Jaundice in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Jaundice in Pregnancy — Find the Cause, Protect Mother & Baby

Jaundice in pregnancy has many causes; some are harmless to the baby, and some kill the mother within days. This sheet gives the causes by timing, the tests that matter, and the plan for each, including hepatitis E.

🎯 AT A GLANCE — JAUNDICE IN PREGNANCY

Jaundice in pregnancy is never normal and always needs a cause; it can threaten both lives

Viral hepatitis is the commonest cause; in India hepatitis E is important because it can cause fulminant liver failure, with fatality of 10 to 20% in pregnancy

Pregnancy-specific causes by timing: hyperemesis in the first trimester; intrahepatic cholestasis (ICP) in the second half; pre-eclampsia and HELLP from 20 weeks (most at 28 to 36 weeks; about 25% after delivery); acute fatty liver (AFLP) in the third trimester, median 36 weeks, sometimes after birth

ICP: itching with raised bile acids (over 10 µmol/L); jaundice occurs in under 25%, and later than the itch

AFLP: jaundice with low glucose, abnormal clotting and kidney injury; about 50% have pre-eclampsia

HELLP and AFLP are treated by delivery

Check the blood pressure, glucose, platelets and clotting in every woman with jaundice, because AFLP and HELLP can kill within days.

🚨 ADMIT AND CALL THE SENIOR IF…

Glucose is low, clotting is prolonged, or she is confused or drowsy — think of AFLP or acute liver failure

BP is 140/90 or more, with platelets 100 ×10⁹/L or less, or AST 70 IU/L or more — HELLP

Urine output falls or creatinine rises — acute kidney injury occurs in up to 90% of AFLP

Severe upper abdominal pain, vomiting or bleeding

Fever with jaundice in a woman from an outbreak or with unsafe water — suspect hepatitis E and admit early (from memory)

Bile acids over 40 µmol/L, or reduced fetal movements in ICP — most complications occur above 40

Colicky pain with fever and jaundice — obstructing gallstone; needs urgent intervention

STEP 1 · FIND THE CAUSE — by timing, symptoms and pattern

🔍 CAUSES AND CLUES

Cause	When	Clues and key tests
Hyperemesis gravidarum	First trimester	Severe vomiting; LFTs rise 1 to 2 times normal in about half of admissions and settle when vomiting stops; jaundice is unusual
Intrahepatic cholestasis (ICP)	Second half, from about 25 weeks	Itch of palms and soles, spreading; no rash; bile acids over 10 µmol/L; transaminases may be very high; jaundice in under 25%
Pre-eclampsia and HELLP	From 20 weeks; HELLP 28 to 36 weeks; 25% after birth	High BP, proteinuria; upper abdominal pain; platelets 100 or less, AST 70 or more, LDH 600 or more, haemolysis
Acute fatty liver (AFLP)	Third trimester, median 36 weeks; may be after birth	Nausea, vomiting, headache, fever, jaundice; low glucose, high white count, high urate, abnormal clotting; Swansea 6 or more
Viral hepatitis A, B, C, E	Any trimester	Fever, malaria-like illness, dark urine, high transaminases; hepatitis E is severe in the third trimester
Gallstones, bile duct obstruction	Any; gallbladder empties slowly in the second trimester	Colicky right upper pain peaking at 12 to 24 hours, fever; ultrasound
Chronic liver disease: PBC, autoimmune hepatitis	Any	Known history; autoantibodies
Drugs, malaria, leptospirosis, haemolysis, sepsis	Any	Drug and herbal history; fever and travel; smear and blood tests (from memory)

🧪 WHAT TO ASK, EXAMINE AND SEND

Ask about the gestation, itch, vomiting, pain, fever, drugs and herbal medicines, water and food source, travel, sick contacts and blood transfusions (from memory)

Examine the BP, temperature, pulse, mental state, abdomen and fetal movements; look for a flapping tremor, bruising and ascites

