The Anaemia in Pregnancy: Indian Perspective

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

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Anaemia in Pregnancy: Indian Perspective

Anaemia affects about half of pregnant women in India and is largely preventable and treatable. This guide covers the burden and causes, diagnosis, prevention under Anaemia Mukt Bharat, treatment by severity, and care at birth, using the HEMES approach.

🎯 AT A GLANCE — ANAEMIA IN PREGNANCY: INDIAN PERSPECTIVE

About one in two pregnant women in India is anaemic: 52.2% in the National Family Health Survey (NFHS-5, 2019–21), up from 50.4% in NFHS-4

Anaemia in pregnancy is a haemoglobin below 11 g/dL: mild 10–10.9, moderate 7–9.9, severe below 7 (WHO categories)

Iron deficiency is the commonest cause, but sickle cell disease, thalassaemia, malaria, worms, and vitamin B12 or folate deficiency are common in India and must be looked for

Anaemia Mukt Bharat gives every pregnant woman iron and folic acid for at least 180 days, tests haemoglobin, and treats by severity

Intravenous iron (iron sucrose or ferric carboxymaltose) can be a first-line treatment when anaemia is found late or tablets are not taken

Severe anaemia raises the risk of heart failure, haemorrhage, preterm birth, low birth weight, and maternal death, so find it early and treat it fully

🚨 ACT NOW IF

Haemoglobin below 7 g/dL — refer to a First Referral Unit or district hospital

Haemoglobin below 5 g/dL, or breathlessness at rest, rapid pulse, swelling, or signs of heart failure — emergency admission, oxygen, and careful blood transfusion

Severe anaemia after about 34–36 weeks — admit and plan delivery and transfusion in a facility with blood available

Anaemia with fever — test for malaria (rapid test) in endemic areas such as Odisha

Antepartum or postpartum bleeding in an anaemic woman — treat early; she tolerates blood loss poorly

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyAdolescent and pre-conception iron and folic acid; treat anaemia early

2 · Booking (first visit)Haemoglobin, blood group and Rh, sickle cell and haemoglobinopathy screening (HPLC), malaria test where needed

3 · From the 4th monthOne iron and folic acid tablet daily for at least 180 days; albendazole once after the first trimester; calcium

4 · Every visit and the 9th of each monthCheck haemoglobin and symptoms (Pradhan Mantri Surakshit Matritva Abhiyan)

5 · Treat by severityOral iron, intravenous iron, or transfusion; recheck haemoglobin

6 · Birth and afterFacility delivery, active management of the third stage, and iron and folic acid for 180 days after birth

STEP 1 · KNOW THE BURDEN AND CAUSES — why it is so common in India

📊 BURDEN AND CAUSES

Topic	Details
Nutritional causes	Low iron intake, a mostly cereal diet, and poor absorption (tea with meals, phytates); vitamin B12 deficiency is common in vegetarians; folate deficiency adds to it
Reproductive causes	Early marriage and pregnancy, short birth intervals, many pregnancies, and heavy periods
Infections and worms	Hookworm, malaria, chronic infections, and tuberculosis
Inherited causes	Sickle cell disease and trait, beta-thalassaemia trait, and other haemoglobin disorders (common in western Odisha and tribal populations)
Social causes	Poverty, low education, food customs that give women less food, poor access to care, and low use of tablets
Effects on mother	Tiredness, infection, pre-eclampsia, heart failure, postpartum haemorrhage, and death
Effects on baby	Preterm birth, low birth weight, poor growth, and later iron deficiency

STEP 2 · DIAGNOSE AND CLASSIFY — find the type and the cause

🔬 DIAGNOSIS

Test	What it tells
Haemoglobin at booking and each visit	A digital haemoglobinometer or a laboratory count (anaemia is below 11 g/dL); some guidelines use 10.5 in the second trimester
Blood count and smear	Small pale red cells (microcytic hypochromic) suggest iron deficiency or thalassaemia trait; large cells suggest vitamin B12 or folate deficiency; look for malaria parasites
Haemoglobin HPLC or electrophoresis	Finds sickle cell disease or trait and thalassaemia trait; test the partner when the woman is a carrier
Ferritin	Below 30 mcg/L suggests iron deficiency; use it when the cause is unclear or the response is poor
Stool and urine tests	Stool for ova (worms) and urine for infection
Malaria test	Rapid test or smear in fever or in endemic areas
Symptoms and signs	Pallor, tiredness, breathlessness, rapid pulse, swelling, and a systolic murmur; a pale tongue and nails are unreliable alone

Do not give iron blindly to a woman with thalassaemia or sickle cell disease; give iron only if iron deficiency is shown, and give folic acid 5 mg a day in sickle cell disease

