisolone 1%, etc) four to six times per day. Taper steroids over 4 week as


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0.1%, prednisolone 1%, etc) four to six times per day. Taper steroids over 4 week as
condition of patient improves. Shield ulcers may need to be scraped to remove superficial
plaque-like material before re-epithelialization will occur.
 Topical antibiotic (e.g.,m oxifloxacin 0.3% eye drop,tobramycin 1% QID) is given if
associated infection is there or steroids are prescribed
 Cycloplegic agent (e.g.,cyclopentolate 1%BD drops or atropine 1% TDS in form of
drops or ointment) if cornea is involved, when there is much pain due to ciliary spasm.
 Consider cyclosporine 0.05% BD if not responding to the preceding treatment. Maximal
effect may not be seen for several weeks.
 Follow-up should be done every 1 to 3 days in the presence of a shield ulcer; otherwise,


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effect may not be seen for several weeks.
 Follow-up should be done every 1 to 3 days in the presence of a shield ulcer; otherwise,
every few weeks. Steroids are tapered slowly as improvement is noted.
 Anti-allergy drops are maintained for the duration of the season and are often reinitiate a
few weeks before the next spring.
 Patients on topical steroids should be monitored regularly, including IOP monitoring,
even if used only on the skin.
 Patients and relatives of children should be strictly instructed not to use or continue
steroids, in any form, withoutmedical advice
Patient education
 Avoid exposure to substances causing atopy. Maintain hygiene to preventsecondary
infection.
 Common symptoms include marked itching, thick ropy discharge and seasonal


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infection.
 Common symptoms include marked itching, thick ropy discharge and seasonal
occurrence (during spring/summer)
 History of atopy may be present. Usually seen in young patients, especially boys.
 Large conjunctival papillae seen under the upper eyelid or along the limbus (limbal
vernal). Often they are so large as to give a cobble stone appearance.
 Superior corneal “shield” ulcer (a well-delineated, sterile, gray–white infiltrate) maybe
seen in some cases.


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Eye Diseases
173
 The patient complains of redness, foreign body sensation, mucoid or mucopurulent
discharge. Itching is much less prominent.
 On examination, purulent discharge, conjunctival papillae and chemosis are seen.
 If severe or recurrent, conjunctival swab for routinecultures and sensitivities and
immediate Gram stain to evaluate for gonococcus.
 Clinical symptoms start within 12 to 24 hours and include severe purulent discharge,
swelling of eyelids
 On examination, conjunctival papillae, marked chemosis and preauricular adenopathy is
observed.Examination of entire cornea for peripheral ulcers (especially superiorly) should
be done because of the risk for rapid perforation.
 Conjunctival scrapings for immediate Gram stain and for culture and sensitivities (e.g.,


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be done because of the risk for rapid perforation.
 Conjunctival scrapings for immediate Gram stain and for culture and sensitivities (e.g.,
bloodagar and chocolate agar) should be taken.
BACTERIAL CONJUNCTIVITIS (NON -GONOCOCCAL)
Acute bacterial conjunctivitis is a common and usually self-limiting condition caused by
direct eye contact with infected secretions. The most common isolates areS. pneumoniae,
S.aureus, H. influenzaeand Moraxella catarrhalis.
Salientfeatures
Non -pharmacological treatment
 Patients should avoid touching their eyes, shaking hands, sharing handkerchiefs, towels,
etc.
 Restrict work and school for patients with significant exposure to others.
 Frequent hand washing.
Pharmacologicaltreatment


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etc.
 Restrict work and school for patients with significant exposure to others.
 Frequent hand washing.
Pharmacologicaltreatment
 Use topical antibiotic therapy [m oxifloxacin 0.5% drops QID or more frequent in severe
cases] for 5to 7 days.
 H. influenzaeconjunctivitis should be treated with oralamoxicillin/clavulanic acid (20 to
40 mg/kg/day in three divided doses) because of occasionalextra ocularinvolvement
(e.g., otitis media, pneumonia, and meningitis). Antibiotic therapy is adjusted according
to culture and sensitivity results.
 If associated with dacryocystitis, systemic antibiotics are necessary.
Patienteducation
 Follow up every 2 to 3 days initially, then every 5 to 7 days until resolved.
 Maintain ocular hygiene
GONOC OCCAL CONJUNCTIVITIS
Salientfeatures


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 Follow up every 2 to 3 days initially, then every 5 to 7 days until resolved.
 Maintain ocular hygiene
GONOC OCCAL CONJUNCTIVITIS
Salientfeatures
Pharmacological treatment


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Eye Diseases
174
 Complaints of mild itching and irritation of the eyes and eyelids, purulent or mucoid
discharge from the eyes, photophobia, blurred vision and eye pain are common.
 Diseases progresses slowly, and the more painfulsymptoms may not emerge until
adulthood.
 Presence of at least two of the following signs: superior tarsal follicles, limbal follicles
(Herbert’s pit), typical conjunctival scarring and vascular pannus.
 Transmission of the disease occurs vial ocular and nasal secretions (direct spread, indirect
via fomites, coughing/sneezing).
Initiated if the Gram stain shows gram negative intracellular diplococci or there is a high
suspicion clinically of gonococcal conjunctivitis.
 Inj. ceftriaxone 1 g intramuscularly in a singledose.


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suspicion clinically of gonococcal conjunctivitis.
 Inj. ceftriaxone 1 g intramuscularly in a singledose.
 If corneal involvement exists, or cannot be excluded because of chemosis and eyelid
swelling, hospitalize the patient and treat withInj.ceftriaxone 1 g intravenously every 12
to 24 hours.
 In penicillin-allergic patients, consider an oralfluoroquinolone (e.g.,Tab. ciprofloxacin
500 mg, for 5 days) or a single oral dose ofTab.azithromycin 1 g.
 Topicalciprofloxacin ointment QID orfluoroquinolone dropsevery two hours(e.g.,
gatifloxacin,m oxifloxacin, orciprofloxacin).
 Saline irrigation QIDuntil the discharge resolves.
 Treat for possible chlamydial co-infection (e.g.,Tab.azithromycin 1 g single dose orTab.
doxycycline 100 mg BD for 7 days).


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 Treat for possible chlamydial co-infection (e.g.,Tab.azithromycin 1 g single dose orTab.
doxycycline 100 mg BD for 7 days).
 Treat sexual partners with oral antibiotics for both gonorrhea and chlamydia as described
previously.
Patient education
 The patient should be followed daily until consistent improvement is noted, and then
every 2 to 3 days until the condition resolves.
 The patient and sexual partners should be evaluated by their medical doctors for other
sexually transmitted diseases.
TRACHOMA
Trachoma is an infectious disease caused by theChlamydia trachomatistype A, type B, type
C bacterium which produces a characteristicrougheningof the inner surface of the eyelids. It
is also calledgranular conjunctivitisand Egyptianophthalmia and is theleading cause of


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is also calledgranular conjunctivitisand Egyptianophthalmia and is theleading cause of
infectiousblindnessin the world.
Salientfeatures
Grading of severity


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Eye Diseases
175
MacCallan Classification
 Stage 1: Superior tarsal follicles, mild superior SPK, and pannus, oftenproceededby
purulent discharge andtender preauricular nodes.
 Stage 2: Florid superior tarsal follicular reaction (2a) or papillary hypertrophy (2b)
associated with superior corneal SEIs, pannus, and limbal follicles.
 Stage 3: Follicles and scarring of superior tarsal conjunctiva.
 Stage 4:No follicles, extensive conjunctival scarring.
 Late complications: Severe dry eyes, trichiasis, entropion, keratitis, corneal scarring,
superficial fibrovascular pannus, Herbert pits (scarred limbal follicles), corneal bacterial
superinfection, and ulceration.
World Health Organization (WHO) Classification


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superinfection, and ulceration.
World Health Organization (WHO) Classification
 TF (Trachomatous inflammation: follicular): More than five follicles on the upper tarsus.
 TI (Trachomatous inflammation: intense): Inflammation with thickening obscuring more
than 50% of the tarsal vessels.
 TS (Trachomatous scarring): Cicatrization of tarsal conjunctiva with fibrous white bands.
 TT (Trachomatous trichiasis): Trichiasis of at least one eyelash.
 CO (Corneal opacity): Corneal opacity involving at least part of the pupillary margin.
Treatment
The SAFE strategy for trachoma management supported by the WHO and other agencies
encompasses
S Surgery for trichiasis,
A A ntibiotics for active disease,
F Facial hygiene and
E Environmental improvement


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encompasses
S Surgery for trichiasis,
A A ntibiotics for active disease,
F Facial hygiene and
E Environmental improvement
 Antibioticsshould be administered to those affected and to all family members. Single
antibiotic course is not always effective in eliminating infection in an individual, and
communities may need to receive annual treatment to suppress infection.
- A single dose of azithromycin (20 mg/kg up to 1g) is the treatment of choice.
- Topical 1% tetracycline ointment is less effective than oral treatment; it should be given
for 6 weeks.
 Facial cleanlinessis a critical preventative measure.
 Environmental improvementsuch as access to adequate water and sanitation,as well as
control of flies, is important.


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 Environmental improvementsuch as access to adequate water and sanitation,as well as
control of flies, is important.
 Surgeryis aimed at relieving entropion and trichiasis and maintaining complete lid closure
with bilamellar tarsal rotation.
CORNEAL ULCER


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 Source of infection can be exogenous or endogenous (from other ocular structures)
 Patient presents with history of trauma to the eye with pain and redness. Concomitant
photophobia,discharge and dimness of vision can also be present.
 On examination, conjunctival and circumcorneal vessels may be engorged and inflamed
with localized epithelium disintegrated and cast off.  Ulcer is saucer shaped, walls project
above the normal cornealsurface. Surrounding area shows grey discoloration (cloudiness)
suggestive of the progressive stage of the ulcer-microscopic tissue examination reveals
leucocytic infiltration.In severe cases there is pronounced anterior chamber reaction, often
with hypopyon.


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leucocytic infiltration.In severe cases there is pronounced anterior chamber reaction, often
with hypopyon.
Defect in the integrity of corneal epithelium along with infiltrationof underlying stroma is
defined as corneal ulcer. It can be due to direct corneal trauma, chronic eyelid disease, tear
film abnormalities, hypoxic trauma from contact lens wear, and deficient nutrition as in
keratomalacia or neuroparalytic keratitis (Bell's palsy).It is classified as;
1. Infective keratitis may be bacterial, fungal or viral.
2. Non infective like traumatic (chemical/thermal/radiation), neoplastic or immune mediated
BACTERIAL KERATITIS
Salientfeatures
Investigations
 Conjunctival swab and ulcer scrapings can be tested with Gram stain, KOH preparation
and culture to determine the etiology.


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Investigations
 Conjunctival swab and ulcer scrapings can be tested with Gram stain, KOH preparation
and culture to determine the etiology.
 Routine investigations like complete blood count, blood sugar, urine examination should
be done. Septic foci should be found.
Non -pharmacologicaltreatment
 Maintain proper ocular hygiene by cleaning discharge twice a day.
 Removal of contributory factors like trichiasis, foreign body etc.
 The eye can be covered with a pad, unless the discharge is copious. In such case, shield
the eye with dark goggles.
 Prevention and treatment of complications– secondary glaucoma
Pharmacologicaltreatment
 Control of infection with antibiotics-Start with empirical broad spectrum antibiotics,
which can be changed according to sensitivity report(Table 1).


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which can be changed according to sensitivity report(Table 1).
Table 1. Indication and doses of antibacterials in treatment of bacterial corneal ulcer
Name Special
Indication
Dose
Systemic Subconjunctival Topical
Gentamicin Gm -ve org. and
Staph.species
3-5 mg/kg/day I/V or
I/M in divided doses
20 mg 0.3% drops and
ointment


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Eye Diseases
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8 hourly
Tobramycin Same as
gentamicin
Same as gentamycin 5-20 mg 0.3% drops
Cefazolin Gm +ve cocci
and Gm -ve rods
25-50 mg/kg/day IV
or IM divided doses
8hrly
100 mg 5% concentration
used as topical drops
Ceftazidime Gm -ve specially
Pseudomonas
1-2 gm IV 8-12
hourly
100 mg
CiprofloxacinBroad spectrum
including most
aerobic Gm-ve
org.,S. aureus
and S.
epidermidis
500 mg orally 12
hourly, 200 mg IV
12 hourly
0.3% drops and
ointment
Ofloxacin Broad spectrum 200-800 mg/day
orally 200 mg I/V 12
hourly
0.3% drops
Norfloxacin Gm +ve and Gm
-ve org. including
Pseudomonas.
Not effective
against anaerobes
400 mg orally 12
hourly
0.3% drops
LomefloxacinGood coverage of
Gm -ve. Less
potent against
Gm +ve
400 mg orally or IV
12 hourly
Initially 5 drops in
20 min or 1 drop


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hourly
0.3% drops
LomefloxacinGood coverage of
Gm -ve. Less
potent against
Gm +ve
400 mg orally or IV
12 hourly
Initially 5 drops in
20 min or 1 drop
every hour for 6/10
hours. Then 1 drop
2-3 times a day.
SparfloxacinBroad spectrum.
Gm +ve and Gm
-ve org. including
anaerobes
400 mg orally on
day 1, followed by
200 mg once a day
0.3% drops
Ampicillin
Gm +ve org.
(except
penicillinase
producingStaph.)
and some Gm -ve
org.
500 mg orally 6
hourly, 3-6 g/day IV
or IM divided doses
6 hourly
50-100 mg
Cloxacillin Penicillinase 250-500 mg orally, 6


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 Common organisms are aspergillus, penicillium, fusariumand candida.Risk factors are
leukemia and diabetes, pre existing corneal disease like dry eye, vegetative injury and long
term treatment with antibiotic and steroids.
 On examination, definite white ring in the mid periphery of the cornea with healthy cornea
between the ring and ulcer margin is seen (Immune ring-diagnostic of fungal infection)
 Presence of hypopyon is the rule. Higher the hypopyon more ominous the sign and chances
of perforation.
producingStaph.hourly
Cephalexin Gm +ve cocci
and Gm -ve rods
500 mg orally 6
hourly
 Use atropine 1% eye drops or ointment for controlling iridocyclitis, to relieveciliary
spasm and to prevent synechia formation.


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hourly
 Use atropine 1% eye drops or ointment for controlling iridocyclitis, to relieveciliary
spasm and to prevent synechia formation.
 Other measures like scraping andcauterization. If the ulcer progresses inspite of the
pharmacological treatment, the removal of the necrotic material may be hastened by
scraping or ulcer may be cauterized with 100% carbolic acid, 10% trichloracetic acid 10%
or 5% povidone iodine.
 In case of non resolving ulcers, surgical methods like vasculoplasty, conjuctival hooding
and patch graft, tectonic penetrating keratoplasty and tarsorraphycan be considered.
Patient education
 Use dark goggles and avoid close contact with other persons for two weeks.
 Restrict work and school for patients with significant exposure to others.
 Frequenthandwashing


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 Restrict work and school for patients with significant exposure to others.
 Frequenthandwashing
FUNGAL KERATITIS
Salientfeatures
Non -pharmacologicaltreatment
 Use dark goggles and avoid close contact with other persons for two weeks.
 Restrict work and school for patients with significant exposure to others.
 Frequent handwashing
Pharmacologicaltreatment
- Treatment should be instituted promptly with topical antifungal drops, initially every hour
during the day tapered to 4 hrly interval for 3-4 days, then reduced to 4 times a day for at
least 14-21 days or till there is resolution of active stage(Table 2).
- Subconjunctival injections also may be used in cases of severe keratitis, or when poor
compliance exists.


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- Subconjunctival injections also may be used in cases of severe keratitis, or when poor
compliance exists.
- An oral antifungal (eg,ketoconazole,fluconazole 100mg) should be considered for cases
of deep stromal infection.


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- Fluconazolehas been shown to penetrate better into the cornea after systemic
administration compared to other azoles and is associated with fewer adverse effects.
Table 2. Doses of antifungal drugs used in the treatment of fungal infections
Drugs Topical Sub conjunctival/oralIntravitreal
Amphotericin–B 1-10mg/ml drops 0.37mg sc 5-10µg
Natamycin 5% drops 25µg
Miconazole 1% drops
2% oint
Ketokonazole 1% 200-800mg oral/day 0.5mg
Fluconazole 0.2%-2% 100-200mg  6 hourly 0.1mg
Intra-cameral
 Inj. amphotericin-B (5-7.5% µg in 0.1ml in 5% dextrose)
Intra-corneal
 Inj. amphotericin-B (5µg in 0.1ml) four to five places around the lesion intrastromaly, not
in thin area
 Inj. voriconazole (50 µg in 0.1% in RL solution)
Systemic antifungal


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in thin area
 Inj. voriconazole (50 µg in 0.1% in RL solution)
Systemic antifungal
Oral fluconazole and ketoconazole are absorbed systemically with good levels in the anterior
chamber and cornea-therefore they should be considered in the management of   deep fungal
keratitis fungal abscess, endothelial plaque.
 Cycloplegics are mandatory and antiglaucoma drugs maybe added to the treatment
depending on the intraocular pressure etc.
 Frequent corneal debridement with a spatula is helpful. It debulks fungal organisms and
epithelium, and enhances penetration of the topical antifungal agent
 Surgery is considered in thosepatients whofail to respond to medical treatment and may
result in corneal perforation. The treatment of choice is therapeutic penetrating
keratoplasty.
V IRAL KERATITS


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result in corneal perforation. The treatment of choice is therapeutic penetrating
keratoplasty.
V IRAL KERATITS
Common viruses that cause corneal disease areHerpes simplexvirus (HSV ), Varicella zoster,
Epstein Barr and Adenovirus. Cytomegaloviruscan also cause keratitis and is more
commonly associated with AIDS.
HERPES SIMPLEX K ERATITIS
Salient features


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 Herpessimplex keratitis occurs in two forms– primary and recurrent
 Primary infection of any of the 3 branches (ophthalmic, maxillary, mandibular) of cranial
nerve V leads to latent infection of nerve cells in trigeminal ganglion.
 Interneuronal spreadof HSV within ganglion allows patients to develop ocular disease
without ever having had primary ocular HSV infection
 Recurrent infection has been thought of as reactivation of virus in the sensory ganglion.
 The disease manifests as vesicular blepharoconjunctivitis occasionally with corneal
involvement as punctate keratitis.
 The patient presents with irritation, photophobia, reduction in vision (when central cornea is
affected) and corneal anaesthesia.


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 The patient presents with irritation, photophobia, reduction in vision (when central cornea is
affected) and corneal anaesthesia.
 Corneal ulceration and scarring can occasionally be theonly sign of recurrent herpetic
infections. Typical branching, linear pattern with feathery edges and terminal bulbs at ends
are visualized by fluorescein staining.
Pharmacologicaltreatment
 Antiviral drugs
- Trifluridine and acyclovir are much more effective in epithelial disease than others.
- Idoxuridine and trifluridine are frequently associated with toxic reactions.
Table 3. Antiviral drugs used in the treatment of viral keratitis
Drug Strength Frequency
Trifluridine 1% solution Every 2 hours while awake
Acyclovir 3% ointment 5 times daily
Idoxuridine 0.1% solution Hourly while awake


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Trifluridine 1% solution Every 2 hours while awake
Acyclovir 3% ointment 5 times daily
Idoxuridine 0.1% solution Hourly while awake
Vidarabine 3% ointment 5 times daily
- Oral acyclovir may be useful in treatment of severe herpetic eye disease particularly in
atopic individuals.
- For active treatment 400 mg five times daily in non immunocompromised patients.
- 800 mg five times daily in compromised and atopic patients.
- Prophylactic dosage in recurrent disease is 400 mg twice daily.
- Famciclovir or valacyclovir may also be used.
 Topical corticosteroids accelerate corneal thinning, increasing risk of corneal perforation
 Epithelial debridement is an effective way to treat dendritic keratitis before acyclovir.


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 Epithelial debridement is an effective way to treat dendritic keratitis before acyclovir.
Infected epithelium is easy to remove with tightly wound cotton tip applicator.
Adjunctive therapy with topical antiviral accelerates epithelial healing
 Surgical management like penetrating keratoplasty is indicated for visual rehabilitation in
patients with severe corneal scarring. It should not be undertaken until herpetic disease
has been inactive for many months.
GLAUCOMA


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 The disease is insidious and usually asymptomatic, until it has caused a significant loss
of visual field. Patients may experience mild headache,eye acheand visual field defect
in late cases.
 Reading and close work often present increasing difficulties owing to accommodative
failure due to constant pressure on the ciliary muscle and its nerve supply. Therefore,
patients usually complain offrequent changes in presbyopic glasses.
 Ocular examination including slit-lamp biomicroscopy may reveal normal anterior
segment. In late stages pupil reflex becomes sluggish and cornea may show slight haze.
 In the initial stages the IOP may not be raised permanently, but there is an exaggeration


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 In the initial stages the IOP may not be raised permanently, but there is an exaggeration
of the normal diurnal variation. Therefore, repeated observations of IOP (every 3-4hour),
for 24 hours is required during this stage (Diurnal variation test).Applanation tonometry
should be preferred over Schiotz tonometry.
 Gonioscopy reveals open angles.Optic disc changes are typically progressive,
asymmetric and present a variety of characteristic clinical patterns. It is essential,
therefore, to record the appearance of the nerve head in such a way that will accurately
reveal subtle glaucomatous changes over the course of follow-up period.
The classical triad of increasedintraocular pressure (IOP), optic nerve head cupping and


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The classical triad of increasedintraocular pressure (IOP), optic nerve head cupping and
visual field changes are always present and are signs of progress of the disease and bench
mark for assessing response totherapy.
PRIMARY OPEN ANGLE GLAUCOMA
In open angle glaucoma the structure of the trabecular meshwork appears normal but offers
an increased resistance to the outflow of aqueous which results in an elevated ocular pressure.
Salient features
Investigations
 Perimetryto detect the visual field defects.
 Nerve fibre layer analysis and disc topography analysisto detect early damage and for
progression analysis.
Pharmacologicaltreatment
 Identification of target pressure.From the baseline evaluation data a ‘target pressure’


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progression analysis.
Pharmacologicaltreatment
 Identification of target pressure.From the baseline evaluation data a ‘target pressure’
should be identified for each patient. Progression of disease is uncommon if IOP is
maintained at less than 16 to 18 mm of Hg in patients having mild to moderate damage
and 10 to 12 mmHg in patients with severe damage.
 Single drug therapy. One topical antiglaucoma drug should be chosen after due
consideration to the patient’s personal and medical factors. If the initial drug chosen is
ineffective or intolerable, it should be replaced by the drug of second choice.


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 Combination therapy.If one drug is not sufficient to control IOP then a combination
therapy with two or more drugs should be tried.
 Monitoring of therapyby disc changes, field changes and tonometry is most essential on
regular follow-up. In the event of progression of glaucomatous damage, the target
pressure should be reset at a lower level and any risk factors should be evaluated(Table
4).
Table 4.Drugs used for treatment of glaucoma
Topical agent Side effects
Beta-blockers
(timolol 0.5%, levobunolol 0.5%,
betaxolol 0.5% -selective)
Exacerbate asthma and chronic airway disease,
hypotension, bradycardia
Parasympathomimetic
(pilocarpine 2%)
Visual blurring in young patients, in patient with
cataracts, headache due to ciliary spasm
Sympathomimetic (adrenaline


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(pilocarpine 2%)
Visual blurring in young patients, in patient with
cataracts, headache due to ciliary spasm
Sympathomimetic (adrenaline
0.5%, dipivefrine 0.1%)
Redness, headache, mydriasis
Alpha-2 agonist (brimonidine
0.2%)
Redness, headache, drowsiness, allergic reaction
Carbonic anhydrase inhibitors
(Systemic–acetazolamide, topical
– dorzolamide 2%, brinzolamide
1%)
Stinging, bitter test
Prostaglandin analogues
(latanoprost 0.005%, bimatoprost
0.3%, travoprost 0.004%)
Redness, aggravation of inflammation, increased
pigmentation of iris and peri ocular skin, lengthening of
cilia, rarely macular edema.
Hyper osmotic agents 1-1.5g/kg
glycerol, mannitol 1-2g/kg
Mannitol contraindicated in hypertensives and in patient
with pulmonary edema. Glycerol not to be given in
diabetics


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glycerol, mannitol 1-2g/kg
Mannitol contraindicated in hypertensives and in patient
with pulmonary edema. Glycerol not to be given in
diabetics
Lasertreatment
Argon laser trabeculoplasty (ALT) or selective laser trabeculoplasty (SLT) are indicated in
patients intolerant to topical medication, failure of medical therapy or non compliance to
treatment. Since IOP reduction with laser is seldom greater than 30%, an IOP higher than 28
mmHg is unlikely to be adequately controlled by laser alone.
Surgicaltreatment
 Uncontrolled glaucoma despite maximal medical therapy and laser trabeculoplasty.
 Non -compliance of medical therapy and
 Intolerance to medical therapy
 Eyes with advanced disease i.e., having very high IOP, advanced cupping and advanced


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 Intolerance to medical therapy
 Eyes with advanced disease i.e., having very high IOP, advanced cupping and advanced
field loss should be treated with filtration surgery as a primary line of management.


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 Patient presents acutely (congestive glaucoma) with coloured halos around lights due to
corneal oedema, ocular pain and headache.
 The IOP rise maybe often be so severe as to cause nausea and vomiting and mimic a case of
acute abdomen.
 Precipitating factors include watching television or movie in a darken room, reading,
pharmacological mydriasis or miosis, acute emotional stress and rarely systemic medications
like parasympathetic antagonists or sympathetic agonists (e.g. inhalers, motion sickness
patches and cold remedies) and topiramate.
 On examination,IOP is usually very high (> 40 - 50 mmHg) with conjunctival hyperaemia,
corneal edema, unreactive mid dilated vertically oval pupil.
 Fellow eye generally shows an occludable angle.


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corneal edema, unreactive mid dilated vertically oval pupil.
 Fellow eye generally shows an occludable angle.
 Types of surgeries-trabeculectomy, shunt & valve surgeries, non penetrating glaucoma
Patient education
 Treatment of glaucoma whether medical or surgical is aimed to decrease further damage
to optic nerve. Once damage has occurred, it is irreversible
PRIMARY ANGLE -CLOSURE GLAUCOMA
The term ‘angle-closure’ refers to occlusion of the trabecular meshwork by the peripheral iris,
obstructing aqueous outflow.
I. ACUTE ANGLE CLOSURE GLAUCOMA
Salientfeatures
Pharmacologicaltreatment
Treatment intensity should be individualized dependent on severity. Hospital admission is
usually required in an acute presentation.


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Treatment intensity should be individualized dependent on severity. Hospital admission is
usually required in an acute presentation.
 The patient should assume a supine position to encourage the lens to shift posteriorly
under the influence of gravity.
 Inj. mannitol 20% 1–2 g/kg intravenously over half hour or glycerol 50% 1 g/kg orally,
having checked for contraindications.
 Pilocarpine 2–4% one drop to the affected eye, repeated after half an hour, and one drop
of 1% as prophylaxis into the fellow eye. Some practitioners prefer to omit pilocarpine in
an acutely presenting eye with very high IOP until a significant IOP fall has taken place,
as the associated ischaemia will compromise the action of pilocarpine on the pupillary
sphincter and it may also aggravate the pupillary block.


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as the associated ischaemia will compromise the action of pilocarpine on the pupillary
sphincter and it may also aggravate the pupillary block.
 An additional oral dose ofTab.acetazolamide 500 mg may be given.
 Topical timolol 0.5%, prednisolone 1% or dexamethasone 0.1% to the affected eye,
leaving 5 minutes between each instillation.
 Analgesia and an antiemetic may often be required.
Subsequent medical treatment


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 Many patients with angle-closure maybe asymptomatic, including those with intermittently
or chronically elevated IOP.
 They may have intermittent milder symptoms of blurring (‘smoke -filled room’)
unassociated with pain.
 Pilocarpine 2%QID to the affected eye and 1%QID to the fellow eye.
 Topical steroid (prednisolone 1% ordexamethasone 0.1% QID) if the eye is acutely
inflamed.
 Any or all of the following should be continued as necessary according to response:
timolol 0.5%BD and oralacetazolamide 250 mgQID may be required.
Surgical treatment
 Definitive treatment is laser iridotomy or iridoplasty after corneal oedema clears. Topical
steroids and any necessary hypotensives canbe continued for at least a week. Surgical


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steroids and any necessary hypotensives canbe continued for at least a week. Surgical
options in resistant cases include surgical peripheral iridectomy, lens extraction,
goniosynechialysisand trabeculectomy.
Patient education
 Do not ignore headache or chronic ache in the eyes and report to the ophthalmologist if
coloured halos around light appear.
II. CHRONIC ACUTE ANGLE CLOSURE GLAUCOMA
Salientfeatures
Pharmacological treatment
 Timolol 0.5% or betaxolol0.5% eye drops twice a day usually required lifelong.
Surgical treatment
 Laser or surgical iridotomy is done to eliminate any element of pupillary block in
affected as well as fellow eye.
III.LENS INDUCED GLAUCOMA
Lens induced glaucoma is classified into phacolytic, phacomorphic, phacoanaphylactic


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affected as well as fellow eye.
III.LENS INDUCED GLAUCOMA
Lens induced glaucoma is classified into phacolytic, phacomorphic, phacoanaphylactic
glaucoma, lens particle glaucoma and glaucoma due to dislocated lens. In addition to
medically lowering the IOP, the cataractous lens needs to be removed, under steroid cover to
suppress the inflammatory element.
ANTERIOR UVEITIS
It is the inflammation of the uveal tract i.e. iris, ciliary body and choroid. Inflammation of iris
and ciliary body constitutes iridocyclitis and anterior uveitis.
Salient features


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 Symptoms of acute uveitis include pain, redness, photophobia, consensual photophobia
(pain in the affected eye when a light is shown in the fellow eye), excessive tearing and
decreased vision.
 Symptoms of chronic uveitis include decreased vision (from vitreous debris, cystoid
macular edema (CME), or cataract, periods of exacerbations and remissions with few
acute symptoms [e.g. juvenile idiopathic (rheumatoid) arthritis].
 Cells andflare in the anterior chamber, ciliary flush and keratic precipitates (KP) are
observed by slit lamp microscopy.
 Complete ocular examination, including an IOP check and a dilated fundus examination.
The vitreous should be evaluated for cells.
Non -pharmacologicaltreatment
 Wear dark glasses
Pharmacological treatment


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The vitreous should be evaluated for cells.
Non -pharmacologicaltreatment
 Wear dark glasses
Pharmacological treatment
 Cycloplegic e.g.,cyclopentolate 1% eye drops BD for mild to moderate inflammation;
atropine ointment 1% TDS for severe inflammation.
 Topical steroid likeprednisolone acetate 1% one drop1 to 6 hourly, depending on the
severity. Most cases of moderate to severe acute uveitis require1 to 2 hourlydosing
initially. Consider FML(flurometholone) 1% ophthalmic ointment at night.
 If the anterior uveitis is severe and is not responding to topical steroids, then consider
periocular repository steroids (e.g.,triamcinolone 20 to 40 mgsubtenon injection).
 If there is no improvement on maximal topical and repository steroids, or if the uveitis is


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 If there is no improvement on maximal topical and repository steroids, or if the uveitis is
bilateral and severe, consider systemic steroids(Tab. prednisolone 1mg/kg), or
immunosuppressive therapy.
 Treat secondary glaucoma with betablockers, not withpilocarpine orprostaglandin
analogues.
 If an exact etiology for the anterior uveitis is determined (herpes, tuberculosis, ankylosing
spondylitis etc.), then appropriate systemic management is required.
 Follow-up is done every 1 to 7 days in the acute phase, depending on the severity and
every 1 to 6 months when stable. At each visit, the anterior chamber reaction and IOP
should be evaluated.
 If the anterior chamber reaction is improving, then the steroid drops can be slowly tapered


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should be evaluated.
 If the anterior chamber reaction is improving, then the steroid drops can be slowly tapered
[usually one drop per day every 3 to 7 days (e.g.,QID for 1 week, thenTDS for 1 week,
thenBD for 1 week)].
Patient education
 Recurrent nature of the disease which may interfere with vision should be explained and
possible complications like cataract and glaucoma should be mentioned.
 Possible side effects of long term topical, periocular andsystemic corticosteroidtherapy
should be explained.


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 Common caus es includeStreptococcus pneumoniae, Staphylococcus aureus, Streptococcus
pyogenesand Haemophilus influenzae.
 Symptoms include swelling of eyelids, severe pain which is increased by movements of eye
or pressure and fever, nausea, vomiting and sometimes loss of vision.
 A marked swelling of lids with chemosis of conjunctiva is observed. Restriction of ocular
movements is also seen.
 Fundus examinationmay show congestion of retinal veins and signs of papillitis or
papilloedema
 Bacterial culturesshould be performed from nasal and conjunctival swabs and blood
samples,X -ray to identify associated sinusitis and orbital ultrasonographyto detect intra-
orbital abscess should be done.
ORBITAL CELLULITIS


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samples,X -ray to identify associated sinusitis and orbital ultrasonographyto detect intra-
orbital abscess should be done.
ORBITAL CELLULITIS
Orbital cellulitis refers to an acute infection of the soft tissues of the orbit behind the orbital
septum. The infection can be exogenous (trauma, foreign body), endogenous (septicemia)or
extension of infection from neighbouring structures (paranasal sinuses, teeth, face, eyelids).
Salient features
Non -pharmacological treatment
 Warm compresses
Pharmacologicaltreatment
 Intensive antibiotic therapy:
- After obtaining nasal, conjunctival and blood culture samples, intravenous higher broad
spectrum antibiotics should be administered.
- Tab.amoxicillin andclavulanic acid 625mg TDS should be given OR


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spectrum antibiotics should be administered.
- Tab.amoxicillin andclavulanic acid 625mg TDS should be given OR
- Inj. cefotaxime 1-2 gm every 12 hours in adults and 100-150 mg/kg in 2 to 3 divided
doses in children are given. Antibacterials are changed according to the culture sensitivity
reports and continued till resolution of symptoms.
- Ciprofloxacin orvancomycinmay be used an alternative.
 Analgesic and anti-inflammatory drugsare helpful in controlling pain and fever.
 Surgical intervention is needed when the patient isunresponsive to antibacterials,
decrease in vision and presence of an orbital or subperiosteal abscess.
Patient education
 Any ear, sinus or dental infection especially in children should be treated promptly


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Patient education
 Any ear, sinus or dental infection especially in children should be treated promptly
 Any patient presenting with unexplained lid edema or cellulitis should be immediately
referred to an ophthalmologist.
ENDOPHTHALMITIS


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 Etiological agents includeStaphylococcus aureus, coagulase negativeStaphylococci,
Streptococci, Pseudomonas aeruginosa, Hemophilus influenzaand fungus likeCandida,
Aspergillus, Histoplasmaetc.
 History of eye surgery, penetrating injury, fever, infection or predisposing systemic diseases
leading to metastatic endophthalmitis.
 Sym ptoms include visual loss, pain, discharge, photophobia, lid swelling. Signs include
conjunctival congestion, hypopyon, vitrous exudates and loss of red fundus reflex.
 Smear of aqueous humour, vitreous humour can be taken for smear and culture testing.
An tibiotic susceptibility testing can also be done.
It is an inflammation of the internal coats of the eye along with inflammatory conditions of


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An tibiotic susceptibility testing can also be done.
It is an inflammation of the internal coats of the eye along with inflammatory conditions of
intraocular cavities, aqueous and vitreous humour, retina and uvea. Endophthalmitis can be
endogenous (due to hematogenous spread of infective agents) and exogenous (direct
inoculation of infecting agents through breach in continuity of ocular coats e.g. post
traumatic).
Salientfeatures
Pharmacologicaltreatment
 Post operative endophthalmitis
- Intravitreal injection of antibiotics- Inj. vancomycin hydrochloride 1 mg in0.1 ml plus
Inj.ceftazidime 2 mg in 0.1 ml or Inj.amikacin sulfate 0.4 mg in 0.1 ml.
- Subconjunctival Inj.vancomycin 25 mg/0.5 ml plusInj.ceftazidime 100 mg/0.5 ml plus
dexamethasone 0.25 mg/0.5 ml.


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- Subconjunctival Inj.vancomycin 25 mg/0.5 ml plusInj.ceftazidime 100 mg/0.5 ml plus
dexamethasone 0.25 mg/0.5 ml.
- Vancomycin eye drops 50 mg/ml plus amikacin eye drops15 mg/ml 1 drop every 6
hours.
- Homatropine 2% eye drops 3 times a day oratropine 1% eye ointment 2 times a day.
- Prednisolone acetate 1% eye drops ordexamethasone orbetamethasone 0.1% eye drops
every 6 hours.
- Tab.prednisolone 1 mg/kg/day in a single morning dose after 24 hours of antibiotic use
and continue for 10-14 days 2 times a day for 5-10 days.
- Parenteral antibiotics are of questionable value and given only as a supportive therapy.
Surgical treatment
Pars plana vitrectomy is indicated if visual acuity is limited to light perception or if there is
poor response to above treatment in 30-36 hours.


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Pars plana vitrectomy is indicated if visual acuity is limited to light perception or if there is
poor response to above treatment in 30-36 hours.
 T raumatic endophthalmitis
- Hospitalize the patient and give immunization for tetanus.
- Inj. vancomycin 1 g IV infused over 1 hour, 12 hourly.
- Inj. gentamicin 2 mg/kg every 12 hour or Inj. ceftazidime 2 g IV every 12 hour or inj.
ceftriaxone 2 g IV/day.
- Topical fortified eye drops, subconjunctival injection and intravitreal injection
and cycloplegic drops as in cases of postoperative bacterial endophthalmitis.


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 Surgery
- Repair the ruptured eyeball at the earliest.
- Pars plana vitrectomy- indications are similar to that of postoperative bacterial
endophthalmitis.
 Treatment for fungal endophthalmitis
Exogenous fungal infections may occur postoperatively or secondary to trauma.
Endogenous bacterial endophthalmitis should be treated as an emergency treatment.
- Vitrectomy to debulk the vitreous of fungi.
- IntravitrealInj.amphotericin B 5-10 mcg/0.1 ml orInj.fluconazole 25 mcg/0.1 ml.
- Inj. amphotericin B 0.5-1.5 mg/kg/day slow infusion over 2-6 hours. (50 mg vial in
powder form and is dissolved in 5% dextrose) for 10-14 days. Or
- Tab. fluconazole 400 mg loading dose followed by 200 mg daily, total dose should not


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- Tab. fluconazole 400 mg loading dose followed by 200 mg daily, total dose should not
exceed 600 mg/day.In children 12 mg/kg loading dose followed by 6 mg/kg/day.Or
- Tab. ketoconazole 200 mg orally 2 times a day or daily. In children above 2 years of age,
3.3-6.6 mg/kg/day.
- Homatropine 2% eye drops 4 times a day or a tropine 1% eye ointment 2
times a day.
Patient education
 All patients with open globe injury must contact an ophthalmologist after getting initial
treatment.
 Cataract operated cases should never ignore pain, tearing and photophobia and decrease in
vision in the operated eye and must consult the ophthalmologist at the earliest.
OPTIC N EURITIS
Optic neuritis includes inflammatory and demyelinating disorders of the optic nerve like


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OPTIC N EURITIS
Optic neuritis includes inflammatory and demyelinating disorders of the optic nerve like
papillitis (inflammation of the optic disc), retrobulbar neuritis (inflammation of retro-ocular
portion of optic nerve) and neuroretinitis (when bothoptic nerve and retina are inflamed).
Etiology may be hereditary, systemic bacterial/viral infections, endophthalmitis, orbital
cellulitis, demyelinating disorders or idiopathic in nature.
Salientfeatures


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 Sudden, progressive and profound visual loss is the hallmark of acute optic neuritis.
 Decreased dark adaptation and impairment of colour vision, visual obscuration in bright light
and episodic obscurationon physical exertion, hot bath, fatigue etc.
 Depth perception,particularly for the moving object may be impaired (Pulfrich’s
phenomenon). Patient may complain of mild dulleye ache. It is more marked in patients
with retrobulbar neuritis than with papillitis. Pain is usually aggravated by ocular
movements, especially in upward or downward directions due to attachment of somefibers
of superior rectus to the dura mater.
 Marked abnormality in papillary responses to light reflex (sluggish or afferent pupildefect).


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of superior rectus to the dura mater.
 Marked abnormality in papillary responses to light reflex (sluggish or afferent pupildefect).
 Fundus examination revealshyperaemia of the disc and blurring of the margins. Disc
becomes oedematous and physiological cup is obliterated. Retinal veins are congested and
tortuous. Splinter haemorrhages and fine exudates may be seen on the disc.
 Slit-lamp examination may reveal inflammatory cells in the vitreous. The most common
field defect in optic neuritis is a relative central or centrocaecal scotoma.
Pharmacological treatment
 Efforts should be made to find out and treat the underlying cause. There is no effective
treatment for idiopathic and hereditary optic neuritis and that associated with
demyelinating disorders.


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treatment for idiopathic and hereditary optic neuritis and that associated with
demyelinating disorders.
 Corticosteroid therapymay shorten the period of visual loss, but will notinfluence the
ultimate level of visual recovery in patients with optic neuritis.
 Oralprednisolone therapy alone is contraindicated in the treatment of acute optic neuritis,
since, it did not improve visual outcome and was associated with a significant increase in
the risk of new attacks of optic neuritis.
 Indications for intravenousm ethylprednisolone in acute optic neuritis patients with a
normal brain MRI scan are:
- Visual loss in both eyes simultaneously or subsequently within hours or days of each
other.
- When the only good eye is affected.
- When the slow progressive visual loss continues to occur.