Send a full blood count and smear, liver tests (bilirubin and transaminases, ALP, GGT), fasting bile acids, clotting, glucose, creatinine, urate and urine protein

The alkaline phosphatase rises in normal pregnancy, so do not rely on it (from memory)

Send hepatitis serology: HBsAg, anti-HCV, and HAV and HEV IgM; test for malaria in endemic areas

Do an abdominal ultrasound for gallstones and bile duct dilatation; a raised GGT in ICP suggests MDR3 disease or non-pregnancy liver disease

Assess the fetus: movements, cardiotocography and growth scan

STEP 2 · TREAT — by the cause

🧭 FROM JAUNDICE TO THE PLAN

💊 MANAGEMENT BY CAUSE

Cause	Mother	Delivery and baby
ICP	Ursodeoxycholic acid 10 to 15 mg/kg improves itch and tests in about 75%; rifampicin if it fails	Consider delivery at 37 weeks; risks are prematurity, fetal distress and stillbirth; resolves within 6 weeks, otherwise look for another cause
HELLP	Stabilise the BP; give labetalol if 150/100 or more	Prompt delivery is the most effective treatment
AFLP	Early recognition, supportive and intensive care, treat low glucose and clotting	Deliver promptly; caesarean was the safest route; transplantation or plasma exchange is rarely needed
Hepatitis A	Supportive care; hydration and nutrition	Immune globulin and vaccine after exposure; newborn immune globulin if illness in the last month
Hepatitis B	Monitor; antiviral for a high viral load as per specialist (from memory)	Baby gets immunoglobulin and vaccine at birth, then completes the vaccine course; transmission falls below 3%
Hepatitis C	No treatment proved to prevent transmission; avoid interferon	Test the baby later (from memory)
Hepatitis E	Admit early; supportive care; no specific antiviral	High risk of fulminant failure and fetal loss; prevent with clean water
Gallstones with obstruction	Surgery, usually laparoscopic cholecystectomy	Fetal loss about 6%
PBC, autoimmune hepatitis	Continue ursodeoxycholic acid or azathioprine	Pregnancy is generally safe with good control

STEP 3 · COUNSEL AND FOLLOW UP — what she and her family need to hear

🗣️ WHAT TO TELL HER

The cause decides the treatment; some causes need delivery, others only monitoring

ICP usually resolves within 6 weeks after delivery; repeat the tests after birth, and look for another disease if it persists beyond 3 months

ICP tends to recur in later pregnancies (from memory)

After pre-eclampsia or HELLP, she has a higher risk in later pregnancies and of heart and kidney disease

Drink boiled or safe water and wash hands, to prevent hepatitis A and E (from memory)

Avoid herbal remedies and unprescribed drugs during pregnancy (from memory)

Make sure the baby gets the hepatitis B vaccine at birth, with immunoglobulin when advised

⚠️ COMMON PITFALLS

Calling jaundice in pregnancy “just hepatitis” without checking BP, glucose and clotting

Missing AFLP or HELLP because the platelets, glucose or clotting were not checked

Treating itch as a skin problem without bile acids

Delay in delivery for HELLP or AFLP

Missing hepatitis E in a woman from an outbreak area

Not giving the newborn hepatitis B immunoglobulin and vaccine

Giving a drug that is hepatotoxic (from memory)

Not repeating liver tests after delivery

Memory Aid

LIVER

Five steps for jaundice in pregnancy.

L

Look at the pattern — itch, BP, glucose, platelets, fever

I

Investigate — LFT, bile acids, clotting, smear, serology, ultrasound

V

Viral hepatitis — A, B, C and E; hepatitis E is deadly in pregnancy

E

Emergency — HELLP and AFLP: stabilise and deliver

R

Review — ICP: bile acids, fetal checks, delivery at 37 weeks; repeat tests after birth

Remember: in a pregnant woman with jaundice, look for the cause that kills first.