STEP 3 · PREVENT — the Anaemia Mukt Bharat approach

💊 PREVENTION

Measure	Details
Iron and folic acid	One tablet daily (60 mg elemental iron and 500 mcg folic acid) from the 4th month (14–16 weeks) for at least 180 days and another 180 days after birth; take with water or vitamin C, away from tea, milk, and calcium by 2 hours
Deworming	Albendazole 400 mg once, after the first trimester
Calcium	Calcium supplementation from about 14 weeks as per national guidance; take at a different time from iron
Diet	Green leafy vegetables, legumes, jaggery, ragi, eggs, fish, and meat where eaten; fruit rich in vitamin C; cook in iron utensils
Fortified foods	Iron-fortified rice and salt in government programmes (supplementary nutrition and mid-day meal)
Behaviour change	ASHA home visits, group counselling, and family involvement
Six interventions (Anaemia Mukt Bharat)	Iron and folic acid supplementation, deworming, behaviour change, testing and treatment with digital methods, fortified foods, and action on non-nutritional causes (malaria, haemoglobin disorders, and fluorosis)

STEP 4 · TREAT BY SEVERITY — oral, intravenous, or transfusion

🩺 TREATMENT

Haemoglobin	What to do
Mild (10–10.9 g/dL)	Counsel, check the diet, give the daily iron and folic acid tablet, and recheck in 1 month
Moderate (7–9.9 g/dL)	Treatment doses of oral iron (the programme advises two tablets a day, about 120 mg elemental iron); treat worms and malaria; recheck in 1 month; a rise of less than 1 g/dL after 2 months means refer for another cause or for intravenous iron
Intravenous iron	Iron sucrose or ferric carboxymaltose can be a first-level treatment for anaemia found late in pregnancy, poor tolerance, or poor adherence; give from the second trimester, in a facility with resuscitation equipment, after a test dose or observation; the total dose is calculated from the weight and the haemoglobin deficit
Severe (below 7 g/dL)	Refer to a First Referral Unit or district hospital; find the cause; intravenous iron if the woman is stable
Blood transfusion	For haemoglobin below 5, heart failure, heavy bleeding, or severe anaemia close to term; give packed red cells slowly with a diuretic if needed, and monitor
Folic acid and vitamin B12	Folic acid 5 mg a day and vitamin B12 injections or tablets when deficiency is shown
Response	Haemoglobin should rise about 1 g/dL in 2–4 weeks; if not, review adherence, cause, and absorption

Avoid intravenous iron in the first trimester and in anyone with a past severe reaction; iron tablets for severe anaemia close to term are too slow

STEP 5 · BIRTH AND AFTER — protect her from haemorrhage

🏥 DELIVERY AND POSTPARTUM CARE

Topic	Advice
Place of birth	Facility delivery with blood available when haemoglobin is below 8–9; plan transfer early
In labour	Keep the woman rested, give oxygen if breathless, avoid fluid overload, and have blood cross-matched
Third stage	Active management (oxytocin, controlled cord traction, uterine massage) and treat any bleeding without delay
After birth	Check haemoglobin at 24–48 hours or before discharge; give iron and folic acid for 180 days; intravenous iron if low and not improving
Family planning	Advise a gap of at least 2 years and offer contraception
Newborn	Delayed cord clamping for 1–3 minutes; exclusive breastfeeding; iron supplements as per the programme

⚠️ COMMON PITFALLS

Not testing haemoglobin at every visit or relying on pallor

Giving the same tablets to every woman for months without a recheck or a search for another cause

Missing sickle cell disease or thalassaemia and giving iron without proof of deficiency

Waiting for tablets to work in late pregnancy instead of using intravenous iron or transfusion

Poor counselling on tablets: side effects, taking them with tea or calcium, and stopping early

Forgetting malaria, worms, and vitamin B12

Leaving an anaemic woman to deliver at home or without blood available

Memory Aid

HEMES

Five steps for anaemia in pregnancy.

H

Haemoglobin at every visit — test at booking and recheck; below 11 g/dL is anaemia

E

Enrol on iron and folic acid — one tablet daily from 14–16 weeks for 180 days, plus albendazole

M

Manage by severity — oral iron, intravenous iron, or transfusion; refer below 7 g/dL

E

Evaluate the cause — sickle cell, thalassaemia, malaria, worms, vitamin B12 and folate

S

Safe delivery and follow-on — facility birth with blood, active third stage, 180 days of iron after birth

Remember: find it early, treat it fully, and prepare for bleeding before the birth.

