Liver and Pancreatic Diseases in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Liver and Pancreatic Diseases in Pregnancy — Pattern, Diagnosis & Management

Abnormal liver tests in pregnancy can be harmless, pregnancy-specific, or a sign of coincidental disease. This guide covers normal changes, ICP, HELLP, acute fatty liver, viral and chronic liver disease, gallstones, and pancreatitis, using the LIVER approach.

🎯 AT A GLANCE — LIVER, GALLBLADDER AND PANCREAS

Abnormal liver tests occur in about 3–5% of pregnancies; the cause is either unique to pregnancy (ICP, HELLP, acute fatty liver) or unrelated (viral hepatitis, gallstones, chronic liver disease)

The trimester points to the diagnosis: hyperemesis in the first, intrahepatic cholestasis from the late second, and pre-eclampsia, HELLP, and acute fatty liver in the third

Pregnancy-specific liver diseases can progress quickly to liver failure, bleeding, and fetal death; timely delivery is often the treatment

Acute pancreatitis is rare (about 1 in 1,000–4,000) and is usually gallstone-related; early supportive care gives good outcomes

In India, think of hepatitis E. It carries a high risk of fulminant liver failure in the third trimester, and hepatitis B screening is needed in every antenatal woman.

🚨 URGENT — SENIOR REVIEW, LIVER AND CRITICAL-CARE TEAM

Jaundice with confusion, flapping tremor, or drowsiness — acute liver failure; check glucose, INR, ammonia, creatinine

Third-trimester vomiting with jaundice, hypoglycaemia, and raised uric acid — acute fatty liver of pregnancy

Epigastric or right upper quadrant pain with hypertension and low platelets — HELLP syndrome; sudden severe pain and shock suggests hepatic rupture

Severe epigastric pain with vomiting and lipase more than 3 times normal — acute pancreatitis; fever and jaundice suggest cholangitis

🗺️ THE PATHWAY AT A GLANCE

1 · AskGestation, itch, jaundice, vomiting, pain, blood pressure, drugs, travel, and contacts

2 · TestLiver tests, bile acids, platelets, INR, glucose, creatinine, urate, and viral markers

3 · ImageUltrasound of the liver, gallbladder, and bile ducts; MRCP if needed

4 · DiagnoseMatch the pattern to ICP, HELLP, AFLP, viral, gallstone, or pancreatic disease

5 · TreatStabilise, give disease-specific therapy, and decide timing of delivery

6 · Follow upRepeat tests after birth; vaccinate the newborn; counsel for the next pregnancy

STEP 1 · KNOW THE NORMAL — liver tests in pregnancy

🔬 LIVER TESTS — WHAT CHANGES IN PREGNANCY

Test	In normal pregnancy	Comment
Alkaline phosphatase (ALP)	Rises 2–4 times (placental isoenzyme)	Not useful alone in pregnancy
ALT, AST, GGT, bilirubin	Normal or slightly low	Any rise above the upper limit is abnormal; ALT above 40 IU/L needs a cause
Albumin	Falls by 20–30% (haemodilution)	Low albumin does not mean liver failure
Bile acids	Fasting level under 10 µmol/L	Raised in ICP; non-fasting levels are acceptable
Fibrinogen, clotting factors	Rise; prothrombin time unchanged	Prolonged PT or low fibrinogen points to AFLP, DIC, or liver failure
Skin signs	Spider naevi and palmar erythema are common	Not signs of chronic liver disease unless persistent after delivery

STEP 2 · PREGNANCY-SPECIFIC — ICP, HELLP, fatty liver, hyperemesis

⚖️ COMPARING THE FOUR PREGNANCY-SPECIFIC LIVER DISEASES

Feature	Intrahepatic cholestasis (ICP)	HELLP syndrome	Acute fatty liver (AFLP)	Hyperemesis
Timing	Late 2nd–3rd trimester (from about 28 weeks)	Late 2nd–3rd trimester (20 weeks to after birth)	Third trimester (30–38 weeks)	First trimester, settles by 20 weeks
Main features	Itching of palms and soles, worse at night; no rash	Pain in epigastrium or right upper quadrant, hypertension, headache	Nausea, vomiting, abdominal pain, jaundice, thirst, confusion	Severe vomiting, weight loss, ketosis
Liver tests	Raised bile acids (≥ 10 µmol/L); ALT often 2–10 times normal	AST and ALT raised, LDH high, haemolysis, platelets under 100 × 10⁹/L	ALT 3–10 times normal, bilirubin high, low glucose, high urate, ammonia, creatinine, long INR	Mild ALT rise in up to 50%
Treatment	Ursodeoxycholic acid (UDCA) 10–15 mg/kg/day in divided doses for itch; vitamin K if INR prolonged	Magnesium sulfate, BP control, steroids for lung maturity; deliver	Resuscitate, give glucose, plasma, and treat coagulopathy; deliver promptly	Fluids, antiemetics, thiamine
Risk	Stillbirth, preterm birth, meconium	Hepatic haematoma, rupture, DIC, AKI	Liver failure, DIC, death (maternal mortality about 10–20% without care)	Wernicke encephalopathy (rare)
After delivery	Itch and tests normalise in 2–6 weeks; recurrence 60–90%	Resolves in days; watch for AKI	Recovery in days to weeks; test for LCHAD deficiency in baby and mother	Resolves

🧪 ICP — BILE ACIDS AND DELIVERY TIMING

Bile acid level	Risk	Delivery (RCOG, Royal College of Obstetricians and Gynaecologists)
Under 19 µmol/L	Low	Usually at term (about 40 weeks); earlier if severe itch
19–39 µmol/L	Moderate	38–39 weeks is reasonable
40–99 µmol/L	Higher	Consider induction at 36–38 weeks
100 µmol/L or more	Highest (stillbirth risk about 3% after 35 weeks)	Deliver at 35–36 weeks after steroids and counselling

Monitoring: weekly liver tests and bile acids; fetal movement counts; cardiotocography is not reliable for predicting stillbirth in ICP

Differential for pruritus: skin disease, scabies, hepatitis (A, B, C, E), gallstones, pre-eclampsia, and autoimmune liver disease

Never wait for fetal tests to reassure the woman: stillbirth in ICP is sudden and not predicted by cardiotocography or ultrasound.