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

Clinician-facing summary. Checked against: a PMC review of pregnancy-associated liver diseases (timing of hyperemesis, ICP, pre-eclampsia, HELLP and AFLP; bile acid thresholds; ursodeoxycholic acid dose; Swansea and HELLP criteria; delivery) and the Patient.info professional article “Jaundice in pregnancy” (viral hepatitis, hepatitis E, gallstones, PBC, AIH, investigations and management). The Patient.info article gives the bile acid unit as mmol/L, which is a typing error; the sheet uses µmol/L as in the review. Items marked “from memory” (history details, ALP in pregnancy, drug and herbal causes, hepatitis B antiviral, hepatitis C testing of the baby, ICP recurrence, safe water) were not checked. Both sources are from outside India: follow your local obstetric and hepatology protocols.

DYSURIA- Burning Micturition

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Burning Micturition — Find the Cause, Test & Treat

Burning micturition is one of the commonest complaints in women. This sheet gives how to tell cystitis from vaginitis and infection of the urethra, which tests to send, which antibiotics to choose, and when to worry.

🎯 AT A GLANCE — BURNING MICTURITION

Burning micturition (dysuria) means pain or burning on passing urine; the commonest cause is acute cystitis

E. coli causes about 86% of uncomplicated cystitis; others are Staph. saprophyticus, Klebsiella and Proteus

The history matters most: one classic symptom raises the chance of UTI from about 5% to about 50%

New dysuria and frequency with no vaginal discharge or irritation has about 90% positive predictive value for UTI

Vaginal discharge or irritation points to vaginitis or cervicitis rather than UTI

A midstream dipstick for nitrite and leucocyte esterase is enough for a typical case

Nitrofurantoin for 5 days is first-line in most guidelines; avoid fluoroquinolones as first choice

Do not assume every burning is a UTI: ask about discharge, examine, and send a culture when there are red flags or when the symptoms come back.

🚨 DO NOT JUST GIVE A SHORT COURSE IF…

She has fever, chills, loin pain, vomiting, a fast pulse or looks ill — suspect pyelonephritis; culture and treat as complicated

She is pregnant — send a culture; treat per obstetric protocol

Symptoms lasted over 7 days, or she has diabetes, is over 65, or has had a UTI in the last 4 weeks — complicated cystitis

Symptoms do not settle, or return within 2 to 4 weeks — urine culture

There is discharge, a new partner, or ulcers — examine and swab for vaginitis and sexually transmitted infection

Haematuria persists, or there is colic — think of stones or other disease and image the urinary tract (from memory)

She cannot take tablets — admit for IV treatment

STEP 1 · FIND THE CAUSE — bladder, vagina, urethra or something else?

🔍 CAUSES OF BURNING MICTURITION

Cause	Clues	Test
Acute cystitis	Dysuria, frequency of small volumes, urgency; sometimes haematuria; no discharge	Dipstick: nitrite, leucocyte esterase
Pyelonephritis	Fever, loin pain or tenderness, tachycardia, ill	Culture; consider ultrasound or CT if no response
Vaginitis: candida, bacterial vaginosis, trichomonas	Discharge, itch, irritation; burning when urine touches the skin	Speculum, vaginal pH, microscopy or swab
Urethritis, cervicitis (chlamydia, gonorrhoea)	New partner or partner with symptoms; discharge; lower abdominal pain (from memory)	NAAT or swabs from the endocervix
Genital herpes	Painful vulval ulcers or blisters; severe burning (from memory)	Swab for PCR (from memory)
Atrophic vaginitis	After the menopause; dryness, discomfort (from memory)	Examination
Stone, bladder pain syndrome, irritants, tuberculosis	Colic or haematuria; pain with a clean culture; soaps, spermicide or scented products; sterile pyuria (from memory)	Culture, imaging, further tests as clinically indicated