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

Clinician-facing summary. Checked against public sources: the NFHS-5 and NFHS-4 prevalence figures (a data article), the WHO haemoglobin categories, the Anaemia Mukt Bharat statements that at least 180 iron and folic acid tablets are given and that intravenous iron sucrose or ferric carboxymaltose may be a first-level treatment, and referral of haemoglobin below 7 g/dL (a trial protocol that cites the Ministry guidance). The Ministry of Health and Family Welfare guideline itself could not be opened. Tablet strength, deworming, calcium, intravenous iron conditions, transfusion indications, and delivery advice are from memory of Indian and international guidance: check the current Anaemia Mukt Bharat guideline before use. Doses and thresholds must be set by the treating obstetrician; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

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Genetic Screening and NIPT

Genetic screening gives a chance, not a diagnosis, and non-invasive prenatal testing (NIPT) is its most accurate form for common chromosome conditions. This guide covers carrier screening, screening test options, how NIPT works, what to do with the result, and counselling and the law, using the GENES approach.

🎯 AT A GLANCE — GENETIC SCREENING AND NIPT

Genetic screening estimates the chance of a condition; diagnostic testing (chorionic villus sampling or amniocentesis) confirms it

Non-invasive prenatal testing (NIPT) measures cell-free DNA in the mother’s blood; it can be done from 10 weeks and carries no risk of miscarriage

For Down syndrome it detects over 99% with a false-positive rate under 0.1–0.5%, better than the combined test or quadruple test

NIPT is still a screening test: a positive result needs confirmation by a diagnostic test before any decision about the pregnancy

In western Odisha, screening for sickle cell disease and thalassaemia at booking, with partner testing, is the most useful genetic screening and should never be missed

NIPT is a screening test, so say “chance”, not “diagnosis”, and keep fetal sex undisclosed as the PCPNDT Act requires

🚨 DO NOT MISS

High-chance NIPT result — never advise termination on NIPT alone; offer chorionic villus sampling or amniocentesis, with a genetic counsellor

No result (low fetal fraction) — do not simply reassure; it can be linked to trisomy 13 or 18 or triploidy, so counsel and consider a diagnostic test

Abnormal anomaly scan or thick nuchal translucency (3.5 mm or more) with a low-chance NIPT — offer a diagnostic test with microarray

Both parents carriers of sickle cell, beta-thalassaemia, or the same condition — offer early prenatal diagnosis by chorionic villus sampling at 11–13 weeks

Any request to disclose or hint at fetal sex — refuse; it is prohibited by the PCPNDT Act

🗺️ THE PATHWAY AT A GLANCE

1 · Before or at bookingFamily history, consanguinity, previous affected child; carrier screening (HPLC for haemoglobinopathies) for both partners

2 · CounsellingExplain what screening can and cannot tell; written consent

3 · 10–14 weeksNIPT (from 10 weeks), or combined test (nuchal translucency, PAPP-A, free beta-hCG at 11–13+6 weeks)

4 · 15–20 weeksQuadruple test if first-trimester screening was missed

5 · 18–22 weeksDetailed anomaly scan for every woman

6 · High chanceChorionic villus sampling (11–14 weeks) or amniocentesis (from 15 weeks), then genetic counselling

STEP 1 · UNDERSTAND GENETIC SCREENING — what is offered and when

🧬 TYPES OF GENETIC SCREENING

Type	What it does
Carrier screening	Finds healthy people who carry a gene change; in India, HPLC for sickle cell and beta-thalassaemia is the key test, and the partner should be tested if the woman is a carrier
Aneuploidy screening	Estimates the chance of trisomy 21, 18, or 13 (combined test, quadruple test, or NIPT)
Structural screening	Anomaly scan at 18–22 weeks finds many major anomalies; it is offered to all
Diagnostic testing	Chorionic villus sampling or amniocentesis with karyotype or chromosomal microarray gives a definite answer for chromosome conditions
Who should be offered	Every pregnant woman should be offered screening; women with higher risk (age 35 or over, previous affected pregnancy, abnormal scan, family history) are offered diagnostic testing directly

STEP 2 · COMPARE THE SCREENING TESTS — choose with the woman

🧪 SCREENING OPTIONS FOR DOWN SYNDROME

Test	Timing	Approximate detection for trisomy 21
Combined first-trimester test	11–13+6 weeks	About 85–90% at a 5% false-positive rate; nuchal translucency, PAPP-A, free beta-hCG, and maternal age
Quadruple test	15–20 weeks	About 80% at a 5% false-positive rate; AFP, hCG, uE3, inhibin A
NIPT (cell-free DNA)	From 10 weeks	Over 99% with a false-positive rate under 0.1–0.5%
Contingent approach	Combined test first, NIPT only for the intermediate-risk group	Lower cost, with most of the benefit of NIPT
Practical point	Where NIPT is unaffordable	The combined test with a good nuchal translucency scan remains a sound choice

Detection rates are from studies of single pregnancies and vary with the laboratory; read the performance stated in your laboratory’s report