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other.
- When the only good eye is affected.
- When the slow progressive visual loss continues to occur.
 Inj. m ethylprednisolone 1gm/day (or 15 mg/kg/day) intravenously in 2-4 divided doses
for 3 days followed byTab.prednisolone 1 mg/kg/day orally for 11 days tapered over the
next week.
Patient education
 Explain the recurrent nature of the disease and that permanent vision loss can occur.
 Avoid factors provoking transient visual obsurations like physical exertion, hot weather,
stress, anger etc.
DIABETIC RETINOP ATHY


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 Rhegmatogenous RD is characterized by formation of a tear in the retina. Symptoms include
flashes of light, presence of floaters in visual field and loss of central vision, if macula is
involved. The diagnosis is done by examination of the fundus with indirect ophthalmoscopy.
The retina appears grey wit oscillating folds.
 Tractional RD is caused by gliotic bands on retina.
 Exudative RD is caused by collection of serous fluid between neurosensory retina and retinal
pigment epithelium.
Itis the microangiopathy of retinal vasculature occurring in long standing diabetes mellitus
classified as non proliferative and proliferative. Itisthe sixth leading cause of blindness in
the world. Risk factors include increased duration of diabetes, uncontrolled diabetes,


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the world. Risk factors include increased duration of diabetes, uncontrolled diabetes,
abnormal lipid profile, smoking, renal disease etc.
Non -pharmacologicaltreatment
 Early diagnosis, proper diabetic control, regular follow up and fundus examination are
important. In certain cases laser photocoagulation and vitrectomy surgery can help.
Pharmacological treatment
 No tested or proven pharmacological treatment exists which can delay, prevent or
curdiabetic retinopathy.
Patient education
 Explain the importance of yearly fundus examination. Laser treatment can prevent
deterioration of vision but cannot correct existing visual defects.
RETINAL DETACHMENT
Retinal detachment (RD) is the separation of the sensory retina from retinal pigment


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RETINAL DETACHMENT
Retinal detachment (RD) is the separation of the sensory retina from retinal pigment
epithelium. It may be localized or entire retina may be involved. Retinaldetachment that
includes the macula results in significant visual loss.The three types areRhegmatogenous
RD, exudative RD and tractional RD.
Salient features
Non -pharmacologicaltreatment
 Treatment of choice is reattachment surgery involving identification ofall retinal breaks
areas of vitreous or retinal tractions and induction of aspectic chorioretinal inflammation
around the breaks to seal them.
 Ensuring chorioretinal apposition by approximating choroid/retinal pigment epithelium to
neurosensory retina by external tamponade, internal tamponade and drainage of subretinal
fluid


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neurosensory retina by external tamponade, internal tamponade and drainage of subretinal
fluid
 Adhesion between retinal pigment epithelium and retina can be achieved by cryotherapy,
diathermy or photocoagulation.
Pharmacologicaltreatment


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N o pharmacological treatment which canprevent or cure rhegmatogenous RD.Exudative RD
due to inflammatory conditions like panuveitis can be treated with systemic corticosteroids as
described in treatment of uveitis. The refractory patients can be treated with
immunosuppresants.
Patient education
 Patients with high myopia, family history of RD, post cataract surgery, past episodes of
chorioretinal inflammation should be warned about the premonitory signs of impending
RD (sudden onset of floaters, flashes of light and sudden obscuration of one part of visual
field). In such cases, an opthalmologist should be contacted immediately.
VITAMIN A DEFICIENCY
The term xerophthalmia is now reserved (by a joint WHO and USAID Committee, 1976) to


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VITAMIN A DEFICIENCY
The term xerophthalmia is now reserved (by a joint WHO and USAID Committee, 1976) to
cover all the ocular manifestations of vitamin A deficiency,including not only the structural
changes affecting the conjunctiva, cornea and occasionally retina, but also the biophysical
disorders of retinal rods and cones functions.
Salient features
WHO Classification
Primary signs Secondary signs
X1: Conjunctival Xerosis: XN: Night blindness
X1A -without Bitot spot XF: Fundal changes
X1B -with Bitot spot XS: Corneal scarring
X2: Corneal Xerosis
X3: Cornel ulceration
X3A: < 1/3 of corneal ulceration
X3B: > 1/3 of corneal ulceration
Pharmaco logicaltreatment
 Vitamin A deficient diet is the main reason especially in young growing children of


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X3B: > 1/3 of corneal ulceration
Pharmaco logicaltreatment
 Vitamin A deficient diet is the main reason especially in young growing children of
developing countries. It is usually associated with protein energy malnutrition.
 In some cases, decreased absorption of vitamin A due to gastro-intestinal disorders like lipid
malabsorption or chronic alcoholism can occur.
 Presentation can be as
- Nyctalopia-night blindness is the earliest presenting symptom.
- Conjunctival xerosis
- Bitot spot: It is a metaplastic keratinisation of conjunctiva.
- Persistent epithelial defect (usually in chronic alcoholics) and corneal ulcer
- Keratomalacia:a diffuse corneal necrosis occurring in severevitamin A deficiency.


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 Severe xerophthalmia is a medical emergency, so treatment should begin as early as
possible.
 Treatment is aimed at restoring vitamin A level to normal and addressing associated
protein energy malnutrition.
- Oral vitamin A:
0-6 month of age : 50,000 IU (on 0 day, 1stday & after 4 weeks)
6-12 month of age : 1 lakh IU (on 0 day, 1stday & after 4 weeks)
More than 1 year of age : 2 lakh IU (on 0 day, 1stday & after 4 weeks)
 Intramuscular water soluble vitamin A is given to children with persistent vomiting or
severe malabsorption.
 Topical preservative free lubricating eye drops and antibiotic drops (e.g.m oxifloxacin
eye drops1 to 6 hourly) to prevent secondary infection can be given.
Patient education


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eye drops1 to 6 hourly) to prevent secondary infection can be given.
Patient education
 Regular consumption of VitaminA rich foods particularly fresh dark green leafy
vegetables which constitute very rich and cheap sources.
 Pregnant women and lactating mothers should also consume Vitamin A rich diet
regularly.
 Breast feeding including feeding of new born with rich colostrum.
 High dose universal distribution schedule for prevention of Vitamin A deficiency.
- Infants less than 6 months of age– 50,000 IU orally
- Infants 6-12 months of age-100,000 IU orally.
- Children more than 12 months-200,000 IU orally every 4-6 months till 5 years of age.
 Mothers-200,000 IU orally within 8 weeks of delivery.
SENILE CATARACT


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 Mothers-200,000 IU orally within 8 weeks of delivery.
SENILE CATARACT
It isage related opacification of crystalline lensaffecting persons of either sex usually above
the age of 50 years. By 70 years, over 90% of the individuals develop senile cataract. The
condition is usually bilateral, but almost always one eye is affected earlier than the other.
Salient features


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 Gradual painless progressive diminution of vision in one or both eyes. Symptoms include
glare, uniocular diplopia or polyopia, coloured haloes, distortion of images and misty vision
and fixed black spots in visual field.Ocular examination reveals greyish white to white
lenticular opacity on torch light examination which depends on the stage of cataract.
Depending upon the location and maturation of cataract, the visual acuity may range from
6/9 to just perception of light.
 Slit-lamp examinationshould be performed with a fully-dilated pupil. The examination
reveals complete morphology of opacity (site, size, shape, colour pattern and hardness of the
nucleus).
 Hypermetropia (hyperopia) or long-sightedness is the refractive state of the eye wherein


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nucleus).
 Hypermetropia (hyperopia) or long-sightedness is the refractive state of the eye wherein
parallel rays of light coming from infinity are focused behind the retina with accommodation
being at rest. Symptoms include astheopic symptoms (tiredness and watering of eyes, frontal
headache) and defective vision, more for near vision.
 M yopia or short-sightedness is a type of refractive error in which parallel rays of light
coming from infinity are focused in front of the retina when accommodation is at rest.
 Astigmatism- The optical power of the cornea in different planes is not equal.Parallel rays
of light passing through these different planes are brought to different points of focus.
Surgical treatment


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of light passing through these different planes are brought to different points of focus.
Surgical treatment
No medical management can halt the progression of cataract.Surgery in the form of small
incision cataract surgery or phacoemulsification is the preferred option.
Patient education
 Do not wait for maturation of cataract for undergoing lens extraction.
 Secondary glaucoma or other complications can develop if total cataract remains
unoperated fora long time.
 Visual rehabilitation in early post operative period is faster in small incision cataract
surgery.
REFRACTIVE ERRORS
Refractive errors (ametropia) are the optical defects of eye in which the parallel rays of light
entering the eye do not come to focus on the fovea centralis. Ametropia includes myopia,


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entering the eye do not come to focus on the fovea centralis. Ametropia includes myopia,
hypermetropia and astigmatism.
Salient features
Surgicaltreatment
 No pharmacological treatment is available for ametropia.
 Accurate retinoscopy and corrective spectacles or contact lens.Keratorefractive surgery
STRABIS MUS (SQUINT)


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Any child presenting with strabismus should have the following conditions ruled out:
 Refractive error-refraction should be done under full cycloplegia i.e. Atropine Ointment 1%
3 times a day for 3 days prior to performing retinoscopy. If any refractive error is present,
that should be fully corrected by spectacles for at least 3-6 months, before performing
definitive surgical therapy for strabismus.
 An y opacity in the media e.g. cataract, corneal opacity, retinoblastoma etc.
 Amblyopia element whether induced by strabismus or vice versa should be treated with
occlusion therapy or other modality before treating strabismus.
 C haracterized by visual symptoms which result from interaction with a computer display


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 C haracterized by visual symptoms which result from interaction with a computer display
or its environment. In most cases, symptoms occur because the visual demands of the
task exceed the visual abilities of the individual to comfortably perform the task.
 C ontributing factors: Decreased blinking reflex, prolonged near focusing efforts,
repeated head posture change/fixation in a wrong posture,  Environmental factors of
computer workstations like contrast and resolution of the display, viewing distances and
angles, room lighting, sustained viewing etc.
 Symptoms include tiredness of eyes, headache, blurred near and distant vision, dry or
irritated eyes, neck pain and/or backaches, diplopia (double vision), difficulty in re-


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irritated eyes, neck pain and/or backaches, diplopia (double vision), difficulty in re-
focusing the eyes.Diagnostic tests include tear film break-up timeand Schirmer test.
Cervical spondylitis, anxiety and migraine are the differential diagnosis.
Salient features
Surgicaltreatment
 Correct the refractive error or associated cataract, corneal opacity etc. Fusion exercises
for intermittent exotropia and other orthoptic exercises.Definitive therapy is surgical
realignment of axis once other associated features have been treated.
Patient education
Functional improvement in strabismus is best between 3-5 years of age.It is a misconception
that squint is spontaneously corrected as the child grows.
COMPUTER VIS ION SYNDROME


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that squint is spontaneously corrected as the child grows.
COMPUTER VIS ION SYNDROME
Computer Vision Syndrome (CVS) is the complex of eye and vision problems related to near
work which are experienced during or related to computer use.
Salient features
Non -pharmacological treatment


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 Counselling regarding the syndrome andwork environment modification
Steps for relieving computer eye strain
- Get a computerized eye exam before start using computer. Repeat once a year.
- Use proper lighting. Eliminate exterior light by closing drapes, shades or blinds. Reduce
interior lightingby using lower intensity bulbs and tubes.
- Minimize glare: To install an anti-glare screen on your monitor. Paint bright white walls a
darker color with a matt finish.
- Upgrade your display. Use LCD monitor instead of a CRT monitor.
- Adjust the brightnessand contrast of your computer screen.
- Blink more often.
- Exercise your eyes: Follow 20-20-20 rulei.e.after every 20 minutes, look at 20 feet
distance for 20 seconds.


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- Blink more often.
- Exercise your eyes: Follow 20-20-20 rulei.e.after every 20 minutes, look at 20 feet
distance for 20 seconds.
- Take frequent breaks- two 15-minute breaks-four additional five-minute "minibreaks"
throughout the work day (6-8 hrs).
- Modify your workstation. Proper posture during computer work. Position computer
screen 20 to 24 inches from your eyes. The center of your screen should be about 10 to 15
degrees below your eyes. Top of the screen tiltedback slightly (10-20 degree) away from
the operator.
- Consider customized eyeglasses specific for use during work on a computer screen. Anti-
reflective coating in the lenses should be used and avoid contact lens use during computer
work.
Pharmacological treatment


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reflective coating in the lenses should be used and avoid contact lens use during computer
work.
Pharmacological treatment
 Tear substitute should be considered if symptoms are aggravated during computer work.
Commercially available tear substitutes include sodium carboxymethylcellulose and
hydroxypropyl methylcellulose.
References
1. Kanski, Clinical Ophthalmology 7th edition
2. Ready reckoner in ophthalmology by AIOS
3. Wills Eye Manual, The: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition
4. Shields textbook of glaucoma; 6th editionOrbit, Eyelids, and Lacrimal SystemSection 72011-2012 by
American Academy of Ophthalmology.


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196
 Impetigo(Figure 1)-commonly seen in childhood at muco-cutaneous junctions and presents
with bullae that evolves into yellow or honey colored crusts.
 Ecthyma (Figure 2)– it is deeper variant ofimpetigo.-characterised by thick chocolate
colored crust with indurated base that heals with scar.
 Folliculitis(Figure 3)– inflammation of the ostium of hair follicle. Commonly affects scalp
hair margin, beard and extremities.
 Boil/ furuncle(Figure 4)– inflammation of entire hair follicle, perifollicular region and
subcutaneous tissue. Seen as inflammatory indurated nodule associated with fever and
malaise.
 Carbuncle(Figure 5)– group of multiple furuncles, commonly seen in diabetics at back of
neck, shoulder.


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malaise.
 Carbuncle(Figure 5)– group of multiple furuncles, commonly seen in diabetics at back of
neck, shoulder.
 Erysipelas(Figure 6)- it involves upper subcutaneous tissue and lymphatic vessels. Skin
becomes tense, erythematous and slightly elevated which later on becomes brown and
edematous giving peau d’ orange appearance.
 Cellulitis(Figure 7)- it involves deeper subcutaneous tissue, involves larger area and
associated with fever and malaise
 Diagnosis is mainly clinical; if required gram stain and culture-sensitivity.
Chapter 12
SKIN DISEASES
BACTERIAL SKIN INFECTIONS
Salient features
Non -pharmacological treatment
 Good personal hygiene and propernutrition.
 Wash with soap and water, drainage of pus.
Pharmacological treatment


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Non -pharmacological treatment
 Good personal hygiene and propernutrition.
 Wash with soap and water, drainage of pus.
Pharmacological treatment
 Topical antibacterial creams like neomycin or silver sulfadiazine or framycetin to be applied
on the affected sites twice a day for 7-10day
 Systemic antibacterial like Tab. azithromycin 500 mgOD for 3-5 days or
Cap. amoxicillin 250 mg QID/ 500 mg TDS for 7 days or Tab.erythromycin (500 mg QID)
for  5 days.
LEPROSY
It is a chronic bacterial infection caused byMycobacterium lepraethat primarily affects skin and
peripheral nerves.


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197
 Hypopigmented / erythmatous skin lesion with or without loss / impairment of sensation,
sweating  and hair(Figure 8)
 Thickening / tenderness of  peripheral nerves with or without loss / impairment of sensation
 Slit skin smear show acid fast bacilli (M. Leprae)
Salient features
Diagnosis
 Clinical examination of skin and peripheral nerves including sensation.
 Slit skin smear and biopsy.
Pharmacological treatment
WHO Classification for treatment purpose(Table 1)
Paucibacillary (PB) leprosy-≤5 skin lesions and/or single nerve involvement, slit skin smear
negative.
Multibacillary (MB) leprosy- ≥5 skin lesions and/or more than one nerve involvement, slit
skin smear positive.
Table 1.Treatment as per NLEP guideline
Type of
leprosy


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skin smear positive.
Table 1.Treatment as per NLEP guideline
Type of
leprosy
Drugs Supervised Supervised Duration for
blister pack
MB (adult) Dapsone
(100mg) daily
Rifampicin
(600mg) monthly
Clofazimine
(300mg) monthly
+ 50 mg daily
12 months
PB (adult) Dapsone
(100mg) daily
Rifampicin
(600mg) monthly
6 months
MB (pediatric)Dapsone (50mg)
daily
Rifampicin
(450mg) monthly
Clofazimine
(150mg) monthly
+ 50 mg alternate
day
12 months
PB (pediatric)Dapsone (50mg)
daily
Rifampicin
(450mg) monthly
6 months
Non -pharmacological treatment
 Care of insensitive hands and feet– emollient application, avoidance of trauma, burn,
daily inspection, and rest.
 Care of eyes– protective glasses.
 Proper nutrition.
 Active and passive exercises.


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daily inspection, and rest.
 Care of eyes– protective glasses.
 Proper nutrition.
 Active and passive exercises.
 In case of deformity– use correct splints, modula grip aids for household works, MCR
(Micro cellular rubber) shoes.


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Lepra reaction
 It is immunologically mediated episodes of acute or chronic inflammation which interrupt
the chronic course of disease affecting skin, nerves, mucous membrane and systemic
involvement.
 Type 1 reaction:Characterized by pain, tenderness of pre-existing lesions with or without
new lesions/ peripheral nerves (neuritis).
 Type 2 reaction: Characterized by sudden appearance of tender nodules or plaques which
are evanescent, neuritis, pain and swelling of joints with or without systemic
involvement.
Treatment
Type 1 reaction
 Mild reaction- NSAIDS like Tab. paracetamol (500 mg) TDS/Tab. aspirin (375-625 mg)
BD
 Severe reaction-corticosteroids like Tab.prednisolone (1-2 mg/kg/day) in tapering dose
 Surgical decompression of nerves SOS
Type 2 reaction


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BD
 Severe reaction-corticosteroids like Tab.prednisolone (1-2 mg/kg/day) in tapering dose
 Surgical decompression of nerves SOS
Type 2 reaction
 Mild to moderate reaction-Rest and NSAIDs like Tab. paracetamol (500 mg) TDS
/Tab.aspirin (375-625 mg) BD
 Severe reaction : As above plus,
- Cap.clofazimine 300 mg daily.
- Corticosteroids (in tapering dose) such as Tab.prednisolone 40 mg daily for 15 days
followed by 30 mg daily for 15 days, 20 mg daily for 15 days, 15 mg daily for 15
days,10 mg daily for 15 days and 5 mg daily for 15 days.
- Thalidomide (to be used with caution especially in chronic recurrent and steroid
dependent cases at tertiary care centre).
 Surveillance / follow up for 2 years and 5 years period for PB and MB cases respectively
for relapse and reactions.


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 Surveillance / follow up for 2 years and 5 years period for PB and MB cases respectively
for relapse and reactions.
Patient education
 Leprosy is curable disease. The treatment is widely available and free of chargeunder
NLEP (National leprosy eradication programme).
 Risk of developing disease is very low. Children and elderly are more prone.
 Early detection and proper treatment prevents disabilities.
 Disease can be managed easily.The patient should not suffer any discrimination.Patient
should be encouraged and supported by the family and society so that they are able to live
a normal life.
 Explain the importance of multidrug treatment and patient compliance,ADRs of drugs.
All members of family and close contacts should be examined.


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 Lupus vulgaris– occurs in high immunity host having granulomatous lesion with marginal
activation, central clearing andatrophy.
 Scrofuloderma– seen in low immunity host,involvement of skin overlying any internal
tuberculous focus such as bone, lymph node and joint.
 Tuberculosis veruccosa cutis(Figure 9)- occurs in high immunity host with
verrucous plaque.
 Characterized by nocturnal itching,excoriated papules, papulo vesicles, burrows on inter
digitalcleftso fhands, wrist, axillary folds, breasts, periumblical region, medial side of
thigh andgenitals.Face, palms, soles and scalp involvement in infants
CUTANEOUS TUBERCULOSIS
It is caused bymycobacterium tuberculaeand has varied manifestations depending on the
host immunity and root of entry.
Salient features


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It is caused bymycobacterium tuberculaeand has varied manifestations depending on the
host immunity and root of entry.
Salient features
Diagnosis
 Clinical
 CBC, ESR, mantoux test, chest x-ray
 Sputum AFB and  biopsy
Non -pharmacological treatment
 Proper nutrition
Pharmacological treatment
According tothe National TBmanagement guidelines, treatment isgiven intwo phases:
Category 1: newly diagnosed cases
 Initialphase -2 HRZE
 Continuation phase-4 HR
Category 2: recurrence, relapse, defaulter
 Initial phase : 1HRZES + 2HRZE
 Continuation phase: 5HRE
H – isoniazid    R-rifampicin  Z-pyrazinamide  E-ethambutol   S-streptomycin
Patient education
 Explain that it is a curable disease.
 Counselling for regular follow up and adherence to treatment.Screening of close contacts


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Patient education
 Explain that it is a curable disease.
 Counselling for regular follow up and adherence to treatment.Screening of close contacts
for tuberculosis.
SCABIES
Scabies is caused by arthropod mite(sarcoptesscabiei),transmittedby close personal
contact.Family historyispositive.
Salient features


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 Pediculosis capitis- localised to scalp, mainly confined to sub-occipital region predominant
symptom is itching,-nits are attached to hair shaft.
 Pediculosis corporis – characterised by intense itching accompanied by
erythematous macules, excoriated papules and scratch marks.
 Phthiriasis pubis– itching of pubic region, Peduculli and nits are seen in pubic region, blue
grey macules (maculae caeruleae) are seen in lower abdomen and upper thigh.
Diagnosis
 Clinical
 Inspection of mites from scabetic burrows.
Non pharmacological treatment
 Maintenance ofpersonal hygiene.
 Disinfection ofbedding and clothing.
 Allfamily members should be treated simultaneously.
Pharmacological treatment
 Tab. ivermectin 200 mcg/kg asa single stat doseto be repeated after2 weeks.


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Pharmacological treatment
 Tab. ivermectin 200 mcg/kg asa single stat doseto be repeated after2 weeks.
 Antihistamines like Tab. cetirizine 10 mg daily
 Gamma benzene hexachloride (GBHC) lotion1%. Singleovernight application below
neck on  entirebody surfaceaftera thorough scrub bath,to be washed offnext
morning.
 For infants, neonates, children,pregnant and lactating mothers.
 Permethrin 5% to be applied generously,afterbath,at bedtime, covering entire
surfaceof thebody below neck (except face).
 Systemic and topical antibacterial SOS
PEDICULOSIS (LICE INFESTATION)
 Three different species namelypediculosis humanuscorporis(body louse),pediculosis
humanus capitis(head louse),pediculosis humanus pubis(pubic louse).


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humanus capitis(head louse),pediculosis humanus pubis(pubic louse).
 Transmission occurs bypersonal contact, sharing of combs, infectedclothing, poor
personal hygiene while transmission ofpubic liceisby sexual-contact.
Salient features
Diagnosis
 Finding lice in occipital region inP. capitis, in sieves of clothes inP. corporis and in
pubic region in phthiriasis pubis.
Non -pharmacological treatment
 Maintenance ofpersonal hygiene.
 Disinfection ofbedding and clothing.
 All the family member should be treated simultaneously.


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Three formsseen:
 Creeping myiasis– most superficial
 Furuncle myiasis– boil like lesion and
 W ound myiasis
 Asymptomatic hypo or hyperpigmented irregular maculeswith branny scales usually seen on
upper trunk.Recurrence is common.
 To shave pubic hair.
 Treatment of partner in case of pubic lice infestation.
Pharmacological treatment
 Antihistamines likeTab. cetirizine 10mg daily or Tab. pheniramine maleate 25mg 3
timesa day for7 days.
 Lotion GBHC/ permethrin1% to be applied onscalp(inhead louseinfestation) fora
periodof more than 30 minutes tobe washed offlater.
MYIASI S (MAGGOTS)
Myiasisis the infestation of the body byflylarvae that feed on body tissues in people with
poor hygiene.
Salient features
Non -pharmacological treatment


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poor hygiene.
Salient features
Non -pharmacological treatment
 Apply liquid paraffin, turpentine oil.
 Remove mechanically by forceps.
 Explain the patient about personal hygiene and proper care of wound.
Pharmacological treatment
 Systemic antihelminthics like Tab. albendazole 400mg stat.
 Systemic antibiotics if secondary infection present.
 Wound ma nagement.
ITYROSPORUM  INFECTIONS
Mild superficial fungal infection of stratum corneum characterised by scaly hypo or
hyperpigmented irregular macules caused by mycelial form of malassezia species(Fig.10).
Salient features
Diagnosis
 Clinical
 Wood’s lamp – yellowish fluorescence.
 10 % KOH mount - non branching mycelia and yeasts giving “banana and grapes”
appearance.


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 Sharply marginated patches with active scaly border and central clearing.
 Extremely pruritic condition
Pharmacological treatment
 Topical antifungal cream like– ketoconazole or miconazole or clotrimazole or terbinafine
 Topical selenium sulfide 2.5% shampoo or lotion
 Systemic antifungals like Cap. fluconazole 400 mg stat
 For recurrence Tab.ketoconazole 400 mg once per month
PITYRIASIS CAPITIS (DANDRUFF)
Mild superficial fungal infection of stratum corneum caused by yeast form of malassezia.
Salient features
 Diffuse itchy scaly lesions over scalp, eyebrows, eyelashes and naso-labial folds
Diagnosis
 Clinical
Non -pharmacological treatment
 Frequent hair washes by shampooing with light massage.
 Avoid oil and soap application.
Pharmacologicaltreatment


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Non -pharmacological treatment
 Frequent hair washes by shampooing with light massage.
 Avoid oil and soap application.
Pharmacologicaltreatment
 Antifungal lotions / shampoos that contain antifungals like ketoconazole or econazole,
keratolytics like salicylic acid or coal tar that should be applied 15 min before bath to the
affected areas.
 Topical steroids like betamethasone lotion in combination with antifungal lotion after hair
wash.
TINEA CRURIS AND CORPORIS
Tinea cruris is a superficial fungal infection of groin and axilla, also known as dhobi’s itch.
Tinea corporis involves trunk and extremities. It is more common in obese and diabetics.
Salient features
Diagnosis
 Clinical and  KOH mount
Non -pharmacological treatment
 Maintain hygiene and avoid tight clothing.


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Salient features
Diagnosis
 Clinical and  KOH mount
Non -pharmacological treatment
 Maintain hygiene and avoid tight clothing.
Pharmacological treatment
 Topical antifungals like– clotrimazole or miconazole or ketoconazole cream to be applied
twice daily.


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 Gray patch: Circular patches of partial hair loss thatare broken off, dull gray and lusterless
in appearance
 Black Dot: Multiple, polygonal areas of sparse hair, broken hair follicles are seen as black
dots.
 Kerion: Inflamed, boggy, indurated and tender swelling studded with vesicles and pustules
(Figure 11).
 Favus: Rare type of tinea capitis presenting with cup shaped scutula around the hair orifice.
 Characterized by involvement of only a few nails, brownish or yellowish streaks,
onycholysis and thickend nail plate.
 Types- distal and lateral subungual onychomycosis(Figure 12), w hite superficial
onychomycosis, proximal subungual onychomycosis, total dystrophic onychomycosis.


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onychomycosis, proximal subungual onychomycosis, total dystrophic onychomycosis.
 Extensive cases– in addition to topicals, systemic antifungals like Cap.fluconazole-150
mg/ week x 2-4 weeks or Tab. terbinafine (62.5 mg daily for <20 kg weight, 125 mg daily
for 20-40 kg weight, 250 mg daily for >40 kg weight) for 2 weeks.
 Cap. itraconazole-200 mg daily for 1 week.
TINEA CAPITIS
Tinea capitis is a dermatophyte infection of the scalp most commonly seen in childhood.
Salient features
Diagnosis
 Clinical
 Wood’s lamp: greenish yellow fluorescence
 KOH mount and  hair mount
Non -pharmac ological treatment
 Not to share caps and combs.
 Removal of matted crusts.
Pharmacological treatment
 Tab.griseofulvin: 15-25 mg / kg per day with food preferably at night for 4-6 weeks.


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 Removal of matted crusts.
Pharmacological treatment
 Tab.griseofulvin: 15-25 mg / kg per day with food preferably at night for 4-6 weeks.
 Tab.fluconazole:3-6 mg / kg per day administered for 6 wks.
 Tab.terbinafine: according to weight of the patient.
 Cap.itraconazole-5mg/kg/d for 7 days.
ONYCHOMYCOSIS
Onychomycosis is fungal infection of nail.
Salient features
Diagnosis
 Clinical.


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 Neonatal candidiasis (due to infection acquired during delivery or postnatally) is
characterized by oral thrush as well as pink–red patches with satellite papules and pustules
that favor the diaper area, other intertriginous sites and the face.
 Oral candidiasis is characterized by curdy white patches covered by pseudomembrane over
the gums, teeth, cheeks and palate(Figure 13).
 Flexural candidiasis (candidal intertrigo) it is characterized by moist erythematous exudates
deep in the folds and gradually develops characteristic fringed erosions. Satellite popular or
pustular lesions are characteristic.
 Balanoposthitis(candidabalanitis) is acquired through direct sexual contact with a partner
who has vulvovaginal candidiasis presents with intense erythema wit h


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who has vulvovaginal candidiasis presents with intense erythema wit h
desquamation/superficial erosions, maculopapular rash over glans and foreskin is seen a
white subpreputial discharge, increased skin marking, fissuring of glans and foreskin may be
seen.
 Vulvovaginitis:vulvar pruritus, vaginal discharge, dysuria, and dyspareunia physical
examination findings include a vagina and labia that are usually erythematous, a thick curd
like discharge, and a normal cervix upon speculum examination.
 Microscopy-KOH mount.
 Culture-sabouraud’s dextrose agar.
Non pharmacological treatment
 Avoid tight fitting footwear and working in wet areas.
Pharmacological treatment
 Topical antifungal agents like clotrimazole, miconazole or tolnaftate.


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Pharmacological treatment
 Topical antifungal agents like clotrimazole, miconazole or tolnaftate.
 Oral antifungal agents such as Tab.fluconazole:150-300mg once a week for 6-12 months
or Tab.terbinafine: 250mg daily for 6-12 weeks or Cap.itraconazole200mg daily for 2-3
months.
CANDIDIASIS
Candidiasis is an infection caused by the yeast candida albicans or sometimes other species of
candida.
Salient features
Diagnosis
 Clinical
 Microscopy-demonstration of candida by 10% KOH–yeast cells, mycelia is seen.
Non -pharmacological treatment
 Daily bath and maintain personal hygiene.
 Keep the affected area dry and clean.
 Control of diabetes mellitus.
 Care of dental prosthesis.
 Avoid prolonged use of diaper.


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 Diaper dermatitisis characterized by joined patches of erythema and scaling mainly seen on
the convex surfaces, with the skin folds spared.
 Signs and symptoms are restricted in most individuals to the area covered by diapers.
 Diagnosis is mainly clinical.
 Most common form occurring between 1-5 years.
 Disease starts with fever and malaise and subsequently small vesicles develop.
 Vesicular lesions rupture to form shallow ulcers with yellow exudative base and
erythematous halo.
Pharmacological treatment
Topical antifungals (1% clotrimazole, 1% ciclopirox, 2% miconazole nitrate etc) creams.
Clotrimazole vaginal pessaries for vulvovaginal candidiasis.
Systemic– Cap.fluconazole 150mg single dose.
DIAPER DE RMATITIS


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Clotrimazole vaginal pessaries for vulvovaginal candidiasis.
Systemic– Cap.fluconazole 150mg single dose.
DIAPER DE RMATITIS
Known as napkin dermatitis or diaper rash is a prototypical example of irritantcontact
dermatitis; caused by overhydration of the skin, maceration, prolonged contact with urine and
feces, retained diaper soaps, and topical preparations and oftentriggered by an episode of
diarrhoea; commonly seen in infants; induced by occlusion of areas covered by impermeable
diapers.
Salient features
Non -pharmacological treatment
 Avoid impermeable diapers and keep affected skin dry.
 Maintain personal hygiene.
 Avoid use of topical antiseptics and medicated soaps.
Pharmacological treatment
 Zinc oxide paste.


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 Maintain personal hygiene.
 Avoid use of topical antiseptics and medicated soaps.
Pharmacological treatment
 Zinc oxide paste.
 A ntifungal (clotrimazole 1% cream; econazole nitrate cream; miconazole 2%) cream after
every diaper change or at least 4 times per day can be applied.
 Topical corticosteroids e.g. hydrocortisone 1% can be used for the first 1-2 days.
HERPES LABIALIS
 It is an infection of the lip by herpes simplex virus (HSV-1)(Figure14).
Salient features
Diagnosis
 Clinical
 Microscopy-Tzanck smear showing multinucleategiant cells.


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 Generalized pruritic vesicular rash, preceded by 2-3 days of fever, chills, headache, malaise,
anorexia.Characterized by polymorphic vesicular lesions with central haemorrhagic
crusting, centripetal in arrangement, mainly over trunk
 Prodromal symptoms fever, malaise, paraesthesia.Characterized by unilateral radicular
severe pain and grouped vesicular eruption involving dermatome, not crossing the midline.
Mucous membrane of the affected dermatome is also involved.
Pharmacological treatment
 1% silver sulphadiazine cream.
 Tab. acyclovir 200 mg 5 times daily for 5/7 days or Tab.famcyclovir 250 mg TDS for 7
days or Tab.valacyclovir 1000 mg BD for 7 days.
 Tab.paracetamol 500mg TDS for 5 days.
Patient education


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days or Tab.valacyclovir 1000 mg BD for 7 days.
 Tab.paracetamol 500mg TDS for 5 days.
Patient education
 Patient should avoid contact until all the lesions are crusted.
CHICKEN POX
It is a febrile illness characterized by generalized pruritic vesicular rash, caused by varicella
zoster virus, providing lifelong immunity and is most prevalent in childhood.
Salient features
Diagnosis
 Clinical and microscopy-Tzanck smear.
Non -pharmacological treatment
 Rest, cold compresses,  tepid baths
Pharmacological treatment
 Symptomatic treatment with rest, analgesics, antibiotics and topical calamine lotion.
 In severe varicella and immune-compromised oral acyclovir: children 20 mg/ kg QID,
adults 800 mg 5 times for 10 days.
HERPES ZOSTER


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 In severe varicella and immune-compromised oral acyclovir: children 20 mg/ kg QID,
adults 800 mg 5 times for 10 days.
HERPES ZOSTER
Localized disease caused by reactivation of varicella zoster virus lying dormant in sensory
ganglia(Figure15).
Salient features
Diagnosis
 Clinical and microscopy– Tzanck smear.
Non -pharmacological treatment
 Rest and isolation
Pharmacological treatment
 Topical like calamine lotion till symptoms resolve.


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 The lesions are generally multiple, occur on exposed part.
 It is characterized by shiny, pearly white, hemispherical, umbilicated papule which may
show a central pore(Figure16).
 Manifest as common warts, flat warts, filiform warts; depending on the site, palmar and
plantar warts. Characterised by asymptomatic skin coloured verrucous papules or plaques.
 Tab. acyclovir 15-20 mg/kg 5 times daily for 5/7 days or Tab. valacyclovir1000 mg BD
for 7 days.
MOLLUSCUM CONTAGIOSUM
It is a viral infection of the skin caused by molluscum contagiosum virusseen inchildren.
Salient features
Diagnosis
 Clinical
 Extraction of molluscum body and  biopsy
Non -pharmacological treatment
 Avoid scratching.
 Avoid shared towels, contact sports and communal bathing.


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Non -pharmacological treatment
 Avoid scratching.
 Avoid shared towels, contact sports and communal bathing.
Pharmacological treatment (at tertiary care centres)
 Chemical cauterisation by trichloroacetic acid 10-20%, phenol or salicylic acid or
potassium hydroxide 10% solution (to be applied onthe lesion with application of liquid
paraffin over surrounding area).
 Surgical removal by curettage.
WART
It is a viral infection of the skin caused by different groups of human papilloma viruses.
Salient features
Diagnosis
 Clinical and biopsy
Non pharmacological treatment
 Avoid scratching.
 Avoid shared towels, contact sports and communal bathing.
 Safe sex practice in case of genital warts.
Pharmacological treatment


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 Avoid shared towels, contact sports and communal bathing.
 Safe sex practice in case of genital warts.
Pharmacological treatment
 Podophyllotoxin 0.5% solution or 0.15% cream twice daily for 3 days followed by 4 days
rest-give for 3 cycles.
 Cryotherapy.


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 Peak in 14-17 years in women and16-19 years in men
 Characterized by comedones (mild), papules (moderate), nodules (severe) over face, back
and shoulders(Figure17).
 Sequelae are hyperpigmentation, acne excoriee and different types of scars
 Miliaria crystalline is characterized by itchy, discrete or confluent transparent thin walled
vesicles.Milaiaria rubra ischaracterized by discrete erythematous macules and papules.
Miliaria profunda-characterized by flesh coloured 1-3 mm sized papules.
 Trichloroacetic acid application.
 Podophyllin 10%-25%.
ACNE VULGARIS
It is chronic, self limiting, inflammatory disease of pilosebaceous unit, manifesting generally
in adolescence. In addition to pathogens- the p.acnes, hormonal, immunological,


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in adolescence. In addition to pathogens- the p.acnes, hormonal, immunological,
environmental and genetic factors also play a role.
Salient features
Diagnosis
 Clinical.
 Hormonal assay if severe acne, menstrual irregularity, hirsutism is present.
Non -pharmacological treatment
 Avoid sugar rich diet, milk, etc.
 Avoid use of drugs causing acne like steroid, androgens, halogens.
 Avoid use of oils, pomades and cosmetics.
 Patient education about premenstrual flare and stress.
 Washing or cleaning of face to keep skin dry, shampooing of scalp.
Pharmacological treatment
 Mild – benzoyl peroxide (2.5%) cream or azelaic acid 10% cream.
 Moderate– Topical retinoids like tretinoin 0.025% gel or adapelene 0.1% gel and topical
antibacterials clindamycin 1% cream or nadifloxacin 1% cream.


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antibacterials clindamycin 1% cream or nadifloxacin 1% cream.
 Severe– in addition to topical therapy, systemic antibiotics like Tab. azithromycin 500
mg daily for 5 days in a month or Cap. doxycycline 100mg BD or, Tab. minocycline
50/100 mg daily or Tab. isotretinoin 0.5-1mg/kg for 3-6 months (tertiary care centre).
 Hormonal therapy for unresponsive female patients with menstrual irregularity.
MILIARIA
Miliaria is a common ailment in hot and humid conditions during the summer season.
Salient features


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 Lesionsare characterized by itching, redness, edema, and papulovesicles in acute stage,
edema and scaling in subacute stage and lichenification in chronic stage.
Diagnosis
 Clinical
Non -pharmacological treatment
 Cool baths, aeration.
 Avoid heat and occlusion dueto tight clothing, oils, creams, cosmetics etc.
Pharmacological treatment
 Calamine lotionand talc.
 Systemic antibacterial if infection present.
ECZEMA
Eczema is an inflammatory response of the skin to various exogenous and endogenous
allergens. Exogenous allergens cause irritant contact dermatitis, allergic contact dermatitis,
photodermatitis and infective dermatitis. The endogenous allergens result into atopic
dermatitis, seborrheic dermatitis, nummular eczema, asteatotic eczema, stasis dermatitis.


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dermatitis, seborrheic dermatitis, nummular eczema, asteatotic eczema, stasis dermatitis.
Salient features
Diagnosis
 Clinical and skin biopsy.
Non -pharmacological treatment
 Avoid allergens, cold compresses, emollients.
Pharmacological treatment
 Topical corticosteroids like betamethasone valerate 0.05 % cream and mometasone
furoate 0.05% cream/ointment.
 Topical and /or oral antibacterial in case of secondary infection.
 Oral antihistaminics like Tab.cetirizine (10mg/day) and Tab. Chlorpheniramine 4mg/day
 Severe cases Tab. prednisolone 0.5-1 mg/kg/day.
 Regular follow up of the patient.
Patient education
 Explain about the side effects of local and systemic corticosteroids
CONTACT DERMATITIS
Inflammatory response of skin to an exogenous substance immunologically or none


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CONTACT DERMATITIS
Inflammatory response of skin to an exogenous substance immunologically or none
immunologically mediated(Figure18).Common allergens are cement (nickel, chromium,
cobalt), epoxy resins, rubber, plastics, photographic chemicals, paints, flowers, clothing, shoe
materials, watches, jewellery, cosmetics (bindi, lipstick, sindoor, hair dyes), topical
medications (antibacterials, antifungals and antiseptic lotions), plants, fertilizers, insecticides,
pesticides, soap, detergents, vegetables, toothpaste.


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 Irritation, itching, pain.Erythema, papules, vesicles, erosions, scaling and crusts can be seen.
 Lesions may or may not be confined to the site of contact.
 Diagnosis is clinical
 A typical lesion is well-defined depigmented patch, which shows depigmented hair without
any change in skin texture.
 Common sites are extensors body surfaces such as pre tibial lesion, sides of ankle, knees,
elbows and skin overlying the digits, periocular region located generally bilaterally
symmetrical.
Salient features
Non -pharmacological treatment
 Evaluation of alleged contactants and their avoidance.
 Wet compresses and soaks for exudative lesions.
Pharmacologicaltreatment
 Topical corticosteroids like betamethasone valerate 0.05 % cream or mometasone furoate


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Pharmacologicaltreatment
 Topical corticosteroids like betamethasone valerate 0.05 % cream or mometasone furoate
0.05% cream/ointment.
 Topical and oral antibacterial in case of infection.
 Oral antihistaminics like Tab.cetrizine (10mg/day) or Tab. chlorpheniramine (4mg/day).
 Severe cases Tab. prednisolone 0.5-1 mg/kg/day.
 Regular follow up.
PITYRIASIS ALBA
Usually found in children, mostly on face.They present as asymptomatic hypopigmented,
mildly scaly lesions, generally over face. Diagnosis is clinical.
Treatment
 Em ollient
 Topical steroids:  fluticasone (0.005%) or fluocinolone (0.05%) or mometasone (0.1%) to
be applied till the lesion heal.
VITILIGO
It is an acquired primary, progressive melanocytopenia of unknown etiology and


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be applied till the lesion heal.
VITILIGO
It is an acquired primary, progressive melanocytopenia of unknown etiology and
characterized by asymptomatic depigmented lesions.
Salient features
Diagnosis
 Clinical
Non -pharmacological treatment
 Counselling and reassurance.


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211
 It can be acute(less than 6 weeks) or chronic (>6 weeks).C haracteristic wheals with or
without angioedema.Dermatographism may be present.
 Good general health and balanced nutritious diet enriched with adequate proteins, vitamin
B complex, vitamin E, minerals such as copper, zinc and iron.
 Avoid trauma.
 Avoid soaps and detergents containing phenolic compound and rubber goods.
Pharmacological treatment
 Topical steroids like mometasone furoate 0.1 % cream, betamethasone valerate 0.05%
cream ointment.
 Topical calcineurin inhibitors like tacrolimus 0.03% or 0.1% ointment.
 PUVA therapy Tab. methoxsalen (0.6mg/kg) or topical psoralens followed by sun
exposure.
ALBINISM
Albinism (from latin albus, "white") is a congenital disorder characterized by the complete or


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exposure.
ALBINISM
Albinism (from latin albus, "white") is a congenital disorder characterized by the complete or
partial absence of pigmentin the skin, hair and eyes due to absence or defect of  tyrosinase.
There is generalisedand diffuse depigmentation ofskin with white hair from birth.Diagnosis
is clinical.
Treatment
 Reassurance, patient education,protection from sunlight.
MELASMA
It is a pigmentary disorder of the skincharacterized by malar hyperpigmentation. It is
particularly common in women, especially during pregnancy and those taking oral
contraceptives or hormone replacement therapy.
Diagnosis
Clinical and woodslamp examination
Non -pharmacological treatment
 Reassurance in pregnancy induced melasma.
 Avoid sun exposure and causative factor like hormonal therapy.


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Non -pharmacological treatment
 Reassurance in pregnancy induced melasma.
 Avoid sun exposure and causative factor like hormonal therapy.
Pharmacological treatment
 Topical agents like hydroquinone 2-5% cream or azelaic acid 10-20% cream or glycolic
acid 6-12% cream or hydroquinone + tretinoin + steroid (fluticasone, mometasone,
fluocinolone).
 Photoprotection.
URTICARIA
Urticaria is characterized by transient erythematous wheals with burning or stinging
sensation. Most common causes are idiopathic, infections, food and drugs.
Salient features


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 Chronic plaque psoriasis(Figure19) is clinically characterized by erythematous scaly
plaques with micaceous scaling predominantly over extensorsurfaces of body, scalp scaling
and nail pitting is seen (when involved). Winter aggravation is a feature.
 Scalp psoriasis-erythematous scaly plaques on the scalp with itching.
 Guttate psoriasis- dew drop like crop of erythematous scaly papules and plaques all over
body. Associated with preceding streptococcal infection.
 Psoriatic arthritis-asymmetrical oligoarticular arthritis involving distal interphalangeal joints
of fingers and toes.
Diagnosis
 Clinical
Non -pharmacological treatment
 Eradicate the etiological factor if any.
 Avoid the food causing urticaria.
 Cold water sponging and soothing applications.