🩺 HISTORY, EXAMINATION AND TESTS

Ask about onset, frequency, urgency, haematuria, fever, loin pain, discharge, itch, a new partner, spermicide or diaphragm use, diabetes, pregnancy, and recent antibiotics

Examine the temperature, suprapubic and loin tenderness, and look at the vulva; do a speculum if there is discharge

Collect a midstream clean-catch specimen; cleansing first makes no significant difference

Use a dipstick for nitrite and leucocyte esterase; both are the most accurate

Send a culture for suspected pyelonephritis, symptoms that persist or recur within 2 to 4 weeks, atypical symptoms, pregnancy, complicated cystitis, or relapse

A count of 10³ CFU/mL or more is diagnostic; over 10² CFU/mL with typical symptoms is positive

Do not send routine tests after treatment when she is well

STEP 2 · TREAT — by the cause, and by local resistance

🧭 FROM THE SYMPTOM TO THE TREATMENT

💊 ANTIBIOTICS FOR CYSTITIS

Tier	Drug	Notes
First line	Nitrofurantoin 100 mg twice daily for 5 days	Avoid if early pyelonephritis is suspected; take with food
First line	Fosfomycin 3 g single dose	May be less effective; availability varies
If local resistance is 20% or less	Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days	Avoid if used in the last 3 months
Alternative	Cephalexin 250 mg four times daily for 5 days	Beta-lactams are generally less effective than first-line drugs
Second tier	Ciprofloxacin 250 mg twice daily for 3 days	Reserve for allergy or serious infection; avoid fluoroquinolones first-line because of resistance
Complicated cystitis	Culture first; ciprofloxacin 500 mg twice daily or cefpodoxime 200 mg twice daily for 10 to 14 days	Choose by the culture; resistance to both drugs is common in India (from memory)
Pregnancy	Culture; treat according to the obstetric protocol	Asymptomatic bacteriuria in pregnancy: treat if more than 100,000 CFU/mL
Cannot take tablets, or pyelonephritis	Admit; IV ceftriaxone 1 g daily is one option	Adjust to the culture and local guidance

Other measures: a urinary analgesic for the first 1 to 2 days, plenty of fluids and rest. (from memory) Cranberry products have no proven benefit once symptoms are present. Review if she is not better in 2 to 3 days.

🧪 WHEN IT IS NOT A UTI

Cause	Treatment
Candidal vaginitis	Antifungal, vaginal or oral, as in your local protocol (from memory)
Bacterial vaginosis, trichomonas	Metronidazole; treat the partner for trichomonas (from memory)
Chlamydia, gonorrhoea	Treat per the current STI protocol, test and treat the partner, advise no sex until treated, offer HIV and syphilis testing (from memory)
Herpes	Antiviral and pain relief (from memory)
Atrophic vaginitis	Vaginal oestrogen (from memory)

STEP 3 · COUNSEL AND PREVENT — what she needs to hear

🗣️ WHAT TO TELL HER

Finish the antibiotic even when she feels better, and come back if there is no improvement in 2 to 3 days

Drink enough water; pass urine after sex; wipe from front to back; avoid scented soaps and washes, and spermicide or a diaphragm if she gets repeated UTIs (from memory)

Return at once for fever, loin pain, vomiting or blood in the urine

If she has repeated UTIs: send a culture each time, consider low-dose prophylaxis or post-coital treatment, and in post-menopausal women vaginal oestrogen (from memory)

Treat her partner when a sexually transmitted infection is found

⚠️ COMMON PITFALLS

Treating every burning as a UTI without asking about discharge

Using a fluoroquinolone first, or repeating the drug she had in the last 3 months

No culture in pregnancy, relapse or suspected pyelonephritis

Giving nitrofurantoin when pyelonephritis is likely

Routine culture after treatment in a well woman

Treating asymptomatic bacteriuria in a non-pregnant woman (from memory)

Missing a sexually transmitted infection, herpes or genitourinary tuberculosis (from memory)

Forgetting diabetes (from memory)

Memory Aid

BURNS

Five steps for burning micturition.