STEP 3 · KNOW NIPT IN DETAIL — how it works and what it can and cannot do

🩸 NON-INVASIVE PRENATAL TESTING

Topic	Details
How it works	Cell-free DNA in the mother’s blood comes mainly from the placenta (fetal fraction about 4–10% or more, from 10 weeks); the laboratory counts chromosome fragments to find extra or missing copies
Sample	One blood tube from the mother; no fasting; result in about 1–2 weeks
What it screens	Trisomy 21, 18, and 13; some laboratories add sex chromosome conditions and selected microdeletions, which are less reliable
What it does not find	Single gene conditions, structural anomalies, neural tube defects, most small deletions, and mosaicism that is confined to the placenta
Positive predictive value	Depends on how common the condition is: for trisomy 21 it is high in older women, but lower in young women, and lower again for trisomy 13 and 18 and sex chromosome conditions (about 50–60% at age 25 and over 90% at age 40 for Down syndrome; approximate)
Causes of a false result	Confined placental mosaicism, a vanished twin, maternal chromosome change, maternal cancer, organ transplant, recent blood transfusion, or low fetal fraction
Twins and IVF	Can be used in twins for trisomy 21 with slightly lower accuracy; not suitable after donor egg from a different woman without advice, or with a vanished twin
No result	Occurs in about 1–5%; more often with higher maternal weight or early sampling; repeat once if the fetal fraction is low, and offer other testing if it fails again

Scientific bodies (ACOG, ACMG) now support offering NIPT to all pregnant women, but a screening test must always be paired with counselling and diagnostic confirmation (recommendations differ between countries)

STEP 4 · ACT ON THE RESULT — what to do next

📋 RESULT AND ACTION

Result	What to do
Low chance	Reassure that the chance is very low but not zero; continue the anomaly scan and routine care
High chance	Counsel the same day, offer chorionic villus sampling (11–14 weeks) or amniocentesis (from 15 weeks); the woman decides whether to proceed
No result	Review dating and weight, repeat once, and offer a scan review or diagnostic test
Discordant findings	Normal NIPT with abnormal scan means diagnostic testing with microarray
Diagnostic procedure	Karyotype and, where available, chromosomal microarray; fetal loss risk is low (about 0.1–0.3% or less), done by an experienced operator under ultrasound
After a procedure	Anti-D immunoglobulin to Rh-negative women; advise rest for the day and warning signs (bleeding, fluid loss, fever)
Confirmed abnormality	Refer to a fetal medicine or genetic team; discuss outcome, options, and support

STEP 5 · COUNSEL, CONSENT AND THE LAW — do it properly

💬 COUNSELLING AND LEGAL POINTS

Topic	Advice
Counselling before testing	Explain what is tested and what is not; that the result is a chance; the possible results; cost; and the right to decline
Counselling style	Non-directive, in a language she understands, and with her partner if she wishes
Consent	Written, informed consent before NIPT and before any invasive test
PCPNDT Act	Sex determination and disclosure are prohibited; testing should be done in registered centres and laboratories, with the required forms; laboratories must not report fetal sex (check the current rules and your laboratory’s policy)
MTP Act	Termination is lawful within the limits of the Medical Termination of Pregnancy Act (as amended in 2021); beyond the usual limit, a medical board decides for substantial fetal abnormality (confirm the current provisions)
Privacy	Keep results confidential; share only with the woman unless she agrees
Support	Offer follow-up counselling, and a team for care of a child with Down syndrome if she continues

⚠️ COMMON PITFALLS

Calling NIPT a diagnostic test and advising termination on it alone

Skipping the anomaly scan because the NIPT was normal

Missing carrier screening for sickle cell and thalassaemia and not testing the partner

Sending blood too early (before 10 weeks) or without confirming dates

Reading a sex chromosome result without counselling or disclosing fetal sex

Offering the tests without pre-test counselling or without consent

Forgetting anti-D after a diagnostic procedure in an Rh-negative woman

Memory Aid

GENES

Five steps for genetic screening and NIPT.

G

Gather the history — family history, consanguinity, carrier screening for both partners

E

Explain — screening gives a chance; diagnosis gives an answer

N

NIPT or combined test — NIPT from 10 weeks; nuchal translucency at 11–13+6 weeks

E

Establish the diagnosis — chorionic villus sampling or amniocentesis if the chance is high

S

Support and stay within the law — non-directive counselling, PCPNDT and MTP Acts

Remember: NIPT screens, it does not diagnose; confirm before acting, and never disclose fetal sex.