🔴 HELLP AND ACUTE FATTY LIVER — THE EMERGENCIES

Topic	HELLP syndrome	Acute fatty liver of pregnancy
Diagnosis	Hypertension and proteinuria usually present; LDH ≥ 600 IU/L, AST ≥ 70, platelets under 100 × 10⁹/L (Tennessee criteria)	Swansea criteria (6 or more): vomiting, pain, polydipsia, encephalopathy, bilirubin above 0.8 mg/dL, glucose under 72 mg/dL, urate above 5.7 mg/dL, white cells above 11, bright liver or ascites on ultrasound, ALT above 42, ammonia above 47 µmol/L, creatinine above 1.7 mg/dL, PT above 14 s, steatosis on biopsy
First steps	Magnesium sulfate; BP control (labetalol, nifedipine); blood, platelet, and plasma ready; dexamethasone 10 mg IV to mature lungs	Glucose infusion; fresh frozen plasma, cryoprecipitate, platelets; treat hypoglycaemia and acidosis; HDU or ICU
Delivery	At 34 weeks or more, or if unstable: deliver after stabilisation; before 34 weeks: steroids for 24–48 hours if mother and fetus are stable	Prompt delivery after stabilisation; caesarean often needed with coagulopathy
Complications	Subcapsular haematoma, hepatic rupture, DIC, pulmonary oedema, AKI	Hepatic encephalopathy, AKI, pancreatitis, sepsis
Postpartum	Watch BP and platelets; HELLP can start after delivery	Maternal recovery in 1–2 weeks; screen child for long-chain fatty acid oxidation disorders

STEP 3 · VIRAL AND CHRONIC LIVER DISEASE — hepatitis A, B, C, E, and cirrhosis

🦠 VIRAL HEPATITIS IN PREGNANCY

Virus	Key points	Management
Hepatitis A	Faeco-oral; usually mild; vertical transmission is rare	Supportive care; vaccinate contacts and newborn if mother has jaundice at delivery; hygiene
Hepatitis B	Screen every woman (HBsAg); vertical transmission 70–90% if HBeAg positive; chronic carriage in over 90% of infected babies	Check HBV DNA and ALT; tenofovir 300 mg daily from 28–32 weeks if DNA ≥ 200,000 IU/mL (or HBeAg-positive where DNA is unavailable); vaccine within 12–24 hours and HBIG (0.5 mL) for the newborn
Hepatitis C	Screen high-risk women; vertical transmission about 5% (higher with HIV)	No direct-acting antivirals in pregnancy; treat after delivery; test the baby at 18 months (or by RNA at 2–6 months); breastfeeding allowed
Hepatitis E	Common in India (genotype 1, waterborne); fulminant failure in 20–25%; mortality up to 20–30% in the third trimester	Supportive care, glucose, vitamin K, plasma; early ICU care; safe water and sanitation; no specific antiviral
Herpes simplex hepatitis	Fever, very high ALT, little jaundice; often fatal if missed	Start IV aciclovir early while awaiting PCR

🏥 INDIA — HEPATITIS B IN PREGNANCY (NVHCP)

The National Viral Hepatitis Control Programme (NVHCP) promotes HBsAg screening of every pregnant woman, but reported routine antenatal screening is only about 65%

Newborns of HBsAg-positive mothers need the birth-dose hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) within 24 hours; birth-dose coverage is reported at over 92%

Complete the full vaccine course and test the baby for HBsAg and anti-HBs at 9–12 months

Referral: women with high viral load or raised ALT go to a hepatology or gastroenterology service; free treatment is available through the programme

Note: these programme figures come from a secondary summary of NVHCP; check the NVHCP operational guidelines for the exact antenatal antiviral protocol.

🩺 CHRONIC LIVER DISEASE AND LIVER TRANSPLANT

Condition	Pregnancy advice
Cirrhosis and portal hypertension	Fertility is reduced; risk of variceal bleeding (about 20–30%), liver failure, and preterm birth; screen for varices by endoscopy in the second trimester; non-selective beta-blocker or variceal banding; assisted second stage to limit pushing
Autoimmune hepatitis	Continue prednisolone and azathioprine; flares can occur after delivery; fetal outcomes good if disease is quiet
Primary biliary cholangitis	Continue ursodeoxycholic acid; watch for itch and portal hypertension
Wilson disease	Continue treatment (zinc; reduce penicillamine or trientine dose by 25–50%); stopping causes liver failure
Budd–Chiari syndrome	Anticoagulation with low-molecular-weight heparin; specialist care
Liver transplant recipients	Wait 1 year after transplant with stable graft; tacrolimus, azathioprine, prednisolone are acceptable; stop mycophenolate before conception
Non-alcoholic fatty liver disease	Common with obesity and diabetes; raises gestational diabetes and pre-eclampsia risk; weight and glucose control

STEP 4 · GALLBLADDER AND PANCREAS — gallstones and pancreatitis

🪨 GALLSTONE DISEASE

Condition	Features	Management
Biliary colic	Right upper quadrant or epigastric pain after meals; gallstones are 2–3 times more common in pregnancy	Analgesia, fluids, antiemetics; low-fat diet; laparoscopic cholecystectomy in the second trimester if recurrent
Acute cholecystitis	Fever, tenderness, raised white cells; thickened gallbladder wall on ultrasound	Antibiotics (cephalosporin ± metronidazole); laparoscopic cholecystectomy in any trimester if not settling
Choledocholithiasis and cholangitis	Jaundice, fever, pain; dilated bile duct	Endoscopic retrograde cholangiopancreatography (ERCP) with shielding and sphincterotomy; antibiotics
Imaging	Ultrasound first; magnetic resonance cholangiopancreatography (MRCP) without gadolinium if needed	Avoid CT unless the diagnosis is uncertain and life-threatening

🔥 ACUTE PANCREATITIS IN PREGNANCY

Topic	Details
Causes	Gallstones (about 65–100%), hypertriglyceridaemia (triglycerides above 1,000 mg/dL, usually late pregnancy, worse with diabetes), alcohol, hyperparathyroidism, drugs, and pre-eclampsia, HELLP, or AFLP
Diagnosis	Epigastric pain radiating to the back with vomiting; serum lipase more than 3 times normal (amylase is less specific); ultrasound for gallstones; MRCP if needed
Severity	Revised Atlanta classification: mild, moderately severe, severe (persistent organ failure over 48 hours)
Management	IV fluids (Ringer's lactate), analgesia, antiemetics; early oral or enteral feeding; oxygen; HDU or ICU for organ failure; no routine antibiotics (only for infected necrosis or cholangitis)
Gallstone pancreatitis	ERCP if cholangitis or persistent obstruction; cholecystectomy in the same admission (or the second trimester or after delivery) to prevent recurrence
Hypertriglyceridaemia	Insulin infusion (with glucose) or plasmapheresis if triglycerides are very high; fenofibrate or omega-3 fatty acids after the acute phase; very low-fat diet
Pregnancy outcome	Maternal mortality is now under 1%; preterm birth about 20%; fetal loss 10–20% in severe disease; deliver for obstetric reasons, not pancreatitis alone

Chronic pancreatitis and cystic fibrosis: continue enzymes, manage diabetes, and plan pregnancy only if lung function (FEV₁) is above about 50–60% and nutrition is good.