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 Eradicate the etiological factor if any.
 Avoid the food causing urticaria.
 Cold water sponging and soothing applications.
 Clearance of airway in case of laryngeal oedema.
Pharmacological treatment
 Acute urticaria with/without angioedema- Inj. chlorpheniramine maleate, Inj.
dexamethasone IV or IM.
 Chronic urticaria with/without angioedema- Tab. levocetrizine 5mg OD and/or Tab.
chlorpheniramine maleate 4mg HS.
 Laryngopharyngeal edema Inj. epinephrine 0.5 to 1 ml SC and Inj. hydrocortisone 100mg
IV immediately.
PSORIASIS
Psoriasis is characterized by hyperproliferation and abnormal differentiation of epidermal
keratinocytes, lymphocyte infiltration and various endothelialvascular changes in the dermis.


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keratinocytes, lymphocyte infiltration and various endothelialvascular changes in the dermis.
It is a multifactorial condition where both genetic and environmental factors act together.
Salient features
Diagnosis
 Clinical and skin biopsy.
Non -pharmacological treatment
 Identify and avoid triggering factors.
 Avoid stress, alcohol and smoking.
 Avoid beta blockers and chloroquine.
Pharmacological treatment
 Topical agents( if< 10% BSA is involved) such as emollients- liquid paraffin, vaseline,
light liquid paraffin, white soft paraffin, clobetasol and betamethasone either alone or in
combination and salicylic acid 3-6%.
 Vitamin D3 analogues-calcitriol, calcipotriol (SOS).


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 Erythematous to violaceous, flat topped, polygonal papules associated with intense pruritus
(Figure20).
 Sites-Dorsal surface of the hands, flexor surfacesof the wrists and forearms; anterior aspect
of the lower legs, neck and sacral area are also common sites.
 Asymptomatic, smooth, well defined round to oval totally bald patch slightly depressed
below the surface.
 Paraesthesia or mild erythema may precede. At the margins of the expanding lesion, the
characteristic ‘exclamation’ mark hair can be found.
 Systemic therapy  ( if > 20%  BSA is involved) at tertiary care centre-Tab. methotrexate
5-7.5 mg/week orTab. cyclosporine 100-200 mg/day(SOS) or Tab. acitretin 25 mg/day.
 Phototherapy SOS.
LICHEN PLANUS


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5-7.5 mg/week orTab. cyclosporine 100-200 mg/day(SOS) or Tab. acitretin 25 mg/day.
 Phototherapy SOS.
LICHEN PLANUS
It is an inflammatory autoimmune, papulosquamous disorder affecting skin, nails and/or
mucous membranes.
Salient features
Diagnosis
 Clinical and skin biopsy
Pharmacological treatment
 Mild – topical fluocinonide 0.05% or clobetasol propionate 0.05% cream and calcineurin
inhibitors like tacrolimus ointment 0.03%.
 Moderate or severe cases- Tab. prednisolone 0.5-1 mg/kg) in gradually tapering doses
over 6 weeks.
 Inj. triamcinolone acetonide (0.5-1 mg/kg) per month for 3-6 months.
 Retinoids– Tab. acitretin (25-50 mg / day for 6-8 weeks).
Patient education
 Inform the patient that condition is non-infectious, self limiting and recurrence may
occur.
ALOPECIA AREATA


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Patient education
 Inform the patient that condition is non-infectious, self limiting and recurrence may
occur.
ALOPECIA AREATA
It is a common condition characterized by patchy loss of hair without scarring.
Salient features
Diagnosis
 Clinical
 Biopsy– peribulbar lymphocytic infiltrate in “swarm of bees” pattern.
Non -pharmacological treatment
 Counselling and reassurance– disease is self limiting.


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214
Pharmacologicaltreatment
 Procedures is done at tertiary care centres with topical application of  irritants-anthralin,
phenol, tazarotene, azelaic acid, tincture iodine or contact sensitizers-squaric acid dibutyl
ester, diphencyprone or
 Intralesional-Triamcinolone acetonide 10 mg/ml 0.2-0.5ml per patch every 3 weeks.
 Topical therapy by hydrocortisone acetate ointments or cream 1% or fluticasone
dipropionate 0.1% or psoralen or minoxidil.
Systemic therapy– for progressive lesions, not responding to topical agents.
 Systemic corticosteroids-pulsed therapy in form of monthly Inj. triamcinolone (40mg/ml)
or oral mini pulse Tab. prednisolone 40mg two successive days in a week.(duration of the
therapy depends on the response).


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or oral mini pulse Tab. prednisolone 40mg two successive days in a week.(duration of the
therapy depends on the response).
 Systemic immunomodulators– Tab. cyclosporine(2mg/kg/day)
 Oral phototherapy (PUVA) (should be given at tertiary centres because it is associated
with side effects and cumulative dose dependent toxicities).
PEMPHIGUS VULGARIS
A group ofblisteringautoimmune diseasesthat affect theskinand mucous membranes.It is
characterised by mucosal involvement, flaccid blister over apparently normal skin(Figure21)
and positive Nikolsky sign.
Diagnosis
 Clinical
 Tzanck smear to demonstrate acantholysis
 Biopsy or anti-desmoglein autoantibodies to confirm
Non -pharmacological treatment
 Hospitalization.
 Fluid replacement.


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 Biopsy or anti-desmoglein autoantibodies to confirm
Non -pharmacological treatment
 Hospitalization.
 Fluid replacement.
Pharmacological treatment (only at tertiary care centre)
 Oral: to prevent infection(Tab. azithromycin  500 mg OD for 5 days/ Tab.cotrimoxazole
2 BD for 7 days  according to culture sensitivity if there is infection).
 IV dexamethasone (1mg/kg-2mg/kg bw).
CUTANEOUS ADVERSE DRUG REACTIONS
I. MACULOPAPULAR RASH
It is milder form of drug reaction also known as scarletiniform rash or morbilliform rash.
Dugs causing maculopapular rash are penicillin, sulfonamides, aspirin, phenytoin,
phenylbutazone, tetracycline, digitalis, thiacetazone, quinine, pas, rifampicin, ibuprofenetc.
It is confluent erythematous maculopaplar rash with itching.
Diagnosis
 Clinical


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 Classical iris or target lesions (central dusky erythema, purpura or blister middle ring of pale
edema with erythematous halo) are present in an acral distribution, may involve palms, dorsa
of hands, feet, elbows and knees.
 Lesions usually fade in one to two weeks.
 Mucosal lesions-lips palate and gingivae are common sites.
Pharmacological treatment
 Stop the causal drug.
 Topical calamine lotion and Tab. cetirizine (10 mg/ day).
II.ERYTHEMA MULTIFORME
A self-limited but potentially recurrent disease characterised by appearance of dull red
erythematous maculopapular lesions with a central vesicle and sometimes with a marginal
ring of vesicle usually acral (hands and feet) distribution.Most common cause is infection
with herpes simplex virus and drugs.


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ring of vesicle usually acral (hands and feet) distribution.Most common cause is infection
with herpes simplex virus and drugs.
Common drugs causing erythema multiforme are penicillin, sulfonamides, aspirin, phenytoin,
phenylbutazone, tetracycline, codeine, digitalis, thiacetazone, quinine, isoniazid, PAS,
rifampicin, glucocorticoids, methotrexate, clindamycin, ibuprofen, minoxidil, griseofulvin,
streptomycin, piroxicam, anticholinergic eye drops, perfumes topical like vitamin E,  5-
fluorouracil, nitrogen mustard.
Salient features
Diagnosis
 Clinical and Complete blood count, liver function tests.
Non -pharmacological treatment
 Discontinue the causal drug.
Pharmacological treatment
 Topical antiseptics for eroded skin lesions.


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Non -pharmacological treatment
 Discontinue the causal drug.
Pharmacological treatment
 Topical antiseptics for eroded skin lesions.
 Antiseptic and local anaesthetic solutions for oral lesion in case of herpes simplex.
 Topical ophthalmic preparations like normal saline or lubricating eye drops for eye
lesions.
 Tab. cetirizine (10 mg) or Tab.chlorpheniramine (4 mg) for 3 or 4 days.
 Tab. prednisone [0.5–1 mg/kg/day].
III.FIXED DRUG ERUPTION
Characteristically recur at the same site following the administration of the offending drug or
occasionally member of the same group of drugs. Occur in 30 mins to 8 hours after drug
administration. Common drugs include sulfonamides, NSAIDs, tetracycline, dapsone,


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administration. Common drugs include sulfonamides, NSAIDs, tetracycline, dapsone,
chlordiazepoxide, barbiturates, ciprofloxacin, phenytoin, codeine, quinine, griseofulvin,
mebendazole, metronidazole, ampicillin and antituberculous drugs.


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 Round, sharply demarcated erythematous/ hyperpigmented patches are seen, sometimes with
a central blister or detached epidermis(Figure22).
 Sites: lips, face, hands, feet and genitalia.
 Generalised bullous FDE is characterized by multiple, sharply defined, deep red macules and
blisters with bilateral symmetrical distribution.
 Lesions consist of wide spread flat atypical target or purpuric macules distributed centrally
with involvement of at least two mucosal sites.
 Cutaneous lesions are preceded by fever, arthralgia, malaise, headache, vomiting, diarrhea
and myalgia. Mucosae involved are eyes, mouth and genitalia.
 In TEN, confluent erythema is present, the epidermis separates in a set forming raised,


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 In TEN, confluent erythema is present, the epidermis separates in a set forming raised,
flaccid bullae. Pain, burning and tenderness of the skin are marked.
Salient features
Diagnosis
 Clinical
Non -pharmacological treatment
 Stop the offending drug.
 Enlist the drugs to be avoided.
Pharmacological treatment
 Topical calamine lotion.
 Tab. cetirizine (10 mg/ day) or Tab. chlorpheniramine (4 mg/day).
 Tab. prednisolone 0.5-1 mg/kg/ day) for generalized bullous FDE.
IV.STEVENS JOHNSON SYNDROME/ TOXIC EPIDERMAL NECROLYSIS
Stevens Johnson Syndrome is an adverse cutaneous drug reactions, characterized by<10%
body surface area of epidermal detachment and mucocutaneous tendernessand erythema
(Figure23). Toxic epidermal necrolysis (TEN) is an adverse cutaneous drug reactions,


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(Figure23). Toxic epidermal necrolysis (TEN) is an adverse cutaneous drug reactions,
characterized by>30% body surface area of epidermaldetachment and mucocutaneous
tenderness and erythema.
Common drugs causing SJ Syndrome/TEN are ampicillin, allopurinol, carbamazepine,
cotrimoxazole, isoniazid, lamotrigine, nevirapine, NSAIDs, phenobarbitol, phenylbutazone,
phytoin, ciprofloxacin, rifampicin, salicylates, tetracyclines, thiacetazone
Salient features
Diagnosis
 Clinical
Non -pharmacological treatment
 Withdraw offending drug.
 Oral liquid diet with protein supplements.


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 Characterized by grouped vesicles followed by erosive lesions associated with burningand
pain.Primary genital herpes-systemic symptoms are prominent and prolonged
 Recurrent genital herpes-recurrent episodes are milder lasting only for 5-7 days
 Primary syphilis-characterized by single well defined painless indurated ulcer and enlarged,
discrete, non tender firm lymphnodes with rubbery consistency.
 Secondary syphilis- begins after 2-12 weeks after the primary chancre.Presentation-
macular, papular, pustular, annular, follicular, mucus membrane lesions and lues maligna
(Figure24(a)). Tertiary syphilis-Gummatous lesions of covering structures / viscera,
Cardiovascular syphilis, Neurosyphilis-Meningeal/ Parenchymatous / Gummatous


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Cardiovascular syphilis, Neurosyphilis-Meningeal/ Parenchymatous / Gummatous
 Oral care: oral hygiene should be maintained with antiseptic mouth washes.
 Maintain optimum temperature of 30-32° C.
Pharmacological treatment (tertiary care centre)
 Hospitalisation.
 Management of fluid and electrolytes.
 Measures to prevent secondary infections.
 Ophthalmic care: saline or antibiotic eye drops
 Systemic antibiotics to prevent infection according to culture sensitivity: Macrolides-
Tab. azithromycin 500mg OD for3/5days/ Tab.erythromycin 500mg QID for 5/7 days.
 Tab. prednisolone (1-2 mg/kg/day),parentral (Inj. dexamethasone 8-16mg/day). It should
be started within 72hr   of onset and continued for 3-5days with rapid tapering.


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be started within 72hr   of onset and continued for 3-5days with rapid tapering.
 Tab. cyclosporine (3-5 mg/kg/day) for two weeks followed by weaning over another two
weeks SOS.
HERPES GENITALIS
Herpes genitalis most commonly caused by HSV 2.
Salient features
Diagnosis
 Clinical andTzank smear and serological-HSV IgM antibody.
Treatment(Table 2)
 Kit 5 by NACO.
Patient education
 Avoid sexual contact and treatment of the partner.
SYPHILLIS
Syphilis is a systemic disease caused by the spirochete,treponema pallidum.
Salient features


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 Multiplepainful, non indurated genital ulceration with painful inguinal lymphaedenopathy
(Figure24(b)).
 Diagnosis is mostly clinicaland confirmation with gram stain andbacterial culturecan be
done.
 Small transient painless papule or herpetiform ulcer develops at the site of inoculation, most
often goes unnoticed by the patient.
 The primary ulcer resolves without treatment after 2 to 6 weeks. The second stage of the
disease is known as the inguinal syndrome/ano rectal genital syndrome.
Diagnosis
 Dark field microscopy
 Direct fluorescent antibody test for treponema pallidum
 Non treponemal test-VDRL, RPR and Treponemal test-FTA -ABS,TPHA,MHA -TP
Treatment(Table 2)
 K it 3 by NACO
Patient education
 Regular follow up and serological examination


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Treatment(Table 2)
 K it 3 by NACO
Patient education
 Regular follow up and serological examination
 Treatment of partner
 Counseling about safe sex practice
CHANCROID
Chancroid is caused by the small gram-negative rod,Haemophilus Ducreyi.
Salient features
Treatment(Table 2)
 K it 4 by NACO
LYMPHOGRANULOMA VENERUM
Lymphogranuloma venereum (LGV ) is caused bychlamydia trachomatisserovars l1, l2, or
l3.
Salient features
Diagnosis
 Clinical
Treatment(Table 2)
 Kit 4 by NACO
URETHRAL DISCHARGE
Caused by N eisseria gonnorhoe, Chlamydia trachomatis,M ycoplasma and U reaplasma
urealyticum.Manifestsas thick whitish-yellow discharge per urethra associated with dysuria.
Diagnosis
 Clinical


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 Gram stain and Culture
Treatment(Table 2)
 Kit 1 by NACO.
Non -pharmacological treatment
 Educate and counsel the client and sexual partner regarding sexually transmitted
infection/ reproductive tract infection safer sex practices and importance of taking
complete treatment.
 Treat partner.Advice sexual abstinence or condom use during the course of treatment.
Provide condoms, educate about correct and consistent condom use.
 Refer all patients to ICTC.
 Follow up after 7 days for all sexually transmitted infections; on 3rd, 7th and 14th day for
lower abdominal pain and on 7th, 14th and 21stday for inguinal bubo.
 If symptoms persist, re-assess for re-infection and advice prompt reference.
 Consider immunization against Hepatitis B.


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 If symptoms persist, re-assess for re-infection and advice prompt reference.
 Consider immunization against Hepatitis B.
Table 2.Drug kits provided byNACO
DERMATOLOGICAL EMERGENCY
Severe acute allergic reactions include urticaria, angioedema, anaphylaxis, Steven Johnson
Syndrome, toxic epidermal necrolysis, life threatening stings andbites. Life threatening
infections include necrotizing soft tissue infections, fungal and viral infections with
complications. Severe dermatological conditions include: autoimmune vesiculo bullous
Kit Color Composition of kit Syndrome/disease
1 Grey Tab. azithromycin 1g stat +
Tab cefixime 400 mg stat
Urethral discharge , cervical
discharge , anorectal discharge,
painful scrotal swelling
2 Green Tab. secnidazole 2g stat +
Cap. fluconazole 150mg stat


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discharge , anorectal discharge,
painful scrotal swelling
2 Green Tab. secnidazole 2g stat +
Cap. fluconazole 150mg stat
Vaginal discharge
3 White Inj. benzathine penicillin 2.4 mu IM
stat + Tab. azithromycin 1g stat
Genital ulcerative disease
(non herpetic)
4 Blue Cap. doxycycline 100mg BD for 15
days + Tab. azithromycin 1g stat
Genital ulcerative disease
(non-herpetic)
5 Red Tab. acyclovir 400mg TDS for 7
days
Genital ulcerative disease  (herpetic)
6 Yellow Tab. cefixime 400mg stat +
Tab. metronidazole 400mg BD for
15 days + Cap. doxycycline 100mg
BD for 14 days
Lower abdominal pain (lap)
7 Black Cap. doxycycline 100mg BD for 21
days + Tab. azithromycin 1g stat
Inguinal bubo


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disorders, collagen vascular disorders, psoriasis- unstable, cutaneous involvement in
paraneoplastic disorders and systemic infections.
Treatment
Dermatological emergencies can only be managed at tertiary care centre.
Non -pharmacological treatment
 Treat the primary cause.
 Maintain CAB (circulation, airway and breathing).
 Careful monitoring of the vitals.
 Fluid and electrolyte management.
 Input and output chart.
Pharmacological treatment (only at tertiary centres)
 Systemic corticosteroids for autoimmune blistering and collagen vascular disorders (dose
depending on the severity of involvement and taper according to the response on follow
up).
 Appropriate antibiotics likeTab .azithromycin 500 mg OD for 3/5days/Tab .erythromycin


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up).
 Appropriate antibiotics likeTab .azithromycin 500 mg OD for 3/5days/Tab .erythromycin
500 mg QID for 5/7 days., antiviral like Tab. acyclovir 400 mg TDS for 7 days ;
antifungals like Cap. fluconazole 50-100 mg/day for 7-10 days(depending on severity).
 Immunosuppressant drugs used with caution and monitoring like cyclophosphamide 1-
1.5mg/kg/day, azathioprine 1-2mg/kg/day, cyclosporine (2mg/kg/day).
 IV Immunoglobulin and biological agents (rarely used).


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Chapter 13
OBSTETRICS AND GYNECOLOGY
NORMAL PREGNANCY
It is a transient physiological state during a woman's reproductive years.H owever, it requires
utmost antenatal care regarding diet, lifestyle and drug therapies to achieve a good foetal
outcome with minimal maternal morbidity and mortality.
Instruct the woman regarding
 Diet
Caloric requirements depend on the physical work done by the women. The increased
requirement of 300 cals for the pregnancy state is to be made available by exogenous supply
of diet. An ideal pregnancy diet should be light, nutritious, easily digestible and rich in
proteins, vitamins and minerals. The diet should consist of at least half-a-liter of milk, plenty
of green leafy vegetables (one katori serving in each meal)and fruits as available, in addition


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of green leafy vegetables (one katori serving in each meal)and fruits as available, in addition
to normal Indian diet consisting of a balanced cereals and pulses combination. Foods rich in
iron like green vegetables, jaggery, and protein rich foodslike nuts should be stressed upon.
Fat consumption can be predominantly of animal source so as to take care of vitamins A & D.
 Exercise
Any exercise, the woman is accustomed to can be continued, but not to the point of fatigue.
Antenatal exercises doneunder medical supervision are useful in pregnancy and labour. No
new exercise should be initiated during pregnancy. Sedentary women should be allowed only
walking. Women with multiple foetuses and complications like heart disease, pregnancy


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walking. Women with multiple foetuses and complications like heart disease, pregnancy
induced hypertension, intrauterine growth retardation, history of preterm labour, anti partum
hemorrhage (APH), threatened abortion should not exercise.
 C lothing
Should be non-constricting.
 Travel
Road travel is allowed with safety belt. Traveling in a pressurized aircraft is of no risk,should
walk about every 2 hours.
 Employment
Jobs requiring prolonged standing (>8 hours/day) are associated with a minimum risk of pre-
term delivery.
 Clinical check up
During each antenatal visit, BP, weight-gain, oedema feet, cardio-vascular, respiratory and
breast examination symphyseal-fundal height, presentation, foetal heart rate(s), amniotic fluid


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breast examination symphyseal-fundal height, presentation, foetal heart rate(s), amniotic fluid
volume, inquiry about daily foetal movement charting, and pelvic assessment at 38 weeks. Rh
negative women (with Rhpositive husband) need to be monitored on similar lines with
additional testing with Indirect Coomb's test (ICT) at first visit, 28 weeks and 34-36 weeks.
Immunoglobulin 300 mcg IM is recommended in ICT negative patients at 28 weeks of
pregnancy and postpartum 300 mcg IM ifbaby is Rhpositive. ICTpositive patients are to be


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managed only at centers with facilities for amniocentesis and/or cordocentesis, amniotic fluid
optical density estimation and intrauterine foetal transfusions.
Tab. folic acid 5 mg once daily, at least 3 months before conception, and continue till 12
weeks of gestation. Dose of iron (60-100 mg elemental iron) and folic acid (Tab. iron folic
acid) once daily and Tab. calcium gluconate 500 mg tablet twice daily from 16 weeks till 3
months postpartum.
 Immunization
2 doses of tetanus toxoid 4-6 weeks apart,(MMR vaccinesiscontraindicated).Rest of the
vaccines can be administered, if indicated as in nonpregnant state.
 Investigations during pregnancy
Haemoglobin, urine (routine and microscopy),blood groups andRh typing, screen for


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 Investigations during pregnancy
Haemoglobin, urine (routine and microscopy),blood groups andRh typing, screen for
syphilis, hepatitis B infection, HIV, cervical cytology, ultrasound forfoetal anomalies if
indicated, diabetes screening
Patient education
 Advise the woman on how to prepare for delivery, when to go, what to bring and where to
go in emergency.Explain the danger signals when she should report to the healthcenter
immediately,day or night, without waiting such as vaginal bleeding, convulsions, severe
headaches with blurred vision, severe abdominal pain, fast or difficult breathing, escape of
fluid from vagina or change in frequency or intensity of foetal movements, persistent
vomiting, oliguria. She should go to the health centre as soonas possible if any of the


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vomiting, oliguria. She should go to the health centre as soonas possible if any of the
following signs: swelling on face or hands, abdominal pain, fever, dysuria, feels ill.
 Explain about black staining of stools due to oral iron, therefore, not to worry about it.Iron
and calcium supplements should be taken at different times of the day at least 2 hours
apart.
 Discuss birth spacing after delivery and counsel on the importance of family planning.
Give advice on correct and consistent use of condoms for dual protection from sexually
transmitted infections or HIV and pregnancy
 Sexual intercourse should be avoided when abortion/pre-term labour threatens, and during
last 4 weeks in any pregnancy.
 Bowel: constipation, fissures and haemorrhoids are common during pregnancy and should


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last 4 weeks in any pregnancy.
 Bowel: constipation, fissures and haemorrhoids are common during pregnancy and should
be treated with fluids, exercise and bulk laxatives and stool softeners.
 Smoking, alcohol and drug abuse are contraindicated. Caffeine is best avoided.
 Daily foetal movement charting (DFMC): After 28 weeks, the woman should keep foetal
movement count.
 Follow-up visits: every 4 weeks till 28 weeks, every 2 weeks till 36 weeks and weekly
thereafter.
NAUSEA AND VOMITING IN EARLY PREGNANCY
Nausea and vomiting of mild to moderate intensity are especially common complaints in
early pregnancy until about 16 weeks. In few cases it may progress to hyperemesis.


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231
 Common complaint on rising in the morning but sometimes occurs at other times of the day;
vomitus is usually small and clear and doesn't produce any impairment of health or restrict the
normal activities of the pregnant woman.
 Severe nausea and persistent vomiting progress to hyperemesis leading to weight loss, ketosis
and there may be muscle wasting. There are usually signs of dehydration with postural
hypotension and tachycardia.
 Diagnosis is by exclusion of medical and surgical causes of vomiting like liver or GIT
disorders, pyelonephritis, diabetes mellitus etc. and molar (and multiple) pregnancy should be
ruledout in all cases of hyperemesis by ultrasound.
Salient features
Mild and moderate cases
Non pharmacologicaltreatment


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ruledout in all cases of hyperemesis by ultrasound.
Salient features
Mild and moderate cases
Non pharmacologicaltreatment
 Reassurance and advice to take frequent small, dry carbohydrate rich meals and avoid
fatty orspicy foods, especially avoid large volume of drinks in the morning.
Pharmacological treatment
 Tab. doxylamine succinate 10 mg + Tab. pyridoxine HC1 10 mg 1-2 tablets at bed time.
If required one more tablet can be added in the morning and afternoon. Or
 Tab. metoclopramide 10 mg 2-4 times a day in moderately severe cases.
Hyperemesis gravidium
Non pharmacological treatment
Admit all cases in the hospital away from a stressful home environment.
 Stop oral intake of fluids and nutrition.
 Serum electrolytes and urinary ketones to be checked at admission and 6 hourly.


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 Stop oral intake of fluids and nutrition.
 Serum electrolytes and urinary ketones to be checked at admission and 6 hourly.
 Emotional support, psychiatric referral if required.
 Rule out multiple or molar pregnancy and liver disorders.
Pharmacological treatment
Adequate and appropriate fluid and electrolyte replacement. Normal saline or Ringer's lactate
solutions are appropriate solutions and KC1 is added as required.
If urinary ketones are present, then 1 liter of 10% dextrose is transfused over 3-4 hours.
For prolonged vomiting
 Tab. thiamine 25-50 mg 3 times a day (if orally tolerated). If vomiting are not controlled
with fluid and electrolytes replacement in 6-8 hours.
 Inj. metoclopramide 10 mg IV or IM 8 hourly
 Inj. ranitidine 50-100 mg 6 hourly.


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with fluid and electrolytes replacement in 6-8 hours.
 Inj. metoclopramide 10 mg IV or IM 8 hourly
 Inj. ranitidine 50-100 mg 6 hourly.
 If not controlled, Inj. promethazine chloride 25-50 mg IM or IV 8 ho urly or Inj.
chlorpromazine 25-50 mg IM 4-6 hourly.
 Once vomiting is controlled for 24 hours, oral intake is gradually started. If well tolerated
then only IV fluids are omitted. At first dry carbohydrate foods are given in the form of


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 Bleeding in first trimester of pregnancy can be due to pregnancy related complications
such as abortion (threatened/inevitable/ incomplete/missed), ectopic pregnancy and molar
pregnancy or due to local causes such as trauma, erosion, polyp, infection, premalignant
or malignant lesions.
 Local lesions are diagnosed on per speculum examination.
small meals at frequent intervals. Gradually full diet is introduced. In prolonged and
severe disease, parenteral nutrition may be necessary. Give Tab. metoclopramide 10 mg
TDS and Tab. ranitidine 150 mg BD
 If well tolerated for 48 hours, patient can be discharged from the hospital with dietary
advice, reassurance and continue Tab. metoclopramide for 5-7 days or longer depending
on the response.
Patient education


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advice, reassurance and continue Tab. metoclopramide for 5-7 days or longer depending
on the response.
Patient education
 Adjust timing of medication in relation to the time of sickness.
 This is a benign disorder and gets relieved by 14-16 weeks of pregnancy
FIRST TRIMESTER BLEEDING
Salient features
Treatment
 Abortion can be treated at a primary centre.
 Molar and ectopic pregnancy should be treated at a secondary/tertiary centre(Table 1)
 Check Bleeding time, clotting time, CRT in missed abortion
Surgical treatment
 Manual vacuum aspiration or suction evacuation, dilatation and evacuation or only
evacuation in all cases of abortion and molar pregnancy except threatened abortion.
 Laparotomy/laparoscopic removal of ectopic pregnancy except a few selected cases of


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 Laparotomy/laparoscopic removal of ectopic pregnancy except a few selected cases of
unruptured ectopic pregnancy.
Table 1. Diagnosis of etiology of first trimester bleeding
Diagnosis Clinical findings USG/ HCG
Threatened abortionUterine size = period of gestation
(POG) Internal Os closed
Consistent with live foetus
Inevitable abortionUterine size = POG
Internal Os open, excessive
bleeding and pain
Cardiac activity + Internal
Os dilated
Incomplete abortionHistory of passing products of
conception (POC) Uterine size < POG
Internal Os open/ closed
POC in uterine cavity
Missed abortion Uterine size < POG Internal Os closed
Brownish discharge +
Cardiac activity absent


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Molar pregnancy History of passing vesicles
± Uterine size > or = or < than POG
Internal Os open/closed
Honeycomb appearance
hCG levels very high
Ectopic pregnancy Cervical excitation +
Unilateral tender fornix,
adnexal mass
Pseudogestational sac
empty uterine cavity
adenexal  mass, HCG rise
<66% in 48 hours
Patient education
 Exactetiology of abortions is not always apparent.Very early abortions are often nature's
selection to abort a nonviable, chromosomally abnormal conceptus.
 Increased abortions are seen with increasing parity and maternal age.Recurrent abortions
3 or more consecutive abortions should beinvestigated before planning the next
pregnancy.
 Effective contraception should be initiated soon after abortion as ovulation can occur as


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pregnancy.
 Effective contraception should be initiated soon after abortion as ovulation can occur as
early as 2-3 weeks after an abortion.
THREATENED ABORTION
Non -pharmacological treatment
Bed rest
Pharmacological treatment
 Inj. pentazocin 15 mg and Inj. promethazine 12.5 mg IM stat for those who have pain and
are anxious. If not available Inj. diazepam 10 mg IM or Tab. alprazolam 0.5 mg.
 Tab. folic acid 5 mg daily.
 Monitor for the continuation of pregnancy after confirming cardiac activity by USG.
 Discharge the patient 48 hours after bleeding stops.
 Progesterone supplementation if serum progesterone < 15 ng/ml only afterconfirming
cardiac activity in cases of spontaneous conception.
Patient education


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cardiac activity in cases of spontaneous conception.
Patient education
 To report immediately if bleeding recurs or it is more than normal periods.Continue bed
rest for at least 2 weeks.
 Abstinence till at least two follow-up visits in the next 4 weeks when normal continuation
of pregnancy is documented.High fiber diet to be givento avoid constipation.
 Need of follow up after 2 weeks for fetal growth by clinical and/or USG parameters.
After suction evacuation for abortion
 Reassurance if no living child.
 Need for contraceptive- can be started immediately after evacuation.Can resume coitus
after 4 weeks if no complications.
 When to attempt conception-after at least 6 months


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Obstetrics andGy necology
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 Fever, tachycardia, abdominal distension and tenderness, pelvic tenderness, and purulent
vaginal discharge. In severe cases there may be endotoxic shock and end organ failure.
 Complications like injury to viscera like uterus and bowel, internal or external
haemorrhage, peritonitis, disseminated intravascular coagulation, renal failure, hepatic
failure, endotoxic shockand tetanus can occur.
SEPTIC ABORTION
Any abortion associated with fever and signs of pelvic or generalized sepsis are considered
septic abortion. Most septic abortions result from illegal abortions but sepsis may follow
spontaneous and elective abortions
Salient features
Before starting antibiotic therapy, high vaginal or cervical swab and blood culture should be
obtained.


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Salient features
Before starting antibiotic therapy, high vaginal or cervical swab and blood culture should be
obtained.
Pharmacological treatment
 IV fluids for correction of electrolyte imbalance
 Oxygen by facemask in severe cases. In cases of adult respiratory distress syndrome
intubation and ventilatory support is required, and hydrotherapy if required.
 If blood pressure is not controlled with fluid replacement, Inj. dopamineinfusion in 5%
Dextrose2 -5 mcg/kg/min and dose titrated according to clinical and haemodynamic
response.
 In case of shock, acidosis is corrected by IVsodium bicarbonate 50-100 mEq in normal
saline.
 Inj. ampicillin 2 g stat followed by 500 mg IV 6 hourly(after test dose)Or
 Inj. cefuroxime or ceftazidime 1-2 g IV 2 times a day (after test dose).


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 Inj. cefuroxime or ceftazidime 1-2 g IV 2 times a day (after test dose).
 Inj. gentamicin 1.5mg/kg then1mg/kg IV 8hourly or Inj. amikacin 250- 500 mg IV 8
hourly.
 Inj. metronidazole 500mg IV 8hourly or Inj. clindamycin 600 mg IV 6 hourly
 Continue antibiotic therapy for 48-72 hours until culture sensitivity results provide an
indication for changing the initial antibiotic regimens or patient does not respond to
therapy. Monitor pulse, temperature, blood pressure, respiratory rate, urine output, and
serum electrolytes.In severe cases,central venous pressure (CVP ) and arterial blood gas
(ABG )monitoring is required. Therapeutic goals are to maintain systolic BP >90 mmHg,
urine output >30 ml/min, arterial PO, >60 mmHg, and CVP 6 -12 cm of H2O .
Surgical treatment


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urine output >30 ml/min, arterial PO, >60 mmHg, and CVP 6 -12 cm of H2O .
Surgical treatment
 Uterine curettage: if patient's condition is stable, within 1 hour of antibiotic therapy,
evacuation of the uterus by gentle curettage to remove infected products. If general
condition is low at admission, curettage after 6-8 hours of antibiotic therapy and treat
hypovolaemia.


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Obstetrics andGy necology
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 Laparotomy in case of injury to the uterus, suspected injury to the gut, presence of
foreign body in the abdomen as evidenced by X ray or feltthrough the fornix, peritonitis
or  colpotomy in cases of pelvic abscess.
ECTOPIC PREGNANCY
Treatment of ectopic pregnancy should be undertaken at a secondary/tertiary care level set
up. Laparoscopic surgery or laparotomy is done in all cases of ectopic pregnancy except in a
few selected cases that are highly compliant and reliable and fulfill the following criteria:
 Unruptured ectopic pregnancy in haemodynamically stable patient.
 Gestational sac size <3.5 cm in greatest diameter.
 Serum hCG titer < 10,000 mlU/ml.
 Gestation <6 weeks.
 Absence of foetal cardiac activity.


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 Gestational sac size <3.5 cm in greatest diameter.
 Serum hCG titer < 10,000 mlU/ml.
 Gestation <6 weeks.
 Absence of foetal cardiac activity.
Pharmacologicaltreatment(for unruptured ectopic pregnancy)
 Obtain pretreatment hCG titers, haemogram, liver and renal function tests.
 Inj. methotrexate 50 mg/sq meter body surface area IM given on day 1.
 Repeat hCG titers on day 4 and 7.
 If day 7, hCG titers reflect a drop of at least 15% from maximum levels then weekly hCG
titers till negative.
 If fall <15% or there is rise then repeat Inj. methotrexate.
Patient education
 Resolution of ectopic pregnancy may take up to 6 weeks.
 5-10% cases require surgery despite medical therapy.
 Signs and symptoms of tubal rupture such as vaginal bleeding, abdominal pain, weakness,


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 5-10% cases require surgery despite medical therapy.
 Signs and symptoms of tubal rupture such as vaginal bleeding, abdominal pain, weakness,
dizziness or syncope must be reported promptly.
 Patient should refrain from alcohol and folic acid containing vitamins during this period.
 Sexual intercourse should be avoided during therapy.
MEDICAL TERMINATION OF PREGNANCY
The government of India has legalized Medical Termination of Pregnancy (MTP) up to 20
weeks of gestation by MTP Act 1971. Under this act, pregnancy can be terminated under
following clauses:
Clauses and requirements
1. Damage to the life of the pregnant woman.
2. Grave injury to the physical or mental health of the pregnant woman.
3. Pregnancy caused by rape.


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1. Damage to the life of the pregnant woman.
2. Grave injury to the physical or mental health of the pregnant woman.
3. Pregnancy caused by rape.
4. Substantial risk, that if the child wasborn, it would suffer from such physical or mental
abnormalities as to be seriously handicapped.
5. Failure of any contraceptive method or device.


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Obstetrics andGy necology
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Necessary consent form as laid down in the Act should be duly filled and signed. Opinion of
two registered medical practitioners is mandatory for second trimester MTP (>12 weeks).
First trimester MTP methods
Medical methods
 It can be done up to 49 days amenorrhoea after proper counseling and excluding
contraindications.
 Tab. mifepristone 200-600 mg given on day 1.
 On day 3 Tab. misoprostol 400mcg orally or 800 mcg vaginally in hospital. Woman
generally aborts in next 4-8 hours and USG on day 14 to confirm complete abortion.
 Asked to report if excessive bleeding anytime in between. The procedure should be done
onlyin centers approved under MTP Act.
Surgical method
 Suction and evacuation done in all centers approved under MTP Act. Manual Vacuum


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onlyin centers approved under MTP Act.
Surgical method
 Suction and evacuation done in all centers approved under MTP Act. Manual Vacuum
Aspiration (MVA) can be done in all PHCs.
Patient education
 Details of the method and small risk of complications should be explained. Medical
method fails in around 5% cases and these will require surgical curettage.
 Patient should be motivated for concurrent contraception and option of all available
methods both temporary and permanent should be discussed.
Second trimesterMTP methods
 To be conducted in secondary and tertiary care level. None of the second trimester
methods are 100% safe and effective. That is why many methods both surgical and
medical, are available and being used. For second trimester MTP medical methods are
preferred.


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medical, are available and being used. For second trimester MTP medical methods are
preferred.
 Methods are usually combined so as to increase the success rate and to shorten induction
abortion interval. Most commonly extra amniotic0.1% ethacridine lactate 10 ml per week
of gestation (maximum 150 ml) with IV oxytocin after 6-24 hours or IM 15 methyl
PGF2α. Abortion is induced in 32 – 36 hours with a success rate of 75-80%.
 Better results if some method for cervical ripening is used 6-12 hours before.
 If some method fails switch over to other method or surgical method
ANEMIA IN PREGN ANCY
Prevalence of anaemia in pregnancy in India is 80% and severe anaemia is 10-15%. Causes
of anaemia in pregnancy are the same as those encountered in the non pregnant state.


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of anaemia in pregnancy are the same as those encountered in the non pregnant state.
However, iron deficiency anaemia is commonest in pregnancy. In about 40-50% of cases
there is associated folic acid deficiency. Anaemia in pregnancy is defined as haemoglobin
concentration of less than 11 g/dl and haematocrit of less than 33%. It is further classified
depending on Hb levels as mild 10-11 g%, moderate 7-10 g% and severe <7 g%.


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Obstetrics andGy necology
237
 M ild to moderate cases- weakness, exhaustion, lassitude, anorexia, glossittis, and
stomatitis, while severe cases present with palpitation, dyspnoea, oedema and cardiac
failure.
 Important basic investigations required are haemoglobin, haematocrit, total RBC counts,
peripheral smear for type of anaemia and haematological indices, plasma proteins and
stool for ova and cyst.
Salient features
Iron deficiency anemia
All cases of severe anaemia to be admitted especially those with features of anoxia or cardiac
insufficiency.
Non pharmacological treatment
 Diet rich in iron- jaggery, green leafy vegetable, sprouted pulses, meat, cooking food in
iron utensils.
 Diet rich in protein-pulses, lentils, milk and milk products, nuts, eggs and meat.


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iron utensils.
 Diet rich in protein-pulses, lentils, milk and milk products, nuts, eggs and meat.
Pharmacological treatment
 Oral iron therapy- ferrous sulfate andferrous fumarate. Recommended dose is 200 mg
elemental iron daily in divided doses. Not to be taken with meals, milk, coffee or tea.
Continue therapy till blood picture returns to normal and then continue with 100 mg
elemental iron for 3 months to build up the stores. Government of India recommends
minimum of 100 mg of elemental iron and 5 mg folic acid for 100 days starting at 20
weeks (Common side effects are epigastric pain, nausea, vomiting, constipation, and
diarrhoea).
 Deworming to be done after first trimester, if necessary. Tab. mebendazole 100 mg 2
times a dayfor 3 daysor Tab. albendazole 400 mg single dose.


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 Deworming to be done after first trimester, if necessary. Tab. mebendazole 100 mg 2
times a dayfor 3 daysor Tab. albendazole 400 mg single dose.
Monitoring of response to therapy
Subjective improvement of feeling better, weight gain and improved appetite is seen after 1-2
weeks. Reticulocyte response observed in 5-10 days (increases to 5-6%) and rise in
Hb/haematocrit in 2-3 weeks. The concentration is expected to rise at the rate of 0.1-0.25
g/dl/day or 0.8-1 g/dl/week.If no improvement in 3 weeks, reevaluate for: incorrect
diagnosis, non compliance, defective absorption, continuing loss, associated deficiencies.
Role of parenteral therapyis limited as rate of rise of haemoglobin with parenteral iron is
similar to oral iron preparation.
Specific indications


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Role of parenteral therapyis limited as rate of rise of haemoglobin with parenteral iron is
similar to oral iron preparation.
Specific indications
Severe intolerance to oral iron, malabsorption, non compliance and moderate to severe
anaemia inadvanced pregnancy
Total dose of iron to be given is calculated using following formulae:
2.4 Xweight in kgX deficit in Hb in gm + 500mg should be added for pregnancy.
(Caution:Oral iron is suspended at least 24 hours prior to therapy to avoid reaction).
Intravenous routeisto be given after hospitalization.


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Obstetrics andGy necology
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 Patients may be asymptomatic or may have vomiting, diarrhoea, pallor,hepatosplenomegaly,
and polyneuropathy.
 Diagnosis: is byMCV > 96.11 mc, MCH > 33 pg and MCHC normal. Peripheral smear
macrocytic anaemia with hypersegmentation of neutrophils, neutropenia and
thrombocytopenia.
 Inj. iron dextran is diluted in 5% dextrose. Initial infusion is given slowly at 8 drops per
min. for half an hour to watch for reaction, and thenincrease gradually to 40 drops/min.
Total iron dose is administered in a single sitting. If >2000 mg then only half dose is
given in one day. Monitor for adverse reactionslikerigors, chest pain, and hypotension. If
present stop the infusion.
 Inj.iron dextran oriron sorbitol complex (available as 50 mg ml) IM after an initial test


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present stop the infusion.
 Inj.iron dextran oriron sorbitol complex (available as 50 mg ml) IM after an initial test
dose of 0.5 ml intramuscularly, the injections are given daily or on alternate days in doses
of 2 ml IM using Z technique. To prevent staining of skin one can pass small amount of
saline/air down the needle before withdrawing it.
 Inj.iron sucrose intravenously given in each infusion 200mg of elemental iron in100 ml
of 0.9% NaCl infused over 20-30 minutes. No test dose required. Two infusion of each
200 mg of elemental iron is recommended twice in a week.
(Caution:Emerg ency drugs to be kept ready for resuscitation in case of anaphylactic
reaction).
Indications for blood transfusion


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(Caution:Emerg ency drugs to be kept ready for resuscitation in case of anaphylactic
reaction).
Indications for blood transfusion
Severe blood loss, severe anemia beyond 36 weeks of pregnancy or anemia refractory to oral
and parental therapy or anemic patient with anoxiaor cardiac failure. Management of anemic
patients during labour:
 Propped up position, oxygen therapy.
 Sedation and pain relief.
 Cut short 2nd stage of labour byforceps.
 Active management of 3rd stage of labour with Inj.m ethylergometrine maleate 0.2 mgIV
at the delivery of anterior shoulder or injection oxytocin 10 UIM .
 Inj. methylergometrine to be avoided in patients of anaemia with cardiac failure.
 Packed cell transfusion if necessary and ifHb < 5 g after giving diuretics.
MEGALOBLASTIC ANAEMIA IN PREGNANCY


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 Packed cell transfusion if necessary and ifHb < 5 g after giving diuretics.
MEGALOBLASTIC ANAEMIA IN PREGNANCY
Salient features
Pharmacological treatment
 Tab.folic acid 5 mg daily to be continued for at least 4 weeks in puerperium.
 Inj. cyanocobalamine 250 mcg intramuscular every month.
Dimorphic anaemia
 Both iron and folic acid in therapeutic doses.
Patient education


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Obstetrics andGy necology
239
 Hypertension (blood pressure > 140/90 mmHg recorded at 4-6 hours interval) with
proteinuria and/or non-dependant oedema, developing after 20 weeks of gestation in a
previously normotensive nonproteinuric patient.
 Pre-eclampsia is considered mild if diastolic BP < 100 mmHg, protineuria trace to 1+ with
minimal elevation of liver enzymes.
 Signs of severe pre eclampsia are: BP > 160/110, 24 hour's urinary proteins >2 g, elevated
serum uric acid,   thrombocytopenia (platelet count <50,000/ mm3), microangiopathic
haemolysis, raised liver enzymes, has diastolic BP 110 mmHg and foetal growth retardation.
 Dietary advice as mentioned earlier.
 Common side effects of therapy should be explained to the patient. Explain to the patient


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 Dietary advice as mentioned earlier.
 Common side effects of therapy should be explained to the patient. Explain to the patient
that stools turn black after oral iron therapy, so no need for concern.
 Iron supplementation should continuefor at least 3 months in postpartum period.
 Adequate spacing of at least 3 years between two pregnancies.
PREGNANCY INDUCED HYPERTENSION (PIH)
 Hypertension is diagnosed whendiastolic blood pressure is 90 mm Hg or moreon two
consecutive readings taken four hours or more apart.
 If hypertension occursafter20 weeks of gestation,during labour and/or within 48hours
of deliveryit is classified as pregnancy inducedhypertension.
 If hypertension occursbefore 20 wksof gestation, it is classified as chronichypertension.