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

Clinician-facing summary drawn from memory of guidance from the American College of Obstetricians and Gynecologists (ACOG), the American College of Medical Genetics and Genomics (ACMG), the International Society for Prenatal Diagnosis, the Fetal Medicine Foundation, and Indian law and practice; no source was read for this sheet. Performance figures, predictive values, and timing are approximate and vary between laboratories and studies. The PCPNDT Act and MTP Act points are from memory: check the current Acts, rules, and your laboratory’s policy. Test choice and result handling must be set by the senior obstetrician with a genetic counsellor; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

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Vaginal Discharge

Vaginal discharge is common and usually benign, but the cause must be found. This guide covers normal and abnormal discharge, the four common pictures, bedside tests, treatment by cause, special groups, and counselling, using the SWAB approach.

🎯 AT A GLANCE — VAGINAL DISCHARGE

Vaginal discharge is one of the commonest reasons women attend a clinic; most is normal or caused by bacterial vaginosis, candidiasis, or trichomoniasis, but cervicitis, pelvic inflammatory disease, and cancer can present the same way

Normal discharge is clear to white, odourless, non-itchy, and varies with the cycle; the vaginal pH is 3.8–4.5

Diagnose with a speculum examination, vaginal pH, the whiff test, and a wet mount rather than guessing from the smell or colour

Treat the cause: metronidazole for bacterial vaginosis and trichomoniasis, an azole for candidiasis, and treat the partner for trichomoniasis and gonorrhoea or chlamydia

Where tests are not available, use syndromic management as in the national programme, and always screen for HIV and syphilis

Never treat blindly more than once: persistent or recurrent discharge needs a speculum examination and tests

🚨 ACT NOW IF

Lower abdominal pain, fever, pain on intercourse, or cervical motion tenderness — pelvic inflammatory disease: start treatment and consider admission

Blood-stained or foul discharge, post-coital bleeding, or any discharge after menopause — exclude cervical or endometrial cancer

Watery leaking in pregnancy — suspect rupture of membranes; offensive discharge with fever after delivery, abortion, or a procedure — retained products or infection

Discharge in a young girl who has not reached puberty — foreign body, worms, or abuse; refer

Discharge after sexual assault, or with genital ulcers or warts — treat, test, and counsel

🗺️ THE PATHWAY AT A GLANCE

1 · AskColour, smell, itch, timing, partners, pregnancy, drugs, and danger signs

2 · ExamineVulva, speculum, cervix, vaginal walls, and bimanual if pain

3 · TestpH, whiff test, wet mount, and nucleic acid tests for chlamydia, gonorrhoea, trichomonas

4 · DiagnoseBacterial vaginosis, candidiasis, trichomoniasis, cervicitis, or other

5 · TreatThe cause, plus the partner when needed

6 · CounselHIV and syphilis tests, condoms, hygiene, review if not better

STEP 1 · NORMAL OR ABNORMAL — know what is physiological

🔬 WHAT IS NORMAL

Topic	Details
Normal discharge	Clear to white and thin, no smell, no itch; more mucus at mid-cycle (egg-white), in pregnancy, with arousal, and with hormonal contraception
Normal pH	3.8–4.5, kept acidic by lactobacilli making lactic acid
What upsets it	Douching, scented products, antibiotics, diabetes, new partners, sex without condoms, pregnancy, and smoking
When it is abnormal	Change in colour, smell, or amount; itch, soreness, pain on passing urine or on intercourse; bleeding

🧫 THE FOUR COMMON PICTURES

Cause	Typical features
Bacterial vaginosis	Thin grey-white discharge with a fishy smell (worse after sex or periods), little itch; not sexually transmitted in the strict sense but linked to new partners
Vulvovaginal candidiasis	White curdy (cottage-cheese) discharge with itch, soreness, redness, and pain on passing urine; more common in pregnancy, diabetes, and after antibiotics
Trichomoniasis	Frothy yellow-green discharge, itch, smell, and a 'strawberry' cervix; sexually transmitted
Cervicitis (chlamydia, gonorrhoea)	Mucopurulent discharge, bleeding after sex or between periods, pain on passing urine; often no symptoms

STEP 2 · ASSESS — history, examination, and tests

🩺 HISTORY AND EXAMINATION

Step	Details
History	Onset and duration, colour, smell, itch, pain, bleeding, last period, pregnancy, contraception, partners, condom use, previous infections, diabetes, drugs (antibiotics, steroids), and douching
Examine the abdomen	Lower abdominal tenderness and masses
Inspect the vulva	Redness, fissures, ulcers, warts, and the discharge at the introitus
Speculum examination	Colour and amount of discharge, the cervix (mucopus, friability, 'strawberry' spots), and any foreign body, growth, or fistula
Bimanual examination	If there is pain or fever: cervical motion tenderness, uterine or adnexal tenderness suggests pelvic inflammatory disease
Always consider	A pregnancy test and, in the right setting, cervical screening