⚠️ COMMON PITFALLS

Attributing a raised ALP to liver disease, or ignoring a raised ALT because 'pregnancy changes the tests'

Missing ICP in a woman with itching and normal liver tests (repeat the tests; check bile acids) — and delaying delivery when bile acids are very high

Confusing HELLP or AFLP with hepatitis, or pancreatitis with hyperemesis; delay in delivery can be fatal

Forgetting hepatitis B: not screening the mother, or missing the newborn's vaccine and HBIG within 24 hours

Missing hepatitis E in a jaundiced third-trimester woman, or stopping essential drugs (Wilson disease, immunosuppressants)

Memory Aid

LIVER

Five steps for liver and pancreatic disease in pregnancy.

L

Look at the gestation and the labs — ALP rises normally; ALT, bile acids, platelets, INR, and glucose do not

I

Itch means bile acids — treat ICP with UDCA and plan delivery by the level

V

Viral screen — HBsAg for all; HEV in jaundiced women; vaccine and HBIG for the newborn

E

Emergencies — HELLP and acute fatty liver: stabilise, then deliver

R

Rule out gallstones and pancreatitis — ultrasound, lipase, fluids, and early surgery or ERCP

Remember: use pregnancy ranges, find the pattern, and deliver on time when the liver disease is pregnancy-specific.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the Royal College of Obstetricians and Gynaecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), and the National Viral Hepatitis Control Programme (NVHCP), India; written largely from memory; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

Renal Disorders Complicating Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Renal Disorders Complicating Pregnancy — Infection, Injury & Chronic Kidney Disease

Renal disorders range from urinary tract infection to acute kidney injury, chronic kidney disease, glomerular disease, dialysis, and transplant. This guide covers normal changes, infection, stones, acute and chronic disease, drug safety, delivery, and follow-up, using the KIDNEYS approach.

🎯 AT A GLANCE — KIDNEYS AND PREGNANCY

Pregnancy changes normal kidney function, so the usual adult limits do not apply — a serum creatinine of 0.9 mg/dL may signal significant disease

Urinary tract infection (UTI) is the commonest renal problem; untreated asymptomatic bacteriuria leads to pyelonephritis in about 30% and to preterm birth

Acute kidney injury (AKI) is still frequent in India, mainly from septic abortion, haemorrhage, pre-eclampsia, and sepsis

Chronic kidney disease (CKD) raises the risk of pre-eclampsia, preterm birth, growth restriction, and permanent loss of kidney function; the baseline creatinine and blood pressure predict the outcome

Pregnancy is a stress test for the kidney: plan before conception, share care between the obstetrician and the nephrologist, and never miss a UTI.

🚨 URGENT — ADMIT AND CALL THE NEPHROLOGIST

Pyelonephritis with fever, rigors, vomiting, sepsis, or no response in 48–72 hours — think of obstruction (a stone) or an abscess

Oliguria (under 400 mL/day), rising creatinine, or creatinine above 1.0 mg/dL in a woman without known kidney disease

Pulmonary oedema, severe hyperkalaemia, acidosis, or uraemic symptoms — plan urgent dialysis

Severe pre-eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), or thrombotic microangiopathy

🗺️ THE PATHWAY AT A GLANCE

1 · ScreenUrine culture and dipstick at the first visit; BP and creatinine if known renal disease

2 · ClassifyInfection, stone, acute injury, chronic disease, glomerular disease, dialysis, or transplant

3 · Review drugsStop ACE inhibitors, ARBs, mycophenolate; start aspirin and calcium as indicated

4 · MonitorCreatinine, urine protein ratio, BP, urine culture; growth scans from 24–28 weeks

5 · TreatAntibiotics, BP control, thromboprophylaxis, dialysis by indication

6 · Deliver and followTimed delivery, then nephrology review and contraception counselling

STEP 1 · KNOW THE NORMAL — how pregnancy changes the kidney

🔬 PHYSIOLOGICAL CHANGES AND TEST LIMITS

Parameter	Normal pregnancy	Why it matters
Glomerular filtration rate (GFR)	Rises by 40–50% from the 6th week; peaks at about 12–16 weeks	Creatinine falls: normal is about 0.4–0.8 mg/dL
Serum creatinine	Above 0.8–0.9 mg/dL (72–80 µmol/L) is abnormal	Do not accept 'normal for an adult'; urea falls to about 9–12 mg/dL
Urine protein	Up to 300 mg/day (spot protein:creatinine ratio under 0.3)	Ratio above 0.3 needs evaluation; above 3.5 g/day is nephrotic
Collecting system	Dilated (hydronephrosis), right more than left, from progesterone and uterine pressure	Not obstruction by itself; symptoms or infection raise concern
Acid–base	Bicarbonate 18–22 mEq/L (respiratory alkalosis with compensation)	A bicarbonate below 18 suggests acidosis
Glycosuria	Common (reduced tubular reabsorption)	Does not diagnose diabetes

Use pregnancy ranges. Cystatin C and eGFR formulae are not reliable in pregnancy; measure creatinine and proteinuria directly.

STEP 2 · INFECTIONS — bacteriuria, cystitis and pyelonephritis

🦠 URINARY TRACT INFECTION IN PREGNANCY

Condition	Diagnosis	Treatment
Asymptomatic bacteriuria (2–10% of women)	Urine culture at the first visit: ≥ 10⁵ CFU/mL (colony-forming units) of one organism, no symptoms	Treat always: 4–7 days by culture; repeat culture 1–2 weeks after (test of cure); screen again later in pregnancy if high risk
Acute cystitis	Dysuria, frequency, urgency, suprapubic pain, no fever; culture and sensitivity	Oral antibiotic for 5–7 days by sensitivity; repeat culture after treatment
Acute pyelonephritis	Fever above 38 °C, flank pain, vomiting, costovertebral tenderness; pyuria; blood and urine cultures	Admit; IV fluids; IV ceftriaxone 1–2 g daily (or cefazolin, or an aminoglycoside); change to oral after 24–48 hours afebrile; total 10–14 days
Recurrent UTI	Two or more episodes in pregnancy	Prophylaxis after treatment: nitrofurantoin 50–100 mg or cefalexin 250–500 mg at night until delivery, plus post-coital advice

Complications of pyelonephritis: sepsis, acute respiratory distress syndrome (2–8%), anaemia, preterm labour, and AKI; monitor oxygen saturation and urine output; avoid beta-agonist tocolytics (risk of pulmonary oedema) and give IV fluids carefully.