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 If hypertension occursbefore 20 wksof gestation, it is classified as chronichypertension.
 Diastolic blood pressure alone is an accurate indicator of hypertension in pregnancy.
Elevated blood pressure with proteinuria, is defined as pre-eclampsia.
 Women with pregnancy-induced hypertension disorders may progress from mild disease
to a more serious condition. The classes of pregnancy-induced hypertension are:
hypertension without proteinuria; mild pre-eclampsia; severe pre-eclampsia; eclampsia.
 Mild pre-eclampsia often has no symptoms.
 Increasing proteinuria is a sign of worsening pre-eclampsia.
 Oedema of the feet and lower extremities is not considered a reliable sign of pre-
eclampsia.
 In pregnancy-induced hypertension, there may be no symptoms and the only sign may be


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eclampsia.
 In pregnancy-induced hypertension, there may be no symptoms and the only sign may be
hypertension.
PRE -ECLAMPSIA
Pre-eclampsia is one of the commonestcauses of maternal and perinatal morbidity and
mortality. It affects around 5-8% of all pregnancies. Pre-eclampsia is principally a syndrome
of signs, occurring more frequently in primigravida. When superimposed with convulsions it
is termed as eclampsia.Other high risk factors are- multiple pregnancy, hydramnios, and
molar pregnancy.
Salient features


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Obstetrics andGy necology
240
Treatment
Hospitalize all cases. Definitive therapy is to terminate pregnancy. The choice between
immediate delivery and expectant management depends on:severity of disease, condition of
mother and foetus and period of gestation (POG).
Mild pre-eclampsia
Expectant management: in cases of mild pre-eclampsia without foetal and maternal
compromise, with gestational ageless than37 weeks.
Non pharmacologicaltreatment
 Complete bed rest preferably in left lateral position and regular diet adequate in proteins
and calories with omission of extra table salt.
Pharmacological treatment
 Antihypertensive treatment is started if there is persistent diastolic bloodpressure over
100 mmHg. Aim of treatment is to achieve a systolic BP about 130 mmHg and diastolic


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100 mmHg. Aim of treatment is to achieve a systolic BP about 130 mmHg and diastolic
BP around 90 mmHg. Tab. methyldopa 250 mg 8 hourly or 6 hourly (maximum dose 2
g/day)orTab. atenolol 50-100 mg once a day.
 If BP is not controlled in 72 hours with the above, add any of the following:
Cap. nifedipine 10 mg 8 hourly or Tab. nifedipine retard 10 mg 12 hourly (maximum 30
mg 12 hourly) orTab. labetalol 100-200 mg 8 hourly (maximum 600 mg 6 hourly).
 Daily monitoring of weight gain, BP, urine albumin, urine output.
 Weekly lab investigations- haemogram with platelet count, liver and kidney function
tests specially serum uric acid, fundoscopy.
 Foetal monitoring by clinical and USG growth assessment, daily foetal movement count,


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tests specially serum uric acid, fundoscopy.
 Foetal monitoring by clinical and USG growth assessment, daily foetal movement count,
non stress test twice weeklyand biophysical score weekly, doppler studies in IUGR.
 In case of mild pregnancy induced hypertension without proteinuria, if after
hospitalization BP is controlled with rest without any antihypertensive drug, patient can
be discharged afterinitial evaluation if no maternal/foetal compromise is detected. It can
be practiced only in reliable patients who will follow instructions for monitoring as
above, and also will reportominous symptoms immediately (ominous symptoms are
persistent severeheadache, visual disturbances such as dimness of vision, double vision
or blindness, epigastric pain, nausea, vomiting and oliguria).


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or blindness, epigastric pain, nausea, vomiting and oliguria).
Definitive management
Induction of pregnancy by labour induction/caesarean section in the following conditions:
 Gestational age 37 weeks, foetal compromise like severe growth retardation,
oligohydramnios, abnormal non-stress test or biophysical score, maternal compromise
like development of features of severe pre-eclampsia, onset of labour, rupture of
membrane or bleeding.
Severe pre-eclampsia
Treatment is preferably done in a tertiary care center.
Non pharmacological treatment
 Observation in intensive care unit for 24 hours.


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Obstetrics andGy necology
241
 Assessment of maternal and foetal conditions. BP monitoring 2-4 hourly, hourly urine
output monitoring, watch for sign and symptoms of impending eclampsia and foetal
distress.
 Lab Investigations: haemogram with platelet count, liver and kidney function tests,
urinary proteins, coagulation profile, fundus examination, obstetric ultrasound with BPS.
 Intravenous fluids Ringer's lactate at rate of 60 ml/h (maximum 125 ml/h).
Pharmacological treatment
The aim of the treatment is gradual lowering of blood pressure so that diastolic BP is
maintained between 90-100 mmHg.
Immediate management
 Tab. nifedipine 10 mgorally can be repeated after 30-60 min. (maximum dose 20 mg 4
hourly).


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maintained between 90-100 mmHg.
Immediate management
 Tab. nifedipine 10 mgorally can be repeated after 30-60 min. (maximum dose 20 mg 4
hourly).
(Caution:Side effects-Tachycardia, headache, flushing, and aggravation of angina. Rapid
fall in BP can cause foetal distress).
 If BP is not controlled with oral treatment then IV drugs are started with intensive
monitoring.
 Inj. labetalol initial dose is 50 mg slow IV followed by infusion at 60 mg/h, doubling
every 15 min until BP is controlled or maximum dose 220 mg in 24 hours is reached.
Maintenance therapy
 After initial control ofacute hypertension, patient is started on maintenance therapy with
antihypertensives as described in management of mild pre-eclampsia.


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antihypertensives as described in management of mild pre-eclampsia.
 Manage with antihypertensives, bed rest and more frequent maternal and foetal
monitoring.
Definitive management is induction of pregnancy
Pregnancy beyond 34 weeks-stabilize maternal condition and induce pregnancy.
Pregnancy less than 24 weeks-stabilize maternal condition and induce pregnancy.
Patient on expectant management develops following features: uncontrolled hypertension
despite maximum dose of 2 antihypertensive drugs, eclampsia, raised liver enzyme >2 time
with right upper quadrant pain and tenderness, pulmonary oedema, platelet < 1 lac/mm1,
creatinine > 1 mg/dl over baseline
After delivery, intensive monitoring should be continued for 72 hours with prophylactic


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creatinine > 1 mg/dl over baseline
After delivery, intensive monitoring should be continued for 72 hours with prophylactic
anticonvulsant continued till 24 hours postpartum. Dose of antihypertensives should be
gradually reduced.
Prophylactic anticonvulsants
 Required in women with severe pre-eclampsia especially in cases with signs and
symptoms of impending eclampsia. Dose is same as for eclampsia.


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Obstetrics andGy necology
242
 Loading dose is magnesium sulfate-4g IV as 20% solution over 20 minutes and 10 g IM
as (50% solution, 10 ml (5 g) in each buttock (total of 14 g) followed by second dose in
alternate buttocks every 4 hours.
 Before each dose, monitor for presence of patellar reflex, respiratory rate >16/min and
urine output > 25 ml/h. It should be discontinued after 24 hours after BP is lowered.
 After initial evaluation and stabilization of thepatient further management is decided
depending on foetal maturity and maternal response.
 Expectant management- Considered if pregnancy is between 24-34 weeks and
hypertension controlled with maximum of two drugs, urine output is normal, lab
investigations are normal and no foetal compromise. Patient should be hospitalized till


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investigations are normal and no foetal compromise. Patient should be hospitalized till
delivery.
ECLAMPSIA
Salient features
Treatment (to be managed at a tertiary care level)
Principles of management are control and prevention of recurrence of convulsion andcontrol
of hypertension. Treat any complication that arise and deliver safely as soon as possible.
Continue anticonvulsant therapy 24 h after delivery or last fit whichever is latest.
Non pharmacological treatment
 Place the patient in left lateral position in a separate, quiet room.
 Secure and maintain airway.
 Use mouth gag or airway to prevent tongue biting/tongue falling back.
 Intubate if patient is deeply unconscious, poor arterial blood gases, extensive laryngeal
oedema, and extreme restlessness.


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 Intubate if patient is deeply unconscious, poor arterial blood gases, extensive laryngeal
oedema, and extreme restlessness.
 Suction to remove oropharyngeal secretions. Oxygen by face mask.
 Set up IV access.
 Monitor heart rate and respiration, BP, urine output.
 Laboratory investigations: haemogram with platelet count, liver and kidney function tests,
urinary proteins, coagulation profile, serum electrolytes, fundus examination.
Pharmacological treatment
 Inj. magnesium sulphate loading dose of 14 g of which, 4 g as 20% solution given slowly
IV over 5-10 minutes and 5 g as 50% solution given deep IM in each buttock (total 10 g
 Occurrence of generalized convulsions associated with signs of pre eclampsia during


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 Occurrence of generalized convulsions associated with signs of pre eclampsia during
pregnancy, labour or within 7 days of delivery and not caused by epilepsy or other
convulsive disorders.
 Eclampsia occurs antepartum in 46%, intrapartumin 16% and postpartum in 36%
cases.
 Patient may develop acute left ventricular failure, cerebral haemorrhage, renal cortical
necrosis, DIC, foetal distress, abruptio placentae, foetal death and maternal death.


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Obstetrics andGy necology
243
IM) Iffits are not controlled in 15 min, give 2 g magnesium sulfate as 20% solution slow
IV.
 Maintenance dose 5 g magnesium sulfate as 50% solution deep IM every 4 hours in
alternate buttock Or Continuous IV regimen 4 g loading dose over 20 minutes followed
by 1 g/h slow continuous IV infusion.(Caution:Side effects are respiratory depression
and neuromuscular depression in mothers. Neonatal respiratory and neuromuscular
depression). If respiratory depression occurs, give calcium gluconate 1 g IV as 10% sol. If
respiratory arrest occurs, immediate endotracheal intubation and ventilation is to be done.
Monitor: Check for respiratory rate to be more than 16/min, patellar reflex to be present
and urine output >25 ml/h before giving magnesium sulfate. Or


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and urine output >25 ml/h before giving magnesium sulfate. Or
 Inj. phenytoin loading dose of 15-25 mg/kg slow IV not exceeding 25 mg/ min diluted in
normal saline for first 750 mg and then 12.5 mg/min followed by 100 mg IV 8 hourly.
o ECG tracing to be taken every minute for 10 min during infusion of first 750 mg.
o Fluid management should be closely monitored to prevent complications such as
pulmonary oedema, left ventricular failure and adult respiratory distress
syndrome.
 Antihypertensives: as described in pre-eclampsia. Aim is to gradually lower the BP to
140-150/90-100 mm Hg.
Definitivemanagement is termination of pregnancy irrespective of the foetal maturity.
Termination is by labour induction and vaginal delivery or caesarean section.


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Termination is by labour induction and vaginal delivery or caesarean section.
Indications of caesarean section are: all deeply unconscious patients unless delivery is
imminent, uncooperative patient due to restlessness, if vaginal delivery is unlikely to occur
within 6-8 hours from the onset of 1st eclamptic seizure or eclamptic seizures are not
controlled in 6-8 hours, and other obstetric indications.
Care after delivery
 Patients of eclampsia and severe pre-eclampsia need intensive monitoring for at least
initial 72 hours.
 Continue anticonvulsant till 24 hours after delivery or fit, whichever occurs later.
Graduallydecrease the dose of antihypertensives.
 Patient is discharged after 10-14 days of delivery or earlier if BP controlled without
antihypertensives.


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 Patient is discharged after 10-14 days of delivery or earlier if BP controlled without
antihypertensives.
 Follow up after 6 weeks for reevaluation.
Patient education
 Delivery is the only definitive treatment. Underlying disease remains till delivery and
complications canarise despite control of BP on treatment.
 Symptoms of severe pre-eclampsia like headache, vomiting, epigastric pain, decreased
urine output, blurring of vision should be immediately reported.
 Need for prolonged hospitalization.
 Early booking in next pregnancy as there is 25-30% risk of recurrence.
 Prophylactic measures like low-dose aspirin can be started in early pregnancy.


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Obstetrics andGy necology
244
 Need for reevaluation at 6 weeks postpartum for reclassification and investigations of
hypertension and need for long-term antihypertensives. High risk of development of
chronic hypertension in later life.
PREGNANCY WITH DIABETES
Pregnancy can be complicated by pre-existing insulin dependent or noninsulin-dependent
diabetes or gestational diabetes. Gestational diabetes is defined as the carbohydrate
intolerance of variable severity with onset or first recognition during pregnancy.
Normal values-FBS less than 90 mg%, 2 hrs post prandial less than 120 mg%, RBS  less
than 100.  All pregnancies in diabetic females should be managed at atertiary care center.
Non pharmacologicaltreatment
Dietary advice
 Total daily calorie intake should be 30Cal/kg.


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Non pharmacologicaltreatment
Dietary advice
 Total daily calorie intake should be 30Cal/kg.
 Complex carbohydrates should provide about 50% of the total calories, which should be
well distributed throughout the day.
 Meals should besplit in 3 major meals and 3-4 snacks.
 High fiber diet is beneficial with 30-50 g fibers daily. Total diet should be distributed in 3
major meals and 3 mid meal snacks.
General measures
 Ultrasound assessment of foetal gestational age is to be done as earlyas possible.
 Foetal congenital anomalies should be ruled out bylevel II USG scan at 16-18 weeks,
foetal echo at 22 weeks.
 Serial USG for foetal growth monitoring and biophysical scoring for assessment of foetal
well being after 32 weeks of gestation.
Pharmacologicaltreatment


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well being after 32 weeks of gestation.
Pharmacologicaltreatment
(I) Antenatal management.
Initial evaluationshould include blood sugarand fundoscopy.
(a)Pre-existingdiabetes
 Oral hypoglycaemic agents are contraindicated during pregnancy. If patient is on oral
hypoglycaemics, switch over to insulin therapy as soon as pregnancy is diagnosed.
 Inj.Insulin: 0.6-0.8 U/kg in 1st trimester, 0.7- 0.9 U/kg in 2nd trimester and 0.8- 1.2
U/kg in 3rd trimester.
 Usually a combination of intermediate acting and regular insulin in proportion of 2:1 is
given. 2/3 of the total requirement is given in the morning before breakfast and 1/3 is
given at night with regular insulin before dinner and intermediate at bedtime.
 Dose adjustment is done to maintain blood sugar level between fasting <95 mg% and


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 Dose adjustment is done to maintain blood sugar level between fasting <95 mg% and
postprandial between 70 and 120 mg%.
 Sampling of blood should be done initially fasting, pre and post breakfast, pre and post
lunch, pre and post dinner and 2 AM regularly till controlled and then daily monitoring by
fasting and postmeal sugars.


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Obstetrics andGy necology
245
 Hospitalization is required in cases of excessive vomiting, infections, maternal
complications like hypertension, retinopathy, nephropathy, foetal compromise like
macrosomia or intra uterine growth retardation (IUGR) or poor diabetic control.
(b) Gestational diabetes.
Generalmanagement is same as outlined above.
 Patient is reassessed after 1 week. If control not achieved, insulin therapy is started.
Confirmation of blood sugar and regular insulin if required may be given before
breakfast, before lunch and before dinner or combination of regular and long acting can
be given before breakfast and dinner. Hypoglycaemia should be avoided.
 If fasting plasma sugar is > 105 mg% insulin is usually required for control. Regular


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 If fasting plasma sugar is > 105 mg% insulin is usually required for control. Regular
insulin is adjusted to normalize post breakfast glucose andintermediate for post lunch
glucose control. If evening or fasting glucose is elevated, 2nd daily injection is added. If
both are elevated, mixture of intermediate and regular insulin before dinner is added. If
only fasting is elevated, add intermediate acting insulin at bedtime. Or
 Inj. regular insulin 3 times a day before each main meal which can be combined with one
dose of intermediate acting insulin at bed time in case there is fasting hyperglycaemia.
 Apart from routine antenatal monitoring, blood sugar monitoring is required throughout
pregnancy. Therapeutic goal is to achieve plasma blood sugar levels fasting <95 mg% and


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pregnancy. Therapeutic goal is to achieve plasma blood sugar levels fasting <95 mg% and
2 hour postprandial <120 mg%. When levels are high daily monitoring with insulin dose
adjustment is required. Once control is achieved, patient can be managed at home with
weekly blood sugar profile.
 Glycosylated Hb (HbA lc) to be done in 1st trimester. Value of 9% or above
indicates poor glycemic control, carries higher risk of congenitalmalformation; MTP may
be offered after properevaluation.
(II)Management during labour
 In uncomplicated case with good glycaemic control pregnancy can be continued till
expected date of delivery.
 In presence of complications or foetal compromise pregnancy is terminated at 38 weeks
or earlier if required.


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expected date of delivery.
 In presence of complications or foetal compromise pregnancy is terminated at 38 weeks
or earlier if required.
 If estimated foetal weight is >4 kg, caesarean section is performed.
 Labour is managed with intensive monitoring. Blood sugars are monitored 3-4 hourly aim
is to keep blood sugars between 100-120 mg%, using the sliding scale method using
regular insulin.In the postpartum period, the requirement of insulin is decreased.
Patient education
 In known diabetics, good blood sugar control should be achieved in preconception period
to avoid high risk of congenital anomalies.
 Strict adherence to the dietary advice and insulin therapy is essential throughout
pregnancy. As insulin requirements change throughout pregnancy therefore, frequent


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pregnancy. As insulin requirements change throughout pregnancy therefore, frequent
blood sugar monitoring is required throughout pregnancy.


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Obstetrics andGy necology
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 All pregnant women with heart disease shouldbe managed at a tertiary level center
with multidisciplinary approach. Depending on the limitation of physical activity
patient is classified into class I to IV of New York Heart Association (NYHA).
 Severe or progressive dyspnoea, progressive orthopnoea,paroxysmal nocturnal
dyspnoea, haemoptysis, syncope with exertion or chest pain related to effort or
emotions.Echocardiography is diagnostic
 Clinical approach to the pregnant women with heart disease is according to NYHA
class irrespective of the aetiology of the heart disease.
 Patient on insulin therapy should be told about symptoms of hypoglycaemia like
palpitations, sweating, dizziness, and its management.


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 Patient on insulin therapy should be told about symptoms of hypoglycaemia like
palpitations, sweating, dizziness, and its management.
 In cases of gestational diabetes, there is risk of recurrence in subsequent pregnancies and
later on risk of frank diabetes is there.
Contraceptive advice
Combined oral contraceptive pills and intrauterine devices are preferably avoided. Barrier
methods, progestogen only pills/ implants/injectables or sterilization can be offered.
PREGNANCY WITH HEART DISEASE
Organic heart disease in pregnancy is commonly due to rheumatic heart disease or congenital
heart disease. Pregnancy with its increased cardiovascular stress is a potential cause for
worsening of the existing heart disease.
Salient features
Non -pharmacological treatment


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worsening of the existing heart disease.
Salient features
Non -pharmacological treatment
 NYHA class III and IV patients are to be hospitalized throughout the pregnancy while
class I and II can be managed as outdoor patients with more frequent antenatal visits and
admission at 38 weeks.
 Rest for 10 hours each night and 1 to 2 hour after each meal. Light housework and
walking without climbing stairs is permitted. No heavy work is allowed.
 Avoid high salt intake.
 Screen and treat at the earliest for excessive weight gain, abnormal fluid retention,
anaemia, pregnancy induced hypertension, infections.
Pharmacological (in consultation with the cardiologist)
In caseof rheumatic heart disease,
 Inj. benzathine penicillin 1.2 mega units IM 3 weekly.


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Pharmacological (in consultation with the cardiologist)
In caseof rheumatic heart disease,
 Inj. benzathine penicillin 1.2 mega units IM 3 weekly.
 Treat any infections with appropriate antibiotics.
 In patients with mechanical prosthetic valves, give Inj. heparin throughout pregnancy to
maintain PTT at 1.5 to 2.5 times the normal control.
(Caution:Oral anticoagulants are not safe during pregnancy because of risk of congenital
anomalies in the foetus. But if required, can be given after first trimester and continued till 4
weeks before delivery. However, oral anticoagulants are safe during lactation).


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Obstetrics andGy necology
247
Labour management
Caesarean is performed for only obstetrical indications.
 Pain relief is important during labour. Best option is to give continuous epidural
analgesia. It is contraindicated in women with intra cardiac shunts, aortic stenosis,
pulmonary hypertension, and hypertrophic cardiomyopathy. Inj. morphine can also be
given for pain relief.
 Fluids should be restricted to 75 ml/min. Bolusoxytocin andm ethyl ergometrine should
be avoided.
 Antimicrobial prophylaxis forinfective endocarditis required in all patients with cardiac
lesions undergoing any operative procedure or in labour.
 Inj. ampicillin 2 g andInj. gentamicin 1.5 mg/kg (maximum 120 mg) IV or IM 30 min


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lesions undergoing any operative procedure or in labour.
 Inj. ampicillin 2 g andInj. gentamicin 1.5 mg/kg (maximum 120 mg) IV or IM 30 min
before procedure followed by Cap. ampicillin 1 g IM orIV; or Cap. amoxycillin I g orally
6 hours after initial dose.
 If patient is allergic to penicillin Inj. vancomycin 1 g IV (over 1-2 hours) plus Inj.
gentamicin 1.5 g/kg (maximum 120 mg). Infusion to be completed within 30 min before
procedure.
Patient education
 Depending on the type and severity of cardiac lesion maternal risk of pregnancy should
be discussed with the patient ideally before pregnancy
 Option of corrective surgery preferably before pregnancy.
 2 -5% risk of congenital heart disease in foetus if mother has congenital heart disease.


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 2 -5% risk of congenital heart disease in foetus if mother has congenital heart disease.
 Contraceptive advice: sterilization after 2 weeks, progestogen only method or barrier
method. Counsel husband for male sterilization preferably by nonscalpel vasectomy.
 In severe cases option of medical terminationof pregnancy if pregnancy <12 weeks.
ANTEPARTUM HEMORRHAGE (APH)
Antepartum haemorrhage is defined as bleeding from genital tract after 20 weeks of
pregnancy and before completion of second stage of labour. It is a major cause of maternal
morbidity, mortality and perinatal loss. APH is due to placental cause in as high as 70% cases
and in 25-30% of cases cause may remain undetermined.
Salient features
 Clinical presentation varies depending on the severity of blood loss and cause of


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Salient features
 Clinical presentation varies depending on the severity of blood loss and cause of
bleeding
 In mild haemorrhage there may be no maternal or foetal compromise, while massive
haemorrhage can lead to hypovolaemic shock, coagulation failure, renal failure, foetal
distress and may result in maternal and foetal death.
 Ultrasound is confirmatory for placenta praevia.


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Obstetrics andGy necology
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Clinical presentation and severity of blood loss
Acute blood loss Clinical findings
1000 ml None
1000-1500 ml Orthostatic blood pressure changes, positive tilt test,
Pulse Pressure = 30 mmHg, reduced peripheral perfusion,
prolong capillary refill time
1500-2000 ml Cold clammy skin, tachycardia, tachypnoea, hypotension
> 2000 ml Profound shock, non-palpable pulse, intrauterine death of the
foetus
Causes of bleeding
Placenta praevia Abruptio placentae
Painless recurrent bleedingAssociated pain abdomen
Relaxed non-tender uterus Tense tenderuterus
Free-floating presenting partFoetal parts not easily palpable
Abnormal lie Foetal heart irregular or absent
Pregnancy induced hypertension
Treatment


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Free-floating presenting partFoetal parts not easily palpable
Abnormal lie Foetal heart irregular or absent
Pregnancy induced hypertension
Treatment
All patients of APH should be hospitalized in a well equipped center with facilities for blood
transfusion, emergency caesarean section and neonatal care unit.
(I) Massive hemorrhage
Following resuscitative measures are started immediately in massive hemorrhage.
Simultaneously prepare the patient for induction of labour by vaginal, caesarean section
depending on thecause of bleeding.
Non -pharmacological treatment
 Establish intravenous line (one or two 14/16 gauge cannula
 Draw 20 ml blood for cross-match, haemogram, coagulation profile.
 Start fluid therapy rapidly as described below.
 Head down tilt, keep the patientwarm.


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 Start fluid therapy rapidly as described below.
 Head down tilt, keep the patientwarm.
 Oxygen by mask at 8 liters/minute.
 Empty bladder (Foley's catheter for urine output).
Pharmacological treatment
 IV fluids and blood replacement therapy.
 Definitive treatment is induction of labour by caesarean section in cases of placenta
praevia andby vaginal/caesarian section in cases of abruptio placentae.
(II) Mild APH
Expectant management
 In a case of placenta praevia without maternal and foetal compromise, expectant
management is planned if pregnancy is less than 37 weeks and patient is not havingactive
bleeding and labour pains.


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Obstetrics andGy necology
249
 Hospitalize and bed rest with foetal and maternal monitoring.
 Inj. dexamethasone 12 mg IM 12 hourly for 2 doses should be given for foetal lung
maturity if POG < 35 weeks.
 Definitive treatment is induction of labour in case of following: occurrence of life-
threatening bleeding, pregnancy > 37 weeks, patient is in labour, in all cases of abruptio
placentae, baby is dead, congenitally malformed baby and bleeding recurring or
premature rupture of membranes on expectant management leading to maternal or foetal
compromise.
 Indications for caesarean section are:m ajor degree placenta praevia,non vertex
presentation,case of abruptio placentae with live foetus if cervix is unfavourable (labour


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presentation,case of abruptio placentae with live foetus if cervix is unfavourable (labour
is likely to be longer than 6 hours),Failure to progress after amniotomy and oxytocin
infusion and other obstetrical indications for caesarean section.
 Indications for vaginal delivery inAPH are: Minor degree placenta praevia with vertex
presentation and slight bleeding with favourable cervix and abruptio placentae with mild
bleeding and no increased uterine tone, foetus is dead or has major congenital
malformation incompatible with life.
 For induction artificial rupture of membranes followed by oxytocin infusion is done.
Oxytocin infusion is continued in the postpartum period to prevent postpartum
haemorrhage. In abruptio placentae monitoring is done to detect maternal complication


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haemorrhage. In abruptio placentae monitoring is done to detect maternal complication
early (pulse,BP, uterine height girth chart, vaginal bleeding, urinary output,BT, CT, clot
retraction time).
Patient education
 APH irrespective of type and cause results in increased perinatal morbidity and mortality.
 Incidence of placental abruption and placenta praevia are both increased with increasing
age and parity.
 Hypertension, cigarette smoking, cocaine abuse etc. predispose to placental abruption.
PREMATURE RUPTURE OF MEMBRANES
Prelabour rupture of membranes (PROM) is rupture of the membranes before labor has
begun. PROM can occur either when the fetus is immature (preterm or before 37 weeks) or at
term.
General management
 Confirm accuracy of calculated gestational age, if possible.


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term.
General management
 Confirm accuracy of calculated gestational age, if possible.
 Per speculum examination to assess vaginal discharge (amount, colour, odour) and
exclude urinary incontinence.
Diagnosis of vaginaldischarge(Table 2)
a) Light bleeding: takes longer than five minutes for a clean pad or cloth to be soaked.
b) Determine cause and treat accordingly.
Confirm diagnosis
 The typical odour of amniotic fluid confirms the diagnosis.


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Obstetrics andGy necology
250
 Ifmembrane rupture is not recentor whenleakage is gradual, confirming the diagnosis
may be difficult:
 Place a vaginal pad over the vulva and examine it (visually and by odour) one hour later.
 On per speculum examination: Fluid may be seen coming from the cervix or forming a
pool in theposterior fornix; and on coughing; there may a gush of fluid.
 If available, perform tests:
-The nitrazine testdepends upon the fact that vaginal secretions and urine are acidic while
amniotic fluid is alkaline.
- For theferning test, spread some fluidon a slide and let it dry. Examine it with a
microscope. Amniotic fluid crystallizes and may leave a fern-leaf pattern. False
negatives are frequent.


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microscope. Amniotic fluid crystallizes and may leave a fern-leaf pattern. False
negatives are frequent.
Table 2. Clinical presentation of patients with vaginal discharge in pregnancy
Presenting symptoms
and symptoms & signs
Present symptoms and signs sometimes
present
Probable
diagnosis
Watery vaginal discharge • Sudden gush or intermittent leaking of fluid
Fluid seen at introitus
•No contractions within 1 hour
Premature
rupture of
membranes
Foul smelling watery
discharge after 22 weeks
• Fever/chills
• Abdominal pain
• History of loss of fluid
• Tender uterus
• Rapid fetal heart rate
• Light vaginal bleeding
Amnionitis
Foul smelling
vaginal discharge
• No history of loss of fluid
• Itching, Frothy/curdish discharge
• Abdominal pain
• Dysuria
Vaginitis
or cervicitis


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Foul smelling
vaginal discharge
• No history of loss of fluid
• Itching, Frothy/curdish discharge
• Abdominal pain
• Dysuria
Vaginitis
or cervicitis
Bloody vaginal discharge •Abdominal pain
Loss of fetal movements
• Heavy, prolonged vaginal bleeding
Antepartum
haemorrhage
Treatment
 If there isvaginal bleeding with intermittentor constant abdominal pain, suspect abruptio
placentae.
 If there aresigns of infection(fever, foul-smelling vaginal discharge), give antibiotics as
for amnionitis
 If there areno signs of infectionand thepregnancy is less than 37 weeks(when fetal
lungs are more likely to be immature):give antibiotics to reduce maternal and neonatal
infective morbidity and to delay delivery
 Pre-labourrupture of membranes


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Obstetrics andGy necology
251
- Tab. erythromycin 250 mg by mouth three times per day for seven daysoramoxicillin
500 mg by mouth three times per day for seven days;
- Consider transfer to the most appropriate service for care of the newborn, if possible
- Give corticosteroids to the mother to improve fetal lung maturity:betamethasone 12
mg IM , two doses 24 hours apartor Inj.  dexamethasone 6 mg IM, four doses 12
hours apart.
Note: Corticosteroids should not be used in the presence of frank infection.
 Induce labour using oxytocin at 37 weeks and give prophylactic antibiotics to help reduce
Group B streptococcus infection in the neonate, even if the woman received antibiotics
previously: penicillin G 2 million units IV every six hours until delivery; or Inj.


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previously: penicillin G 2 million units IV every six hours until delivery; or Inj.
ampicillin 2 g IV every six hours until delivery.
 If there arepalpable contractions andblood-stained mucus discharge, suspect preterm
labour.
 If there areno signs of infectionand thepregnancy is 37 weeks or more:
- If themembranes have been ruptured for more than 18 hours, give prophylactic
antiboitics to help reduce Group B streptococcusinfection in the neonate.
- Assess the cervix
- If thecervix is favourable(soft, thin, partly dilated), induce labour using oxytocin.
- If the cervix is unfavourable(firm, thick, closed), ripen the cervix using
prostaglandins and    infuse oxytocin or deliver by caesarean section.
Amnionitis
 Give a combination of antibiotics until delivery


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prostaglandins and    infuse oxytocin or deliver by caesarean section.
Amnionitis
 Give a combination of antibiotics until delivery
-Inj. ampicillin 2 g IV every six hours; plus gentamicin 5 mg/kg body weight IV every 24
hours
-If thewoman delivers vaginally, discontinue antibiotics postpartum
-Ifthewoman has a caesarean section, continue antibiotics and give Inj. metronidazole
500 mg IV every eight hours until the woman is fever-free for 48 hours.
 Assess the cervix
-If thecervix is favorable(soft, thin, partly dilated), induce labour using oxytocin
-If thecervix is unfavourable(firm, thick, closed), ripen the cervix using prostaglandins
and infuse oxytocin or deliver by caesarean section.
 Ifmetritis is suspected(fever, foul-smelling vaginal discharge), give antibiotics.


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and infuse oxytocin or deliver by caesarean section.
 Ifmetritis is suspected(fever, foul-smelling vaginal discharge), give antibiotics.
 Ifnewborn sepsisis suspected, arrange for a blood culture and antibiotics.
PRETERM LABOR
Onset of labour pains in pregnant women after 20 weeks and before 37 weeks of gestation
associated with progressive dilatation and effacement of the cervix is known as preterm
labour.


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Obstetrics andGy necology
252
Salient features
Non pharmacological treatment
 Hospitalization with complete bed rest, preferably in a centre with neonatal intensive care
unit.
 Laboratory investigations: haemogram, urine culture,endocervical swab for culture and
sensitivity.
Pharmacological treatment
 Inj. pentazocine 15mg + Inj. promethazine 25 mg IM stat and can be repeated 8 hourly.
 Immediate tocolysis in pregnancies <35 week
 If membranes are intact and labour is not advanced (cervical dilatation <4 cm), there is no
indication for immediate delivery and no contraindication for tocolysis.
 Inj. isoxsuprine HCl 10 mg IM every 6 hours in case of mild contraction; Intravenous
infusion if strong contractions are established 0.2-0.4 mcg/min in 5% dextrose. Maximum


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infusion if strong contractions are established 0.2-0.4 mcg/min in 5% dextrose. Maximum
dose is 0.8 mcg/min to be continued at least 2 hours after the contractions cease.
Followed by IM therapy for 24 hours.
(Caution: Side effects tachycardia and hypotension, hypokalaemia, neonatal tachycardia,
hypotension and rarely pulmonary oedema and acute respiratorydistress syndrome). Or
 Inj. ritodrine infusion 3 ampoules (150 mg) in 500 ml of 5% dextrose or ringer lactate at
50- 100 mcg/min (5-6 drops/min), increase by 50 mcg every 10 min till contractions
cease or side effects appear (maximum dose 350 mcg/min), continue for 12 hour after
contractions stop. This is followed by oral treatment- 10 mg every 2 hours for 24 hours


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contractions stop. This is followed by oral treatment- 10 mg every 2 hours for 24 hours
then 10-20 mg every 4-6 hours.(Contraindications: Poorly controlled diabetes or thyroid
disease, sickle cell disease). Or
 Cap. Nifedipine 30mg loading dose followed by 10-20 mg every 4-6 hours.
(Caution: Do not administer along with magnesium sulfate; contraindicated in maternal
hypotension (< 90/50 mmHg), cardiac disease. Use with caution in renal disease.
Maternal side effects include flushing, headache, nausea, dizziness, and hypotension.) Or
 Inj. magnesium sulfate 4-6 g as 20% solution bolus over 30 minutes followed by infusion
of 4-6 g/h.(Contraindicated in patients with myasthenia gravis, cardiac decompensation.


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of 4-6 g/h.(Contraindicated in patients with myasthenia gravis, cardiac decompensation.
Use with caution in renaldisease. It can cause flushing, lethargy, headache, muscle
 Uterine contraction of duration of 30 sec or more at interval of 10 minutes or less
accompanied by cervical dilatationand effacement with or without leaking or
bleeding per vaginum.
 Risk factors include: low socioeconomic status,  heavy manual labour, extremes of
age (<20 years and >40 years),  previous history of abortion or preterm delivery,
cervical or vaginal infection, multiple gestation or over distended uterus, hypoxic
conditions like anaemia, heart disease, preeclampsia, IUGR, foetal congenital
malformations and antepartum haemorrhage in present pregnancy.


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Obstetrics andGy necology
253
weakness, dryness of mouth, nausea and foetal distress, transient non-reactive non-stress
test (NST).
 Monitor pulse, BP, and cessation of the uterine contractions. If pulse rate >120/min and
BP < 90/50 mmHg stop tocolysis. Monitoring in magnesium sulfate therapy is as outlined
in eclampsia. Monitor for onset of chorioamnionitis (fever, tachycardia with uterine
tenderness).
Maintenance therapy
 Tab. isoxsuprine orally 10 mg 6 hourly or 20 mg 12 hourly (maximum daily-dose is 40 to
80 mg/day) to be continued till 34 weeks of pregnancy (long term therapy is
controversial).
 In pregnancies at 28-34 weeks of maturity, steroids are given for foetal lung maturity.
 Inj. betamethasone 12 mg IM 2 doses 24 hours apartor  Inj. dexamethasone 6 mg IM four


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 Inj. betamethasone 12 mg IM 2 doses 24 hours apartor  Inj. dexamethasone 6 mg IM four
doses 12 hours apart or 12 mg IM two doses 12 hours apart.
(Caution:Contraindicated if clinical or laboratory evidence of chorioamnionitis is
present).
 Cap. ampicillin 500 mg or erythromycin 500 mg 4 times a dayfor 5-7 days, only if
PROM is present.
 Patient may be discharged after 1 week of tocolysis followed by regular antenatal
surveillance.
Delivery
In cases of ineffective tocolysis or with contraindications for tocolysis, labour is allowed to
progress and mode of delivery is decided as per obstetric indications. Careful foetal
monitoring required throughout labour.  If any sign of hypoxia, caesarean section is better but


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monitoring required throughout labour.  If any sign of hypoxia, caesarean section is better but
foetus should have a fairly good chance of survival depending on neonatal care facility.
Patient education
 Restricted physical activity after discharge.
 Sexual abstinence till at least 34 weeks of gestation.
 Explain the risk of recurrence in subsequent pregnancy. Therefore need for early booking
and prophylactic measures in next pregnancy.
NORMAL LABOUR
Diagnosis
 Painful uterine contractions after 22 weeks gestation;
 Pain associated with blood-stained mucus vaginal discharge (show);
 Watery vaginal discharge or a sudden gush of water.
 Cervical dilatation and effacement


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Table 3. Stagesof normal labour
Stages of
labour
Definition Duration
First stage Cervical dilatation Nullipara Multipara
Latent phase
Active phase
< 3 cm 12h 8h
> 3 cm 6-8 h or rate of cervical
dilatation 1 cm/h
4-6 h or rate of cervical
dilatation 1.5 cm/h
Second stage Full dilatation of cervix to
explusion of foetus
1 h 30 min
Third stage From expulsion of foetus
to the delivery of placenta
15 min 15 min
Management of labour
When thepatient reports to the hospital with labour pains, examination should be conducted
by a doctor on duty and risk category to be assigned(Table 4).
Table 4.Common risk factors during labour
Maternal
factors
Past reproductive
history Present pregnancy Associatedmedical/
surgical problem
Age < 16, >35 >1 abortion Bleeding in


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Maternal
factors
Past reproductive
history Present pregnancy Associatedmedical/
surgical problem
Age < 16, >35 >1 abortion Bleeding in
pregnancy
Heart disease
Parity-0, >5 Previous stillbirth Prematurity, PROM Diabetes
Obesity Previous caesarean
section
Postmaturity Anaemia
Height < 145 cmPrev  PPH/MRP PIH Jaundice
PIH, Eclampsia IUGR Hypertension
IUGR Multiple pregnancy Renal disease
Congenital anomaly in
baby
Malpresentation Thyroid disease
Previous early neonatalMalposition Epilepsy
Death Asthma
General examination
 Record height and weight.
 Pulserate (PR), blood pressure (BP), respiratory rate (RR), temperature.
 Look for pallor, pedal oedema, jaundice and cyanosis.
 Auscultate cardiovascular and respiratory system.
Per abdomen examination
 Height of the uterus/POG.


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 Auscultate cardiovascular and respiratory system.
Per abdomen examination
 Height of the uterus/POG.
 Presentation, attitude, palpable foetal head (rule of fifths).
 Foetal heart rate.


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Obstetrics andGy necology
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 Uterine contractions-+/-, intensity, duration and frequency per 10 minutes.
 Amount of liquor.
 Size of the baby/estimated baby weight.
 Look for overriding of foetal head over symphysis pubis.
 Features of obstructed labour and contour of the uterus.
Per vaginum examination
 Observe aseptic precautions-hand washing and sterile gloves. Note:
 Cervical dilatation and effacement.
 Presentation and station of presenting part.
 Position and degree of flexion (suturesand fontanelle).
 Status of membranes and if leaking present then colour of liquor.
 Cord prolapse or presentation to be ruled out.
 Pelvic adequacy and rule out cephalopelvic disproportion (CPD).
 Vaginal examination should be carried out atleast once every 4hours during first


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 Pelvic adequacy and rule out cephalopelvic disproportion (CPD).
 Vaginal examination should be carried out atleast once every 4hours during first
stage of labour and after rupture of membranes.
Investigations
 Minimum investigations required during labour are:
 Hb, urine albumin and sugar, blood grouping.
 Urine acetone in prolonged/obstructed labour.
ASSESSMENT OF PROGRESS OF LABO UR
 Measure changes in cervical effacement and dilatation  during the latent phase
 Measure the rate of cervical dilatation and fetal descent during the active phase
 Assess further fetal descent during the second stage.
 Progress of the first stage of labourshould be plotted on a partograph once the patient
enters the active phase of labour.
PARTOGRAPH


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 Progress of the first stage of labourshould be plotted on a partograph once the patient
enters the active phase of labour.
PARTOGRAPH
The WHO partograph has been modified to make it simpler and easier to use. The latent
phase has been removed and plotting on the partograph begins in the active phase when the
cervix is 4 cm dilated.  Record the following on the partograph:
Patient information
 N ame, gravida, para,
 H ospital number, date and time of admission,
 Time of ruptured membranes or time elapsed since rupture of membranes (if rupture
occurred before charting on the partograph began).
Fetal heart rate: Record every half hour.
Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination:
 I: membranes intact;
 R: membranes ruptured;


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 C: membranes ruptured, clear fluid;
 M: me conium-stained fluid;
 B: blood-stained fluid.
Moulding:
 1: sutures apposed;
 2: sutures overlapped but reducible;
 3: sutures overlapped and not reducible.
Cervical dilatation:Assessed at every vaginal examination and marked with a cross (X ).
Begin plottingon the partograph at 4 cm.
Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at
the rate of 1 cm per hour.
Action line: Parallel and four hours to the right of the alert line.
Descent assessed by abdominal palpation: Refers to the part of the head (divided into five
parts) palpable above the symphysis pubis; recorded as a circle (O ) at every abdominal


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parts) palpable above the symphysis pubis; recorded as a circle (O ) at every abdominal
examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis.
Hours:Refers to the time elapsed since onset of active phase of labour .
Time:Record actual time.
Contractions:Chart every half hour; count the number of contractions in a 10-minute time
period, and their duration in seconds.
 Less than 20 seconds:
 Between 20 and 40 seconds:
 More than40 seconds:
Oxytocin:Record the amount of oxytocin per volume IV fluids in drops per minute every 30
minutes when used.
Drugs given: Record any additional drugs given.
Pulse:Record every 30 minutes and mark with a dot (!).
Blood pressure: Record every four hours and mark with arrows.
Temperature: Record every two hours.