📋 BEDSIDE TESTS

Test	What it shows
Vaginal pH (swab on pH paper)	Above 4.5 in bacterial vaginosis and trichomoniasis; 4.5 or below in candidiasis and normal
Whiff test (10% potassium hydroxide on the discharge)	A fishy smell suggests bacterial vaginosis (or trichomoniasis)
Wet mount (saline) microscopy	Clue cells (bacterial vaginosis), motile trichomonads, and many white cells (cervicitis, trichomoniasis)
Potassium hydroxide wet mount	Yeast buds and hyphae in candidiasis
Amsel criteria for bacterial vaginosis	Three of four: thin homogeneous discharge, pH above 4.5, positive whiff test, clue cells (20% or more of epithelial cells)
Nucleic acid amplification tests	For chlamydia, gonorrhoea, and trichomonas (vaginal swab or first-void urine); culture or microscopy if not available
Other tests	Pregnancy test, blood glucose if recurrent candidiasis, and HIV, syphilis, and hepatitis B serology

STEP 3 · TREAT — by cause, with the partner when needed

💊 TREATMENT (ADULT, NON-PREGNANT)

Condition	First-line treatment (varies by guideline)
Bacterial vaginosis	Metronidazole 400 mg or 500 mg twice daily for 7 days, or metronidazole 0.75% gel or clindamycin 2% cream vaginally at night for 5–7 nights; partner treatment is not routinely needed
Vulvovaginal candidiasis	Clotrimazole 500 mg vaginal pessary as a single dose (or 200 mg for 3 nights), or fluconazole 150 mg by mouth as a single dose; treat only if symptomatic
Recurrent candidiasis (4 or more a year)	Confirm with culture, check for diabetes, induction with fluconazole then weekly fluconazole for 6 months (specialist advice)
Trichomoniasis	Metronidazole 500 mg twice daily for 7 days (or 2 g as a single dose in some programmes); treat the partner at the same time; avoid sex until both finish
Cervicitis (chlamydia, gonorrhoea)	Doxycycline 100 mg twice daily for 7 days plus ceftriaxone 500 mg intramuscularly once (or the national programme combination of azithromycin and cefixime); treat the partner and retest
Pelvic inflammatory disease	Ceftriaxone 500 mg intramuscularly once, doxycycline 100 mg twice daily, and metronidazole 400–500 mg twice daily, for 14 days; admit if unwell, pregnant, or no improvement
Atrophic vaginitis (after menopause)	Vaginal moisturiser or low-dose vaginal oestrogen; exclude other causes of bleeding

Syndromic management (national programme): when tests are not possible, treat vaginal discharge for bacterial vaginosis, trichomoniasis, and candidiasis, and add treatment for cervicitis where risk is high (kits and drugs are provided under the programme)

STEP 4 · SPECIAL SITUATIONS — pregnancy, children, and the menopause

🧭 SPECIAL GROUPS

Group	Points
Pregnancy	Bacterial vaginosis and trichomoniasis are linked to preterm birth: test and treat with oral metronidazole (safe in all trimesters); candidiasis: use vaginal azoles for 7 days, not oral fluconazole; chlamydia: azithromycin 1 g, not doxycycline
Postmenopausal women	Atrophic vaginitis is common, but any blood-stained or persistent discharge needs examination, ultrasound, and biopsy if needed
Girls before puberty	Poor hygiene, worms, foreign body, and infection are common; blood-stained discharge or repeated infection needs a paediatric or gynaecology review; think of sexual abuse and involve a senior and child protection services
Women with an intrauterine device	Check for infection and the position of the device; do not remove it automatically unless severe infection
Women with HIV or diabetes	More frequent and persistent candidiasis and cervical disease; control glucose and screen the cervix
After delivery or abortion	Foul discharge with fever suggests retained products or endometritis; admit

STEP 5 · PREVENT AND FOLLOW UP — counsel, test, and review

🛡️ COUNSELLING AND PREVENTION

Topic	Advice
Hygiene	Wash the vulva with water only; no douching, scented soaps, wipes, or sprays; cotton underwear; wipe front to back; change out of wet clothes
Safer sex	Condoms with new or multiple partners; partner treatment and no sex until both are treated
Test and screen	Offer HIV, syphilis, and hepatitis B tests; cervical screening at the right age and human papillomavirus vaccine for girls
Take the medicine fully	Finish the course; avoid alcohol while on metronidazole and for 24 hours after it
Follow up	Review if symptoms persist after treatment or return within 3 months; retest for chlamydia, gonorrhoea, and trichomonas after about 3 months
Do not	Treat every itch with an antifungal-steroid cream; use leftover antibiotics

⚠️ COMMON PITFALLS

Treating by colour or smell alone without a speculum examination or pH test

Treating every discharge as candidiasis, especially with steroid combination creams

Forgetting to treat the partner in trichomoniasis, gonorrhoea, and chlamydia

Missing pelvic inflammatory disease because the pain is mild

Missing cancer in blood-stained or persistent discharge, or in postmenopausal women

Not testing for pregnancy, HIV, and syphilis

Using doxycycline or fluconazole in pregnancy

Memory Aid

SWAB

Four steps for every woman with vaginal discharge.