B

Bladder or vagina? — ask about discharge and examine

U

Urine dipstick — nitrite and leucocyte esterase; culture when indicated

R

Red flags — fever, loin pain, pregnancy, diabetes, relapse

N

Nitrofurantoin first — chosen by local resistance

S

Swab and stay alert — STIs, herpes, recurrence

Remember: the cause may be the bladder, the vagina or the urethra: look before you prescribe.

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

Clinician-facing summary. Checked against: the AAFP article “Diagnosis and Treatment of Acute Uncomplicated Cystitis” (2011): causes, symptom probabilities, dipstick, culture indications, first-line and second-line drugs; and WikEM “Acute cystitis” (edited 2023): diagnosis, uncomplicated and complicated regimens, urethritis, pregnancy, red flags and resistance. Both are from the United States and are not Indian guidelines; E. coli resistance to fluoroquinolones, cephalosporins and cotrimoxazole is high in India, so use your local antibiogram and national antimicrobial guidance. Items marked “from memory” (other causes, STI treatment, symptomatic relief, recurrence, counselling) were not checked. Doses are from these sources: confirm against your own formulary.

Adolescent Gynecology Corner: Understanding Menstrual Disorders

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menstrual Problems in Teenagers — Heavy, Painful, Irregular & Absent

Menstrual problems in teenagers are common and often dismissed. This sheet gives what is normal, what to investigate, and how to treat heavy bleeding, painful periods and absent periods.

🎯 AT A GLANCE — MENSTRUAL PROBLEMS IN TEENAGERS

The menstrual history is a vital sign: ask at every visit about the last period and the pattern

Menarche is at 12 to 13 years on average, and 98% have started by 15

In teenagers about 90% of cycles are 21 to 45 days long, and a period lasts 2 to 7 days

Anovulation is common for the first 12 to 18 months and usually does not last more than 3 months

Heavy bleeding from the first periods suggests a bleeding disorder, most often von Willebrand disease

About 90% of painful periods are primary and begin 6 to 12 months after menarche; about 10% are secondary, most often endometriosis

Teach girls and parents what is normal early, from about 7 to 8 years

Irregular is often normal in the first two years; heavy, very painful, very late or absent is not. Exclude pregnancy first, then look for the cause.

🚨 EVALUATE OR REFER IF…

She soaks a pad or tampon every 1 to 2 hours, floods the sheets, or is faint, pale or has a fast pulse — check haemodynamic stability and consider admission

There is no menarche by 15 years, or within 3 years of breast budding, or no breast development by 13

There is monthly pain with no bleeding — suspect a blocked outflow, such as an imperforate hymen or a transverse septum

Periods stop for more than 3 months, or bleeding lasts over 7 days, or a cycle is under 21 or over 45 days

Pain started at menarche, worsens, or continues after 3 to 6 months of treatment; or pain with passing urine or stool during periods — think of endometriosis or an anomaly

Weight loss, over-exercise or an eating disorder, or signs of thyroid disease

Pregnancy, sexual abuse or a sexually transmitted infection is possible — ask confidentially, even if she says she is not sexually active

STEP 1 · RECOGNISE — normal or not?

🔍 NORMAL AND WHEN TO EVALUATE

Feature	Normal in a teenager	Evaluate if
Menarche	12 to 13 years; usually around breast stage IV	None by 15, or 3 years after breast budding, or no breasts by 13
Cycle length	21 to 45 days (60 to 80% are 21 to 34 days by 3 years after menarche)	Under 21 or over 45 days, or no period for over 3 months
Length of period	2 to 7 days	More than 7 days
Flow	Pads or tampons last several hours	Changed every 1 to 2 hours, clots over 2 cm, floods

🩺 HISTORY AND EXAMINATION

Date of the last period and the pattern; a diary or phone app helps

Pregnancy, sexual activity, sexual trauma and infection: ask her alone and confidentially, even if she denies sex