💊 ANTIBIOTIC CHOICES — SAFE AND UNSAFE

Antibiotic	Use in pregnancy
Cephalosporins (cefalexin, cefixime, ceftriaxone), amoxicillin-clavulanate	Safe and commonly used by sensitivity
Nitrofurantoin	Acceptable in the second trimester; avoid in the first trimester if alternatives exist and near term (haemolysis in G6PD deficiency); not for pyelonephritis
Fosfomycin 3 g single dose	Option for cystitis or bacteriuria where available
Trimethoprim and co-trimoxazole	Avoid in the first trimester (folate antagonism) and near term; use only if no alternative
Fluoroquinolones, tetracyclines	Avoid in pregnancy
Aminoglycosides	Use with levels and kidney monitoring only when necessary

Follow the local antibiogram. Resistance in Indian E. coli, including extended-spectrum beta-lactamase (ESBL) producers, is common — always send a culture and check the national antimicrobial guidance.

STEP 3 · STONES AND ACUTE INJURY — obstruction and AKI

🪨 UROLITHIASIS (KIDNEY STONES)

Flank pain, haematuria, or infection; stones occur in about 1 in 1,500–3,000 pregnancies; hydronephrosis is normal, so look for a stone (or an absent ureteric jet)

First-line imaging: ultrasound; magnetic resonance urography or low-dose CT if unclear

Most stones pass (about 70%) with fluids, analgesia (paracetamol, opioids), and antiemetics; avoid NSAIDs late in pregnancy

Infected obstructed system is an emergency: ureteric stent or percutaneous nephrostomy with antibiotics; ureteroscopy for persistent stones

Shock-wave lithotripsy is contraindicated in pregnancy

⚡ ACUTE KIDNEY INJURY (AKI)

Cause	Examples	Management
Pre-renal	Hyperemesis, haemorrhage (APH, PPH), sepsis, dehydration	Restore volume, correct blood loss, treat the cause
Intrinsic	Acute tubular necrosis, severe pre-eclampsia or HELLP, septic abortion, acute fatty liver of pregnancy, bilateral cortical necrosis	Deliver if it is pre-eclampsia or fatty liver; antibiotics and source control for sepsis
Thrombotic microangiopathy	TTP, atypical HUS (thrombotic thrombocytopenic purpura; haemolytic uraemic syndrome): haemolysis, low platelets, renal failure	Plasma exchange or eculizumab with a specialist; ADAMTS13 level
Post-renal	Stone, ureteric injury, or pressure from a gravid uterus	Ultrasound; stent or nephrostomy
Dialysis indications	Urea above 100 mg/dL (some use lower thresholds), creatinine rising, hyperkalaemia, acidosis, fluid overload	Start early and aim for pre-dialysis urea below 50 mg/dL

Drugs to avoid in AKI: NSAIDs, ACE inhibitors, ARBs, aminoglycosides unless necessary, and contrast media unless essential; dose-adjust all drugs to the GFR.

STEP 4 · CHRONIC DISEASE — CKD, glomerular disease, dialysis and transplant

🩺 CHRONIC KIDNEY DISEASE (CKD) IN PREGNANCY

Baseline (before pregnancy)	Risks	Approach
Mild: creatinine below 1.4 mg/dL (eGFR above 60)	Mostly good outcomes (live birth above 95%); pre-eclampsia 20–30%; small risk of GFR loss	Monthly review; BP target about 130/80 (some use under 140/90); aspirin
Moderate: creatinine 1.4–2.4 mg/dL (eGFR 30–60)	Preterm birth and growth restriction 40–60%; pre-eclampsia up to 60%; 40% lose GFR permanently	Joint renal–obstetric clinic every 2–4 weeks; anaemia, acidosis, and BP care
Severe: creatinine above 2.4 mg/dL (eGFR below 30)	Live birth about 50–60%; most deliver preterm; about 50% reach end-stage kidney disease	Counsel against pregnancy or weekly care; consider dialysis if urea high

Topic	Advice
Before conception	Stable disease, BP below 140/90, proteinuria under 1 g/day; stop ACE inhibitors, ARBs, statins; folic acid 5 mg
Antihypertensives	Labetalol, nifedipine, or methyldopa; avoid ACE inhibitors, ARBs, spironolactone
Aspirin and calcium	Low-dose aspirin (75–150 mg nightly from 12 weeks); calcium 1–1.5 g/day where intake is low
Anaemia	Iron; erythropoietin if haemoglobin stays low; target 10–11 g/dL
Monitoring	Creatinine, urine protein ratio, urea, electrolytes, urine culture every 4 weeks; growth scans from 24–28 weeks

🧪 GLOMERULAR DISEASE, LUPUS NEPHRITIS AND OTHER CONDITIONS

Condition	Key points
Nephrotic syndrome (proteinuria above 3.5 g/day, low albumin, oedema)	High risk of thrombosis: prophylactic heparin if albumin is below 2.0–2.5 g/dL; careful diuretics; avoid statins; treat the cause (steroids for minimal change)
IgA nephropathy and other glomerulonephritis	Outcome depends on baseline GFR, BP, and proteinuria; flare can mimic pre-eclampsia; biopsy before 28 weeks only if rapid deterioration
Lupus nephritis	Disease quiet for at least 6 months; continue hydroxychloroquine; azathioprine, prednisolone, tacrolimus allowed; stop mycophenolate (6 weeks before conception), cyclophosphamide, and ACE inhibitors; aspirin
Diabetic nephropathy	Tight glucose; high pre-eclampsia and preterm risk; aspirin; retinal and BP review
Polycystic kidney disease, reflux nephropathy, solitary kidney	Hypertension and UTI risk; screen urine cultures; solitary kidney with normal GFR does well; donors have a small excess of pre-eclampsia

Pre-eclampsia versus a renal flare: in a flare, active urinary sediment (red cells and casts), low complement, rising anti-dsDNA, and early onset (before 20 weeks) are common; in pre-eclampsia, sFlt-1:PlGF ratio is high and platelets, liver enzymes, and uric acid change.

🔁 DIALYSIS AND KIDNEY TRANSPLANT

Group	What to do
Women on dialysis	Fertility is low; if pregnant, intensify dialysis (more than 20 hours/week, ideally nocturnal or daily); pre-dialysis urea below 50 mg/dL; avoid hypotension; live birth about 70–80% but preterm
Transplant recipients	Wait 1–2 years after transplant with stable graft (creatinine below 1.5 mg/dL, proteinuria under 500 mg/day, no recent rejection); live birth above 90%; preterm birth and pre-eclampsia common
Drugs after transplant	Prednisolone, azathioprine, tacrolimus (monitor levels) are safe; stop mycophenolate, sirolimus, and everolimus before conception; cyclosporine acceptable
Delivery	Mode by obstetric indication; transplant kidney sits in the pelvis but rarely blocks labour; give steroid cover and prophylactic antibiotics
Breastfeeding	Safe with prednisolone, azathioprine, and tacrolimus