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Blood pressure: Record every four hours and mark with arrows.
Temperature: Record every two hours.
Protein, acetone and volume: Record when urine is passed.
Partograph passes to the right ofAlert line- reassess and consider criteria for referral; call
senior person, if available.
Partograph passes to the right ofAction line- refer urgently to hospital unless birth is
imminent.
Drugs and IV fluids if administered are recorded.
Maintain intake-output chart
SECOND STAGE OF LABOUR
 Shift the patient to delivery table.
 Inform the paediatrician. Ensure all delivery equipment and supplies, including newborn
resuscitation equipment, are available, and place of delivery is clean and warm(25°C).
 Put her in dorsal/squatting position.


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 Observe universal precautions
 Clean and drape the parts.
 Infiltrate the perineum with local anaesthetic agent if episiotomy is planned.
 Woman is encouraged to bear down.
 Episiotomy is given if required
 To control birth of the head, keep the baby's head flexed and gently support the perineum
as the head delivers. Suction of the nose and mouth.
 After external rotation, deliver the shoulders one at a time followed by rest of the foetus.
 Clamp and cut the umbilical cord.
 Ensure establishment of respiration in baby or institute resuscitation if required.
 Administration of oxytocin 5 Units IM at the delivery of the anterior shoulder to prevent
PPH.
THIRD STAGE OF LABOUR


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 Administration of oxytocin 5 Units IM at the delivery of the anterior shoulder to prevent
PPH.
THIRD STAGE OF LABOUR
 Recognize signs of placental separation: Uterus becomes globular and firmer, suprapubic
bulge appears, sudden gush of blood and permanent lengthening of cord.
 Deliver the placenta by controlled cord traction. As the placenta passes through the
introitus, care is taken to prevent the membranes from being torn off and left behind.
 Examine the placenta for its completeness and anomalies.
 Administer Inj.oxytocin 5-10 U IM.
 Active management of third stage should be done unless contraindicated.
 Examine the woman for any tears and repair if any. Stitch the episiotomy. Observe the
woman closely for one hour after delivery, record her PR and BP.


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woman closely for one hour after delivery, record her PR and BP.
 Evaluate the uterusfrequently, and inspect the perineum to detect excessive bleeding and
haematoma formation.
Transfer from labour room
 Observe for 2 hours
 Check the following before transfer: pulse rate, BP, uterus, bleeding pre vaginum, inspect
external genitalia for condition of stitches and any haematoma, passed urine.
Episiotomy (Incision of the perineum)
 Not to be performed routinely.
 Applied selectively for: breech, forceps or vacuum delivery, occiput posterior positions,
rigid perineum, scarred perineum, and shoulderdystocia.
 Clean the area with antiseptic solution.
 Infiltrate beneath the vaginal mucosa, beneath the skin and deeply into the perineal
muscle using 10 ml of 0.5-1% lignocaine.


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 Infiltrate beneath the vaginal mucosa, beneath the skin and deeply into the perineal
muscle using 10 ml of 0.5-1% lignocaine.
 Check at the incision site for effect of local anaesthetics by pinching witha forceps before
giving incision.
 Perform episiotomy at crowning. Place two fingers between the baby's head and the
perineum and cut 3-4 cm of perineum in mediolateral direction.


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 After delivery of the baby and placenta, carefully examine for extensions oftears.
 Repair the episiotomy with vicryl rapide 2-0 suture (chromic catgut if vicryl is not
available). Close the vaginal mucosa with continuous suture starting 1 cm above the apex.
Perineal muscles are approximated using interrupted sutures. Skin is closed with
subcuticular (or interrupted) sutures.
Care of episiotomy
Perineal hygiene: Clean the area with antiseptic solution after urination and defaecation.
Analgesics are prescribed for allaying pain.
Respond to following problems during labour and delivery
Assess facilities and expertise available and appropriate timely referral iffoetal heart rate <


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Assess facilities and expertise available and appropriate timely referral iffoetal heart rate <
120 or> 160 beats per minute, prolapsed cord, breech presentation, stuck shoulders, multiple
births
FETAL DISTRESS IN LABOR
Abnormal fetal heart rate (less than 100 or more than 180 beats per minute) with thick
meconium -stained amniotic fluid.
General management
 If a maternal cause is identified(e.g. maternal fever, drugs), initiate appropriate
management.
 If amaternal cause is not identifiedand thefetalheart rate remains abnormalthroughout
at least three contractions, perform a vaginalexamination to check for explanatory signs
of distress:
 If there isbleedingwith intermittent or constant pain, suspect abruptio placentae.


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of distress:
 If there isbleedingwith intermittent or constant pain, suspect abruptio placentae.
 If there aresigns of infection(fever, foul-smelling vaginal discharge) give antibiotics as
for amnionitis.
 A normal fetal heart ratemay slow during a contraction but usually recovers to normal as
soon as the uterus relaxes.
 A very slow fetal heart ratein the absence of contractions or persisting after contractions
is suggestive of fetal distress.
 A rapid fetal heart ratemay be a response to maternal fever, drugs causing rapid maternal
heart rate (e.g. terbutaline or ritodrine), hypertension or amnionitis. In the absence of a
rapid maternal heart rate, a rapid fetal heart rate should be considered a sign of fetal
distress.


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rapid maternal heart rate, a rapid fetal heart rate should be considered a sign of fetal
distress.
 If thecord is below the presenting part or in the vagina, manage as prolapsed cord .
 Iffetal heart rate abnormalities persistor there areadditional signs ofdistress(thick
meconium -stained fluid), plan delivery:
 If thecervix is fully dilatedand thefetal head is not more than 1/5 abovethe symphysis
pubis or the leading bony edge of thefetal head is at 0 station, deliver by vacuum
extraction or forceps


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Obstetrics andGy necology
259
 If thecervixis not fully dilatedor thefetal head is more than 1/5 abovethe symphysis
pubis or the leading bony edge of thefetal head is above 0 station, deliver by caesarean
section
MECONIUM STAINED LIQUOR
Meconium staining of amniotic fluid is seenfrequently as the fetus matures and by itself is
not an indicator of fetal distress. A slight degree of meconium without fetal heart rate
abnormalities is a warning of the need for vigilance.Thick meconium suggests passage of
meconium in reduced amnioticfluid and may indicate the need for expedited delivery and
management of the neonatal upper airway at birth to prevent meconium aspiration. Inbreech
presentation, meconium is passed in labour because of compression of the fetal abdomen.


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presentation, meconium is passed in labour because of compression of the fetal abdomen.
This is not a signof distress unless it occurs in early labour
Management
 Prop up the woman or place her on her left side.
 Stop oxytocin if it is being administered.
 Give oxygen 4–6 L by mask or nasal cannulae.
Advice on postpartum care
 To always have someone near her forthe first 24 hours to respond to any change in her
condition.
 Not to insert anything into the vagina.
 To have adequate rest and sleep.
 The importance of hand washing to prevent infection of the mother and her baby.
 To wash perineum daily and after faecalexcretion.
 To avoid sexual intercourse until the perineal wound heals.
 Counsel for birth spacing and family planning (for details see section on contraception).


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 Counsel for birth spacing and family planning (for details see section on contraception).
 Advise on routine postpartum care visits-within the first week, preferably within 2-3 days
and second visit after 4-6 weeks. Earlier if problems- fever, UTI, perineal infection,
hypertension, urinary incontinence, severe anaemia, postpartum blues, HIV positive.
Counsel on exclusive breastfeeding
 Babies should start breastfeeding within 1 hour of birth. The baby should not be given
any other food or drink before breastfeeding.
 Babies should be exclusively breastfed for the first 6 months of life.
 Breast milk contains exactly the nutrients a baby needs, is easily digested and protects the
baby againstinfection.
INDUCTION AND AUGMENTATION OF LABOUR


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baby againstinfection.
INDUCTION AND AUGMENTATION OF LABOUR
Induction of labourrefers tostimulating the uterus to begin labour. While augmentation of
labourmeans stimulating the uterus during labour to increase the frequency, duration and
strength of contractions.


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Obstetrics andGy necology
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A good labour pattern is established when there are three contractions in 10 minutes, each
lasting more than 40 seconds. If themembranes are intact, it is recommended practice in both
induction and augmentation of labour to first perform artificial rupture of membranes (ARM).
In some cases, this is all that is needed to induce labour. Membrane rupture, whether
spontaneous or artificial, often sets off the following chain of events:
-Amniotic fluid is expelled;
-Uterine volume is decreased;
-Prostaglandins are produced, stimulating labour;
- Uterine contractions begin (if the woman is not in labour) or become stronger (if she is
already in labour).
Artificial rupture of membranes


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- Uterine contractions begin (if the woman is not in labour) or become stronger (if she is
already in labour).
Artificial rupture of membranes
 Note: In areas where HIV and/or hepatitis are highly prevalent, it is prudent to leave the
membranes intact for as long as possible to reduce perinatal transmission of HIV
 Monitor the fetal heart rate.
 Ask the woman to lie on her back with her legs bent, feet together and knees apart.
 Wearing sterile gloves, use one hand to examine the cervix and note the consistency,
position, effacement and dilatation.
 Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina.
 Guide the clamp or hook towards the membranes along the fingers in the vagina.


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 Guide the clamp or hook towards the membranes along the fingers in the vagina.
 Place two fingersagainst the membranes and gently rupture the membranes with the
instrument in the other hand. Allow the amniotic fluid to drain slowly around the fingers.
 Note the colour of the fluid (clear, greenish, bloody). Ifthick meconium is present,
suspect fetaldistress.
 After ARM, listen to the fetal heart rate during and after a contraction. If thefetal heart
rate is abnormal(less than 100 or more than 180 beats per minute), suspect fetal distress.
 If membranes have been ruptured for 18 hours, give prophylactic antibiotics to help
reduceGroup B streptococcusinfection in the neonate- penicillin G 2 million units IV; ,
or  Inj. ampicillin 2 g IV, every six hours until delivery


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reduceGroup B streptococcusinfection in the neonate- penicillin G 2 million units IV; ,
or  Inj. ampicillin 2 g IV, every six hours until delivery
 Ifgood labour is not established one hour after ARM, begin oxytocin infusion
 Iflabour is induced because of severe maternal disease(e.g. sepsis or eclampsia), begin
oxytocin infusion at the same time as ARM.
Assessment of the cervix
 The success of induction of labour is related to the condition of the cervix at the start of
induction. To assess the condition of the cervix, a cervical exam is performed and a score
is assigned based on the criteria(Table5):
 If thecervix is favourable(has a score of 6 or more), labour is usually successfully
induced with oxytocin alone.


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 If thecervix is favourable(has a score of 6 or more), labour is usually successfully
induced with oxytocin alone.
 If the cervix is unfavourable(has a score of 5 or less), ripen the cervix using
prostaglandins or a Foley catheterbefore induction.


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Obstetrics andGy necology
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Table 5.Assessment of cervix for induction of labour
Rating
factor
Dilatation Length of
cervix
Consistency Position Descent by
station of head
0 Closed More than 4 Firm posterior -3
1 1-2 3-4 Average Mid -2 to-1
2 3-4 1-2 Soft Anterior 0+1
3 More than 5 Less than 1 Soft Anterior +2
Oxytocin
 Use oxytocin with great caution, as fetal distress can occur from hyperstimulation and,
rarely, uterine rupture can occur. Multiparous women are at higher risk for uterine
rupture.
 The effective dose of oxytocin varies greatly between women. Cautiously administer
oxytocin in IV fluids (dextrose or normal saline), gradually increasing the rate ofinfusion
until good labour is established (three contractions in 10 minutes, each lasting more than


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until good labour is established (three contractions in 10 minutes, each lasting more than
40 seconds). Maintain this rate until delivery. The uterus should relax between
contractions.
 Monitor the woman’s pulse, blood pressure and contractions, a nd check the fetal heart
rate.
 When oxytocin infusion results in a good labour pattern, maintain the same rate until
delivery.
 Carefully observe women receiving oxytocin.
 Record the following on a partograph every 30 minutes rate of infusion of oxytocin.
 Look forfetal heart rate. Listen every 30 minutes, always immediately after contraction.
If thefetal heart rate is less than 100 beats perminute, stop the infusion and manage for
fetal distress.
 Infuse oxytocin 2.5 units in 500 mL of dextrose (or normalsaline) at 10 drops per minute


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fetal distress.
 Infuse oxytocin 2.5 units in 500 mL of dextrose (or normalsaline) at 10 drops per minute
in case of multigravida. In case of primigravida start with 5 unit oxytocin in 500 ml of
dextrose.
 Increase the infusion rate by 10 drops per minute every 30 minutes until a good
contraction pattern is established (three contractions in 10 minutes, each lasting more than
40 seconds).
 Maintain this rate until delivery is completed.
 Ifhyperstimulation occurs(any contraction lasts longer than 60 seconds) or if there are
more than four contractions in 10 minutes, stop the infusion and relax the uterus using
tocolytics:
- terbutaline 250mcg IV slowly over five minutes or
- salbutamol 10 mg in 1 L IV fluids (normal saline or Ringer’s lactate) at 10 drops per
minute.


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- terbutaline 250mcg IV slowly over five minutes or
- salbutamol 10 mg in 1 L IV fluids (normal saline or Ringer’s lactate) at 10 drops per
minute.
• If a good contraction pattern has not been established with the infusion rate at 60 drops per
minute:


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Obstetrics andGy necology
262
- Increase the oxytocin concentration to 5 units in 500 mlof dextrose (or normal saline)
and adjust the infusion rate to 30 drops per minute (15 mIU per minute);
- Inmultigravidaand inwomen with previous caesarean scars,induction has failed; deliver
by caesarean section.
Prostaglandins
Prostaglandins are highly effective in ripening the cervix during induction of labour.
 Monitor the woman’s pulse, blood pressure and contractions, and check the fetal heart
rate.Record findings on a partograph.
 Prostaglandin E2 (PGE2) is available in several forms (3 mg pessary or 2–3 mg gel). The
prostaglandin is placed high in the posterior fornix of the vagina and may be repeated
after six hours if required.


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prostaglandin is placed high in the posterior fornix of the vagina and may be repeated
after six hours if required.
 Discontinue use of prostaglandins and begin oxytocin infusion if: membranes rupture;,
cervical ripening has been achieved;, good labour has beenestablished;,  or 12 hours have
passed.
Misoprostol
 Use misoprostol to ripen the cervixonly in highly selected situationssuch asseverepre-
eclampsia or eclampsia when the cervix is unfavourable and safe caesarean section is not
immediately available or the baby is too premature to survive; fetal death in-utero if the
woman has not gone into spontaneous labour after four weeks and platelets are
decreasing.
 Place misoprostol 25 mcg in the posterior fornix of the vagina. Repeat after six hours, if
required.


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decreasing.
 Place misoprostol 25 mcg in the posterior fornix of the vagina. Repeat after six hours, if
required.
 If there isno response after two doses of 25 mcg, increase to 50 mcg every six hours;
 Do not use more than 50 mcg at a time and do not exceed four doses (200 mcg).
 Monitor uterine contractions and fetal heart rate of all women undergoing induction of
labour with prostaglandins.
Foley catheter (mechanical dilation)
The Foley catheter is an effective alternative to prostaglandins for cervical ripening and
labour induction. It should, however, be avoided in women with obvious cervicitis or
vaginitis.
 Gently insert a high-level disinfected or sterile speculum into the vagina.
 Hold the catheter with a high-level disinfected or sterile forceps and gently introduce it


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 Hold the catheter with a high-level disinfected or sterile forceps and gently introduce it
through the cervix. Ensure that the inflatable bulb of the catheter is beyond the internal
os.
 Inflate the bulb with 30ml of water. Give traction to rest of the catheter and strap it with
the thigh. Leave the catheter in place until contractions begin, or for at least 12 hours.
 Deflate the bulb before removing the catheter and then proceed with oxytocin infusionto
augment induction of labour.


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Obstetrics andGy necology
263
 Primary PPH i.e. bleeding within 24 hours of delivery is commonly due to atonic uterus
(90% cases) or cervical/vaginal tears (traumatic PPH). It can also be due to occult uterine
inversion, rupture uterus or coagulation defect.
 Abnormal bleeding can also occur between 24 hours and 6 weeks of delivery (secondary
PPH) due to sepsis, retained placental bits, or placental polyp, choriocarcinoma.
 PPH requires prompt and effective management, failing which it may result in
complications like hypovolaemic shock, coagulation failure, renal failure, hepatic failure,
adult respiratory distress syndrome and may also result in maternal death.
• Monitor pulse rate, blood pressure, respiratory rate and urine output. While resuscitative


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• Monitor pulse rate, blood pressure, respiratory rate and urine output. While resuscitative
measures are underway, a thorough clinical examination is made toascertain the cause of
PPH and definitive treatment is planned accordingly.
POSTPARTUM HAEMORRHAGE (PPH )
Postpartum haemorrhage is excessive blood loss from the genitaltract after delivery of the
foetus exceeding 500 ml or affecting the general condition of the mother.
Salient features
Pharmacologicaltreatment
IV fluids and blood replacement therapy
ATONIC PPH
Prevention
Identify risk factors and anticipate the problem.
Active management (oxytocin 5 units intramuscularly at the birth of anterior shoulder or after
delivery of placenta) should be done in all cases unless contraindicated.
Non pharmacological treatment


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delivery of placenta) should be done in all cases unless contraindicated.
Non pharmacological treatment
Placental removal with cord traction if already separated uterine massage and bimanual
compression.
Pharmacological treatment(Table6)
 Oxytocin infusion (10-40 units in 500 ml Ringer's lactate/normal saline at125 ml/min)
 Methyl ergometrine maleate0.2 mg IV may be repeated IM after5-10 min. (Caution:
Contraindicated in heart disease, hypertension).
Table 6. Drugs used in the treatment of post partum haemorrhage
Drug Dose and Route Continuing Dose Maximum Dose Precautions and
Contraindications
Oxytocin IV: Infuse 20
units in 1 L IV
fluids at 60
drops per minute
IM:  5-10 units
IV: Infuse 20
units in 1 L IV
fluids at 40 drops
per minute
Not more than 3
L of IV fluids
containing
oxytocin


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drops per minute
IM:  5-10 units
IV: Infuse 20
units in 1 L IV
fluids at 40 drops
per minute
Not more than 3
L of IV fluids
containing
oxytocin
Do not give as an
IV bolus
Ergometrine/ IM or IV Repeat 0.2 mg Five doses (TotalHigh blood


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Obstetrics andGy necology
264
 Prostaglandins shouldnot be given intravenously. It  may be fatal
 If bleeding is not controlled15-methyl PGF2 A 0.25 mg IM intramyometrial, may be
repeated every15-90 min up to a maximum of 2 mg. (Caution:Contraindicated in
bronchial asthma, epilepsy).
 In patients with bronchial asthma and epilepsy, administer with caution Tab. misopristol
600 mcg per rectum.
Indication for referral
If patient is still bleeding despite medical therapy and if facilities for transfusion and further
management are not available arrange for transfer to a higher center. Intrauterine packing
may be done in the mean time.
Surgical treatment
 Retained placenta-Manual removal of placenta under general anaesthesia (GA)
 Cervical/ vaginal tears-Exploration and repair


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Surgical treatment
 Retained placenta-Manual removal of placenta under general anaesthesia (GA)
 Cervical/ vaginal tears-Exploration and repair
 Rupture uterus-Laparotomy with repair/ hysterectomy
 Uterine inversion-Reposition under GA
 Atonic PPH not controlled-Laparotomy with uterine artery ligation with medical measures
 Internal artery ligation/Hysterectomy
Patient education
 Higher parity and previous atonic PPH predispose to PPH.
 Hospital delivery is mandatory in women with PPH in a previous pregnancy, grand
multipara, multiple pregnancy, APH and severe anaemia.
PREVENTION OF MATERNAL TO CHILD TRANSMISSION
Transmission rate during pregnancy 5-10%, during labor and delivery10-15% and during
breastfeeding   5-20%.
Risk factors for vertical transmission


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Transmission rate during pregnancy 5-10%, during labor and delivery10-15% and during
breastfeeding   5-20%.
Risk factors for vertical transmission
 Viral load >50000 RNA copies/ml at time of delivery
 CD4 count <700/cumm
 Chorioamnionitis
 Duration of ruptured membranes over 4 hrs doubles the risk
 Intrapartum haemorrhage
Methyl-
Ergometrine
(slowly): 0.2 mg IM after 15
minutes. If
required, give 0.2
mg IM or IV
(slowly) every
four hours
1.0m g) pressure, pre-
eclampsia, heart
disease
15-Methyl
ProstaglandinF2
IM: 0.25 mg 0.25 mg every 15
minutes
Eight doses
(Total 2 mg)
Asthma


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Obstetrics andGy necology
265
 Mod e of delivery
 Invasive fetal monitoring
 Breastfeeding
Basic mechanism for mother to child transmission
 Transplacental
 Exposure to maternal blood and vaginal secretion at the time of delivery.
 Postnatal exposure to maternal secretions such as breast milk.
2006 guidelinesrecommended that only women with a low CD4 count should receive a
combination ofHIV and AIDS drugs to prevent mother-to-child transmission and all HIV-
positive mothers were advised to exclusively breastfeed for 6 months and then rapidly wean
to avoid transmitting HIV to their infant.
New 2010 guidelines, recommended that all HIV-positive mothers, identified during
pregnancy, should receive a course of antiretroviral drugs to prevent mother-to-child


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pregnancy, should receive a course of antiretroviral drugs to prevent mother-to-child
transmission. All infants born to HIV-positive mothers should also receive a course of
antiretroviral drugs and should be exclusively breastfed for 6 months and complementary fed
for up to a year.
Four key strategies for preventing mother-to-child transmission
1. Keeping women of reproductive age and their partners HIV -negative through
reproductive health and HIV prevention services.
2. Avoiding unwantedpregnanciesamong HIV -infected women and women at risk of HIV,
through family planning and HIV testing and counselling services.
3. Ensuring HIVtestingof pregnant women and timely access to effective antiretroviral
therapy, both for the health of HIV-infected mothers and for PMTCT, during pregnancy,


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therapy, both for the health of HIV-infected mothers and for PMTCT, during pregnancy,
delivery and breastfeeding.
4. Better integration of HIV care,treatmentand support for HIV-infected women and their
families.
Following should be avoided
 Artificial rupture of membranes
 Routine use of fetal scalp electrodes for fetal monitoring
 Operative delivery with forceps or a vacuum extractor and/or episiotomy
CD4 count has to be done.  If CD4 count less than or equal to 350 cells/mm3 start
antiretroviral drugs for their own health. CD4 count higher than 350 cells/mm3 – no need of
ART for mother’s health. But helps in preventing transmission.
Mothers, when identified in pregnancy as being HIV positive, should begina triple


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ART for mother’s health. But helps in preventing transmission.
Mothers, when identified in pregnancy as being HIV positive, should begina triple
antiretroviral regimen immediately after being diagnosed, irrespective of their CD4 count.
Mothers should remain on the same triple antiretroviral regimen throughout pregnancy and
continuing for life.


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266
Infants born to HIV positive mothers shouldreceive a course of medication for PMTCT.
Under the infant should receive daily NVP or AZT from birth until age 4-6 weeks, regardless
of infant feeding method.
Three options for PMTCT(Table7):
Table 7. Treatment options for prevention of mother to child transmission of HIV
Treatment
(for CD4 count <350
cells/mm3)
Prophylaxis
( for CD4 count >350
cells/mm3)
Infant recieves
Option A Triple ARVs starting as
soon asdiagnosed,
continued for life
Antepartum:AZT
starting asearly as 14
weeks gestation
Intrapartum:at onset of
labour
-single-dose NVP and
first doseof AZT/3TC
Postpartum:daily
AZT/3TC through 7
days postpartum
Daily NVP from birth
until 1week after
cessation of all
breastfeeding; or, if not
breastfeeding or if


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AZT/3TC through 7
days postpartum
Daily NVP from birth
until 1week after
cessation of all
breastfeeding; or, if not
breastfeeding or if
mother ison treatment,
through age4–6 weeks
Option B Triple ARVs starting as
soon asdiagnosed,
continued for life
Triple ARVs starting as
early as14 weeks
gestation and
continued intrapartum
and through childbirth if
notbreastfeeding or
until 1 weekafter
cessation of all
breastfeeding
Daily NVP or AZT
from birththrough age
4–6 weeks
regardless of infant
feeding method
Option B+ Triple ARVs starting as
soon asdiagnosed,
continued for life
Triple ARVs starting as
soon asdiagnosed,
continued for life
Daily NVP or AZT
from birththrough age
4–6 weeks
regardless of infant
feedingmethod
AZT: Zidovudine,  sd-NVP: Single-dose Nevirapine,  NVP: Nevirapine,


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from birththrough age
4–6 weeks
regardless of infant
feedingmethod
AZT: Zidovudine,  sd-NVP: Single-dose Nevirapine,  NVP: Nevirapine,
AZT: Zidovudine,  3TC: Lamivudine
VA GINAL DISCHARGE
Reproductive tract infections (RTI), including sexually transmitted infections(STI), represent
a major public health problem. Syndromic management of symptomatic individuals is
recommended.  NACO algorithm for the management of vaginal discharge (Figure1, Table
8):


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267
Figure 1. NACO algorithm for the management of vaginal discharge
Table 8.NACO algorithm for the management of vaginal discharge
There are seven pre-packed colour coded STI/RTI drug kits under NACP for syndromic
management of STI/RTI and procured by NACO. These drug kits have been developed based
on the National Guidelines on Prevention, Management and Control of Reproductive Tract
Infections including Sexually Transmitted Infections, Ministry of Health & FW, August
2007.Syndromic Case Management Protocol
Kit No. Syndrome Colour Contents
Kit 1 Cervicitis
Urethral Discharge
Presumptive treatment
Grey T. Azithromycin 1 g (1) and
T. Cefixime 400 mg (1)
Kit 2 Vaginitis Green T. Secnidazole 2g (1) and
T. Fluconazole 150 mg (1)
Kit 3 Genital Ulcer Disease– Non


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T. Cefixime 400 mg (1)
Kit 2 Vaginitis Green T. Secnidazole 2g (1) and
T. Fluconazole 150 mg (1)
Kit 3 Genital Ulcer Disease– Non
Herpetic
White Inj. Benzathine Penicillin 2.4 MU (1)
and T.Azithromycin 1 g (1)
Kit 4 Genital Ulcer Disease– Non
Herpetic (for patients allergic to
Penicillin)
Blue T. Doxycycline 100 mg (30) and
T. Azithromycin 1 g (1)
Kit 5 Genital Ulcer Disease-Herpetic Red T. Acyclovir 400 mg (21)
Kit 6 Lower Abdominal Pain (PID) Yellow T. Cefixime 400 mg (1) and
T. Doxycycline 100 mg (28) and
T. Metronidazole 400 mg (28)
Kit 7 Inguinal Bubo Black T. Doxycycline 100 mg (42) and
T. Azithromycin 1 g (1)


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 Lower abdominal pain, cervical motion tenderness and adenexal tenderness,fever,
cervical discharge and leucocytosis.
 In severe cases patient may be toxic with high-grade fever, vomiting,dehydration,
and abdominal distension.
 Long term sequelae can be infertility, ectopic pregnancy, chronic pelvic pain.
 Failure of acute PID to resolve completely results in chronic PID with featuresof
severe, persistent and progressive pelvic pain, repeated acute exacerbationof PID,
tubo-ovarian inflammatory mass, dyspareunia or bilateral ureteralobstruction from
ligamentous cellulitis.
PELVIC INFLAMMATORY DISEASE (PID)
Pelvic inflammatory disease (PID)results frominfection of cervix, uterus,tubes, ovaries


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ligamentous cellulitis.
PELVIC INFLAMMATORY DISEASE (PID)
Pelvic inflammatory disease (PID)results frominfection of cervix, uterus,tubes, ovaries
and pelvic peritoneum. The disease may have acute or chronic presentation. The
commonest cause is sexually transmitted diseases, however, other causes include post
abortaland puerperal sepsis, operative procedures like dilatation and curettage, endometrial
biopsy, and insertion of intrauterine device.
Salient features
Investigations
 Haemogram with ESR, LFT, RFT, serum electrolytes,blood culture, endocervical
swab culture, ultrasonography if adenexal mass.
Treatment (Acute PID)
The patient can be treated as an outpatient or inpatient depending on the severityof clinical
features.
I. Outpatient treatment- mild PID


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The patient can be treated as an outpatient or inpatient depending on the severityof clinical
features.
I. Outpatient treatment- mild PID
Either of the following two regimens can be given:
Regimen A
 Inj. cefoxitin 2 g IM, plusprobenecid 1 g orally, as a single doseor Inj. ceftriaxone
250 mg IM as a singledose or Inj. ceftizoxime or cefotaxime 500 mg IM as a single
dose.
 Cap. doxycycline 100 mg 2 times a day for 14 days.
Regimen B
1. Tab. ofloxacin 400 mg oral 2 times a day for4 days.
2. Tab. Clindamycin 450 mg oral 4 times a day for 14 daysor Tab. metronidazole 400
mg 2 times a day for 14 days
Follow up after 2- 3 days of initiation of therapy; patient is reevaluated forclinical
response. If poor response, patient is to be admitted for intravenous antibiotics.


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response. If poor response, patient is to be admitted for intravenous antibiotics.
II. Indoor treatment- severe illness or nausea and vomiting, HIV positive, unable to
followor tolerate an outpatient regimen and outpatient therapy failed.
 Bed Rest. Hydrotherapy, if febrile.
 IV fluids in cases of vomiting and dehydration and correction of electrolyteimbalance.


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Monitoring
Clinical condition, vital monitoring, signs and symptoms of pelvicabscess and peritonitis.
Either of the following regimens may be instituted at the earliest without waitingfor culture
reports:
Regimen A
 Inj. cefoxitin 2 g IV every 6 hoursorInj. cefotetan 2 g IV every 12 hours.
 Inj. doxycycline 100 mg IV or orally every 12 hours.
 Inj. metronidazole 500 mg IV 8 hourly.
Regimen B
 Inj. clindamycin 900 mg IV every8 hours.
 Inj. gentamicin 2 mg/kg IV followed by 1.5 mg/kg every 8 hours.
 Inj. diclofenac sodium 75 mg deep IM 8 hourlyorInj. paracetamol 500 mg IM SOS.
 Inj. metronidazole 500 mg IV 8 hourly.
Injectable regimen should be continued for at least 48 hours after the patientdemonstrates


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 Inj. metronidazole 500 mg IV 8 hourly.
Injectable regimen should be continued for at least 48 hours after the patientdemonstrates
clinical improvement (becomes afebrile, decrease in lowerabdomen and pelvic tenderness,
improvement in constitutional symptoms).After this, doxycycline 100 mg 2 times a day
orally or clindamycin 450mg oral 4 times a day should be continued for total of14 days.
Clinical improvement should occur within 3 days of initiation of therapy.  Considerfurther
diagnostic tests /laparoscopy if symptoms do not improve or worsen.Different procedures
may be required in the following situations:
 Colpotomy for drainage of midline pelvic abscess
 Dilatation and evacuation of septic products of conception in post abortal sepsis.


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 Colpotomy for drainage of midline pelvic abscess
 Dilatation and evacuation of septic products of conception in post abortal sepsis.
 Laparotomy in cases of pyoperitoneum, resistant peritonitis, intestinalobstruction,
ruptured tubo-ovarian abscess,enlarging pelvic mass despite medical therapy,
 Laparoscopy: if diagnosis is uncertain, no response to treatment,to reconfirm the
diagnosis, obtain cultures from cul de sac and fallopian tubes and drain pus if necessary.
Treatment of the sexual male partner
Asymptomatic male partner:Inj. ceftriaxone 125 mg IM followed by oral doxycycline 200
mg 2 times aday for 14 days.
Treatment (ChronicPID)
Treatment is surgical, considering pathological lesion, patient's age, and desire for child


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mg 2 times aday for 14 days.
Treatment (ChronicPID)
Treatment is surgical, considering pathological lesion, patient's age, and desire for child
bearing. Definitivesurgery is total abdominal hysterectomywith bilateral salpingo-
oophorectomy, but in young females conservative surgery is preferred.Chronic PID can be
due to pelvic tuberculosis.
Treatment (Pelvic tuberculosis)
Primary treatment is medical therapy withanti tubercular drugs for 6 months. Daily dose of
the drugs is:
 Tab. isoniazid 5 mg/kg (maximum 300 mg).
 Cap. rifampicin 10 mg/kg (maximum 600 mg).


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 Somatic symptoms include feeling of bloating, bodyaches, breasttenderness,
headache, food cravings and poor concentration.
 Emotional symptoms include emotional hypersensitivity, depression, irritability,
mood swings, anxiety, tension, fear of loss of control and confusion.
 Diagnosis is confirmed by excluding the concomitant medical or psychiatric
disorders with which it may be confused(depending on the symptoms).
 Tab. pyrazinamide 15-30 mg/kg (maximum 2 g).
 Cap. ethambutol 15-25 mg/kg (maximum 2.5 g).
All 4 drugs are given in the initial phase for 2 months followed by INHand rifampicin for
4 months.
Indications of surgery are: primary unresponsiveness,persistence or enlargement of


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4 months.
Indications of surgery are: primary unresponsiveness,persistence or enlargement of
adenexal mass after 4- 6 months of treatment,persistence or recurrence of pelvic painon
treatment. Definitive surgery is totalabdominal hysterectomy with bilateral salpingo-
oophorectomy.
Patient education
 Emphasize behavioural and contraceptive methods to prevent the acquisition of STDs.
 Encourage to complete the antibiotic treatment forthe full course i.e. 14 days.
 Sexual abstinence until complete treatment. Sexual partner of patientdiagnosed with
PID must be treated to prevent reinfection.
PR E M E NS T R U AL  S Y N D RO ME
P r em en s t r u a l  s yn d ro m e  ( P M S )  is a cyclic recurrence of physical, psychological or


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PR E M E NS T R U AL  S Y N D RO ME
P r em en s t r u a l  s yn d ro m e  ( P M S )  is a cyclic recurrence of physical, psychological or
behavioural symptoms after ovulation and resolve after the onsetof menstruation. It
requirestreatment when the symptoms are severe to interfere with the woman'slifestyle,
relationships and occupational functioning.
Salient features
Non -pharmac ological treatment
Life-style advice should be offered to all women as first line of treatment.
1. Daily charting of symptoms for two months.
2. Dietary modifications like: increase complex carbohydrate meals, reduce or eliminate,
especially in the luteal phase- salts, chocolate, caffeine and alcohol;and several small
meals per day.


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especially in the luteal phase- salts, chocolate, caffeine and alcohol;and several small
meals per day.
3. Moderate regular aerobic exercise like brisk walk 1-2 miles per day for 4-5 days/week.
4. Stress management courses/counseling.
Pharmacological treatment
1. Tab. pyridoxine 100 mg/dayfor 10-14 days (during luteal phase) (maximumdaily dose is
150 mg) or Tab. Eveningprimrose oil 500 mg 3 times a day.
2. NSAIDs like mefenamic acid 500 mg 3 times a day for premenstrual dysmenorrhea.
3. In case of predominantly physical symptoms (bloatedness, irritabilityswelling,


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271
 Disturbances of the menstrual cycle, regular andirregular uterine bleeding and
alteration in the amount or duration of the menstrual blood loss.
 Due to anovulatory cycles but can also occur in the ovulatory cycles. Anovulatory
cycles are usual in postmenarche, premenopausal agegroups and are usually irregular,
variable in duration and amount of bleeding.
weight gain, breast tenderness), Tab. spironolactone 100 mg/dayOr Tab. bromocriptine
1.25- 5 mg/day in the luteal phase for mastalgia. (Common side effects are nausea and
vomiting. Tablet can be given vaginallyif side effects are very severe.)
4. If no relief in symptoms with above measures in 2- 3 cycles and symptoms are
predominantly emotional, then the following drugs are used preferablyin consultation


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predominantly emotional, then the following drugs are used preferablyin consultation
with a psychiatrist:Tab. fluoxetine 5-20 mg/day
5. In non-responders to the above therapy, ovulation suppression may bebeneficial; any
of the following can be used:Low dose combined oral contraceptive pills, 1 pill daily
from 5th to 25thday of the cycle.
D YSFUNCTIONAL UTERINE BLEEDING (DUB)
Dysfunctional uterine bleeding (DUB) is an abnormal uterine bleeding in the absence
of organic disease of the genital tract.
Salient features
Treatment (Acute bleeding-first episode)
I.Severe bleeding (hemodynamically unstable patient)
 IV line, fluid replacement, blood transfusion, oxygen inhalation and monitoring of vitals.
 Dilatation and curettage to arrest bleeding except incases of puberty menorrhagia where


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 Dilatation and curettage to arrest bleeding except incases of puberty menorrhagia where
medical management is preferred. IVtranexamic acid can be tried before resorting to
surgical intervention.
II. Less severe bleeding (haemodynamically stable patient)
 High dose progestogen: norethisterone 10 mg 3 times a day until bleeding stops(not >3
days) followed by norethisterone 5-10 mg or medroxyprogesterone acetate 10 mg per
day for 21 days. Withdrawal bleedingoccurs after 2-4 days of stopping the drug and
stops in 4-5 days. Or combined oral contraceptive pills (OCs) containing 50 mcg
ethinyloestradiol 1pill 2 times a day for 7-10 days followed by progestins for 7-10 days,
followed by withdrawal bleeding.
III.If bleeding is not controlled with progestogens


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followed by withdrawal bleeding.
III.If bleeding is not controlled with progestogens
Patient is having heavy bleeding for many days, endometrial curettage yieldsminimal
tissue, or when the patient has been on progestogen medication (OC's orDepot MPA) and
the endometrium is shallow and atrophic.
Treatment schedules of high dose oestrogens, depending on the severity of thebleeding the
following can be used:
1. Conjugated oestrogen 25 mg IV every 4 h till bleeding abates or for 12 h.Progestin


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Obstetrics andGy necology
272
treatment is started at the same time.
2. Oral treatmentconjugated oestrogen 1.25 mg or 2 mg oestradiol valerate given
orally every 4 h for maximum of 24 h followed by single daily dose for 7-10 days.
All treatments must he followed by progestin coverage (10 mg MPA daily) alongwith
oestrogen for 7 days.
Moni toring
Clinical monitoring by vital charting and observation of blood loss per vaginum
Treatment (Chronic DUB - not actively bleeding)
 Iron therapy: elemental iron maximum 60 mg 3 times a day
 Histopathological diagnosis is must before starting hormonal therapy in allcases except
puberty menorrhagia.
I. Anovulatory DUB
 If contraception is desired: OCPs for 3-6 cyclesor norethisterone 5-10 mg.


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puberty menorrhagia.
I. Anovulatory DUB
 If contraception is desired: OCPs for 3-6 cyclesor norethisterone 5-10 mg.
 Medroxyprogesterone acetate (MPA) 10 mg 16-25th day of the cycle for3-6 cycles.
 In cases of endometrial hyperplasia without atypia on histology norethisteroneacetate 5 mg
three times a day or MPA 10 mg twice a day 5-25th day of cycle for 3-9 cycles
followed by repeat endometrial biopsy.
 If fertility desired: ovulation induction is advised.
 Levonorgestrel IUD can be offered after counseling and is beneficial in DUB.
II. Ovulatory DUB
 NSAIDs: mefenamic acid 500 mg 3 times a day for 3-5 days during periods. Or
 Oral combined contraceptive pills if contraception is desired.
If the above treatment is not effective in first cycle patient should be referredfor


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 Oral combined contraceptive pills if contraception is desired.
If the above treatment is not effective in first cycle patient should be referredfor
tertiary care. Following treatment can be considered as analternative to surgery:
 Tab. danazol 200 mg daily for 3 months.
 Levonorgestrel IUCD can be offeredafter counseling and is beneficial in DUB.
Follow up
After 1, 3, 6 months of therapy. Treatment is stopped after3-6 months. If symptoms
recur medical treatment is to be continued or surgery canbe offered.
Surgical treatment- endometrial curettage
 Acute bleeding in haemodynamically unstable patient to quickly control thebleeding.
 In acute episode, if bleeding doesn't decrease significantly in 12-24 hours with


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 In acute episode, if bleeding doesn't decrease significantly in 12-24 hours with
medical treatment, then reevaluation is mandatory and surgical curettageshould be
done.
 If age is >35 years- premenstrual dilatation and curettage for endometrialhistology is
a must to rule out endometrial pathology.
If medical therapy is not effective then endometrial ablation or hysterectomy isto be
performed.


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273
 Hot flushes, night sweats, palpitations, vaginal dryness, itching, atrophy ofthe
breast and skin, urethral syndrome, stress incontinence, mood changeslike anxiety,
irritability, depression, insomnia and joint pains.
 Diagnosis is always clinical. However, in doubt, estimateserum FSH levels and
oestradiol levels may be helpful.
Patient education
 Common side effects of high dose oestrogens are: nausea, vomiting,headache,
depression, and fluid retention. Contraindicated in liver disease,history of
thromboembolic disorder, cardiovascular disease, and oestrogen dependant neoplasm.
 Common side effects of progestogens are depression, fluid retention, fatigue,insomnia,
dizziness, nausea, and breast tenderness.
MENOPAUSE


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 Common side effects of progestogens are depression, fluid retention, fatigue,insomnia,
dizziness, nausea, and breast tenderness.
MENOPAUSE
Permanent cessation of menses for one year is known as menopause. The usual age is
between 40 to 50 years, mean age being 48 years. Long term consequences due to
decreased oestrogens can increase the risk of ischaemic heart disease due to adverselipid
profile and pathological fractures due to osteoporosis.
Salient features
Non -pharmacological treatment
 Balanced diet with fruits, vegetables, semi-skimmed milk adequate in vitaminsand
minerals. A reduction or avoidance of smoking and alcohol consumption.
 Exercise: walking or swimming for 20-30 min every day.
Pharmacological treatment
 Tab. calcium 1500 mg daily.


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 Exercise: walking or swimming for 20-30 min every day.
Pharmacological treatment
 Tab. calcium 1500 mg daily.
 Hormone replacement therapy (HRT). Rule out contraindications to HRT like
endometrial/breast cancer, acute phase myocardial infarction,undiagnosed breast
lump/abnormal vaginal bleeding and acute liver disease.Hypertension and diabetes if
present should be controlled before HRT isprescribed.
Oestrogen therapy
 For hysterectomized patients- conjugated equineoestrogen 0.625-1.25 mg.or oestriol
1-2 mg is given daily 1-25th day every month or daily without anybreak. If symptoms
recur during drug free period then give continuoustherapy. Or
 Transdermal oestradiol patch 50 or 100 mcg/day applied twice a week away from breast,


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recur during drug free period then give continuoustherapy. Or
 Transdermal oestradiol patch 50 or 100 mcg/day applied twice a week away from breast,
preferably on the shaved skin of buttock, thigh or legs (Limitingfactor is local skin
reactions).Transdermal oestradiol patch is preferred in case of gall bladder disease,
hypertriglyceridimea, history of thromboembolism, poorly-controlled hypertension,
recent myocardial infarction, vascular diseases, migraine,chronic hepatic dysfunction,
malabsorption syndrome.
 Combined therapy with oestrogens and progestin in women with intact uterus.