S

Speculum — look at the vulva, vagina and cervix

W

Whiff and wet mount — smell test and microscopy

A

Acidity — vaginal pH above or below 4.5

B

Bugs and barriers — test for chlamydia, gonorrhoea and trichomonas; treat the partner; use condoms

Remember: look, test, treat the cause, treat the partner when needed, and review.

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

Clinician-facing summary drawn from memory of Centers for Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines, British Association for Sexual Health and HIV (BASHH), Royal College of Obstetricians and Gynaecologists (RCOG), and World Health Organization (WHO) guidance; no source was read for this sheet. No Government of India document was read: the national syndromic management kits and regimens are recalled from memory, so check the National AIDS Control Organisation guidelines. Drug doses and durations vary between guidelines; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior doctor in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

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Pre-eclampsia: Prediction and Prevention

Pre-eclampsia is a major cause of maternal and newborn harm, and part of it can be predicted and prevented. This guide covers risk stratification, screening tests, aspirin and calcium, monitoring, and counselling, using the SCREEN approach.

🎯 AT A GLANCE — PRE-ECLAMPSIA PREDICTION AND PREVENTION

Pre-eclampsia is new high blood pressure (140/90 mmHg or more) after 20 weeks with protein in the urine or organ damage; it affects about 2–8% of pregnancies and is a leading cause of maternal and fetal illness and death

Prediction starts with the clinical history: high-risk and moderate-risk factors identify women who need prevention without any special test

Combined first-trimester screening (history, mean arterial pressure, uterine artery Doppler, and placental growth factor) can detect most preterm pre-eclampsia where available

Low-dose aspirin from 12 weeks (before 16) cuts the risk of preterm pre-eclampsia in high-risk women; calcium helps where dietary intake is low

Blood tests such as the sFlt-1 to placental growth factor ratio help to rule out or confirm disease in women with symptoms, not to screen well women

Pre-eclampsia can appear without warning, so check BP and urine at every antenatal visit and teach every woman the danger signs

🚨 ACT NOW IF

BP of 160/110 mmHg or more — severe: give antihypertensive treatment within 30–60 minutes, magnesium sulfate, and refer

Severe headache, visual disturbance, upper abdominal pain, vomiting, or sudden swelling — assess for pre-eclampsia the same day

Convulsions — eclampsia: airway, left side, magnesium sulfate, and delivery after stabilisation

Breathlessness, reduced urine, or low platelets or abnormal liver tests — severe features or HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)

Reduced fetal movements or poor growth — same-day cardiotocography and ultrasound

🗺️ THE PATHWAY AT A GLANCE

1 · BookingRisk assessment from the history; baseline BP, urine protein, weight, and tests

2 · 11–14 weeksCombined screening where available; start aspirin if high risk

3 · 12–16 weeksAspirin 75–150 mg nightly; calcium if intake is low

4 · 20–24 weeksUterine artery Doppler in selected women

5 · Every visitBP, urine, symptoms, fetal growth from 28 weeks

6 · After birthBP check at days 3–6, and long-term cardiovascular follow-up

STEP 1 · PREDICT FROM RISK FACTORS — who needs prevention

🔎 RISK STRATIFICATION

Topic	Details
Rule	One high-risk factor, or two or more moderate-risk factors means offer low-dose aspirin (NICE, ACOG, and FIGO use a similar approach)
High-risk factors	Previous pre-eclampsia or hypertension in pregnancy, chronic hypertension, diabetes before pregnancy, chronic kidney disease, autoimmune disease (lupus, antiphospholipid syndrome), and multiple pregnancy
Moderate-risk factors	First pregnancy, age 40 or over, body mass index above 30–35, family history of pre-eclampsia, interval above 10 years since the last birth; some guidelines add IVF, low income, and previous small baby, abruption, or stillbirth
Why	The history alone catches about a third to half of cases; adding scans and blood tests improves detection

STEP 2 · PREDICT WITH TESTS — where available

🧪 SCREENING TESTS

Test	What it adds
Combined first-trimester screening (11–13+6 weeks)	Maternal history, mean arterial pressure, uterine artery pulsatility index, and placental growth factor, combined in a validated algorithm (Fetal Medicine Foundation model); about 75–90% of preterm pre-eclampsia is found at a 10% false-positive rate (varies between studies)
Mean arterial pressure	Measured with a validated device, seated, in both arms; higher values early in pregnancy increase risk
Uterine artery Doppler	At 11–14 weeks (as part of combined screening) or 20–24 weeks; a high pulsatility index or notching means high resistance and risk; not useful alone in low-risk women
Placental growth factor and sFlt-1	Low placental growth factor, or a high sFlt-1 to placental growth factor ratio, supports the diagnosis in women with suspected pre-eclampsia (20–35 weeks); a ratio of 38 or less makes pre-eclampsia unlikely within a week (cut-offs depend on the assay)
Basic tests in suspected disease	Urine protein (strip, protein-to-creatinine ratio), blood count with platelets, liver and kidney tests, uric acid
Practical point	Where advanced tests are not available, risk factors, BP, and urine at every visit remain the mainstay