STEP 5 · DELIVER AND FOLLOW UP — timing, labour, and after

🏥 DELIVERY AND AFTERWARDS

Topic	Advice
Fetal surveillance	Anomaly scan; growth scans every 3–4 weeks from 24–28 weeks; uterine artery Doppler; amniotic fluid; kick counts
Timing of delivery	Stable CKD: up to 37–40 weeks; deteriorating function, severe pre-eclampsia, or fetal compromise: earlier; deliver in a unit with a neonatal intensive care unit
Mode	Vaginal birth preferred; caesarean for obstetric indications; fluid balance and urine output are closely monitored
After delivery	Creatinine and BP checks; avoid NSAIDs; GFR may fall in the first 6 months; nephrology review at 6 weeks
Contraception	Progestogen-only methods or intrauterine devices are preferred; avoid oestrogen if hypertensive, nephrotic, or with active lupus
Long-term	Lifelong follow-up: BP, proteinuria, and kidney function; pre-eclampsia and AKI raise the later risk of CKD

⚠️ COMMON PITFALLS

Accepting a 'normal' adult creatinine (such as 1.0 mg/dL) as normal in pregnancy

Not sending a urine culture, or stopping antibiotics early without a test of cure

Using ACE inhibitors, ARBs, NSAIDs, or mycophenolate in a woman who may conceive

Missing thrombosis risk in nephrotic syndrome, or missing AKI after haemorrhage or sepsis

Treating a lupus or glomerulonephritis flare as pre-eclampsia — or the reverse

Memory Aid

KIDNEYS

Seven points for renal disease in pregnancy.

K

Know the physiology — GFR up, creatinine down, proteinuria up to 300 mg/day

I

Infection — culture at the first visit; treat bacteriuria; admit pyelonephritis

D

Drugs — stop ACE inhibitors, ARBs, mycophenolate; avoid NSAIDs

N

Nephrotic syndrome — think of thrombosis; give heparin when albumin is low

E

Evaluate pre-eclampsia versus a renal flare

Y

Your team — obstetrician and nephrologist together, with a neonatal unit

S

Surveillance — creatinine, urine protein, BP, urine culture, and growth scans

Remember: use pregnancy ranges, treat infection fully, protect the kidney from harmful drugs, and plan before conception and after delivery.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), KDIGO (Kidney Disease: Improving Global Outcomes), the UK Kidney Association, and standard obstetric nephrology texts; written from memory, not from a Government of India renal protocol; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Diabetes in Pregnancy — Gestational & Pregestational Diabetes

Diabetes in pregnancy includes gestational diabetes mellitus (GDM) and pregestational type 1 and type 2 diabetes. This guide covers screening and diagnosis, the Government of India guideline, diet and drug treatment, fetal surveillance, delivery, newborn care, and postpartum follow-up, using the SUGARS approach.

🎯 AT A GLANCE — DIABETES AND PREGNANCY

Gestational diabetes mellitus (GDM) is glucose intolerance first recognised in pregnancy; in India it affects roughly 10–20% of pregnant women, among the highest rates in the world

Pregestational (overt) diabetes, type 1 or type 2, carries higher risks: congenital anomalies, miscarriage, stillbirth, pre-eclampsia, and diabetic ketoacidosis

Maternal hyperglycaemia causes fetal hyperinsulinaemia, leading to macrosomia, shoulder dystocia, neonatal hypoglycaemia, and later obesity and diabetes

Good glucose control, timely delivery, and postpartum testing prevent most complications and detect future type 2 diabetes

Every pregnant woman should be tested — early in pregnancy for undiagnosed diabetes, and again at 24–28 weeks for GDM.

🚨 URGENT — SENIOR AND ENDOCRINE REVIEW

Diabetic ketoacidosis (DKA): nausea, vomiting, abdominal pain, fast breathing, drowsiness — it can occur at glucose below 250 mg/dL in pregnancy; test ketones

Severe hypoglycaemia (below 70 mg/dL with symptoms, or any episode needing help)

Fasting glucose above 200 mg/dL, or glucose above 250 mg/dL after meals despite treatment, or insulin above 20 units a day (Indian referral criteria)

Reduced fetal movements, polyhydramnios, estimated fetal weight above the 90th centile, pre-eclampsia, or retinopathy or kidney disease

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyHbA1c below 6.5%, folic acid 5 mg, stop teratogenic drugs, review eyes and kidneys

2 · First visitTest everyone for overt diabetes or early GDM; aspirin if high risk

3 · 24–28 weeks75 g OGTT if the first test was normal; start treatment at diagnosis

4 · TreatDiet and exercise first; insulin or metformin if above target

5 · MonitorGrowth scans at 28–30 and 34–36 weeks; glucose records; fetal movements

6 · Deliver and followTimed delivery, newborn glucose checks, OGTT at 6 weeks, and yearly screening

STEP 1 · SCREEN AND DIAGNOSE — who, when, and which test

🔬 DIAGNOSIS — INTERNATIONAL CRITERIA

Test	Threshold	Notes
Overt diabetes in early pregnancy	Fasting plasma glucose ≥ 126 mg/dL, HbA1c ≥ 6.5%, random glucose ≥ 200 mg/dL with symptoms, or 2-hour OGTT ≥ 200	Treat as pregestational diabetes; confirm with a repeat test if no symptoms
75 g OGTT (IADPSG / WHO 2013), after overnight fast	Fasting ≥ 92, 1 hour ≥ 180, or 2 hours ≥ 153 mg/dL — any one value makes the diagnosis	Done at 24–28 weeks, or earlier in high-risk women
Two-step test (ACOG)	50 g glucose challenge ≥ 130–140 mg/dL, then 100 g OGTT (Carpenter-Coustan: 95, 180, 155, 140)	Two or more abnormal values diagnose GDM
HbA1c	Not used to diagnose GDM; useful in early pregnancy for overt diabetes	Falls physiologically in pregnancy

High-risk women (obesity, previous GDM or macrosomia, family history of diabetes, PCOS, age over 35, glycosuria, South Asian origin) need testing at the first visit, and again at 24–28 weeks if normal.

INDIA · MoHFW GUIDELINE — diagnosis and management of gestational diabetes mellitus

🏥 GOVERNMENT OF INDIA — SCREENING AND DIAGNOSIS

Universal testing of all pregnant women, with a single-step 75 g OGTT (Oral Glucose Tolerance Test) given regardless of fasting status or the last meal

Test 1 at the first antenatal contact; Test 2 at 24–28 weeks if the first is negative, at least 4 weeks apart; a woman first seen after 28 weeks gets one test

Diagnosis: 2-hour plasma glucose ≥ 140 mg/dL (read on a plasma-calibrated glucometer); if she vomits within 30 minutes, repeat the next day or refer

Who does it: the ANM (Auxiliary Nurse Midwife) at the village health and nutrition day or sub-centre; the ASHA (Accredited Social Health Activist) mobilises women and follows up

The national test differs from the international criteria (a single 2-hour value of 140 mg/dL; no fasting, 1-hour, or 153-mg/dL threshold). Follow the national protocol in public facilities, and use international criteria where the facility applies them.