Stress, eating disorders, weight change, exercise; symptoms of thyroid disease, polycystic ovary syndrome, liver disease or a bleeding disorder

Family history of heavy bleeding, easy bruising, nosebleeds or late menarche

Check pulse and blood pressure (orthostatic if heavy bleeding), weight and height, pallor, bruising, acne, hirsutism, thyroid and breast stage

Inspect the external genitalia; a speculum or pelvic examination is usually not needed

STEP 2 · FIND THE PROBLEM AND TREAT IT — heavy, painful or absent periods

🧭 FROM THE PROBLEM TO THE PLAN

🩸 HEAVY OR IRREGULAR BLEEDING

Cause	Clues
Anovulation	The commonest cause early on, within 12 to 18 months of menarche
Bleeding disorder, most often von Willebrand disease	Heavy from the first period; easy bruising or nosebleeds; family history; about 1 in 4 who need admission or transfusion has a coagulopathy
Thyroid disease, PCOS, obesity	Irregular cycles; acne or hirsutism; weight; high oestrogen with anovulation
Pregnancy, miscarriage, infection, trauma	Always test, whatever she says
Stress, eating disorder	Weight loss, exercise, mood
Structural causes	Rare in teenagers

Tests: hCG, full blood count with platelets, ferritin and TSH. If anaemic or a bleeding disorder is suspected: PT, PTT, INR, fibrinogen, von Willebrand antigen and activity, and factor VIII. Take these before starting hormones, because hormones change the results. A pelvic scan is not routine; a transabdominal scan is enough if needed.

💊 TREATING HEAVY BLEEDING

Situation	Treatment	Notes
Stable, mild or moderate	NSAID first line; tranexamic acid 1 to 1.3 g three times a day on heavy days, up to 5 days	Add iron; check ferritin; medical treatment is first-line and surgery only if it fails
Acute heavy bleeding	High-dose combined pill taper; a high-dose progestin taper if oestrogen is contraindicated	One pill a day is usually not enough to stop acute bleeding
Maintenance	Combined pill, oral or injectable progestin, or levonorgestrel IUS	Many reach amenorrhoea within 6 months with DMPA or the IUS
Unstable or not responding	Admit; IV oestrogen or antifibrinolytic; a Foley balloon, clot evacuation or examination under anaesthesia if needed	Rarely needed; transfusion is often unnecessary
Bleeding disorder	Refer to haematology; counsel about safe medicines and future surgery	Avoid aspirin and NSAIDs if a platelet function disorder is likely (from memory)

😣 PAINFUL PERIODS

Type	Clues	Management
Primary (about 90%)	Starts 6 to 12 months after menarche, with ovulatory cycles; no pelvic disease	NSAID: naproxen 5 mg/kg (maximum 500 mg) twice a day, or mefenamic acid 500 mg three times a day, with food, starting 1 to 2 days before the period and continuing for 2 to 3 days
If not enough	Heavy bleeding as well, or contraception wanted	Combined pill, continuous or extended; or a progestogen, implant or levonorgestrel IUD; review at 3 months
Secondary (about 10%)	Pain from menarche, worse towards the end of bleeding, pain with urine or stool in the period, family history of endometriosis, or no response after 3 to 6 months	Transabdominal pelvic ultrasound; refer to gynaecology; endometriosis is the commonest cause, then obstructive anomalies, adenomyosis, infection and cysts

Non-drug help: heat, exercise and rest may complement medicines or replace them if she cannot take them. (from memory) A vaginal examination is rarely needed in a teenager.