STEP 3 · PREVENT — the measures that work

💊 PREVENTION

Measure	Details
Low-dose aspirin	75–150 mg once daily at night (FIGO suggests 150 mg; ACOG suggests 81 mg) from 12 weeks, ideally before 16 weeks, until 36 weeks or birth; lowers preterm pre-eclampsia by roughly 60% in high-risk women when started early (from trials; effect varies)
Calcium	WHO: 1.5–2 g elemental calcium a day from 20 weeks in populations with low intake; India recommends about 1 g a day; give with iron at different times
Control chronic disease	Treat chronic hypertension (labetalol, nifedipine, or methyldopa; stop ACE inhibitors and angiotensin blockers); optimise diabetes and kidney disease
Lifestyle	Healthy weight before pregnancy, regular moderate physical activity, and balanced diet
Antiphospholipid syndrome	Aspirin plus low molecular weight heparin as advised by a specialist
What does not prevent it	Vitamins C and E, fish oil, garlic, bed rest, and salt restriction (not proven); low molecular weight heparin alone is not recommended for prevention
Spacing and planning	Interpregnancy intervals of 2 years or more and pre-pregnancy counselling

Start early: aspirin started after 16 weeks is less effective, but it may still be given if the woman is at high risk

STEP 4 · SURVEILLANCE — for women at risk

📋 MONITORING

Topic	Details
Every antenatal visit	BP with the correct cuff, urine protein, weight, symptoms, and fundal height
More visits for high-risk women	Every 2–4 weeks from 28 weeks; home BP monitoring where practical
Growth scans	From 28–32 weeks in high-risk women, with umbilical artery Doppler if growth is poor
Diagnosis	BP of 140/90 or more on two occasions 4 hours apart (or 160/110 once) with protein, or with organ dysfunction
Timing of birth	Pre-eclampsia without severe features: about 37 weeks; with severe features: from 34 weeks, earlier if unstable; senior decision
After birth	BP at days 3–6 (eclampsia can occur up to 6 weeks), continue treatment as needed; annual BP, glucose, and lipids because lifetime heart disease risk is higher
Next pregnancy	Counsel early, start aspirin at 12 weeks, and plan care

STEP 5 · COUNSEL — teach her what to watch for

💬 WARNING SIGNS TO TEACH

Topic	Advice
Come at once for	Severe headache, blurred vision or flashing lights, pain below the ribs, vomiting, sudden swelling of the face or hands, breathlessness, fits, or reduced movements
Take aspirin and calcium daily	Do not stop without advice; tell the doctor about bleeding or stomach pain
Plan delivery at a hospital	With a blood bank and newborn care
Family	Explain the signs and who to call; plan transport

⚠️ COMMON PITFALLS

Starting aspirin too late or not at all in a high-risk woman

Using the wrong cuff size or measuring BP after a long wait and missing hypertension

Waiting for protein to diagnose pre-eclampsia when other signs are present

Using placental growth factor tests to screen well women

Stopping BP checks after the first trimester or after birth

Giving calcium and iron together so absorption is poor

Forgetting long-term follow-up after pre-eclampsia

Memory Aid

SCREEN

Six steps for pre-eclampsia prediction and prevention.

S

Stratify — one high-risk or two moderate-risk factors

C

Calcium — 1–2 g a day where dietary intake is low

R

Rx aspirin — 75–150 mg nightly from 12 weeks, before 16 if possible

E

Every visit — BP, urine, symptoms, growth scans from 28 weeks

E

Educate — headache, vision, upper pain, swelling, fits, movements

N

Notify and refer — BP 160/110 or more, or severe features

Remember: identify the risk, start aspirin early, check BP at every visit, and act fast on severe signs.

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

Clinician-facing summary drawn from memory of National Institute for Health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), International Federation of Gynecology and Obstetrics (FIGO), Fetal Medicine Foundation, and World Health Organization (WHO) guidance; no source was read for this sheet. No Government of India document was read: the Indian calcium recommendation is from memory, so check the Ministry of Health and Family Welfare guidelines. Aspirin dose and timing, calcium dose, screening performance, and timing of birth vary between guidelines and must be set by the senior obstetrician; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.