STEP 2 · TREAT — lifestyle, drugs and targets

🥗 DIET, EXERCISE AND GLUCOSE TARGETS

Topic	Advice
First step	Medical nutrition therapy and 30 minutes of walking daily; review after 2 weeks with a 2-hour post-meal glucose
Meals	3 small meals and 2–3 snacks; complex carbohydrates, fibre (pulses, oats), enough protein (about 23 g extra a day); saturated fat under 10% of calories
Calories	Pre-pregnancy needs plus about 350 kcal/day in the second and third trimesters; moderate restriction only in obese women — avoid severe restriction (ketosis)
Indian targets	Fasting below 95 mg/dL and 2-hour after meals below 120 mg/dL
International targets (ADA, American Diabetes Association)	Fasting below 95, 1 hour below 140, 2 hours below 120 mg/dL; HbA1c about 6–6.5% if safe
Self-monitoring	Fasting and after meals; on insulin, check fasting and 2-hour post-meal every 3rd day (Indian guideline) or four times a day in pregestational diabetes

Start medicines if the post-meal glucose stays at or above 120 mg/dL after 2 weeks of diet and exercise (Indian guideline).

💉 INSULIN, METFORMIN AND OTHER DRUGS

Drug	Use in pregnancy	Details
Insulin	First-line in GDM and essential in type 1 and most type 2	Indian GDM guideline: human premixed 30:70 insulin 30 minutes before breakfast; start 4 units for 2-hour glucose 120–160, 6 for 160–200, 8 for above 200 mg/dL; add 2 units before dinner if fasting is high
Basal-bolus insulin	Type 1 and type 2, or GDM needing intensive control	Doses rise through pregnancy (2–3 times by term) and fall sharply after delivery
Metformin	After 20 weeks if diet fails, or if insulin is not acceptable	500 mg twice daily, up to 2 g a day (Indian guideline); crosses the placenta; add insulin if control is inadequate
Glibenclamide (glyburide)	Not recommended by many guidelines	Higher risk of neonatal hypoglycaemia and macrosomia; not in the Indian guideline
Aspirin	75–150 mg nightly from 12 weeks in pregestational diabetes	Lowers pre-eclampsia risk
Antihypertensives	Switch ACE inhibitors and ARBs before conception	Labetalol or nifedipine are used instead
Statins	Stop when planning pregnancy	Not advised in pregnancy

Hypoglycaemia (below 70 mg/dL): give 15–20 g glucose (about 3 teaspoons of glucose powder in water), rest, and eat within 15 minutes; refer if more than one episode a day.

STEP 3 · PREGESTATIONAL DIABETES — extra steps for types 1 and 2

🩺 BEFORE AND DURING PREGNANCY

Phase	Action
Preconception	HbA1c below 6.5% (ideally below 7% before trying); folic acid 5 mg daily; stop statins, ACE inhibitors and ARBs; switch oral agents to metformin or insulin; effective contraception until control is reached
First trimester	Check HbA1c, retinal screening (at booking and again at 16–20 weeks), kidney function, urine protein, thyroid function; watch for hypoglycaemia and vomiting with ketosis
Anomaly scan	Detailed scan at 18–22 weeks with fetal echocardiography (cardiac defects and neural tube defects are more common)
Later pregnancy	Growth scans every 4 weeks from 28 weeks; aspirin and blood pressure checks; antenatal steroids with extra glucose monitoring
Complications	Retinopathy may worsen; nephropathy raises pre-eclampsia and growth restriction; DKA risk

STEP 4 · THE BABY — surveillance, delivery and newborn

📡 FETAL SURVEILLANCE AND DELIVERY

Topic	Recommendation
Ultrasound (Indian guideline)	Anomaly scan at 18–20 weeks if diagnosed before 20 weeks; growth and liquor scans at 28–30 weeks and again at 34–36 weeks, at least 3 weeks apart
Fetal movements	10 kicks within 2 hours after a meal, lying on her side; report the same day if fewer
Visits	High-risk schedule: at least monthly, more often with poor control
Timing — well-controlled GDM	Deliver at a facility; induce at or after 39 weeks if not in spontaneous labour; routine delivery before 39 weeks is not advised (Indian guideline)
Timing — poor control, insulin above 20 units a day, or complications	Refer at 34–36 weeks to a CEmOC centre (Comprehensive Emergency Obstetric and Newborn Care) with a gynaecologist; individualise delivery timing
Timing — pregestational diabetes	Usually induction at 37–39 weeks (earlier with vascular disease or poor control)
Mode	Vaginal birth preferred; consider caesarean section if the estimated fetal weight is over 4 kg (Indian guideline) — 4.5 kg in some guidelines
Antenatal steroids	Dexamethasone 6 mg IM every 12 hours for 2 doses at 24–34 weeks if early delivery is expected; monitor glucose for 72 hours and adjust insulin

🏥 IN LABOUR, THE NEWBORN, AND AFTER DELIVERY

Stage	What to do
Intrapartum	Glucose every hour (every 2 hours in the Indian guideline); hold the morning insulin or metformin; saline at 100 mL/h with regular insulin per 500 mL: 0 units (glucose 90–120), 4 units (120–140), 6 units (140–180), 8 units (above 180 mg/dL); aim to keep glucose about 70–110 mg/dL (international targets)
Newborn	Skin-to-skin contact and early breastfeeding; check glucose within 1 hour, then every 4 hours before feeds until 4 stable readings
Neonatal hypoglycaemia	Below 45 mg/dL (below 54 in growth-restricted babies): feed and recheck in 1 hour; below 20 mg/dL or symptoms: 10% dextrose 2 mL/kg IV, then infusion; refer to a paediatric centre if it persists
Insulin after birth	GDM: stop all drugs and check fasting and 2-hour post-meal glucose; type 1: reduce to the pre-pregnancy dose or lower; type 2: restart metformin (compatible with breastfeeding)
Postpartum test	75 g OGTT at 6 weeks (Indian guideline; 4–12 weeks internationally); fasting ≥ 126 or 2-hour ≥ 200 mg/dL: diabetes; 2-hour 140–199: impaired glucose tolerance
Long-term	Yearly screening through the NCD (non-communicable disease) clinic; up to 50% develop type 2 diabetes within 10–20 years; lifestyle change, contraception and pregnancy planning

Breastfeeding lowers the mother's diabetes risk and the child's obesity risk — encourage it for all women with GDM or diabetes.