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274
 Obese women and women taking hormone replacement therapy (HRT),vaginal atrophy,
lesions and cracks on the vulva may bleed.Bleeding from the upper reproductive system
can be caused by hormone replacements, endometrial cancer (5-10%), endometrial
polyps, cervicalcancer, cervical lesions, uterinetumours, ovarian cancer or oestrogen
secreting tumors in other parts of the body.
 Diagnosis is confirmed by endometrial or cervical biopsy. Non-invasive testsinclude saline
infusion sonography (SIS), a refinement of vaginal probeultrasound.Dilatation and
curettage(D & C) is often necessary for definitive diagnosis.
i. Oestrogen therapy as above.
ii.Progestogen-medroxyproge sterone acetate 5- 10 mg, or dihydrogesterone 10- 20


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i. Oestrogen therapy as above.
ii.Progestogen-medroxyproge sterone acetate 5- 10 mg, or dihydrogesterone 10- 20
mg or norethisterone 2.5 mgor 200 ml micronized progesterone is added from 13th to
25th days in cyclicsequential regimen and 1st to 12th of every month in continuous
sequential regimen.
If withdrawalbleeding is not acceptable then give continuous combinedtreatment (0.625 mg
conjugated equine oestrogen + 2.5 mg medroxyprogesterone acetate or 1 mg micronized
oestrogen + 100 mgmicronized progesterone).
If conventional HRT is contraindicated
 Tab. Tibolone 2.5 mg per day (major side effects are weight gain, oedema, breasttenderness,
GIT symptoms and vaginal bleeding).
 In symptomatic elderly women with atrophic vaginitis and other urogenital symptoms who


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GIT symptoms and vaginal bleeding).
 In symptomatic elderly women with atrophic vaginitis and other urogenital symptoms who
do not desire long term HRT:Oestriol cream dailyapplication of 0.5 g delivering 0.5 mg of
oestriol for 3 weeksfollowed by twice weekly application for 3- 4 weeks.(Key indicator
of response to therapy is improvement in symptoms).
 Follow up at 2-3 months then at 6 monthly intervals. Yearly mammography,Pap'ssmear,
pelvic USG and serum oestradiol are advisable.
Short term treatment is advocated for acute symptoms and oestrogen use forlong term
benefits is controversial.
Patient education
 Explain about the side effectsof estrogen andprogestogens
 Follow up visits at 2-3 months then at 6 monthly intervals are necessary.
POSTMENOPAUSAL BLEEDING


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 Follow up visits at 2-3 months then at 6 monthly intervals are necessary.
POSTMENOPAUSAL BLEEDING
Postmenopausal bleeding (PMB) is bleeding that occurs after menopause has beenestablished
for at least one year. It is different from infrequent, irregular periods thatoccur around the time
of menopause. Salient features


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Obstetrics andGy necology
275
Treatment
Treatment of postmenopausal bleeding according tocause
Cause Treatment
Benign & malignant neoplasm of vulvaRefer to higher center or treatcervix,vagina,
uterus or ovaries according to cause and
facilities available.
Indiscriminate use of oestrogen for HRTStop oestrogen therapy
Infections Antibiotics
Injuries Repair
Coagulation disorder Treat accordingly
Endometritis Antibiotics
Postmenopausal atrophic vaginitis Vaginal oestrogen cream/ointment
Indication for referral to a higher level of care
Urgent referrals:
 Palpable pelvic mass or lesions suspicious of cancer on vulva or vagina orcervixon
examination or on ultrasound.
 More than one or a single heavy episode of PMB in women aged >55 years (not onHRT).


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examination or on ultrasound.
 More than one or a single heavy episode of PMB in women aged >55 years (not onHRT).
 Postcoital bleeding (PCB) in a woman aged >35 years that has persisted for morethan 4
weeks.
 Prolonged or unexpected bleeding thatpersists for more than 4 weeks afterstopping
HRT.
Early Referral(within 4-6 weeks)
Any other woman with PMB not on HRT who does not satisfy the criteria for`urgent
referral'of postmenopausal bleeding
 Unexplained repeated postcoital bleeding.
Note - in women over 45 years with persistent abdominal distension or pain, ovarian
cancer should be considered and therefore a pelvic examination shouldbe performed.If
excessive bleeding, give hemostatic drugs (oral or intravenous)Postmenopausal bleeding


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excessive bleeding, give hemostatic drugs (oral or intravenous)Postmenopausal bleeding
that is not due to cancer and cannot be controlled byany other treatment usually requires a
hysterectomy.
EARLY DETECTION OF CANCER
Screening for Breast Cancer (ACS Guidelines)
 Early detection of breast cancer in average risk women begins at 20 years and consist of a
combination of clinical breast examination (CBE), counseling to raise awareness of breast
symptoms and regular mammography beginning at age 40.
 Between 20 and 39 years, women should undergo clinical breast examination every 3
years. The average risk women should begin annual mammography at 40years and should
continue to be screened with mammography. Self examination of breast should also be


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276
advised to every woman at 20 years.
 Self breast examination from the age of 20years
 Clinical examination once in 3 years by a physician
 Baseline mammogram from age of 40 years and once in 2 years afterwards
 Annual mammography from the age of 50 years
 In countries with limited resources, mammogram is available for diagnosticpurposes not
for screening.
Screening for Cervical Cancer
 Screening for cervical cancer should be approximately 3 years after the onset ofvaginal
intercourse, but not later than age of 21 years.
 Annual screening with conventional cytology smears or biennial screening using liquid
based cytology is recommended until the age of 30 years. At or after 30years, a woman


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based cytology is recommended until the age of 30 years. At or after 30years, a woman
who has had 3 consecutive, technically satisfying normal/negative cytology results may
undergo screening every 2– 3 years using conventional or liquidbased cytology.
 After30 years of age, women who have the same history of normal cytology results may
undergo HPV DNA testing with conventional or liquid based cytology every 3
years.Average risk for women aged 70 years and older with an intact cervix may choose
to cease cervical cancer screening if they have no abnormal /positive cytology tests within
the 10 year period before the age of 70 years.
 Women who are immune -compromised by organ transplantation, chemotherapy or
corticosteroid treatment or HIV+ should be tested twiceduring the first year after


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corticosteroid treatment or HIV+ should be tested twiceduring the first year after
diagnosis and annually thereafter.
 Women with a history or absence of CIN 2/3 before as the indication for the
hysterectomy, should continue until there is a 10 year history of no abnormal positive
cytology tests.
 Every woman at 30 years should undergo Papsmear at least once as it helps in diagnosis
of early cervical cancer (ICMR guidelines).
Screening for cervical cancer
Age group- 3 years after sexual activity, not later than 21years.  In countries with limited
resources all women around the age of 30 years should have onePap test.
Method
 Pap smear (or)VIA (visual inspection after application of 5%acetic acid) incountries
with limited resources.
Precautions-Prior to a pap smear


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 Pap smear (or)VIA (visual inspection after application of 5%acetic acid) incountries
with limited resources.
Precautions-Prior to a pap smear
 Not to douche for 48 hours,or usevaginal cream for 1 week, abstain from coitus for 24
hours,smear to be done on 7th day after menstrual period
Technique
 PAP TEST includes samples from ecto-cervix and endo-cervix
 Use bivalved speculum


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 Place the endocervical brush or cotton tipped swaband roll it firmlyagainst the canal
 Remove the endocervical brush or cotton tipped swab and place samples on the glass
slide
 Place the spatula against the cervix with the longer protrusion in the cervical canal
 Rotate the spatula 360° firmly against the cervix, scrape the entire transformation zone
 Place the sample immediately from the spatula onto the glass slide and fix it (spray
fixative or placing it in a bottle of fixative– 95% ethanol.
Follow up-Abnormal smears should be referred for colposcopyand biopsy
Screening for Endometrial Cancer
Women at high risk due to known hereditary non polyposis colon cancer (HNPCC)


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Screening for Endometrial Cancer
Women at high risk due to known hereditary non polyposis colon cancer (HNPCC)
associated genetic mutation carrier status should consider beginning annual testing for early
endometrial cancer detection at an ageof 35. The endometrial biopsy is still the most
common technique used to obtain endometrial tissue.
 Women at high risk (due to hereditary non-polyposis colon cancer carrierstatus) should
consider annual testing from the age of 35.
 Endometrial biopsy is the most common technique used to obtainendometrial tissue.
CONTRACEPTION
A method or a system, which allows intercourse and yet prevents conception, is called a
contraceptive method. This contraception may be temporary when the effect lasts only till the


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contraceptive method. This contraception may be temporary when the effect lasts only till the
couple uses the method but the fertility returns after the use is discontinued. The permanent
contraceptive methods are surgical and are aimed to achieve sterility after the surgical
procedure.
A couple in the reproductive age group, who desires contraception should be provided
information about all the available methods of contraception and should be counselled and
helped so as to choose a method most suitable for that couple. Various contraceptive
methods available are:
I. Temporary methods
1.Hormonal contraceptives
- Combined oral contraceptive pills.
- Injectable hormonal contraceptives (DMPA and NET-EN)
- Progesterone only pill [ketodesogestrel]
2. Non-hormonal contraceptive pills


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- Injectable hormonal contraceptives (DMPA and NET-EN)
- Progesterone only pill [ketodesogestrel]
2. Non-hormonal contraceptive pills
- Centchroman.
3. Intrauterine contraceptive device
- CuT 200B.
- Multiload 250and Multiload 375.
- CuT 380A
- LNG IUCD [mirena]
4. Barrier methods


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278
- Male condoms.
- Vaginal diaphragms with spermicidal jelly.
- Contraceptive sponge.
II. Permanent methods
1. Female sterilization
- Postpartum sterilization.
- Interval ligation (laparoscopic or minilapligation).
- Ligation concurrent with MTP.
2. Male sterilization
- Vasectomy (traditional or non scalpel).
TEMPORARY CONTRACEPTIVE METHODS
I. Hormonal contraceptives
(i) Combined oral contraceptive pills
Low dose combined oral contraceptive pill containing 30 mcg ethinyl oestradiol and a
progestin (0.3 mg Norgestrel or 0.15 mg Norgestrel or 0.15 mg Desogestrel) can be
prescribed. One tabletto be taken daily with meals ata consistent time. It should be started
during first seven days of the menstrualcycle or at any other time when it is reasonably


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during first seven days of the menstrualcycle or at any other time when it is reasonably
certain that she is not pregnant. If started after first 7 days of menstrual cycle, back up
method (abstinence or barrier method) should be used for 7 days. Pills should be taken for
three weeks followed by1 week of pill-free interval during which placebo tablets are to be
taken if pack contains 28 tablets.
In women >40 years of agevery low dose pills containing ethinyl oestradiol 20 mcg and
desogestrel 0.15 mg can be used. After age 50 years, if woman onoral pills, check FSH
during5 -7 days of pill free interval. If FSH >30 IU/1 change to HRT regimens.
Contraindications
 Combined oral contraceptive pills are contraindicated in cases with current or history of,


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Contraindications
 Combined oral contraceptive pills are contraindicated in cases with current or history of,
thromboembolic disease, cerebrovascular disease, coronary artery disease, complicated
valvular heart disease, acute liver disease., current or past breast cancer., undiagnosed
vaginal bleeding, pregnancy, heavy smokers over 35 years of age, migraine with
neurological symptoms, diabetes >20 years or with vascular disease, current gall bladder
disease, uncontrolled hypertension (BP > 160/100).
 Combined oral contraceptive pills should not be taken during first 6 months postpartum if
breastfeeding and first 3 weeks postpartum in non-breastfeeding females.Pills can be
started immediately after spontaneous or induced abortion; can be used with caution in


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started immediately after spontaneous or induced abortion; can be used with caution in
cases with controlled hypertension, diabetes, migraine without neurological symptoms,
non-smokers with age more than 35 years of age without any other medical illness.
Follow up
First follow up should be within 3 months and then annually. Follow up involves history,
blood pressure, urinalysis, breast examination, liver palpation and pelvic examination.


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279
Patient education
 Common side effects are nausea, vomiting, GI upset, breast changes, weight gain, acne,
breakthrough bleeding, amenorrhoea, rash, vaginal candidiasis. Side effects decrease
usually after2 -3 months of use.
 Report immediately in case of symptoms like chest pain, leg pain, severe headache,
severe stomachache, swelling of one or both legs, visual impairment.
 It is one of the most effective contraceptive methods with failure rate of about 0.1%.
 It has non-contraceptive health benefits like regular periods with less pain and bleeding,
improves premenstrual symptoms, and decreases functional ovarian cysts, pelvic
inflammatory disease, ovarian and endometrial cancer, endometriosis.


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improves premenstrual symptoms, and decreases functional ovarian cysts, pelvic
inflammatory disease, ovarian and endometrial cancer, endometriosis.
 Forgotten pill-if one pill is forgotten, take as soon as remembered and next day take next
pill and continue the schedule. Use back up method for 7 days.
 If 2 pills are forgotten take 2 pills and next day again take 2 pills, and then continue as per
schedule. Use back up method for 7 days.
 If 3 pills are forgotten, this cycle is not protected, use back up method till next cycle and
then restart with new pack.
 Should be discontinued at least 4 weeks prior to any planned major surgery.
 Medicines like rifampicin, barbiturates, phenytoin, carbamazepine, primidone,


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 Medicines like rifampicin, barbiturates, phenytoin, carbamazepine, primidone,
griseofulvin interfere with the effects of oral pills. So use alternative method during their
intake.
(ii) Injectable hormonal contraceptives
Highly effective oestrogen free long acting contraceptive can be given when oestrogens are
contraindicated like sickle cell disease, seizure disorders, age >35 years who smoke;
breastfeeding females after first 6 weeks. In non-breastfeeding females, injections can be
safely given immediately postpartum.
Depot medroxy progesterone acetate- 150 mg injection to be given deep IM every three
months. Next injection can be delayed by 2weeks Or Norethisterone enanthate- 200 mg
injection to be given deep IM every 2 months. Next injection can be delayed by 1 week.


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injection to be given deep IM every 2 months. Next injection can be delayed by 1 week.
Absolute contraindications
 Pregnancy
 Unexplained genital bleeding.
 Severe coagulation disorder.
 Previous sex steroid inducedliver adenoma, active liver disease.
 Breast feeding during initial 6 weeks.
 Current or history of thromboembolic disease, cerebrovascular disease, coronary artery
disease.
 Current or past breast cancer
 Diabetes >20 years or with vascular disease
 Uncontrolled hypertension (BP > 180/110).


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Patient education
 Common side effects are irregular bleeding, breast tenderness, weight gain, depression,
headache, dizziness, abdominal pain.
 Beneficial effects and efficacy is same as that of oral contraceptive pills.
 Fertility return is slightly delayed after discontinuation of use.
 Drug interactions are same as with oral hormonal pills.
II.Non -hormonal oral contraceptive pills (Centchroman)30 mg tablet started on first day
of periods. Take twice weekly for three monthsand then continue as once weekly.
Contraindications
Polycystic ovarian disease, cervical intraepithelial neoplasia, severe allergy, recent history
of liver disease,and first 6 months of lactation
Patient education


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of liver disease,and first 6 months of lactation
Patient education
 It is a non-steroidal contraceptive pill, has no hormonal effects with failure rate is 1-2%.
 Delayed periods can occur in 6% cases. If delay is >15 days, perform urine pregnancy
test.
 If one tablet is missed take as soon as possible and resume scheduled intake. Add back up
method till next period. If tablet missed for >7 days, start fresh regimen.
III. Intrauterine contraceptive devices (IUCD)
Any of the following devices can be inserted inside uterus by trained health personnel. It
should be inserted during or shortly after menstruation and after immediately after
spontaneous or induced abortion. After delivery it should be inserted during 4-8 weeks


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spontaneous or induced abortion. After delivery it should be inserted during 4-8 weeks
postpartum. It can be inserted within 5 days of unprotected coitus. These devices need to
be changed after the duration of their lifespan.
Lifespanof intrauterine contraceptive devices (IUCD)
CuT 200B 3 yrs
Multiload 250 3 yrs
Multiload 375 5 yrs
CuT 380 A 10 yrs
Follow up-first follow up should be after next period to check for complications and to rule
out expulsion, after thatfollow up annually.
Contraindications
Pregnancy, postpartum <4 weeks, septic abortion, distorted uterine cavity, uterine fibroids,
current or within past 3 months PID or STD, increased risk of STD, HIV positive, AIDS,
pelvic tuberculosis, unexplained vaginal bleeding, trophoblastic disease, genital tract


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pelvic tuberculosis, unexplained vaginal bleeding, trophoblastic disease, genital tract
malignancy, complicated valvular heart disease.
Patient education
 Common side effects are increased menstrual bleeding and dysmenorrhea. These decrease
after initial 2-3 months.
 No protection for STDs.
 Failure rates are 0.5-3%. Ectopic pregnancy can still occur.


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281
 IUCD may get spontaneously expelled. Therefore monthly palpation of IUCD string is
important. If not palpable, report immediately.
4. Barrier methods
These are cheap, available over the counter, coitus dependant methods. Male condoms,
vaginal diaphragm, spermicidal jellies, vaginal sponge can be used.
Male condoms
Any of the available condoms can be used. For each act of coitus a new condom is to be used.
If during intercourse, condom breaks or if there is spillage or leakage, woman should contact
a clinician within 72 hours and emergency contraception should be provided to her.
Contraindication-severe allergy to latex rubber.
Vaginal diaphragm
Available in different sizes. Proper size should be checked by a clinician by pelvic


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Vaginal diaphragm
Available in different sizes. Proper size should be checked by a clinician by pelvic
examination. Can be inserted 6 hours prior to intercourse. About a tablespoonful of
spermicidal cream or jelly should be placed in the dome of diaphragm prior to insertion;
should be left in place for approximately 6 hours (but not >24 hours) after coitus. Additional
spermicide should be placed in vagina before each additional episode of sexual intercourse.
After removal wash with soap and water, rinse and dry.
Follow up.Annually to assess proper fitting of diaphragm.
Contraceptive sponge
Contains spermicidal agent Nonoxynol 9. It should be removed at least 6 hours after sexual
intercourse. Maximal wear time is 30 hours.
Patient education


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intercourse. Maximal wear time is 30 hours.
Patient education
 Barrier methods provide protection against STDs and PID. Only condom has been proven
to prevent HIV infection.
 Other advantages are prevention of diseases like pelvic inflammatory disease, carcinoma
cervix, chronic pelvic pain.
 It can be used soon after delivery.
 No hormonal side effects.
 Side effects like vaginal dryness, itching, irritation,allergic reactions can occur.
 Failure rates are very high. Typical failure rates are with condoms 14%, diaphragm with
spermicidal jelly 20%, highest with sponge 28%.
PERMANENT CONTRACEPTIVE METHODS
Permanent contraception is provided by sterilization operation in male or female partners.
 Male client should be <60 years of age.


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Permanent contraception is provided by sterilization operation in male or female partners.
 Male client should be <60 years of age.
 Female client should be >22 years and <45 years of age.
 Client must make informed decision voluntarily and must give consent on the consent
form for sterilization.
I. Female sterilization
Done by laparoscopic ligation in interval ligation and first trimester abortions or tubectomy.


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282
Timing
 Interval sterilization-within 7 days after menstrual period is over.
 Postpartum sterilization- after delivery till 7 days but preferably within48 hours. Later
on after 6 weeks postpartum.
 MTP -concurrently
 Spontaneous abortion- concurrently but under antibiotic cover and in the absence of
infection and anaemia.
Contraindications
There are no absolute contraindications. Relative contraindications are psychiatric disorder,
acute febrile illness, jaundice, Hb< 8 g%, chronic systemic disease, malignancy, bleeding
disorder, severe nutritional deficiency. Postpartum sterilization is contraindicated in
puerperial sepsis or fever, severe pre-eclampsia/eclampsia, premature rupture of membrane
>24 hours, severe APH or PPH, genital tract trauma.


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puerperial sepsis or fever, severe pre-eclampsia/eclampsia, premature rupture of membrane
>24 hours, severe APH or PPH, genital tract trauma.
Post abortal sterilization is contraindicated in sepsis, fever, haemorrhage, severe trauma,
uterine perforation, acute haematometra.
Follow-up
First follow up should be done seven days after the surgery for wound examination. Second
follow up is recommended after one month or next menstrual period whichever is earlier.
Subsequent follow-ups if client develops any complication or has query.
II. Male sterilization
Con traindications
There are no absolute contraindications. Relative contraindications include psychiatric and
physical illness, local genital conditions, including large varicocele, hydrocele, inguinal


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physical illness, local genital conditions, including large varicocele, hydrocele, inguinal
hernia, filariasis, cryptorchidism, previous scrotal surgery, intra scrotal mass.
Follow-up. First follow up after 7 days of surgery for wound examination and stitch removal.
Second follow up after 3 months with semen analysis. Subsequent follow up required in cases
of any complication or queries.
Patient education
 In non scalpal vasectomy stitches are not required.
 It is a safe and simple procedure.
 It is a permanent method to prevent future pregnancies.
 It does not affect sexual pleasure, ability or performance.
 It has a small chance of failure even if performed under optimum circumstances.
 After vasectomy it is necessary to use a back up contraceptive method either for 20


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 After vasectomy it is necessary to use a back up contraceptive method either for 20
ejaculations or for a period of 3 months.
 Sterilization does not provide protection against reproductive tract infections/ STDs or
HIV/AIDS.
 Failure rates with female sterilization are < 0.5% and male sterilization < 0.1 %.


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Obstetrics andGy necology
283
Emergency contraception
Method used to prevent pregnancy after a likely fertile unprotected act of sexual intercourse;
can be used in cases of condom rupture, rape or other circumstances of unprotected sex.
First dose should be taken within 72 hours following unprotected sex and second dose 12
hours after the first dose. Any of the following can be used:
Levonorgestrel 0.75 mg 1 tablet 12 hourly for 2 doses. Or combined oral contraceptive pills
containing 50 meg ethinyl oestradiol with 0.5 mg norgestrel 2 tablets 12 hourly for 2 doses.
Or  Low dose combined oral contraceptive pills containing 30 mcg ethinyl oestradiol with 0.3
mg norgestrel 4 tablets 12 hourly for 2 doses.
Patient education


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mg norgestrel 4 tablets 12 hourly for 2 doses.
Patient education
• Side effects are nausea, vomiting, dizziness, fatigue, headache, lower abdominal pain,
breast tenderness, vaginal bleeding.
 It must be used under medical supervision.
 It decreases risk of pregnancy by 70-90%. Earlier it is taken, success is more.
 If vomiting occurs within 2 hours of the dose, it must be repeated.
 There are no contraindications for emergency contraception.
 After this use a barrier method for each act of intercourse until next menstrual period.
 If period delayed >5 days, rule out pregnancy.
 Use regular contraceptive method.


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284
Chapter 14
PSYCHIATRY DISORDERS
Introductionand General Guidelines
The incidence and prevalence ofpsychiatric disorders is on a rise in the 21st century. The
awareness, regarding the nature of mental illnesses and the need for treatment,and their
acceptanceis also improving. Although psychopharmacology forms the backbone of
treatment in most psychiatric disorders, certain points need to be especially emphasized while
managing psychiatric patients:
1) The formation of a trusting,confidential, non-judgemental andempathetic doctor-patient
relationship is crucial to the practice of psychiatry.
2) Knowing the person as a whole rather than only his symptoms endorses patient
improvement.
3) The psychotic patient often loses his judgementand realityperception. Such patients


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improvement.
3) The psychotic patient often loses his judgementand realityperception. Such patients
often have to be treated against their will.
4) Family has an important role in the causationand management of psychiatric disorders.
5) All patients do well with holistic treatment which includes psychopharmacology, other
biological treatments,psychotherapyand rehabilitation.
6) Psychiatric treatment often continues for a long period, so compliance is a major issue.
SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
Schizophrenia is a chronic debilitating psychiatric disorder of varied and profoundly
disruptive psychopathology affecting cognition, perception, emotion and other aspects of
behavior. Its usual age of presentation is around 25 yrs and affects all social classes equally.


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behavior. Its usual age of presentation is around 25 yrs and affects all social classes equally.
Salient features
 The common symptoms of schizophrenia are false, fixed, firm beliefs (delusion),
perceptual abnormalities e.g. hearing of voices while alone (hallucinations).
 A bnormalities in speechand behavioras irrelevant speech,talking to self,crying or
laughing for no reason are also prominent.
 schizophrenia has been divided into following subtypes for the ease of practice.
- Paranoid schizophrenia- Delusions and hallucinations form predominant features
along with other symptoms.
- Catatonic schizophrenia-Characterized by marked psychomotor retardation or
agitation.
- Hebephrenic schizophrenia-Characterized by marked abnormalities of behavior.


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agitation.
- Hebephrenic schizophrenia-Characterized by marked abnormalities of behavior.
- Residual schizophreniaSimple schizophrenia
Non -pharmacologicaltreatment
 Cognitive behaviorally oriented psychotherapy-understanding of illness,identification of
target symptoms, and development of strategies to cope up with these symptoms.


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 Rehabilitation of the patients in the form of supported employment, individualized job
development, ongoing job support, integration of vocational and mental health services.
 Social skills training, behaviorbased instructions, corrective feedback, and contingent
social reinforcement.
Pharmacologicaltreatment
 Hospitalization is indicated insuicidal patients,non compliant patients,treatment
resistant casesand diagnostically difficult cases(Figure 1).
 Antipsychotics(typical and atypical)are the main treatment for such patients(Table 1).
 Co -administration of Tab. trihexyphenidyl (2– 12 mg/day) is recommended with typical
antipsychotics.
 Benzodiazepines (Inj. lorazepam 2-4 mg, orally,IM or IV preparation) may be co-


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antipsychotics.
 Benzodiazepines (Inj. lorazepam 2-4 mg, orally,IM or IV preparation) may be co-
administered in uncooperative patients initially.
 ECT (electro convulsive therapy)- electric shock of 100-120 volts may be given in
patients with associated suicidal intention and treatment resistant cases. It is given for 1-3
seconds under general anesthesia so that it produces short lasting generalized tonic clonic
convulsions.


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Table 1. Dosage scheduleand adverse effectsof commonly used antipsychotics
Drugs Effective dose Dosage schedule Adverse effect
Typical antipsychotics
Haloperidol 5 – 20 mg/day,
available as tablets,
syrup, injection and
depot preparation
(50 mg/ampoule)
Start with 5 mg twice a
day or 10 mg HS and
increase the dose by
5mg if no response.
Depot injection to be
given once two to three
weeks.
More extra-pyramidal side
effects viz slowness of
movements, blunted facial
expressions, tremors,
rigidity, excessive
salivation, etc.
Non specific-sedation,
reduction in seizure
threshold, orthostatic
hypotension,
anticholinergic side effects
CVS -cardiac toxicity,
sudden death,
Hematological-leucopenia
Endocrinal-
hyperprolactinemia
Sexual-anorgasmia and
decreased libido,


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CVS -cardiac toxicity,
sudden death,
Hematological-leucopenia
Endocrinal-
hyperprolactinemia
Sexual-anorgasmia and
decreased libido,
GIT -nausea, vomiting,
hepatotoxicity
TrifluoperazineAvailable as 5mg
Tab.
Start with 5mg/ day and
can be gradua lly
titrated upto a
maximum of 40
mg/day
Fluphenazine
decanoate
Depot injection
5 mg/2ml
Once in 15-20 days
Zuclopenthixol
Depot injection
200mg/ml
One ampoule IM once
in 2-3 weeks.
Atypical antipsychotics
Risperidone 2-10 mg/day,
available as tablets,
syrup and depot
preparation (25
mg/ampoule)
Start with 2mg once a
day or twice a day and
titrate it to 8mg/day
gradually. Deport
injection to be given
deep IM once every 15
days
Less extra-pyramidal side
effects
Non specific-dizziness,
hyperkinesias, somnolence,
anti-cholinergic side effects


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deep IM once every 15
days
Less extra-pyramidal side
effects
Non specific-dizziness,
hyperkinesias, somnolence,
anti-cholinergic side effects
like dry mouth,
constipation, delirium
GIT -nausea, vomiting.
Endocrinal-
hyperprolactinemia,
hyperglycemia.
Hematological-leucopenia
Sexual-erectile
dysfunction,
orgasmic dysfunction
General-weight gain
Olanzapine 5 – 30 mg/day,
available as tablets
Start with 5 mg once a
day or HS and titrate
gradually by 5 mg/day
if no improvement.
Quetiapine Available as 50,
100, 200 mg
tablets
Start with 50mg twice a
day and build upto 300-
800 mg/ per day
C lozapine 25 – 300 mg/ per
day,  available as
tablets
Get complete blood
counts done before
starting clozapine.
Start with 25 mg HS or
50mg HS gradually
titrate to 500mg.


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287
Figure 1.Treatme nt guidelines for schizophrenia
Patienteducation
 B oth, the patient andthe primary caregiver should be explained that although
schizophrenia is a chronic illnessand requires longterm treatment, it can be effectively
treated in most cases.
 Mild to moderate side effects may develop to medications, but usually tolerance develops
to them.
 Medicines should not be stopped abruptly.
 Family should be encouraged to take up the responsibility for regular treatmentand
follow-up. Family interventionsinclude illness education, crisisintervention, emotional
supportand training for coping skills.
OTHER PSYCHOTIC DISORDERS
Schizophreniform disorder
 Clinical features similar to schizophrenia


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supportand training for coping skills.
OTHER PSYCHOTIC DISORDERS
Schizophreniform disorder
 Clinical features similar to schizophrenia
 Differs from schizophrenia in that duration of symptoms is lesser than 6 months
 Pharmacological treatment is similar as schizophrenia
Brief psychotic disorder
 Clinical features similar to schizophrenia
 Differs from schizophrenia in that duration of symptoms is less than 1 month
 Pharmacological treatment is similar to schizophrenia


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288
 Com mon symptoms of depression are(for a minimum period of two weeks):
- Persistent sadness of mood anddecreased interest in previously pleasurable activities
- Mo re than 5 % weight loss or gain
- Sleep disturbance– insomnia or hypersomnia
- Marked slowing of activity or agitation andeasy fatigability
- Lack of concentration
- Feelings ofworthlessness, helplessness, hopelessness, guilt andsuicidal thoughts /
attempts
- Anxiety symptoms often coexist
Delusional disorder
 Clinical features-characterized by single or multiple non bizarre (false fixed but feasible
beliefs)delusions of 1 month duration
 Differs from schizophrenia in that duration of delusions is 1 month and functioning and
behavior in other areas of life than delusional one is intact


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behavior in other areas of life than delusional one is intact
 Insight oriented psychotherapy forms mainstay of treatment whereas Pharmacological
treatment is similar to schizophrenia
Schizoaffective disorder
 Symptoms of schizophrenia are present continuously and features of bipolar affective
disorder overlap
 Differsfrom schizophrenia by prominence of affective features
 Pharmacological treatment is with antipsychotics and mood stabilizers as in schizophrenia
and bipolar disorder respectively
MAJOR DEPRESSIVE DISORDER
Major depressive disorder (MDD), more commonly known as depression, is one of the most
common psychiatric disorders with lifetime prevalenceof about 10-20 %. Incidence in
females are almost twice that in males.
Salient features
Investigations


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females are almost twice that in males.
Salient features
Investigations
 Diagnosisis based on history and mental state examination (MSE). Test for thyroid
function can be done to rule out the co morbidity.
 Investigations for associated neurological co-morbidities can be done particularly in
elderly patients presenting with depression
Non pharmacological treatment
 Psychological factors are very important in the causing, maintaining as well as
improving depression. For holistic management of depression, some form of
psychotherapy should be co-administered.


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289
 Psychodynamic approach aims at promoting personality change through understanding of
major conflicts, achieving insight into defenses, ego distortions, providing role model
permitting cathartic relief or aggression.
 Cognitive behavioral approach aims at providing symptomatic relief through alteration of
target thoughts, identifyingcognitive distortions, modifying erroneous assumptions,
promoting self control over thinking patterns.
 Interpersonal approach aims at providing symptoms relief through solving current
interpersonal problems, reducing stress involving family and work, improving
interpersonal communication skills.
Supportive approach with techniquessuch as catharsis, realistic problem solving is also
useful.
Pharmacologicaltreatment


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Supportive approach with techniquessuch as catharsis, realistic problem solving is also
useful.
Pharmacologicaltreatment
 Hospitalization is needed inseverely suicidal patients,treatmentresistant casesand non
compliant patients.
 SSRIs (selective serotonin reuptake inhibitors) are currently the drug of choice for
depression.
- Tab. fluoxetine- start with 20 mg/day increaseto 40 mg/day, if no response in 4-6
weeks
- Tab. escitalopram- start with 10mg/day depending on tolerability and gradually
increase upto30 mg/day
- Tab. sertraline- start with 25 mg/day or 50 mg/day depending on the severity of
symptoms in 1 HS dosage preferably and gradually increase to maximum of
300mg/day
 Tab. mirtazepine- start with 7.5 mg/day and gradually increase upto maximum 30
mg/day.


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300mg/day
 Tab. mirtazepine- start with 7.5 mg/day and gradually increase upto maximum 30
mg/day.
 Tricyclic antidepressants like Tab. imipramine for depression with somatic complaints.
Start with 25mg twice a day and gradually increase by 25 mg/day to maximum of 300
mg/day if no response(should be avoided in patients with heart disease,glaucoma,
benign prostatic enlargement and epilepsy).
 Antidepressant action takesabout 2-3 weeksand needs to be continuedfor 6-9 months in
first episode and forlonger period in recurrent depression.
 Initiallybenzodiazepines may need to be co-administered to manage insomniaand
anxiety.
 In cases ofbipolar depression, there might be a sudden switch to mania in which case
anti-depressant should be withdrawn.


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anxiety.
 In cases ofbipolar depression, there might be a sudden switch to mania in which case
anti-depressant should be withdrawn.
 ECT (Electroconvulsive therapy)is a very safe, effective and economical mode of
treatment and is indicated in severe depression with or without suicidal ideas, retarded
depression and resistant depression.


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290
 In manic episode, an elevated, expansive or irritable mood is the hallmark. The
elevated mood is euphoric and characterized by euphoria, impaired judgement, denial
of illness,overtlyreligious, over familiar behavior,increasedtalkativeness, increased
self esteem, increased psychomotor activities and goal directed activities, increased
sexual driveand engaging into high risk behavior.
 Patients with depressed mood experience loss of energy and interest, feelings of guilt,
difficulty in concentrating, loss of appetite and thoughts of death or suicide.
 Other signs  and symptoms of mood disorders include change in activity level,
cognitive abilities, speech and vegetative functions (e.g. sleep, appetite, sexual activity
and other biological rhythms).


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cognitive abilities, speech and vegetative functions (e.g. sleep, appetite, sexual activity
and other biological rhythms).
 These disorders virtually always result in impaired interpersonal, social and
occupational aspects of life.
Patient education
 Explain the nature of illness, consequences of untreated depression, suicidal risk, need for
adequate does for adequate durationand other supportive measures.
 The therapeutic response takes time to appear but side effects may appear earlier.
Common side effects of tricyclic antidepressants are dry mouth, constipation, postural
hypotension (giddiness), blurred vision, sweating, palpitation, tremors,delayed
micturition, sedation, etc.
 Common side effects of fluoxetine are agitation, headache, nausea or heartburn, tremors,


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micturition, sedation, etc.
 Common side effects of fluoxetine are agitation, headache, nausea or heartburn, tremors,
changes in sexual performance, blurred vision, dry mouth andlossof appetite.
BIPOLAR MOOD DISORDER
Bipolar mood disorders are characterized by episodes of mania anddepression or mania
alone with intervening periods of normalcy.
Salientfeatures
Non pharmacologicaltreatment
 Psychoeducation, family therapy and rehabilitation for manic phases
 Psychotherapeutic measures same as in unipolar depression for depressive phases.
Pharmacologicaltreatment(Figure 2, Table 2)
 Antipsychotics like risperidone and olanzapine are used as an adjuvant in treatment.
 Episode of depressionis to be treated as in major depressive disorder butTab.lamotrigine


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 Episode of depressionis to be treated as in major depressive disorder butTab.lamotrigine
25-100 mg is the treatment of choice.
 Prophylactic treatment:to be given to prevent recurrent episodes:Tab. lithium carbonate
900-1500 mg /day in divided doses orTab. sodium valproate 600- 2000 mg /day in
divided doses orTab. carbamazepine 600-1200 mg / day in divided doses


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Psychiatry Disorders
291
Figure2. Management of current manic episode
Table 2. Dosage schedule of anti-manic drugs
Drug treatment of mania :  recommended doses Dosage schedule
Lithium
400 mg / per day. Adjusted after 3–
4  days according to plasma
levels
Start with 600 to 900 mg/day
after getting baseline
investigations done
Sodium valproate As sodium valproate slow release:
Dose is 20– 30 mg/ kg/ day
Start with 200mg thrice aday
and gradually increase upto
the per kg maximum dose if
no or less response
Oxcarbazepine 300mg, build upto 1500 mg Has lesser side effect than
carbamazepine
Patient education
 Emphasize about recurrent course of illness and not to get too much worried regarding
recurrences.
 Relapses can be treated as successfully as the first episode.


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recurrences.
 Relapses can be treated as successfully as the first episode.
 When on lithium, advice to take plenty of fluids especially during summer; not to restrict
salt.


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Psychiatry Disorders
292
 Difficulty in initiating sleep, frequent awakenings from sleep, early morning insomnia or
non-restorative sleep.
 In the elderly, the physiological reduction in number of hours of sleep does not amount to
insomnia. If the patient is distressed by decreased sleep, treatment may be given to increase
the duration of sleep.
 Stressful situation leading to insomnia or the symptoms of the causative illness can be
elicited on careful enquiry.
 Duration of symptoms may vary from few days to many months or years depending on the
cause.
 If fever, vomiting or diarrhea develops while on lithium, reduce the dose of lithium to
half and contact the physician or the psychiatrist.
INSOMNIA


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half and contact the physician or the psychiatrist.
INSOMNIA
Insomnia is one of the commonest complaints in psychiatric, medical and general clinical
practice. Common causes include recent stress, psychiatric illnesses like depression and
anxiety disorders, pain or substance abuse.
Salient features
Non pharmacological treatment
Sleep hygiene
 Keep a regular time for going to bed and arising up; avoid day time naps.
 Limit daily in-bed time to the usual amount present before the sleep disturbance
 Avoid large meals near bedtime; eat at regular times daily. No stimulant medication or
food beverages (caffeine, nicotine, alcohol, etc.) especially in the evenings.
 Mild to moderate physical exercise in the morning.


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food beverages (caffeine, nicotine, alcohol, etc.) especially in the evenings.
 Mild to moderate physical exercise in the morning.
 Avoid evening stimulation: substitute radio or relaxed reading for television.
 Practice meditation or progressive muscular relaxation.
 Maintain comfortable sleeping conditions.
Treat the underlying cause. In both primary insomnia (where no cause is identifiable) and
insomnia due to othercauses, management includes introducing good sleep hygiene and
medications for short period, if required.
Pharmacologicaltreatment
If still sleep is inadequate,
 Tab. nitrazepam 5-10 mg orTab.clonazepam 1-2mg or Tab. zopiclone 7.5-15mg or Tab.
zolpidem5-10 mg can be given for 2-6 weeks, ½ to 1 hr before bedtime.


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zolpidem5-10 mg can be given for 2-6 weeks, ½ to 1 hr before bedtime.
 Patients must be cautioned regarding risk of dependence in diazepam and nitrazepam.
Patienteducation
Follow sleep hygiene instructions, look for tapering off benzodiazepines in 4-6 weeks


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Psychiatry Disorders
293
 Generalized anxiety or excessive worries along with associated symptoms as shakiness,
restlessness, headaches
 Breathlessness, excessive sweating, palpitations and nausea, GI disturbance, sleep
disturbance, irritability, hypervigilance.
 Diagnosis is based on history and mental status examination
 Investigations for co-morbidities like hyperthyroidism, hypothyroidism, hypo
parathyroidism, pheochromocytoma and nutritional deficiencies should be done to rule
out organic causes of anxiety.
G ENERALIZED ANXIETY DISORDER
Generalized and persistent anxiety that is not restricted to any particular situation or
environment is an essential feature of this condition.One year prevalence of GAD is 3 to 8%
and it is twiceascommon in women as men.
Salient features


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environment is an essential feature of this condition.One year prevalence of GAD is 3 to 8%
and it is twiceascommon in women as men.
Salient features
Non pharmacological treatment
3 main psycho-therapeutic approaches are used.
 Cognitive behavior therapy aims at finding out the cognitive distortions and altering
faulty coping strategies. Major techniques used are relaxation and biofeedback.
 Supportive therapy aims at offering reassurance and comfort to the patients.
 Insight orientated psychotherapyfocuses on uncovering unconscious conflicts and
identifying ego strengths.
Pharmacologicaltreatment
 Benzodiazepines are the drug of choicelike diazepam (start from 5mg HS or 10 mg HS),
or Tab. clonazepam (start from 0.5mg HS or TDS depending on the severity of


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or Tab. clonazepam (start from 0.5mg HS or TDS depending on the severity of
symptoms), orTab.lorazepam (start from 2mg HS increase upto 8mg maximum) .
 SSRIs like sertraline,escitalopram or paroxetine (start with Tab.paroxetine 10 mg or 20
mg per day upto maximum 50 mg/day)is effective in GAD.
 Beta blockers(Tab. propranolol 20 mg BD or sustained release preparation upto 80
mg/day in divided doses is used) is used for symptomaticrelief.
Patient education
 It is a chronic disease though easily treatable, but treatment needs to be taken regularly
for a long time.
 Do not stop treatment without consulting your doctor.
 The drugs are quite safe and do not cause anyseriousside effects even if taken for a long
time.


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 Recurrent panic attacks formed an essential feature of panic disorder.Panic attack is
characterized by intense fear or discomfort reaching a peak within 10 minutes.
Associated with palpitations, sweating, shaking, breathlessness, chest pain, nausea,
fainting, feeling of choking, fear of dying or going crazy.
 Persistence concern about having more attacks.
 Change in behavior related to attacks
 Worries about consequences of the attacks
PANIC DISORDER
An acute intense attack of anxiety accompanied by feelings of impending doom is known as
panic disorder.Life time prevalence of panic disorder is 1 to 4%.Women are 2-3 times more
oflikely to be affected than men.
Salient features
Non -pharmacologicaltreatment


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oflikely to be affected than men.
Salient features
Non -pharmacologicaltreatment
Main approaches used are cognitive and behavioral therapies which aimat providing psycho
education and correcting cognitive distortions. It also includes educating the patient about
relaxation techniquesand respiratorytraining.
 Family therapy  includes providing psycho education and support
 Insight orientated psychotherapy is focused on helping patients to understandunconscious
meaning of anxiety and resolution of conflicts.
Pharmacological treatment
 SSRIs particularly paroxetine are effective in treating panic disorders. Other SSRIs like
escitalopram, citalopram,fluvoxamine and sertraline are also useful.
 Alprazolam is the most widely used benzodiazepine (start with 0.25mg/day 1 HS upto


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 Alprazolam is the most widely used benzodiazepine (start with 0.25mg/day 1 HS upto
maximum of 6 mg/day). Theyare used for providing rapid symptomatic relief.
 Inj. lorazepam 2mg/ml and diazepam 5ml/ml can be used in patients presenting with
acute anxiety.
 Tri cyclic anti depressants like amitriptyline are also useful
Patient education
 General reassurance about benign nature of symptoms and possibility of spontaneous
recovery of individual
 Continuing with breathing exercises.
OBSESSIVE COMPULSIVE DISORDER (OCD)
It is characterized by recurrent irrational intrusive thoughts, images or impulses that are ego
dystonic i.e.distressing in nature.Life time prevalence in general population is 2-3%. Men
and women are equally affected by this disorder.