📋 INDIA — WHEN TO REFER

Fasting glucose above 200 mg/dL (with or without treatment), or above 150 mg/dL, or after-meal glucose above 250 mg/dL, despite medication

After-meal glucose above 200 mg/dL at any time, or insulin above 20 units a day

Hypoglycaemia more than once a day, refusal of insulin, or vomiting with inability to eat

Warning signs: reduced fetal movements, premature rupture of membranes, abdominal pain, burning micturition, or fever

Level of care: Medical Officer at the PHC starts metformin or insulin; district hospital and CEmOC centres manage all complicated cases

⚠️ COMMON PITFALLS

Testing only at 24–28 weeks and missing overt diabetes in early pregnancy

Delaying insulin or using strict calorie restriction that causes ketosis

Forgetting folic acid 5 mg, aspirin, and eye and kidney checks in pregestational diabetes

Missing neonatal glucose checks and postpartum testing; lost follow-up is common

Not reducing insulin after birth — a fall in requirement can cause severe hypoglycaemia

Memory Aid

SUGARS

Six steps for diabetes in pregnancy.

S

Screen every woman at the first visit and at 24–28 weeks; confirm with the 75 g OGTT

U

Use diet and exercise first; review the post-meal glucose after 2 weeks

G

Glucose targets — fasting below 95 mg/dL; post-meal below 120 mg/dL

A

Add insulin or metformin when above target; aspirin and folic acid 5 mg in pregestational diabetes

R

Review the baby — anomaly scan, growth scans at 28–30 and 34–36 weeks, fetal movements

S

Schedule delivery, check the newborn's glucose, and test again at 6 weeks and yearly

Remember: tight glucose control, timely delivery, newborn glucose checks, and lifelong follow-up protect both mother and child.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the Ministry of Health & Family Welfare, Govt of India (MoHFW) GDM guideline, the American Diabetes Association (ADA), the American College of Obstetricians and Gynecologists (ACOG), the International Association of the Diabetes and Pregnancy Study Groups (IADPSG), and the World Health Organization (WHO); thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

Ectopic Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Ectopic Pregnancy — Diagnosis, Treatment & Follow-up

Ectopic pregnancy is a time-critical emergency in early pregnancy. This guide covers risk factors, diagnosis with ultrasound and hCG, the Indian standard treatment guideline, expectant, medical and surgical care, special sites, and follow-up, using the ECTOPIC approach.

🎯 AT A GLANCE — ECTOPIC PREGNANCY

An ectopic pregnancy implants outside the endometrial cavity — about 95–97% in the fallopian tube (mostly the ampulla); incidence is about 1–2% of pregnancies (1–3% in the Indian guideline)

It remains a leading cause of first-trimester maternal death; the classic triad is amenorrhoea, pain, and vaginal bleeding, but many women have no risk factor

Diagnosis rests on a transvaginal ultrasound (TVS) and serial serum β-hCG (human chorionic gonadotropin)

Treatment is expectant, medical (methotrexate), or surgical, chosen by stability, hCG level, mass size, fetal heart activity, and follow-up reliability

Think of ectopic pregnancy in every woman of reproductive age with pain or bleeding and a positive pregnancy test — until an intrauterine pregnancy is proven.

🚨 EMERGENCY — SUSPECT A RUPTURED ECTOPIC

Shock: pallor, tachycardia, low blood pressure, fainting, or collapse

Severe or sudden lower abdominal pain, shoulder-tip pain, rebound tenderness, or a distended abdomen

Free fluid in the pouch of Douglas or Morison's pouch on ultrasound, or a positive pregnancy test with cervical motion tenderness

Action: two large IV lines, group and cross-match, resuscitate, call a senior and the anaesthetist, and go to theatre without waiting for hCG

🗺️ THE PATHWAY AT A GLANCE

1 · SuspectPain, bleeding, amenorrhoea, or a positive test; risk factors raise suspicion

2 · StabilisePulse, blood pressure, pallor, and signs of shock; IV access, blood group, cross-match

3 · ImageTransvaginal ultrasound to find the gestational sac and adnexal mass

4 · MeasureSerum β-hCG now and at 48 hours if the location is unknown

5 · TreatSurgery if unstable; otherwise expectant, methotrexate, or surgery by criteria

6 · Follow uphCG to negative, anti-D if Rh-negative, and counsel for the next pregnancy

STEP 1 · RECOGNISE — risk factors and clinical features

📝 WHO IS AT RISK, AND WHAT SHE FEELS

Risk Factors

Previous ectopic (recurrence 10–15%) or tubal surgery or sterilisation failure

Pelvic inflammatory disease, Chlamydia, or tuberculosis

Intrauterine device in place or progestogen-only pill (if pregnancy occurs, a higher share are ectopic)

Infertility, assisted reproduction, or ovulation induction

Smoking, age over 35, endometriosis, previous pelvic surgery

Clinical Features

Amenorrhoea of 6–8 weeks, then lower abdominal pain

Light, dark-brown vaginal bleeding (often not heavy)

Dizziness, shoulder-tip pain, or pain on defecation (blood in the pouch)

Tender adnexa or cervical motion tenderness; uterus often smaller than dates

Up to half have no risk factor; some are asymptomatic

Pregnancy of unknown location (PUL): positive test, no pregnancy seen on a good-quality TVS — about 7–20% turn out to be ectopic, so follow every PUL until the outcome is known.

STEP 2 · DIAGNOSE — ultrasound and β-hCG

🔬 ULTRASOUND AND β-hCG

Finding	Meaning	Next step
Intrauterine sac with yolk sac or embryo	Intrauterine pregnancy (heterotopic is rare, but think of it after assisted reproduction)	Routine care
Adnexal mass or 'tubal ring' with or without fetal heart	Ectopic pregnancy	Choose treatment by criteria
Empty uterus, hCG above the discriminatory level (about 3,500 mIU/mL by the conservative US standard; 1,500 is older practice)	Ectopic or failed pregnancy until proven otherwise	Repeat scan; consider repeat hCG; do not assume miscarriage
Empty uterus, hCG below the discriminatory level	PUL	Repeat hCG at 48 hours; scan again; safety-net advice
Free fluid with echoes (haemoperitoneum)	Likely rupture	Emergency surgery if unstable

hCG change over 48 hours	Interpretation
Rise of at least 49% (starting below 1,500), 40% (1,500–3,000), or 33% (above 3,000)	Consistent with a viable intrauterine pregnancy (but about 20% of ectopics can rise normally)
Fall of 21–35% or more (depends on starting level)	Likely a failing pregnancy; keep following until negative
Plateau, or abnormal rise or fall	Ectopic pregnancy or abnormal intrauterine; repeat scan and plan treatment

A single hCG value cannot diagnose or exclude an ectopic pregnancy; the level does not predict rupture.

INDIA · MoHFW STANDARD TREATMENT GUIDELINE — ectopic pregnancy

🏥 GOVERNMENT OF INDIA APPROACH

Topic	What the guideline says
Definition and risks	Implantation outside the uterine cavity, 1–3% of pregnancies; PID, endometriosis, IUCD, progestogen-only pill, tubal surgery or ligation, ovulation induction or assisted reproduction
Diagnosis	Pregnancy test; abdominal or vaginal ultrasound (empty uterus, pseudosac, adnexal mass, fluid in the pouch); culdocentesis if no ultrasound; blood group and cross-match; histopathology
Expectant management	Stable, ultrasound-diagnosed, hCG falling and below 1,000 IU/L; hCG twice weekly, weekly transvaginal scan, until hCG below 20 IU/L; if it plateaus or rises, switch to active treatment
Methotrexate eligibility	Stable, unruptured; absolute contraindications: breastfeeding, immunodeficiency, alcoholism, blood dyscrasia, active lung disease, peptic ulcer, liver, kidney or blood disease; relative: sac over 3.5 cm, fetal cardiac activity
Methotrexate dose	1 mg/kg or 50 mg/m² IM with leucovorin 0.1 mg/kg IM; hCG on days 4 and 7; another dose if hCG has not fallen by more than 15%; maximum 4 doses
Surgery	Ruptured ectopic: laparotomy to control bleeding and remove the tube; laparoscopic salpingostomy or salpingectomy where skilled; surgery if medical treatment fails
Anti-D	Give if the woman is Rh-negative and the partner Rh-positive
Referral	Secondary level: no serial hCG or medical care, no laparoscopy, heterotopic pregnancy to be continued, or transfusion needed. Super-specialty: major comorbidity, lack of skills, or assisted-reproduction heterotopic pregnancy

Note: this is a summary of the MoHFW Standard Treatment Guideline as reproduced on a secondary website; check the official publication. Its dosing differs slightly from international guidance (for example, leucovorin and the hCG fall of 15%).

STEP 3 · TREAT — choose by stability, hCG and mass

⚖️ CHOOSING THE TREATMENT

Option	Suitable when	Key points
Expectant	Stable, minimal symptoms; hCG under 1,000–1,500 and falling; no fetal heart; reliable follow-up	hCG every 48 hours, then weekly until negative; about 70% resolve; rupture risk remains
Medical (methotrexate)	Stable, unruptured; hCG under 5,000 (best results); mass under 3.5–4 cm; no fetal heart (or low hCG); no intrauterine pregnancy; normal blood count, liver and renal tests	Single dose 50 mg/m² IM on day 1; hCG on days 4 and 7; fall of 15% or more → weekly hCG to negative; less → second dose; success about 70–90%
Surgical	Unstable or rupture; significant pain; free fluid; hCG over 5,000–10,000; fetal heart; failed medical care; unable to follow up	Laparoscopic salpingectomy if the other tube is healthy; salpingostomy if the other tube is damaged and fertility is wanted (risk of persistent trophoblast, 5–15%: check hCG weekly)

Never give methotrexate when the diagnosis is uncertain — a viable intrauterine pregnancy may be exposed to a teratogen.

💉 METHOTREXATE — CHECKLIST AND COUNSELLING

Topic	Advice
Before the dose	Full blood count, liver and kidney tests, blood group; exclude intrauterine pregnancy; confirm reliable follow-up for 4–6 weeks
Do not give if	Breastfeeding, immunodeficiency, liver, kidney or marrow disease, peptic ulcer, active lung disease, or hypersensitivity
Regimens	Single-dose (50 mg/m²) is standard; two-dose (days 1 and 4) for higher hCG; multi-dose with leucovorin is older practice
During treatment	Avoid NSAIDs, alcohol, folic acid supplements, sun exposure, and intercourse; pain for 2–3 days is common ('separation pain')
Return at once if	Severe pain, dizziness, collapse, heavy bleeding, or shoulder-tip pain
Afterwards	Avoid pregnancy for 3 months; hCG until negative; folic acid is restarted

🔪 SURGERY AND SPECIAL SITES

Situation	Management
Unstable woman	Resuscitation and immediate laparoscopy or laparotomy; clamp the tube and control bleeding
Salpingectomy	Preferred when the contralateral tube looks normal; lower recurrence and no persistent trophoblast
Salpingostomy	For damaged contralateral tube and wish for fertility; follow hCG weekly; give methotrexate if it plateaus
Interstitial (cornual)	High rupture risk and heavy bleeding; methotrexate, cornual resection, or hysteroscopic or laparoscopic surgery by a specialist
Caesarean scar pregnancy	Dangerous; refer to a specialist; methotrexate, uterine artery embolisation, or local surgery; avoid curettage
Cervical, ovarian, abdominal	Specialist care with bleeding-control plan; abdominal pregnancy may need laparotomy
Heterotopic pregnancy	Intrauterine and ectopic together (rare, common after assisted reproduction); surgery if the intrauterine pregnancy is wanted — no methotrexate

STEP 4 · FOLLOW UP — after treatment

🔁 ANTI-D, FOLLOW-UP AND THE NEXT PREGNANCY

Rh-negative women: give anti-D immunoglobulin (about 250 IU / 50 micrograms within 72 hours); the national guideline gives it when the partner is Rh-positive

Follow-up hCG weekly until negative (the Indian guideline uses below 20 IU/L); rising hCG means persistent trophoblast

Recurrence risk is 10–15% after one ectopic and higher after two; offer early scan at 5–6 weeks in every later pregnancy

Contraception for 3 months after methotrexate; advise on smoking cessation and screening for Chlamydia

Emotional support: offer counselling and a follow-up visit; fertility advice if there is tubal damage

Women with an IUD: if the test is positive, exclude ectopic first

⚠️ COMMON PITFALLS

Assuming 'threatened miscarriage' without excluding ectopic, especially with no products of conception passed

Giving reassurance on a single hCG value or a 'normal' rise — about 1 in 5 ectopic pregnancies rise normally

Using methotrexate without a clear diagnosis or without checking the blood, liver and kidney tests

Omitting anti-D and safety-net advice, or losing patients with a PUL

Delaying surgery in an unstable woman because the hCG or ultrasound is not yet available

Memory Aid

ECTOPIC

Seven steps for ectopic pregnancy.

E

Early scan and hCG in any woman with pain or bleeding and a positive test

C

Check stability first — pulse, BP, pallor, and signs of shock; then look for rupture (peritonism, free fluid)

T

Transvaginal ultrasound and repeat hCG at 48 hours for a PUL

O

Options — expectant, methotrexate, or surgery, by criteria

P

Prevent Rh isoimmunisation — anti-D if Rh-negative

I

Inform and follow — hCG to negative; return advice

C

Counsel about recurrence, early scan, and contraception

Remember: shock means surgery; for everyone else, an exact diagnosis comes before methotrexate — and follow up until the hCG is negative.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the Ministry of Health & Family Welfare, Govt of India (MoHFW) Standard Treatment Guideline, the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), and the Royal College of Obstetricians and Gynaecologists (RCOG) guidance; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.