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Psychiatry Disorders
295
 Repetitive intrusive thoughts, images or impulses (obsessions) that creates anxiety and
mental and physical actsaredone to relieve the anxiety (compulsions) are the presenting
features of this disorder.
 Com monly observed obsessions are
- Repetitive thoughts and fear of dirt and contamination or germs
- Fearthatsomething terrible will happen
- Forbidden or sexual thoughts and images or impulses.
 Commonly observed compulsions areexcessive hand washing, bathing, checking, ordering
and arranging.
Salient features
Non -pharmacologicaltreatment
 Behavioral therapy is considered as treatment of choice for OCD. Principle approaches
used are exposure and response prevention.Other techniques used aredesensitization,


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used are exposure and response prevention.Other techniques used aredesensitization,
thought stopping, flooding, implosion therapy and aversive conditioning.
 Psychotherapy in form ofC ognitiveB ehaviorTherapy (CBT), psychoanalytical and
psychodynamic therapies are also c+onsidered useful in the treatment.
 Resistant cases can also be treated by ECTs or surgeries.
Pharmacological treatment
 SSRIs like fluoxetine, fluoxamine, paroxetine(start with 10 mg gradually increase to
50mg/day), sertraline are agents of choice in treating OCD.
 Tab. clomipramine is start with 75mgsustained release preparation once dailyand
depending on severity of symptoms gradually increase upto 300mg. It is the only
effective tricyclic anti-depressant used in treating OCD.


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depending on severity of symptoms gradually increase upto 300mg. It is the only
effective tricyclic anti-depressant used in treating OCD.
 Augmenting agents like sodium valproate, lithium or carbamazepine are added to enhance
the response to treatment.
 Benzodiazepinesmay be used as adjuvant treatment.
Patienteducation
 Reassure the patient that although disease is distressingand disabling,itis treatable.
 The drug takes about 2 weeks for its therapeutic response to manifest.
 Side effects may appear before the onset of therapeutic response. Common side effects of
clomipramine are dry mouth, constipation, postural hypotension(giddiness), blurred
vision, and sedation. Side effects of fluoxetine include gastrointestinal distress, nausea,


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vision, and sedation. Side effects of fluoxetine include gastrointestinal distress, nausea,
headache, nervousness, anorexia, restlessness and sexual side effects. Patient usually
adapts to these side effects with time.
 Advice the patient that treatment may continue for a long time. He/she should not leave
drugs without medical advice.
 In case of any untoward effects of drugs, he/she must immediately get in touch with his
clinician.


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296
 Phobia is defined as excessive, irrational fear of specific object, circumstance or
situation.Social phobias are characterized by marked and persistent fear of social or
performance situations exposing a person to unfamiliar people or scrutiny by others.
Women are more likely to be affected by phobia than men.
 Examples of specific phobias are agoraphobia (fear of open spaces), claustrophobia
(fear of closed spaces), acrophobia (fear of heights),etc.
 Exposure to phobic stimulus provokes immediate anxiety sometimes leading to panic
attack. The patient is aware of the irrational nature of fears and avoids the anxiety
provoking stimulus.
 Causes marked distress in interpersonal, occupational and social areas of life.


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provoking stimulus.
 Causes marked distress in interpersonal, occupational and social areas of life.
 Patient must continue all his regular activities as faras possible.
 Yoga, meditation, physical exercises are useful measures along with drug therapy.
PHOBIC DISORDERS
Salient features
N on-pharmacological treatment
 Systematic desensitizationis the most commonly used behavioral technique which
exposes patient to fearful stimulus in a serially graded manner.Imagined or actual
exposure to the phobic stimulus is given as long as the patient can tolerate.
 Insight orientated psycho therapyaims atenabling patients to understand the origin of
phobia, secondarygains and role of resistance and helps them to seek healthy ways of
coping with phobic stimuli.


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phobia, secondarygains and role of resistance and helps them to seek healthy ways of
coping with phobic stimuli.
 Hypnosis, supportive therapy andfamily therapyareuseful in treatment of phobias.
Pharmacological treatment
Following agents are used most commonly in treating phobias.
 SSRIs (e.g.Tab.paroxetine 12.5-50 mg / day in divided doses)
 Benzodiazepinesas mentioned above
Patient education
With regular treatment, most patients show improvement but treatment needs to be continued
for a long time, particularly in childhood onset phobias.
POST -T RAUMATIC STRESS DISORDER (PTSD)
Exposure to a traumatic event consisting of either a direct personal experience or witnessing
an event involving threat of death, serious injury or serious harm can lead topost traumatic


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an event involving threat of death, serious injury or serious harm can lead topost traumatic
stressdisorder (PTSD )in 1.3 to 8% of victims.


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Psychiatry Disorders
297
Common exampl es of such traumatic events arephysical or sexual abuse, domestic/community
violence, kidnapping, terrorist attacks, accidents or disasterslike floods, hurricanes, etc.It is
characterized by a set of symptoms (for more than 1 month) such as:
 Re-experiencing– distressing recollections, flashbacks, imageries of the traumatic event
 Persistent avoidance– conscious effort to avoid places, situations, or events that will remind
the person of the traumatic event
 Hyperarousal– vivid dreams, night terrors, startling responses to even minor stimuli leading
to palpitations, sweating, tremors and other anxiety features
 Sense of detachment from usual social groups and situations, i.e. (emotional numbing is
seen)


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 Sense of detachment from usual social groups and situations, i.e. (emotional numbing is
seen)
 Sleep disturbance, checking for safety and exaggerated startled reactions are also present.
If these symptoms are present for less than 4 weeks it is calledAcute Stress Disorder.
Salientfeatures
Non -pharmacologicaltreatment
Focused Cognitive Behavior Therapy is aimed at givingpsycho education to the patient
regarding the nature of typical emotional and physiological reactions to traumatic events and
PTSD. It also includes teaching techniques of muscle relaxation, focused breathing, affective
modulation, thought stopping and cognitive coping techniques to deal with the stress.
 Gradual exposure: The reminders of traumatic events are gradually introduced.


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 Gradual exposure: The reminders of traumatic events are gradually introduced.
 Crisis Intervention/Psychological Debriefing: It consists of encouraging the patient to
describe the traumatic event in a supportive environment.
If the symptoms persist for more than a year, they do not improve after many years in one
third of patients; so early intervention and treatment is useful.
Pharmacologicaltreatment
 SSRIs are the agents of choice for treating PTSD, the doses are same as in depression.
Propranolol has been used to treat PTSD symptomatically.
CONVERSION DISORDER
It isa type of somatoform disordercharacterized by symptoms or deficits affecting voluntary
motor or sensory functions that is judged to be caused by psychological factors.Illness is


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motor or sensory functions that is judged to be caused by psychological factors.Illness is
preceded by conflicts or stressful situations.It is twice more common in women than men
and is more commonly seen in lower socio economic strata of the society.


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Psychiatry Disorders
298
 Paralysis, blindness and mutism are most common symptoms.
 Parasthesias (altered sensations) and anaesthesias (loss of sensations) especially ofthe
extremities are also seen.
 Abnormal movements, gate disturbance, weakness and paralysis are possible motor
symptoms.
 Diagnosisis based on history and mental status examination.However conversion
episodes should be differentiated from seizures.Seizures are characterized by
repetitive, involuntary jerky movements or episodes of unresponsiveness associated
with tongue bite,frothing, injuries, fecal or urinary incontinence and amnesia (memory
loss) during episodes.Seizures can also occur during sleep and when patient is alone.
A bsence of the above features issuggestive of conversion disorder.EEG and other


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A bsence of the above features issuggestive of conversion disorder.EEG and other
investigations can be used to rule out organic cause.
Salient features
Pharmacological treatment
 Spontaneous resolution of symptoms occurs but insight orientated, supportive or
behavioral therapies can facilitate the same.
 Hypnosis, psychodynamic and psychoanalytical approaches can also be useful.
 Benzodiazepines are used as an adjuvant therapy.
 SSRIs can be used if co morbid depression is present.
DISSOCIATIVE DISORDERS
D issociative disorders are characterized by disruption of integrated functions of
consciousness like memory,identityand perception of environmentwhich can be dissociative
amnesia,dissociative fugue ordissociative identity disorder
Dissociative amnesia


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amnesia,dissociative fugue ordissociative identity disorder
Dissociative amnesia
 Characterized by disturbances in the ability to recall important personal information,
usually traumatic in nature.
 The memory loss is too extensive to be explained by simple forgetfulness.The
disturbances cause socio occupational impairment.
Dissociative fugue
 The disturbance is characterized by sudden, unexpected travel away from home or
customary places of work etc with inability to recall the past events along with partial or
complete assumption of new identity.It causes significant socio occupational impairment.
Dissociative identity disorder
 Presence of two or more personality or identities each with its own patternof reacting to
the environment.


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Dissociative identity disorder
 Presence of two or more personality or identities each with its own patternof reacting to
the environment.
 These personalities take control of person’s behavior and often are accompanied by
inability to recallpersonal information.


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Psychiatry Disorders
299
 Dependence is characterized by compulsion to drink, tolerance, intoxication,
withdrawaland persistence of drinking inspite of overtly harmful consequences.
 Alcohol intoxication is characterized by recent intake of alcohol andbehavioral changes
like slurred speech, unsteady gait, incoordination, nystagmus, impairment in attention
and memory, etc. In extreme cases it can lead to stupor and coma.
 Simple alcohol withdrawal is characterized by abrupt cessation of heavy intake of
alcohol and development of symptoms like sweating, palpitations, tremors,nausea,
vomiting,insomnia,transient visual/tactile/auditory hallucinationsand psychomotor
agitation.
 Withdrawal may be complicated in the form ofseizures,delirium tremens, etc.
Treatment


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agitation.
 Withdrawal may be complicated in the form ofseizures,delirium tremens, etc.
Treatment
 Psychotherapeutic interventions like psychoanalytic psychotherapy,cognitive
psychotherapy,behavioral therapy andhypnotherapy are the mainstay of treatment.
 Pharmacological treatment-antidepressants and antipsychotics have been used with
limited benefits.
ALCOHOL USE DISORDER
Alcohol use disorder is acommon lethal condition that often masquerades as other
psychiatric syndromes.At any time, one of three men are drinkers, with a ratio of persisting
alcohol intake of approximately 1.3 men to 1.0 women.
Salientfeatures
Non -pharmacologicaltreatment
 Motivation enhancing, individual, group and family therapy
Pharmacologicaltreatment


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Salientfeatures
Non -pharmacologicaltreatment
 Motivation enhancing, individual, group and family therapy
Pharmacologicaltreatment
 Hospitalization is advised to most patients for smooth detoxification and to avoid or
mana ge withdrawal complications including seizures and delirium tremens as well as
medical co-morbidities.
 Tab. chlordiazepoxide start from 25mg TDS and may be increased upto 100 mg/day, used
only if liver function tests are normalor
 Tab. lorazepam startingfrom 2mg TDS increased upto 8 mg is used,preferred when liver
functions are compromised or not known.
 Tab. thiamine supplementation to prevent and treat vitamin deficiency (start from 75mg
BD and can be increased upto 300mg/day)
 Injectable vitamins canbe used when signs of severe vitamin deficiency are present.


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BD and can be increased upto 300mg/day)
 Injectable vitamins canbe used when signs of severe vitamin deficiency are present.
 Once the patient is stable, the dose should be gradually tapered off (20% per day) over a
period of 10 to 14 days.


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Psychiatry Disorders
300
 Fluid and electrolyte disturbance should be corrected especially if there is vomiting or
fever.
 Seizures– Rum fits (appearing within 24 hours of abstinence) can be treated with Inj.
diazepam 10 mg or lorazepam 2 mg IV stat especially when seizures are repeated.
Prophylactic treatment is not recommended for true alcohol withdrawal fits.
 Delirium tremens– The patient should be preferably treated in an intensive care unit.
 An intravenous line should be started immediately and thiamine 100 mg IV should be
administered. Thiamine along with multivitamin should be continued parenterally till
normal diet is resumed.
 IV dextrose and saline should be given at a rate adequate to replace fluid losses and
maintain blood pressure.


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normal diet is resumed.
 IV dextrose and saline should be given at a rate adequate to replace fluid losses and
maintain blood pressure.
 Hyperthermia should be managed with cold sponge.Tab. paracetamol 500 mg orally4
times a day may be used in absence of any hepatic dysfunction.
 Inj. diazepam 10 mg should be given slowly IV and should be repeated every 15-20
minutes till sedation is achieved.
 Physical restraint may be necessary if the patient is combative.
 Associated medical and surgical problems shouldbe simultaneously investigated and
treated appropriately.
 Tab.disulfiram (250mg to 500mg daily) is used for relapse prevention. Informed consent
for treatment with disulfiram is mandatory before administering it.


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for treatment with disulfiram is mandatory before administering it.
 Information about the disulfiram reaction and the potential lethality of the same is
explained.
Patient education
Education regarding short-term and long term complications (medical, psychological, social,
legal,etc.) of substance use.
OPIOID USE DI SORDERS
Opioid use disorders consist of physiological,behavioral,cognitive symptoms which indicate
repeated continued use of opioid drugs despite the problems related to it.
Salient features
 Opioid intoxication is characterized by recent opioid intake and development of symptoms as
initial euphoria, later dysphoria,apathy, psychomotor agitation or retardation,impaired
judgement,pupillary constrictions with drowsiness,slurred speech,impairment in attention
and memory.


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judgement,pupillary constrictions with drowsiness,slurred speech,impairment in attention
and memory.
 There usually is impaired social or occupational functioning.
 Opioid withdrawal is characterized by cessation of heavy prolonged use of opioid and
development of symptoms as dysphoric mood,lacrimation, nausea vomiting, muscle aches,
diarrhoea, yawning, fever, insomnia, pupillary dilatation, piloerection, sweating.


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Psychiatry Disorders
301
It is characterized with repetitiveand compulsive consumption of ganja, charas, etc.
 Recent intake of cannabis followed by development of symptoms as impaired motor co
ordination, euphoria, anxiety, slowed perception of time, impaired judgement, social
withdrawal, conjunctival congestion, increased appetite, dry mouth, tachycardia etc.
 C hronic dependence can lead toapathy.
 Mild cannabis withdrawalis characterized by restlessness, craving for cannabis and
dysphoria.Only symptomatic treatment is given for cannabis withdrawal.
Non -pharmacologicaltreatment
 Individual counseling, family support and encouraging the patient to join the self help
groups are also important to help him maintain long-term abstinence.


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groups are also important to help him maintain long-term abstinence.
 However opiate dependence is a highly relapsing disorder, and prolonged inpatient stay in
settings that also provide rehabilitative inputs is usually beneficial.
Pharmacological treatment
 Tab. paracetamol 500mg and dextropropoxyphen 32.5mg - start from BD dosage and
gradually increase to 2tabletsTDS.
 Tab.buprenorphine 2mg and naloxone 0.5mg – start from 1 tabletBD to maximum of
TDS or QID dosages depending on the severity of withdrawal symptoms.
 Tab. clonidine 50 mcg BD is given for symptomatic management of withdrawal. Careful
monitoring of BP is needed.
 NSAIDs are given for muscular pains.
Long term (to be treated by a psychiatrist)


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monitoring of BP is needed.
 NSAIDs are given for muscular pains.
Long term (to be treated by a psychiatrist)
 Tab. naltrexone 50 mg/day orallyis used to reduce craving and thereby to help patient
maintain long-term abstinence (who have remained opioid free for at least 7-10 days).
 Baseline hepatic functions should be assessed, and to be monitored once a month while
on naltrexone treatment.
 The drug is usually continued for a period of 6 months, however, it may have to be
withdrawn in presence of significant liver disease (i.e. several fold increase in the serum
levels of transaminases).
Patient education
Patient should be told about nature of illness, course and treatment modalities available
through individual sessions.
CANNABIS USE DISORDERS
Salient features


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through individual sessions.
CANNABIS USE DISORDERS
Salient features
Pharmacologicaltreatment
Symptomatic treatment fornausea, insomnia and anxietymay be given
Non -pharmacologicaltreatment
M otivation enhancing counseling, individual, family & group counseling


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 Behavioral characteristics include lower intelligence, lack of social smile, poor eye
contact, low level of attachment to caregivers and extreme anxiety when their routine
is disturbed.
 There is a notable deficit in interactions with peer group, delay in development of
spoken language, repetitive movements like hand or finger flapping, rocking body
movements and head banging.
 Diagnosis is based on delayed history and clinical mental status examination (MSE).
AUTISTIC DISORDER
It is characterized by qualitative impairment in social interactions, impairment in
communications and restricted, repetitive and stereotypical patterns of behavior. Its
prevalence is 0.08%and is 4-5 times more common in boys than girls.
Salientfeatures
Non -pharmacologicaltreatment


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prevalence is 0.08%and is 4-5 times more common in boys than girls.
Salientfeatures
Non -pharmacologicaltreatment
 Educational and behavioral interventions are the treatment of choice.
 Structured classroom training in combination with behavioral methods is the most
effective treatment for many autistic children.
 B ehavioral therapies to reinforce socially acceptable behaviors and encourage self care
skills.
 Training of parents with regards to the concepts and skills of behavioral modification has
proved beneficial.
 Language development is added to facilitate communication.
Pharmacologicaltreatment
 No medication has proven its efficacy in treatment of core symptoms of autism but
symptomatic treatment for hyperactivity, obsessions, compulsions, aggression and self


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symptomatic treatment for hyperactivity, obsessions, compulsions, aggression and self
injurious behavior can be given by using escitalopram, methylphenidate, haloperidol,
risperidone, olanzapine, quetiapine. Lithium can be used in self injurious behaviors.
 G uidelines forTab. risperidone prescribingwith autism spectrum disordersin children
and adolescentsare as follows:
- Initiating dose at 0.25 mg per day for patients less than20 kg and 0.5 mg per day for
patients weighing20 kg or more.
- On day 4, the dose may be increased by 0.25 mg for patients beingless than20 kg or
more and by 0.5 mg for patients above 20 kg.
- Assess the response after 2 weeks.
ATTENTION DEFICIT HYPERACTIVITY DISORDER
It is characterized by a pattern of diminished sustained attention and higher levelsof


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ATTENTION DEFICIT HYPERACTIVITY DISORDER
It is characterized by a pattern of diminished sustained attention and higher levelsof
impulsivity in a child or adolescent than expected for someone of that age and developmental
level.Age of onset is before 7 years.Incidence of ADHD is2 to 20%. It is2-9 times more
common in boys.


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 Common symptoms include careless mistakes in school work, lack of concentration,
inability to follow simple instructions, difficulty in organizing tasks and activities, easily
distractible by external stimulus.
 Hyperactivity is seen as fidgety hands or feet, frequently leaving seat in classroom, running
or climbing excessively in inappropriate situations, talking excessively andblurts out before
questions arecompleted
 Diagnosisis based on through case history andMental Status Examination(MSE) .
Salient features
Non -pharmacologicaltreatment
Social skills training, behavioral therapy and group therapy for patient andfamilies are
considered beneficial.
Pharmacological treatment
 Drug of choice is Tab. methylphenidate 5-20mg.


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considered beneficial.
Pharmacological treatment
 Drug of choice is Tab. methylphenidate 5-20mg.
 Other agents are atomoxetine,bupropion, venlafaxine, clonidine,guanfacine.
MENTAL RETARDATION
It is characterized by deficits in cognitive abilities and in behaviors required for social and
personal sufficiency also known as adaptive functioning.An assessment of social adaptation
as well as Intelligence Quotient (IQ) is necessary to determine the level of mental retardation.
Point prevalence of mental retardation is 1-3% of population.It is 1.5 times more common
among men than among women.
Classification of mentally retardation
According to the degrees of severity, mental retardation has been classified into four groups:
 Mild Mental Retardation– (IQ Range 50– 70)


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According to the degrees of severity, mental retardation has been classified into four groups:
 Mild Mental Retardation– (IQ Range 50– 70)
These people can live independently with adequate support and raise their own families.
They can obtain academic skills approximately upto sixth grade.
 Moderate Mental Retardation– (IQ Range 35– 50)
These people can acquire language and can communicate adequately during early
childhood.
They are academically challenged and are unable to go beyond second to third academic
level.
As adults they are able to perform semi-skilled work under appropriate supervision.
 Severe Mental Retardation (IQ Range 20– 35)
These people may fail to develop communication skills in childhood but can learn to


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 Severe Mental Retardation (IQ Range 20– 35)
These people may fail to develop communication skills in childhood but can learn to
count and recognize words critical to functioning.In adulthood, they may adapt well to
supervise living situations and may be able to perform work related tasks under
supervision.
 Profound Mental Retardation (IQ Range Below 20)


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They can be taught some self-care skills and can learn to communicate their needs if they
are given appropriate training.
Investigations
 Detailed history, standardized intellectual assessment and assessment of adaptive
functions in needed for diagnosing mental retardation.
 Examination of physical signs and neurological abnormalities is always necessary to
search for organic causes of MR.
 Laboratory tests– tests like chromosomal analysis, urine and blood testing for metabolic
disorder and neuroimaging are done for ascertaining the cause.
Non -pharmacologicaltreatment
No treatment measures are available except for those to control behavioural symptoms.
Preventive measures form an important strategy.
 Primary prevention


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Preventive measures form an important strategy.
 Primary prevention
It is aimed at implementing measures such as to increase the knowledge and awareness
about MR, to ensure and upgrade public health policies and laws to provide optimal
health care to mother and child, to eradicate known disorders associated with CNS
damage, etc.
 Secondary and tertiary prevention
- It is aimed at treating the associated disorder if any to shorten the course of illness
(secondary prevention) and to minimize the sequelae or consequent disabilities
(tertiary prevention).
- Specialized educational programmes addressing the training & adaptive skills, social
skills and vocation should be developed to improve quality of life.
- Group therapyhas also been successful.


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skills and vocation should be developed to improve quality of life.
- Group therapyhas also been successful.
- Behaviour therapy to reinforce desired behaviours and to reduce objectionable
behaviours is considered useful.
- Cognitive therapieslike dispelling false beliefs and relaxation exercises have been
recommended.
- Psychodynamic therapyhas been used with patients and families to decrease conflicts
about unrealistic expectations.
 Family Education
Educating the family and providing them counseling and supportive help is an important
aspect of management of MR.
 Social Intervention
It is aimed at improving the quantity and quality of social competence of people with MR.
Pharmacologicaltreatment
 Methylphenidate is used successfully for patients of MR with Attention Deficit


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Pharmacologicaltreatment
 Methylphenidate is used successfully for patients of MR with Attention Deficit
Hyperactivity Disorder.
 Antiepileptic agents like sodium valproate and carbamazepine are used for controlling
aggressive and self-injurious behaviour.


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 Antidepressants are used to treat comorbid depression andantipsychotics likehaloperidol,
chlorpromazine are used for reducing stereotyped movements.
 Beta-blockers like propranolol are used to control explosive rages or anger outbursts.
 Development of special schools, supportive groups and NGOs form an essential part of
supportive strategies for people with MR.
SUICIDAL PATIENT
Patients with suicidal ideation need immediate psychiatric intervention. Suicidal ideation can
occur in the background of depression, schizophrenia, adjustment disorders and alcohol and
other psychoactive substance abuse. About two thirds of all depressed patients contemplate
suicide, and 10 to 15 percent commit suicide.


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other psychoactive substance abuse. About two thirds of all depressed patients contemplate
suicide, and 10 to 15 percent commit suicide.
Assessment of suicidal risk can be done with the help of specific questions
Whether the patient often feels sad?
Whether the patient has lost all hopes in life?
Thoughts that it is better to be dead than to face the constant miseries of life.
Thoughts of causing death to self(suicide plans)
Risk factors for predicting the risk of suicide
 Male sex, age above 45 years inmen and above 55 years in women
 Suicidal attempt in past
 Presence of psychiatric illnessespecially schizophrenia and depression, substance abuse
or dependence
 R ecent bereavement, social isolation, family history of suicide, unemployment


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or dependence
 R ecent bereavement, social isolation, family history of suicide, unemployment
 Physical illnesses like malignancy, chronic pain, epilepsy, AIDS and recent will.
Non pharmacological treatment
Treatment is specifically directed at the cause, if identifiable. The patient should be referred
to a psychiatrist immediately after ensuring the following steps:
 Patient should not be left alone and be kept under constant observation.
 Family shouldbe explained the seriousness of the problem and actively included in
management.
 Patient should be offered psychological support and reassurance and not criticized.
 No dangerous or potentially dangerous objects such as knife, blade, sharp edged objects,


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 No dangerous or potentially dangerous objects such as knife, blade, sharp edged objects,
rope, medication supply, etc. should be available in immediate vicinity of the patient.
 Specific treatment for depression, psychotic disorder or whatever may be the cause
should immediately be started.
Patient education
Family should be advised to follow asupportive approach towards the patient and should not
criticize.Suicidal attempt is indicative of distress and needs treatment of the causative illness.


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PSYCHOTROPIC DRUGS IN SPECIAL POPULATIONS
A. Recommendations for use of psychotropic drugs in renalimpairment
Drug groups Recommended drugs
Antipsychotics Haloperidol, olanzapine
Antidepressants Citalopram, sertraline
Mood stabilizers Valproate, carbamazepine, lamotrigine
Anxiolytics and hypnotics Lorazepam, zopiclone
B. Recommendations for use of psychotropic drugs in hepatic impairment
Drug groups Recommended drugs
Antipsychotics Haloperidol, sulpiride/amisulpiride
Antidepressants Imipramine, paroxetine, citalopram
Mood stabilizers Lithium
Anxiolytics and hypnotics Lorazepam, oxazepam, temazepam, zopiclone
C. Recommendations for use of psychotropic drugs in pregnancy
Drug groups Recommended drugs
Antipsychotics Chlorpromazine, haloperidol, trifluperazine


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Drug groups Recommended drugs
Antipsychotics Chlorpromazine, haloperidol, trifluperazine
Antidepressants Nortriptyline, amitriptyline, fluoxetine
Mood stabilizers Consider using anti-psychotics
Anxiolytics and hypnotics Non pharmacological measures preferred
D. Recommendations for use of psychotropic drugs during breast feeding
Drug groups Recommended drugs
Antipsychotics Sulpiride, olanzapine
Antidepressants Sertraline, paroxetine,imipramine, nortriptyline
Mood stabilizers Consider using anti-psychotics
Anxiolytics and hypnotics Lorazepam, zolpidem


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MANAGEMENT OF WANDERING MENTALLY ILL PATIENT OR A MENTALLY
ILL PATIENT WITH NO FAMILY MEMBER OR ATTENDANT
 Mental Health Act, 1987 has provision for hospitalization of the mentally ill patients in
mental hospital.
 If one happens to come across a psychiatric patient wandering aimlessly or indulging in
socially disorganized behavior in a public place, one can approach the local police station.
 The in charge of the local police station under whose jurisdiction the place lies, has a duty
under the Act to take the patient to the concerned Metropolitan Magistrate (in
metropolitan cities) or the Sub-Divisional Judicial Magistrate or Chief Judicial Magistrate
or any Magistrate of first class (in other cities). The Magistrate can issue a reception order


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or any Magistrate of first class (in other cities). The Magistrate can issue a reception order
for admission of the patient to a mental hospital after getting him examined by a medical
officer.
 Admission to mental hospital can alsobe made on the request of the patient, if the patient
is willing to consent (voluntary admission) or on the request of family members, if they
so desire (admission under special circumstances).
PERSONALITY DISORDERS
A pervasive and enduring pattern of behavior, which beginsin early adulthood and which
gives colour to person’s attitude behavior is known as personality. Behavioral patterns that
deviate from person’s sociocultural background are known as personality disorders.
Clusters of personality disorders
 Cluster A-schizoid,schizotypal,paranoid


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Clusters of personality disorders
 Cluster A-schizoid,schizotypal,paranoid
 Cluster B-borderline,histrionic,narcissistic,antisocial
 Cluster C-avoidant dependent personality,obsessive compulsive personality disorders.
Treatment of personality disorders is difficult.Psychotherapies and pharmacological
treatment for symptomatic management can be used with restricted benefits.


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Chapter 15
ORTHOPEDIC CONDITIONS
OSTEOARTHRITIS
Osteoarthritis (OA) of the knee is an end result of the degeneration of articular cartilage.
Salient features
.
Non -pharmacologicaltreatment
 Weight reduction (if overweight); cold fomentation for acutely swollen knee, however,
hot fomentation may give symptomatic relief to some chronicpatients.
 Supervised non-traumatic muscle conditioning and rehabilitation regimens e.g. isometric
quadriceps strengthening exercise (all vigorous exercises to be avoided in acutely
swollen/painful knee).
 Compressive bandage or crepe bandage for effusion.
 A ssistive devices like cane (to be held in the hand contralateral to more painful side),
walker for patients with severe deformities or unsteady gait.


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walker for patients with severe deformities or unsteady gait.
 Brace for various instability helps while walking.
Pharmacological treatment
 Topical applications- containing salicylates, capsaicin, nicotinates, menthol, camphor,
NSAlDs in variouscombinationsmay provide symptomatic relief. (Caution: Avoid hot
fomentation immediately after topical applications). Non-steroidal anti-inflammatory
drugs (NSAIDs) for pharmacological pain palliation. The choice of NSAID depends upon
dosing convenience, physician and patients comfort, price and the past experience on its
frequency and severity of side effects as all are equipotent in full therapeutic dose (Avoid
intra-articularor oral steroids).Commonly used NSAlDs for OAknee


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intra-articularor oral steroids).Commonly used NSAlDs for OAknee
i. Acute painful situation/moderate pain (for initial 7-14 days), preferably take
NSAIDs after meals.
- Tab.paracetamol 500 mg 4-6 hourly(maximum daily dose 4000 mg)
- Tab. ibuprofen 400-600 mg 2 or 3 times aday (maximum daily dose 3200 mg)
- Tab. diclofenac sodium 50 mg 3 times a day or 75 mg 2 times a day(maximum
daily dose 200 mg)
- Tab. aspirin 350 mg 2 tablets 4-6 hourly (maximum daily dose 5000 mg).
For mild to moderate pain/chronic pain control (for 3-6 weeks and then SOS)
 Pain, stiffness after rest, difficulty in climbing stairs, difficulty in getting up from
squatting position, grating sensations and off and on episodes of flare and swelling.


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squatting position, grating sensations and off and on episodes of flare and swelling.
 Erythema and palpable warmth are possible but rare. Genu-varum deformity and/or
fixed flexion contracture in severe cases.
 Classical radiological triad- joint space narrowing, peripheral osteophyte formation
and subchondral sclerosis


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- All above medicines in reduced frequency of dosages.  Or
- Tab.diclofenac sodium 100 mg/75 mg sustained release once a day.O r
- Tab.piroxicam 20 mgonce a day.
 All patients do not uniformly respond to a particularNSAID. It is not unusual for several
different NSAIDs to be tried before a suitably effective and well-tolerated agent is
identified for a particular patient.
 Caution:NSAIDs may cause dose related gastric irritation, nausea, vomiting and
dyspepsia; GI ulceration, perforation and haemorrhage and sometime renal toxicity.
However, one-third remains asymptomatic. NSAIDs can interfere with antihypertensive
therapy due to salt and water retention)
 In case of epigastric burning or nausea or vomiting either discontinue and switch over to


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therapy due to salt and water retention)
 In case of epigastric burning or nausea or vomiting either discontinue and switch over to
safer NSAID or administer Cap.omeprazole 20 mg half an hour before breakfast, in
patients on prolonged therapy with NSAIDs monitor haemoglobin, stool for occult blood
as these drugs may also cause leucopenia, thrombocytopenia and agranulocytosis.
 Refer the patient to an orthopaedic surgeon in case of persistent swelling, presence of
constitutional symptoms or mechanical symptoms like locking or frequent giving away
sensations. Surgical intervention may be required for severe deformities, contractures and
advanced disease with intractable pain, severe enough to affect independent performance
of activities of daily living, for prolonged periods.


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advanced disease with intractable pain, severe enough to affect independent performance
of activities of daily living, for prolonged periods.
Patient education
 There is no curative pharmacological agent for osteoarthritis knee and the disease is
irreversible.Non -pharmacological treatment has a major role to play in treatment
 Take minimal possible medication that provide symptomatic relief and to wait for 1-2
weeks for drug to show its effect.Topical applications do not penetrate into the joint
through skin directly.
 Intra-articular steroid injections give only temporary relief and risks of repeated intra-
articular injections far outweigh its advantages.
 To avoid activities which exacerbate pain like sitting cross legged or squatting on floor.


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articular injections far outweigh its advantages.
 To avoid activities which exacerbate pain like sitting cross legged or squatting on floor.
 To use ramp instead of stairs wherever feasible.Not to do vigorous exercises with acutely
inflamed knee.
 To report back if recurrent effusions in knee or systemic symptoms. Formermay be
caused by mechanical disorder along with OA knee like loose body or meniscal tear.
Later situation could be caused by diseases of knee other than OA
References
1. Acetabular Bone Destruction Related to Non Steroidal Anti-inflammatory Drugs. Lancet 1985; 2:11-14.
2. Osteoarthritis. In: Harrison's Principles of Internal Medicine. Rasper DL, Braunwald E, Fauci AS et al
(eds), 16th Edition, 2005, McGraw Hill Company Inc., New York, pp 2036-2047.


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(eds), 16th Edition, 2005, McGraw Hill Company Inc., New York, pp 2036-2047.
3. Osteoarthritis. In: Conn's Current Therapy, Robert E Rakel (ed), 1999, WB Saunders Company,
Philedelphia.


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 The revised criterion of American College of Rheumatology (1987) aids in diagnosis and
classification.Suspect rheumatoid arthritis if:
> 3 swollen joints
>30 minutes of morning stiffness andinvolvement of metacarpophalangeal or
metatarsophalangealjoints,symmetric arthritis, rheumatoid nodule
RHEUMATOID ARTHRITIS
Rheumatoid arthritis(RA) is characterized by persistent inflammatory synovitis (usually
involving small and large peripheral joints in symmetrical fashion) causing cartilage
destruction andbone erosion leading to changes in joint integrity.
Salient features
Non -pharmacologicaltreatment
 Since theetiology of RA is unknown, therapy remains empirical and palliative, aimed at
relieving the signs and symptoms of the disease.


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 Since theetiology of RA is unknown, therapy remains empirical and palliative, aimed at
relieving the signs and symptoms of the disease.
 In acute pain restand splint. Otherwise exercises directed at maintaining muscle strength
and joint mobility without exacerbating joint inflammation. A variety of orthotic (splints)
and assistive devices (cane, walker) can be helpful in supporting and aligning deformed
joints to reduce pain and improve function.
Pharmacologicaltreatment
 In acute inflammation any of the NSAIDs as given in section on osteoarthritis may be
given exceptparacetamol. The anti-inflammatory action of the NSAIDs may take 2-4
weeks to become evident.Evaluation of persistent polyarthritis.
 Reduced NSAID dosages have to be used in the elderly and in patients with impaired


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weeks to become evident.Evaluation of persistent polyarthritis.
 Reduced NSAID dosages have to be used in the elderly and in patients with impaired
renal function. Concomitant use of more than one NSAID only increases toxicity, and has
no additional benefit. Patient not responding to one NSAID may still show a good
response to another.
 Topicalapplications-containing salicylates, capsaicin, nicotinates, menthol,camphor and
NSAIDs in various combinations may provide symptomaticrelief.
 Refer to a specialist (physician) at a higher centre. Begin disease modifying antirheumatic
drugs (DMARD ) early in the disease. Prediction of response to a particular DMARD is
not possible. It takes 4-6 weeks to show its effect.


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drugs (DMARD ) early in the disease. Prediction of response to a particular DMARD is
not possible. It takes 4-6 weeks to show its effect.
 Tab. m ethotrexate 7.5 mg to 15 mg every week. ConcomitantTab. folic acid 1
mg/day reduces side effects.
Caution: Nausea, mouth sores, liver damage, increases in incidence of chest infection,
macrocytic anaemia. Regular monitoring of LFT is required. Avoid alcohol during
therapy
 For patients with severe disease, affecting activities of daily living and
not responding to adequate trial of NSAIDs and DMARD for sufficient
duration consider following treatment,


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Orthopedic Conditions
311
 Tab. prednisolone 40-60 mg/day for 2-4 weeks. Review periodically and possibly taper
down slowly. If requiredfor a longer duration administer at doses of 5-10 mg/day
 Intra-articular corticosteroids:m ethylprednisolone acetate, 20-80 mg may be needed in
selected cases with predominantly monoarticular arthritis of a large joint.
 Refer the patient to a higher centreif no response to medical therapy after
4-8 weeks, severe extra -articular symptoms, deformities or contractures
present, patient is crippled/or not able to carry out activities of daily living
despite adequate medical treatment.
Surgicaltreatment
Synovectomy in patients with predominantly monoarticular involvement, not responding to


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despite adequate medical treatment.
Surgicaltreatment
Synovectomy in patients with predominantly monoarticular involvement, not responding to
conservative therapy, might be helpful. Reconstructive surgery is indicated for disorganized
joints.
Patient education
 The disease can be controlled but no curative agentisknown. There canbe remissions
and exacerbations.
 At the onset of disease it is difficulttopredict the natural history of an individual patient's
illness.No characteristic features of patients have emerged that predictresponsiveness to
a particular DMARD.
 Life style modification may be required depending on the degree of disability.
 Regular mild exercises as prescribed by the doctor helps in prevention of deformity
maintain range of motion of the joints and muscle strength.


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 Regular mild exercises as prescribed by the doctor helps in prevention of deformity
maintain range of motion of the joints and muscle strength.
 Magic drug for rheumatic arthritis might contain steroids. Better to consult a qualified
doctor before taking it.
References
1.Rheumatoid Arthritis. In: Harrison's Principles of Internal Medicine. Kasper DL, Braunwald E, Fauci AS et al
(eds), 16th Edition, 2005, McGraw Hill CompanyInc., New York, pp 1968-1977
2. Rheumatoid Arthritis. In: Conn's Current Therapy. Robert E. Rakel (ed), 1999, WB Saunders Company,
Philadelphia.
CERVICAL AND LUMBAR SPONDYLOSIS
Itis a clinical syndrome resulting from degeneration of intervertebral discs and facet joints.
Salientfeatures


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CERVICAL AND LUMBAR SPONDYLOSIS
Itis a clinical syndrome resulting from degeneration of intervertebral discs and facet joints.
Salientfeatures
 Pain and stiffness with decreased range of movement of gradual onset. Occasional acute
flare ups of pain with muscle spasm. Neck pain may radiate to occiput, scapular area and
down to one or both arms (may be associated with paraesthesias).
 Back pain is usually diffuse and may radiate up to knees through back of thighs.
 Radiological narrowing of one or more intervertebral spaces, spur formation (osteophytes)
and subchondral sclerosis are the hallmark.


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Orthopedic Conditions
312
Non -pharmacologicaltreatment
 In acute painful situation rest, moist heat in cold weather and light massage (improves
tone, circulation and elasticity) to paraspinal muscles. Cervical traction in the position of
maximum comfort to neck (5-10 pounds) for 10-15 minutes. Ultrasonic exposure on
painful trigger points in cervical and shoulder muscles. Inter ferential therapy (IFT) for
acute neck and back pain. Removable soft cervical collar/back corset/ back belt for
symptomatic relief.
(Caution:No exercises in acute painful situation).
 In chronic pain mobilization and strengthening exercises, moist heat and cervical traction.
Pharmacologicaltreatment
Same as described for osteoarthritis of knee.
Patient education


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Pharmacologicaltreatment
Same as described for osteoarthritis of knee.
Patient education
 In cervical spondylosis avoid prolonged desk work, if must, then intermittent rest is
required and proper writing, typing, sitting posture (avoid low table, use tilt table) and
care of the neck.
 In lumbar spondylosis explain the patient how to manage weightsince extra weight puts
greater stress on the back muscles and to maintain proper body alignment while standing
with feet slightly apart. When standing for long periods, use a small stool to keep one foot
up with knee bent. Do not tense up or concentrate on standing up straight, just stand
naturally. Try to avoid carrying heavy bags on shoulders.
 Care of back while sitting by using well designed fully adjustable chair to provide plenty


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 Care of back while sitting by using well designed fully adjustable chair to provide plenty
of support to the lower back. If chair is uncomfortable use a rolled uptowel or small
pillow to support the back. When sitting for long periods rest your feet on low stool and
use arm rests to support weight of your body. Try not to sit in the same position for long
periods. If prolonged sitting is must take rest for a minuteor two every hour.
 To lift weight cautiously by keeping the back as much upright (vertical) and straight (not
hunched over) as one can. Not to bend over at waist to pick up the object, instead squat,
get under or next to object not on top of it. Lift withyour leg muscles rather than back or


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get under or next to object not on top of it. Lift withyour leg muscles rather than back or
abdominal muscles. Hold the object close to your body while lifting and carrying and do
not twist your body.
 To sleep safely on a firm bed. While sleeping supine legs should be supported with
pillows. Not to sleep on your stomach. Sleeping on your side with knees bent and hips
tilted forward is probably the best.
 Refer to a higher centre in case of severe pain that disturbs sleep/not responding to
conservative treatment for more than 2 weeks/associated with severe restriction of neck or
back movements or torticollis or sciatic pain or constitutional symptoms/neurological
symptoms with back or neck pain.


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Orthopedic Conditions
313
 Mild or grade I sprains-partial tearing of ligament fibers,minimal swelling and no joint
instability.
 Moderate or grade II sprains-pain, oedema, ecchymosis, joint tenderness with some loss
of joint motion but no joint instability.
 Severe or grade III sprains- gross instability of the joint with complete tearing of all
fibers,marked swelling and severe pain.
SPRAINS
An injury to a ligament(s), by sudden unnatural or excessive movement of ajoint, is termed
is a sprain.Sym ptoms are pain, swelling, discolouration of the skin, especiallybruising and
impaired joint function.
Salient features
Non -pharmacologicaltreatment
 Check sensation and circulation distal to the injury. Obtain X-rays of the involved region


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Salient features
Non -pharmacologicaltreatment
 Check sensation and circulation distal to the injury. Obtain X-rays of the involved region
to rule out afracture. Stress X-rays may show abnormal opening of the joint in a grade III
sprain.
 Protection, support and rest.
 Restrict the movement of the affected area.
 Apply cold compresses immediately (this will help to reduce swelling).
 Avoid using ice directlyon the skin.
 Elevation of the limb above the level of the heart-especially at night while sleeping.
 In a grade I sprain, apply a compression bandage for a period of 5-7 days, patient may be
allowed to bear weight after a week.
 In a grade II sprain, splintage (slab later on converted to cast) may be used to restrict joint


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allowed to bear weight after a week.
 In a grade II sprain, splintage (slab later on converted to cast) may be used to restrict joint
motion, but the patient has to remain non-weight bearing for 4-6 weeks.
Pharmacologicaltreatment
 Tab. ibuprofen 400 mg 3 times a day for 5-7 days. OrTab. diclofenac sodium 50 mg 3
times a day for 5-7 days.
Patient education
 Don't massage or hot fomentation in acute stage; it will increase the swelling.
 To give rest to the injured area until the pain subsides (usually 7 to 10 days for mild
sprains and 3 to 5 weeks for severe sprains).Avoid activities that cause pain or swelling.
Practice moderation in physical activities. If the pain and swelling decreases within 48


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Practice moderation in physical activities. If the pain and swelling decreases within 48
hours after a sprain, move the affected joint in all directions. To avoid high heeled shoes
(for ankle sprains).
Reference
1.Apley's System of Orthopaedics and Fractures, 6th edition, 1982, Butterworths and Co. London.


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Orthopedic Conditions
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Diagnosis considered if any of the following two criteria are present,
 Classic symptom of localized pain, fever (with or without chills and rigours), swelling in
the metaphyseal area, warmth, and limited range of motion of the adjacent joint; pus
aspirated from the bone; positive bone or blood culture for pyogenic organism;
radiographic changes typical of acute osteomyelitis (soft tissue swelling, periosteal
reaction, lytic areas in the metaphysis).
 The X-ray changes usually appear 7-10 days after the onset of illness.
ACUTE PYOGENIC OSTEOMYELITIS
Acute osteomyelitis is acute infection of the bone, commonly seen in children less than 10
years of age.
Salient features
Non -pharmacologicaltreatment


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years of age.
Salient features
Non -pharmacologicaltreatment
 Rest, splintage to the part, elevation of the limb and sponging for fever. If aspiration is
positive for pus, drain the pus (must be performed by an orthopaedic surgeon) and send
for culture and sensitivity for antibiotics.
 Postoperative duration of splintage depends upon extent of damage to the bone. Usual
duration is 4-6 weeks. Gradually mobilize the limb and permit gradual weight bearing
thereafter. In case of extensive destruction, bone might require support for a fewmonths.
Pharmacologicaltreatment
Broad spectrum intravenous antibiotics are started depending upon most likely organism
present. Commonest bacterial pathogen isStaphylococcus aureus(40-80% of cases). The


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present. Commonest bacterial pathogen isStaphylococcus aureus(40-80% of cases). The
antibiotic later on may be changed depending upon culture report or response to therapy.
Intravenous administration of antibiotics is continued till favorable clinical response is
achieved, followed by oral antibiotics. Total duration of antibiotic(s) administration ranges
from 4-6 weeks.
 Inj. cloxacillin 50-100 mg/kg/day in four divided doses for 1-2 weeks.
 Inj. gentamicin 5-7.5 mg/kg/day in 2 divided doses for 1-2 weeks Or Inj. amikacin 15
mg/kg/day in 2-3 divided doses if resistantPseudomonas aeruginosa.Or
 Inj. ceftriaxone 100 mg/kg/day in 2 divideddoses for 1-2 weeks (maximum dose 2 g/day)
or
 Inj. cefotaxime 100-200 mg/kg/day by IV infusion or IM or IV in 2-4 divided doses for 1-
2 weeks. Or


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or
 Inj. cefotaxime 100-200 mg/kg/day by IV infusion or IM or IV in 2-4 divided doses for 1-
2 weeks. Or
 If patient is hypersensitive to penicillins and cephalosporins, Inj. clindamycin 40
mg/kg/day in 4 divided doses for 1-2 weeks. Or
 IfMethicillin resistantStaph, aureussuspected, Inj. vancomycin by IV infusion 500 mg
over at least 60 minutes every 6 hours or 1 g over at least 100 minutes every 12 hours;
Neonates upto 1 week 15 mg/kg initially then 10 mg/kg every 12 hours; Infants 1-4
weeks 15 mg/kg initially then 10 mg/kg every8 hours; Children over1 month 10 mg/kg


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Orthopedic Conditions
315
every6 hours. Alternatively linezolid can be given in appropriate dose.
 OralTab.paracetamol 500 mg for fever.
 Monitor therapy by clinical response. Favourable response characterized by decrease in
swelling and fever, improvement in general well being and movements of limb, fall in
ESR and C-Reactive protein (better indicator than ESR because CRP closely follows the
clinical response). After 7-10 days of symptoms, repeat the X-ray to assess the extent of
destruction and damage to bone. Oral therapy usually started 1-2 weeks of IV antibiotic
therapy, if response is favourable.
 The choice of oral antibiotic largely depends on culture and sensitivityreport. In the
absence of culture report give oral: Syr./Cap. cloxacillin 50-100 mg kg day in 4 divided


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absence of culture report give oral: Syr./Cap. cloxacillin 50-100 mg kg day in 4 divided
doses for 3-4 weeks. Or Syr./Cap. cephalexin 25-50 mg/kg/day in 4 divided doses for 3-4
weeks. Or
 Refer the patient to an orthopaedic surgeon if aspiration yields pus from bone or acute
osteomyelitis suspected in an adult/diabetic/haemodialysis patient/IV drug user/ patient
with orthopaedic implant/immunocompromised host.
Patient education
 Antibiotic therapy maybe required for a few weeks depending uponthe response.Plaster
(or any other splintage) might be required for prolonged periods. Not to make the child
walk (in case of lower limb bone involvement) unless permitted.
References
1. A Comparative Study of Osteomyelitis and Purulent Arthritis with Special Reference to Aetiology and


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References
1. A Comparative Study of Osteomyelitis and Purulent Arthritis with Special Reference to Aetiology and
Recovery. Infection, 1984; 12: 75.
2. Osteomyelitis and Suppurative Arthritis. In: Nelson's Textbook of Paediatrics. Berhman, Kliegman, Jenson
et al (eds), 17th Edition, 2004, W.B. Saundcr Company, Philadelphia, pp 2297-2302.
3. Bone and Joint Sepsis. In: Lovell and Winter's Paediatric Orthopaedics. Morissy RT, Weinstein SL (eds),
Vol. 4, 1996, Lippincott-Raven, Philadelphia.
ACUTE SEPTIC ARTHRITIS
Itis inflammation of joint caused by pyogenic microorganisms,usually seen in children <10
years.Hip and knee are the commonest joints to be affected.
Salient features
 Inability to movetheaffected joint, refusal to walk or limp, hip pain referred to knee


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Salient features
 Inability to movetheaffected joint, refusal to walk or limp, hip pain referred to knee
acute local signsof inflammation(warm and painful joint witheffusion) andclinical
signs of sepsis (fever, malaise).M ore than two thirds of infant with septic arthritis are
afebrile.
 Neonates present with pseudo paralysis of extremities, discomfort while changing the
diaper, unhappy or out of sorts but rarely appears to be ill or moribund.Ultrasound
examination of suspected septic hip joint greatly aids in diagnosis.


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Orthopedic Conditions
316
Refer the patient immediately to an orthopaedic surgeon.
Non -pharmacologicaltreatment
 Keep the joint in position of comfort.
 Aspiration of the joint for gramstaining, culture and sensitivity.
 If aspirate is purulent, drainage of the joint on an emergency basis.
 Drain the joint even if the joint aspiration is doubtful in the presence of a strong clinical
suspicion, because the risks of negative arthrotomy are far too less than not draining an
infected joint having pus. The latter situation may be disastrous for the joint resulting in
lifelong permanent disability to the patient.
 After drainage splint the joint with a POP slab or skin traction to relieve pain andprevent


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lifelong permanent disability to the patient.
 After drainage splint the joint with a POP slab or skin traction to relieve pain andprevent
contractures till the patient is a febrile, pain free and the joint is clinically quiescent.
Intermittent mobilization is permitted to preserve the range of movement of the joint.
Pharmacologicaltreatment
The choice of antibiotics, durationof therapy and monitoring of the therapy are same as
mentioned in the section on acute pyogenic osteomyelitis.
References
1. Osteomyelitis and Septic Arthritis. In: Nelson's Textbook of Paediatrics. Berhman, Kliegman, Jenson et al
(eds), 17th Edition, 2004, W.B. Saunder Company, Philadelphia, pp 2297-2302.
2. Bone and Joint Sepsis. In: Lovell and Winter's Paediatric Orthopaedics. Morissy RT, Weinstein SL, Vol. 4,


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2. Bone and Joint Sepsis. In: Lovell and Winter's Paediatric Orthopaedics. Morissy RT, Weinstein SL, Vol. 4,
1996, Lippincott Raven, Philadelphia.


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Chapter 16
SURGERY
PRE -OPERATIVE ASSESSMENT AND PREPARATION S
Pre operative preparation consists of-
 Gather and record concisely all relevant information
 Devise a plan to minimise risk and maximise the benefit to the patients
 Consider possible adverseevents and how to deal with them
 Ensure that everyone, including the patient, understands the surgical plan.
Preoperative assessment of the patient
For achieving the desired optimum result in a surgical patient,apart from evaluating the
nature and extent of the diseases and choice ofsurgery fromavailable options the
assessment of the patient to withstand the stress of surgery and anaesthesia is very
important. The factors that must be considered in preoperative assessment are


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important. The factors that must be considered in preoperative assessment are
 The disease(and its extent)for which the surgery is planned.
 The condition of the patient,organ system.
 The relative urgency of the surgery.
 The type of surgery and its alternatives.
 The relative morbidity and mortality of the disease and the surgical procedure.
 All these factors are interdependentand this assessment is the most fundamental task to
be performed in a surgical patient. Surgeon mayat times, need the help of a physician,
cardiologist or anesthetist,to take the right decision. The preoperative assessmentshould
also include discussion on drugs being taken by the patient and documentation ofknown
allergies.
Informed consent


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also include discussion on drugs being taken by the patient and documentation ofknown
allergies.
Informed consent
Informed consent should be taken after a detailed discussion by the surgeon (or his
responsible assistant)with the patientand his close relatives ,informing them about the nature
of the procedure planned, benefits expected, risks involvedand possible alternatives, giving
full opportunity to them to ask questions and clear doubts.
Preoperative preparation
 Routine investigations Hb, TLC, DLC, CT, BT,urine routine examination, and in patients
over 30 years, chest X-ray and ECGshould be done.
 Special and specific investigations depending upon the nature of the procedure planned
and the physicalcondition of the patientfor evaluating fitness forsurgery.


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and the physicalcondition of the patientfor evaluating fitness forsurgery.
 Lipstick, nail polish and other cosmetics which may mask cyanosis and interfere with
pulse oximetry should be removed.
 D entures, spectacles, contact lenses,artificial limb s, artificial eyes,hearing aid and
jew ellery, cash and mobile phones should be removed before shifting the patient to
operation theatre.


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318
 Withholdingfeeds before surgery depending upon age of the patient and nature of
anaesthesia and surgeryplanned.
 B athing, ifpossible,patient should take aproper bath on the day prior and on the morning
of surgery giving specialattentionto the operative area. Patient should wear only clean
hospital clothing.
 H air rem ovalshould be done asclose to thetime ofsurgeryaspossible. If
 The skinis to be shaved which isbest doneimm ediately before surgery.These arebest
removed w ith a clipperorchemical depilator.Shaving resultsin damage to skinand leads
to abrasions thatmay not be visible and may lead topost operative wound infection.
 One should ask for history of allergic reactions toany chem icalsolutions.


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 One should ask for history of allergic reactions toany chem icalsolutions.
 Wh ile scrubbing, one should work away from the operative site. Visibly soiled skin
should be washed w ith soap and wa ter before using surgical scrub.Preanaesthetic
m edicationasperpolicy.
 Skin preparationfor surgery:Preoperative surgical antisepsis aims at blocking infection
in to surgical w ound and consists of hand w ashing, gloving along withapplication of
antiseptic tosurgical site.Different surgical scrubs available forskin preparation before
surgicalprocedure include anyofthe follow ing:
Povidone-iodine:It acts by oxidation/substitution of free iodine. Povidone iodine is used as
a surgical scrubafter combining with detergent.It is effective againstgram positivebacteria


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a surgical scrubafter combining with detergent.It is effective againstgram positivebacteria
but weaker against other microorganisms.It has a residualactivityand is active in presence
of organic substance. It is absorbed through skin. It can be used on mucus m embranes.
Patient skin sensitivity isoccasionallya problem .
Chlorhexidine gluconate
Itis a broad spectrumantiseptic thatisbetterthan povidone-iodine as a bactericidal.This has
a residual activity that continues to kill microorganism s after application.Itis noteffective in
presence of organic material like soap sand oils,blood and body fluids.Itshould be avoided
inpreparation ofeye.Itm ay be used alone orin combinationw ith cetrimide.
Alcohol (70% ethyl orisopropyl alcohol): It is 95% effective against gram negativeand


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Alcohol (70% ethyl orisopropyl alcohol): It is 95% effective against gram negativeand
gram positive bacteria,m ycobacteria,fungi andviruses.Itis not completelyeffective against
spores.A lltraces of alcohol should be drybefore drapes are put. Alcohol is neverused on
mu cusm embranes and open w ounds as itm ay causesdesiccation.
 Drug treatment:e.g. prophylactic antibiotics (see section on antibiotic prophylaxis),
antihypertensives, IV fluids, anticoagulants, Vitamin Ketc. whererelevant.
 N on drug treatmente.g.,rectal washouts,stom ach wash,etc.w hererelevant.
 Handling of medicolegal cases:First aid has to be provided in allcases who report in an
em ergency state. After stabilizing the patient, patient should be properly guided and
helped in shifting tothe appropriate centre.


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em ergency state. After stabilizing the patient, patient should be properly guided and
helped in shifting tothe appropriate centre.
 In case where wetreatmedicolegal cases, we mustsend information (induplicate) tothe
police. Prepare a m edicolegal report.Preserve and seal clothes etc. Preserve fluid and
stainsamples where indicated.R espond to information sought by thepolice.A rrange to


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319
take dyingdeclaration,whe re indicated.Preserve allX -rays and patientrecords.R espond
to court sum mo ns. In case of death, handover the body to the police. In case of
discharge/referral, police needs tobe informed.Care during transfer.This would depend
on a num ber of factors like nature,patient's condition, and reasons forreferral, readiness
of thereferral centre to accept the patient and whether thetransferis an em ergency or
elective.
Em ergency transfer
 Identify the degreeofemergency.
 R esuscitative measures to be adopted in serious patients withmanag em ent ofshock,
oxygen etc.
 Transfer in a well equipped am bulance to appropriate referral center withprior intimation
and confirmation the readiness at the referralcentre.


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 Transfer in a well equipped am bulance to appropriate referral center withprior intimation
and confirmation the readiness at the referralcentre.
 D octor or paramedicalstaff to accompany the sick patient.
 R eferralslipshould contain information on: Condition of the patient when first seen.
Diagnosis and resuscitative mea sures taken. Reasons for referral. Where referred
Precautionsadvised during transportation. Any other information(e.g. any staff or
equipment sent along with, any com m unication given to referral centre orspecialist
concerned).
POST -OPERATIVE CAR E
I. PO STOPER A T IVE PA IN RE LIEF
 Postoperative pain is associated with allsurgicalprocedures.This varies according to the
surgical procedure. Severe pain can prolong gastrointestinalileus,urinary retention,


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surgical procedure. Severe pain can prolong gastrointestinalileus,urinary retention,
imp air respiratory mov em ents producing atelectasis and predisposes to deep vein
throm bosis due to immobilization.
 Various methods to alleviate postoperativepain are NSAIDs , opioids(intra mu scular,
transdermal or transmucosal),patient controlled analgesia,local infiltration ofanaesthetic
drugs, epidural analgesia and intrapleuralanalgesia. The method used depends uponthe
site and the m agnitude of surgery done, severity of pain,whether the patient isallowed
orally, facilities and expertise available.It is necessary to give analgesics by
intramu scular orintravenous route in the imme diate postoperative period and tillthe
patient isableto accept orally.
Co mm onlyused agents are


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intramu scular orintravenous route in the imme diate postoperative period and tillthe
patient isableto accept orally.
Co mm onlyused agents are
 Inj. diclofenac sodium 75 mg 6-8 hourly Or
 Inj. tram adol (50 mg/ml) IM/IV 4-6 hourly,
 Inj.pentazocine (30m g/ml) 30-60m g IM /IV repeated 3-4hourly.
 Inj. morphine (15 mg/ml)10-15mg ,can be repeated 4-6 times.
 In tertiary care centers, epiduralanalgesia,intravenous patient controlled analgesia,
intrapleural analgesia can beused under expert care.


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320
W hen patient isable to accept orally,
 Tab.paracetamo l500mg3 -4 times a day.Or
 Tab.ibuprofen 400-600mg 8 hourly.
II.POSTOPER A TIV E NAUSEA AND VOMITING
 Post operative nausea and vomi ting lead to significant m orbidity and prolonged
hospitalization. It hasan incidence of 20-30% afterabdominalsurgery.
 Predisposing factors are diabetes m ellitus, pregnancy, dehydration, electrolyte
imbalance, gastroesophageal reflux,em ergency surgery, use of certain anaesthetic drugs
and opioids.
N on-pharmacological treatment
B owe lobstruction (m echanical or paralytic ileus) should be ruled out as acause ofvom iting
by proper examination and investigations. N auseaand vomitingare man aged with bed rest,


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by proper examination and investigations. N auseaand vomitingare man aged with bed rest,
intravenous fluids,analgesics torelieve postoperative pain,nasogastricdecompression
Pharmac ologicaltreatment
 Inj. metoclopram ide (5mg/ml)10 mg IM /IV TDS or SOS. Or
 Inj.ondansetron (2m g/ml) 4 mg slow IV or IM  OD
III.PO STOPERAT IVE PN E UMO N IA
 Pulmonary disorders remain the mo st frequent postoperative problem and 10- 15% of
patients are considered to have clinically significant chest complication after surgery
under generalanaesthesia.
 Factors predisposing to increased chest complications aresm oking,obesity, chronic
restrictive and obstructivelung disease, prolonged general anaesthesiaand presence of
nasogastric tube.Postoperative pneumonia is caused by pathogens such asPseudom onas,


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nasogastric tube.Postoperative pneumonia is caused by pathogens such asPseudom onas,
Serratia,Klebsiella, Proteusand Streptococcus
Salientfeatures
.
Pharmacological treatment
 Antibiotics: Depending upon sputum culture and sensitivity. Initial treatment  can be
started with amino glycoside and cephalosporin.
 Inj.diclofenac 75mg 1M every6-8 hours.
 Chest physiotherapy
 Nebu lized bronchodilators may be used ifbronchospasm is present.
Antibiotic prophylaxis in surgery
The goals ofprophylactic administration of antibioticsto surgicalpatients are to:
 Reduce the incidence of surgicalsite infection;
 Fever,productive cough,dyspnoea,chest pain.
 Bronchial breathingand presence of rales.
 Chest X-ray shows area of  consolidation


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Surgery
321
 U se antibiotics ina man ner that is supportedby evidence of effectiveness;minimize the
effectof antibiotics on the patient's normal bacterial flora; adverse effects.
Prophylaxis is uniformly recomme nded for allclean-contaminated, contam inated and
dirty procedures.It is considered optional for most clean procedures,although it may be
indicated for certain patientsand clean procedures that fulfill specific risk criteria. Itis
important to emphasize that surgical antibiotic prophylaxis is an adjunct to, not a
substitute for good surgicaltechnique.
 Antibiotics prophylaxis should be regarded as one component of an effective policy for
the control of hospital acquired infection in procedure that requires the insertion of


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the control of hospital acquired infection in procedure that requires the insertion of
implants or prosthetic devices,the term.Surgical site infection isused to encom pass the
surgical wound and the implant.Surgical site infection also encompasses infections
involving the body cavity (e.g. subphrenic abscess), bones, joints, meninges and other
tissues involved in the operation. Throughout this guideline the term surgical site
infection (SSl) is used, unless the evidence relates specifically to surgical wound
infection.
SURGICAL SITE INFECTION
Criteria for defining a surgical site infection (SSI)
SuperficialincisionalSSI
 Infection occurs within 30 day after the operation and infection involves only skin of
subcutaneous tissue of the incision and at leastone of the following


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subcutaneous tissue of the incision and at leastone of the following
 Purulent drainage, with or without laboratory confirmation, from the superficial incision
 Organisms isolated from an aseptically obtained culture of fluid or tissue from the
superficial incision.
 At least one of the following signs orsymptoms of infection:Pain or tenderness, localized
swelling,redness, heat and superficial incision is deliberately opened by a surgeon,
unless, incision is culture-negative
 Diagnosis of superficial incisional SSI by the surgeon or attending physician
D eep incisionalSSI
 Infection occurs within 30 days after the operation if no implant is left in place or within
one year if implant is in place and the infection appears to be related to the operation and


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one year if implant is in place and the infection appears to be related to the operation and
infection involves deep soft tissues (e.g. fascialand muscle layers)of the incision and at
least one of the following
 Purulent drainage from the deep incision but not fromthe organ/space component of the
surgical site.
 A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following signs or symptoms:fever (>38°C) localized pain
tenderness unless site is culture-negative
 An abscess or other evidence of infection involving the deep incision is found on direct
examination,during re-operation,or by histopathologyor radiologic examination.


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322
 Diagnosis of deep incisional SSI by a surgeon or attending physician.
Organ/space SSI
 Infection occurs within 30 days after the operation if no implant is left in place or within
one year if implant isin place and the infection appears to be related to the operation and
infection involves any part of the anatomy (e.g. organs or spaces), other than the incision,
which was opened or manipulated during an operation and at least one of the following
 Purulent discharge from a drain that is placed through a stab wound in to the organ/space.
 Organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space.
 An abscess or other evidence of infection involving the organ/space that is found on


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organ/space.
 An abscess or other evidence of infection involving the organ/space that is found on
direct examination, during re-operation, or by histopathologic or radiologic examination.
 Diagnosis of an organ/spaceSSIby a surgeon or attending physician.
Pharmacological treatment
 The antibiotics selected for prophylaxis must cover the commonpathogens. Antibiotics
election is influenced by the organism most commonly causing wound.Infection in the
specific procedure and by the relative costs of available agents.
 Gastrointestinal procedures, oral and intravenous administration of agents with activity
against gram-negative and anaerobic bacteria are warranted, as well as mechanical
preparation of the bowel.Ceftriaxone/cefotaxime provides adequate coverage for most


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preparation of the bowel.Ceftriaxone/cefotaxime provides adequate coverage for most
other types of procedures.The antibiotics chosen for prophylaxis can be those used for
active treatment of infection.However, the chosen antibiotics must reflect local disease-
specific information about the common pathogens and their antimicrobial susceptibility.
A past history of a serious adverse event should preclude administrationof a particular
antibiotic like penicillin.
Timing and duration of prophylaxis
 The first dose should always be given before the procedure, preferably within30 minutes
before incision. Re-administration at one to two half-lives of the antibiotic is
recommended for the duration of the procedure. In general, postoperative administration
is not recommended.


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recommended for the duration of the procedure. In general, postoperative administration
is not recommended.
 There may be situ ations where overriding factors alter the normal timing of
administration.For example, during a caesarean section prophylaxis should be delayed
until the cord is clamped in order to prevent the drug reaching the neonate. When a
tourniquet is to be applied the necessary tissue concentration must be achieved prior to its
application rather than the time of incision. This probably occurs within10 minutes of
administration of an IV antibiotic injection. Antibioticsshould also be administered
immediatelyafter unexpected contamination of the tissues additional doses during the
operation.


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immediatelyafter unexpected contamination of the tissues additional doses during the
operation.
The individual surgeon should be free to givean extra dose for prolonged operations with
m ajor   blood loss ifthey wish.Howe ver,thereisinsufficientevidence to make a general
recommendation.Antibiotic prophylaxis should be confined to the perioperative period.


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323
Route of administration
Intravenous administration of antibiotic prophylaxis immediately before or after induction of
anesthesiais the mostreliablem ethod forensuringeffective serum antibiotic concentrations
at the time ofsurgery.
Dose selection
A single doseof antibiotic at the therapeutic concentration is sufficient for prophylaxis under
most circumstances.In adults,blood loss of up to1500 ml during surgery or haemodilution up
to15 ml/kg does notrequire an additional dose of prophylactic agent.
In theevent of major intraoperativeblood loss(>1500ml) additional doses of prophylactic
antibiotic should be given after fluid replacement.Antibiotic prophylaxis in all cardiac
surgeries and interventions isrecommende d.


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antibiotic should be given after fluid replacement.Antibiotic prophylaxis in all cardiac
surgeries and interventions isrecommende d.
Table 1.Incidence of surgical site infections (SSI) with various types of surgery
Type of surgery Name of Surgeries SSI
rate
Clean
Elective,noteme rgency, non traum atic,prim arily closed;no
acute inflamm ation ;  no break in technique; respiratory,
gastrointestinal,biliary andgenitorurinary  tractsnot entered
<2
C lean-
contaminated
U rgent or emergency  case that is otherwise  clean;elective
opening of  respiratory, gastrointestinal, biliary or genitourinary
tract with minimalspillage (e.g.appendectom y) not
encountering infected urine or bile;minor technique break
<10
C ontaminated
No npurulent inflammation; gross pillage from gastrointestinal


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encountering infected urine or bile;minor technique break
<10
C ontaminated
No npurulent inflammation; gross pillage from gastrointestinal
tract;entry into biliary or genitourinary  tract in the presence of
infected bile or urine; major break in technique;penetrating
traum a <4hoursold;chronic open  wounds to be grafted or
covered
~20
Dirty Purulent inflammation (e.g.abscess);preoperativeperforation of
respiratory, gastrointestinal,   biliary  orgenitourinary tract;
penetrating trauma >4hours old
~40


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324
 Pain is unusuallysevere for thema gnitude of procedureand lastlong.Fever: 101 to
102 Fwithtachycardia is usually present.
 Local exam ination: Wound is warm to touch and m ay be swollen and oedem atous.
Redness of thesurrounding areaand cellulitesis often present.
 Wound infections are generally evident between 3rd to 6th postoperative days
Infection risk factors:Factors associated with increased risk ofinfection are:
Systemic factors: Diabetes, corticosteroid use, obesity, extremes of age, malnutrition, recent
surgery, massive transfusion, multiple(3ormore) preoperative co morbid medical diagnoses
Local factors: foreign body,electrocautery;injection with epinephrine;wound drains; hair
removalwith razor; previous irradiation of site.
Development of local guidelines


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removalwith razor; previous irradiation of site.
Development of local guidelines
It isadvisable to make local surgical site infection prevention protocols be developed by local
hospital management.
Postoperative wound management
 Most postoperative wounds are covered with occlusive dressingsThe occlusive dressing
(semi permeable to water vapours and oxygen but impermeable to liquids) consists of a
hydrating layer (antibiotic ointm ents or petroleum jelly), anon-adherent contactlayer, an
absorbent and cushioning layer(gauze),and a se­  curing layer like hypo allergic tape.
Occlusivedressings should be applied within2 hours of wounding and left on forat least 24
hours foroptim alhealing to occurfor acute wounds. These should never be used on infected


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hours foroptim alhealing to occurfor acute wounds. These should never be used on infected
wounds. Dressing changes can be performed once or twice daily. If other types of occlusive
are used,thetiming of the dressing changes will vary between I to7 days, depending on the
w ound characteristics.
POSTOPERATIVE WOUND INFEC T ION
W ound infections areclassified as
 Mi nore.g.stitch abscess, cellulitis.
 M ajore.g.presence ofdiscrete collection ofpus in wou nd.
 Superficialinfections are limited toskin and subcutaneoustissue.
 D eep infections-involve the areas ofw ound below the fascia.
Postoperative cross infection in wards:Staphylococcus aureus is the mostfrequently involved
organism . Other lesscommon or ganism s areEnterococci,Pseudomon as, Proteus, E. Coliand
Klebsiella.


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organism . Other lesscommon or ganism s areEnterococci,Pseudomon as, Proteus, E. Coliand
Klebsiella.
Salient features


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325
Superficial infection
 D rainage:W ounds are managed by opening up the incision to provide adequate drainage.
 D ressing:D aily dressing with povidone-iodine 5% and awick is placed toprevent premature
closureofthe wound.
 Ana lgesics:Tab. ibuprofen 400mg 3 timesa day tillpain isthere.
D eep infections
 A ntibiotics are given on the basis of pus culture and sensitivity in addition to drainage of
wo und.
Prevention
Postoperativew ound infection ratecan be minimized by adequate skin preparation,bowel
preparation, prophylactic antibiotics, meticulous surgical technique
W O UN D C A RE
Wo unds can be classified as acute or chronic and further as arterial,venous trophic, malignant.
Acute wounds heal uneventfully within an expected time frame e.g.burns.For the purpose of


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Acute wounds heal uneventfully within an expected time frame e.g.burns.For the purpose of
guidelines,chronic wo unds can be defined as an ulcerpresentat least for6 weeks.
Treatment
M eticulous w ound c are includes adequate cleansing, debridemen t, oedema control and
prevention of ischemia,
Acute wounds
 The overall objective in caring for wounds that are incompletely clottedis to minimize
unnecessaryblood loss and to avoid the formation ofa hematoma.
 Irrigate gently with copious quantities of water or normalsaline. Debrisand necrotic tissue
should be remov ed w ithout damaging healthy tissue. Sharp mechanical debridement may be
necessary toexpose viable tissue for large areasof fibrinous exudates or eschar. Chem ical


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necessary toexpose viable tissue for large areasof fibrinous exudates or eschar. Chem ical
debridem ent is useful for those areas that are difficult toaccess by sharp debridement.
Chemical debridement of the wounds may be done using topical antiseptics (chlorhexidine,
povidoneiodine, alcohol, hydrogenperoxide, triclosan) and antibacterials (silver sulfadiazine,
neomycin, polymyxin, bacitracin, mupirocin).When debridement is complete, dressingscan
be applied.
 Healing of acute wound is further facilitated by closure. Alternatively,closure can be delayed
for several days to allow infection to clear. Wound healing is impaired by malnutrition,
oedema ,bacterial contamination, ischemia, smoking and immunosuppressant.
Chronic wounds


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oedema ,bacterial contamination, ischemia, smoking and immunosuppressant.
Chronic wounds
Identify and treat the predisposing factors, e.g. diabetes mellitus, peripheral arterial orvenous
disease, severe anem ia, protein deficiency, rheumatoid arthritis, systemic vasculitis, cushing’s
syndrome andconditions requiringsystemic steroid therapy.


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Non -pharmacological treatment
 Encourage daily or twice a day bath, to avoid walking bare foot or with slippers and patient
should been courage to wear shoes and socks.
 Patients with leg ulcer to reduce standing or excessive walking. In leg ulcer due to chronic
venous insufficiency or oedema, patients should be advised to wear elastic stockings,
elevation of leg and foot end of the bed while a sleep along with some leg exercises to
activate the calf muscle pump.
Pharma cological treatment
Identify the microorganism and treat accordingly. Tubercular ulcer is treated with anti tubercular
drug (2HRZE+7HR) for at least 9 months.
Surgical treatment
 Surgical debridement in ulcer associated with necrotic tissue or slough. Clean the wound


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drug (2HRZE+7HR) for at least 9 months.
Surgical treatment
 Surgical debridement in ulcer associated with necrotic tissue or slough. Clean the wound
with physiological normal saline or tap water only (antiseptics delay wound healing).
 Daily dressing: Gauze adhere to the wound bed and it may remove viable tissue from the
wound surface on removal , resulting in delayed wound healing. Some ofthe commonly used
dressings are:
 Occlusive (moist ureretentive) dressings (Hydrocolloid gel) in case of clean and shallow
ulcers without any pus discharge or other features of infection. Occlusive dressings have
barrier properties that enable to prolong the presence of moisture and wound fluid in the
wound bed.
 Calcium alginate dressing: For bleeding wounds and wounds with a cavity.


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wound bed.
 Calcium alginate dressing: For bleeding wounds and wounds with a cavity.
Patient education
 To prevent ulcer in future, explain about the care of leg ulcers, wearing socks, shoes and
compression stocking.
 Good personal hygiene (daily bath) and after bath the healed scar area should be massaged
with an emollient cream such as lanolin or some other oil to keep the scar tissue soft and
supple and prevent further breakdown.
 Regular use of calf muscle activating exercises and leg elevation and to avoid prolonged
period of standing orsitting with legs down.In case of diabetic patients, control of diabetes is
necessary.
STERILIZATION AND DISINFECTION
Definitions
Sterilization is removal of all viable micro-organisms, vegetative and spores. Disinfection is the


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STERILIZATION AND DISINFECTION
Definitions
Sterilization is removal of all viable micro-organisms, vegetative and spores. Disinfection is the
removal of actively dividing vegetative micro-organisms. Antisepsis is the process whereby the
risk of medical cross-infection by micro-organisms is reduced


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327
 Time of occurrence of wound and its etiology
 Co morbidities like diabetes mellitus, anemia, scurvy, jaundice
 Number, site, size, depth active bleeding, discharge, foreign material, associated
neurovascular injury, tendon injury, bone fracture and make proper documentation of all
injuries to be done in patient records.
Methods of Sterilization
I. Heat
 Dry heat (e.g. incineration, flaming to red hot) is effective but rarely useful. Dry heat
requires temperatures of 160Â°C for at least 60min.
 Moist heat (e.g. autoclave heating using pressurized steam 121Â°C at 15lb/in2 for
15min) is effective and useful especially inoperating theatres.
II. Irradiation, Gamma radiation effective for inorganic material   Filtration: Air or fluids can


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II. Irradiation, Gamma radiation effective for inorganic material   Filtration: Air or fluids can
be sterilized by ultrafine membrane filters but are rarely useful in hospital practice
III. Chemical
 Acids/alkalis, e.g. bleach. Effective for non-human contact use.;
 Alcohols/phenols, e.g. ethyl alcohol skin swabs, alcohol solutions  hand  disinfection
carbolic; chloroxylenols (Dettol), phenol (Clearsol )
 Oxidizers, e.g. povidone-iodine (Betadine) skin disinfection/surgical scrubbing;
H 2O 2 superficial wound cleansing; aldehydes (Cidex) surgical instruments such as
endoscopes; Cationic solutions, e.g. Chlorhexidine antiseptic washes.;
 Organic dyes, e.g. Proflavin
Antisepsis: Principles of antisepsis include the following.
 Always remove gross contamination with simple soap first.


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Antisepsis: Principles of antisepsis include the following.
 Always remove gross contamination with simple soap first.
 Use high potency acid/alkali disinfection on inert surfaces.
 Use less corrosive oxidizers on delicate inert materials.
 Use weak alcohols, oxidizers for skin cleansing.
SUTURING OF PRIMARY WOUND
Suturing is one of the firstand foremost thing any surgeon will perform in his or her career.
Consider following points while suturing primary wounds.
Salient features
Investigations
 Usually not required. X-rays of local part are needed if fracture or foreign body is suspected.
Pha rmacologicaltreatment
 Inj.  tetanus toxoid 0.5 ml IM stat


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 Inj.  diclofenac sodium 3 ml (75mg) IM stat
 Tab. ampicillin 500 mg three times day for  3-5 days
 Tab. diclofenac 50 mg twice day for  3-5 days
 Tab. multivitamins/Iron if patient is deficient of anyfor better healing
 Control of Diabetes mellitus, if present
 Management of local wound: if wound is recent(<6 hrs) cleaning followed by suturing is
done. If duration of injury is >6 hrs, and contamination is present, wound is debrided and
wound is closed by secondary suturing at a later date when wound is clean.
 For primary suturing:Thorough cleaning of wound by saline/Hydrogen Peroxide/Betadine.
 Removal of any foreign material and control of active bleeding.
Choice ofsuturem aterial


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 Removal of any foreign material and control of active bleeding.
Choice ofsuturem aterial
The size of suture material is measured by its width or diameter and is vital to proper wound
closure.
 1-0 and 2-0: Used for high stress areas requiring strong retention, i.e.-deep fascia repair
 3-0: Used in areas requiring good retention, i.e.-scalp, torso, and hands
 4-0: Used in areas requiring minimal retention, i.e.  extremities. Is the most common size
utilized for superficial wound closure.
 5-0: Used for areas involving the face, nose, ears, eyebrows, and eyelids.
 6-0: Used on areas requiring little or no retention. Primarily used for cosmetic effects
Suture Techniques:Wound layers should be placed in close approximation. Minimal amount of


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Suture Techniques:Wound layers should be placed in close approximation. Minimal amount of
tension across the suture lineshould be kept. Wound edges should be slightly everted. Equal
bites, horizontally and vertically are important for wound position and healing. Debride
devitalized tissue.  Alternate day dressing with antiseptic solution till suture removal
Suture removal
 Duration will vary according to the location and depth of the wound. However, the average
timeframe is 7-10 days after application. The following general rules can be sued in deciding
when to remove sutures:
 Face: 4-5 days.
 Body & scalp: 7 days.
 Soles, palms, back or over joints: 10 days
 Any suture with pus or signs of infections should be removed immediately. Once MO


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 Soles, palms, back or over joints: 10 days
 Any suture with pus or signs of infections should be removed immediately. Once MO
determines that the sutures should be removed, a suture removal kit, consisting of scissors
and a pair of tooth forceps is utilized to remove the sutures.
 Using the tooth forceps, grasp the knot and snip the suture below the knot with the scissors as
close as possible to the skin.  Pull the suture line through the tissue and place on a 4x4.  Once
all sutures have been removed count the sutures.  The number of sutures needs to match the


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 Vague periumbilical or sometimes epigastic pain of visceral nature from a dilated appendix
which migrates to right lower quadrant and becomes somatic in nature from contact of
serosa of inflammed appendix against the parietal peritoneum.
 Pain followed by anorexia,nausea and occasional vomiting, fever in 50% of cases
 McBurney's sign : migratory nature of pain that settels at McBurney's point (one third of
the distence from the anterior superior iliac spine to the umbilicus
 Rebound tenderness
 Perforated appendicitis may present with more severe abdominal pain ,progressing from
focal peritonitis to generalized peritonitis with rebound tenderness, voluntory guarding
followed by involuntary guarding and finally rigidity.
number indicated in the patient's health record.


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followed by involuntary guarding and finally rigidity.
number indicated in the patient's health record.
ACUTE APPENDICITIS
It is inflammation of appendix caused by luminal obstruction due to fecoliths (50%), lymphoid
hyperplasia,malignancy or rarely parasitic infection.
Salient features
Diagnosis
 Blood counts (neutrophillia),USG Abdomen (shows inflamed appendix)CECT Abdomen, if
RIF lump is palpable.
Pharmacological treatment
 In early catarrhal appendicitis, with minimally inflamed appendix patient can be given
medical and conservative management which includes-
- Tab. ciprofloxacin 500mg BD and  Tab. metronidazole 400 mg TDS or a second generation
cephalosporin cefotaxim 1 gm BD
 Inj.diclofenac  75 mg IM
 Tab.ranitidine 150 mgBD or Cap. omeprazole 40 mgBD


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cephalosporin cefotaxim 1 gm BD
 Inj.diclofenac  75 mg IM
 Tab.ranitidine 150 mgBD or Cap. omeprazole 40 mgBD
Surgical treatmentAppendicectomy by open or laproscopic approch
HERNIA
I. INGUINAL HERNIA
Inguinal hernias are the most common hernias world wide. Most commonly seen in men. Several
classifications are available worldwide but none has been prove to be perfect, besides, most
surgeons in the world commonly classify them as being Direct or Indirect inguinal hernias.
Direct inguinal hernia is the one which occurs medial to deep epigastric artery, through
Hesselbach's triangle. Indirect inguinal hernia occurs through deep ring.


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 G roin swellingreducible, impulsile,history ofstrenuousactivity,heavy labour,chronic
cough,chronic constipation,urinary complains.Examination of swellingis required.
 Reducible, impulse on coughing present,examination of scrotum and penis
 Per rectal examination, systemic examination ofchest and abdomenis required.
 In history evaluatenature of primary surgery, Wound complications following primary
surgery, presence of malnutritionand associated comorbidities.
 Physical examinationof scar and defectand swelling, reducibleimpulsile on coughing
Salientfeatures
Investigations
 Diagnosis of hernia is purely clinical, investigations are required where diagnosis is
inconclusive or for evaluation of associated conditions.


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 Diagnosis of hernia is purely clinical, investigations are required where diagnosis is
inconclusive or for evaluation of associated conditions.
 USG -local part for defect. USG-KUB for urinary complains.
 S. PSA if prostate is enlarged
 Prostatic biopsy. Pulmonary function tests for chronic cough
Ph armacologicaltreatment
 Treatment of predisposing factors if present any
 Treatment of chronic cough according to cause
 Treatment of Chronic constipation
 Treatment of BPH if present, pharmacological as well surgical
Surgical treatment
 Herniotomy, for congenital hernias
 Hernioplasty for open gold standard for any type of adult hernia at present. Lichtenstein
tension free hernioplasty
 By laparoscopichernioplasty is preferred in small and bilateral hernia.


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tension free hernioplasty
 By laparoscopichernioplasty is preferred in small and bilateral hernia.
 TEP -Totally Extra peritoneal meshplasty
 TAPP -Trans Abdominal Preperitoneal meshplasty
II.INCISIONAL HERNIA
Incisional hernia is defined as hernia occurring through any previous surgical incision.
Predisposing factors are improper techniques of wound closure ,wound infection, wound
dehiscence, malnutrition,malignancy
Salient feature
Investigations
USG local part for defect, Preoperative investigations
Surgical Treatment


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 Underlay: preperitoneal mesh placement under the defect, preferred route
 Inlay: mesh placement thought the defect
 Onlay/Overlay: Mesh placement above the defect in muscular plane
 Laparoscopic mesh placement under the defect, preferred whenever possible
HYDROCOELE
H ydrocele is an abnormal collection of serous fluid in apart of the proccessus vaginalis,usually
the tunica. Acquired hydroceleare primary or idiopathic,or secondary to testicular disease.
Causes includesexcessive production of fluid within the sac,e.g.secondary hydrocele, by
defective absorption of fluid,e.g.primary hydrocele, by interference with lymphatic drainage  of
scrotal structures, by connection with the peritoneal cavity via a patent processus vaginalis.
Salient features
Surgical treatment


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scrotal structures, by connection with the peritoneal cavity via a patent processus vaginalis.
Salient features
Surgical treatment
Congenital hydrocele requires herniotomy while acquired hydrocele-jaboulay's procedure or
Lord's procedure
C HOLELITHIASIS
Cholelithiasis or gall bladder stones are common problem in our country.It may lead to
cholecystitis, cholangitis, choledocholithiasis with obstructive jaundicegall stone pancreatitis.
Gall stones may be of cholesterol stones, pigment stones, mixed stones
 Hydroceles are translucent and it is possible to get above swelling. Primary vaginal
hydrocele is most common in middle and later life butcan also occur in older children.
Swelling is painless. The testis may be palpable within a lax hydrocele, but an ultrasound


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Swelling is painless. The testis may be palpable within a lax hydrocele, but an ultrasound
scan is necessary tovisualizethe testis if the hydrocele sac is tense. Testicular
malignancy is an uncommon cause of hydrocele that can be excluded by ultrasound
examination of the scrotum.
 About 5% inguinal hernia are associated with a vaginal hydrocele of that side. In
congenital hydrocele,pressure onitdoes not always empty it but the hydrocele fluid may
drain into the peritoneal cavity when the childis lying down.
 Encysted hydrocele of cord is smooth oval swelling near the spermatic cord,which is
liable to be mistaken for an inguinal hernia.
 The swelling moves downwards and becomes less mobile if the testis is pulledgently
downwards.