🚫 NO PERIODS

Group	Cause	What to do
Normal breasts, outflow blocked	Imperforate hymen or transverse vaginal septum: monthly pain, a bulging hymen or mass; Müllerian agenesis (MRKH): no vagina or uterus; androgen insensitivity: 46XY	Examine, ultrasound or MRI, karyotype; surgery is curative for hymen or septum
Poor breast growth, high FSH, low oestradiol	Ovarian insufficiency: Turner syndrome (short stature, webbed neck, shield chest), Swyer syndrome, autoimmune or iatrogenic	Karyotype; low-dose oestrogen from about 12, then a progestogen; a combined pill is not for puberty induction; remove intra-abdominal gonads in 46XY
Low or normal FSH	Functional hypothalamic amenorrhoea from weight loss, exercise or stress; hyperprolactinaemia; constitutional delay; thyroid disease; PCOS	Nutrition, weight and stress care; dopamine agonist for prolactin; lifestyle for PCOS

First tests: exclude pregnancy; FSH, oestradiol, TSH, prolactin; transabdominal pelvic ultrasound; karyotype if the uterus is absent or ovarian insufficiency is suspected.

STEP 3 · COUNSEL AND FOLLOW UP — what she needs to hear

🗣️ WHAT TO TELL HER AND HER PARENT

Irregular periods are common in the first two years; heavy, very painful or missed periods deserve a check

Keep a period diary or use an app, and note flow, pain and missed school

Eat iron-rich food and take iron if advised, because anaemia is common in Indian girls (from memory)

Pain medicine works best if she takes it early, with food, at the start of her period

She can talk to you privately about sex, abuse and worries; keep it confidential

Tell her when to come back or go to hospital: soaking a pad every hour, feeling faint, or severe pain

Follow up to check the response, her iron and her quality of life

⚠️ COMMON PITFALLS

Saying “irregular is normal” for a girl with heavy bleeding or none for over 3 months

Missing a bleeding disorder in a girl with heavy bleeding from menarche

Starting hormones before the bleeding disorder tests

Skipping the pregnancy test because “she is not sexually active”

Not looking at the hymen in a girl with monthly pain and no periods

Using a combined pill to induce puberty

Giving the NSAID late or at too low a dose

Missing an eating disorder or over-exercise

No iron, no follow-up

Memory Aid

PERIOD

Six steps for a teenager with a period problem.

P

Pregnancy first — also infection and abuse, asked in private

E

Evaluate against the normal — 21 to 45 days, up to 7 days

R

Red flags — hourly pads, no menarche by 15, cyclic pain with no bleeding

I

Iron and the bleeding screen — ferritin, von Willebrand tests before hormones

O

Offer the right treatment — NSAID, tranexamic acid, hormones; treat the cause

D

Diary and follow-up — review at 3 months, check iron

Remember: a girl’s period is a vital sign; do not dismiss it, and do not forget to ask in private.

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

Clinician-facing summary. Checked against: a Contemporary OB/GYN summary of ACOG Committee Opinion 785 on heavy menstrual bleeding in adolescents; the Contemporary Pediatrics article “Menstruation as the sixth vital sign”; Exxcellence pearls on abnormal uterine bleeding in adolescents (tranexamic acid 1,300 mg); the Royal Children’s Hospital Melbourne dysmenorrhoea guideline (NSAIDs, hormones, atypical features); and an Obstetrics & Gynaecology Magazine review of primary amenorrhoea (2019, now several years old). Tranexamic acid dosing differs between sources (1 g and 1.3 g). Items marked “from memory” (platelet disorders and NSAIDs, non-drug measures, anaemia in India) were not checked. These sources are from the United States and Australia; drugs and services differ in India: follow local protocols.

URINARY INCONTINENCE IN WOMEN

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Urinary Incontinence in Women — Label, Train & Step Up

Urinary incontinence is common and under-reported. This sheet gives how to classify the leak, what to exclude, first-line training, and the next steps in drugs, devices and surgery.

🎯 AT A GLANCE — URINARY INCONTINENCE IN WOMEN

Estimates of urinary incontinence range from 3% to 55% of women, depending on the definition; at least half never tell a doctor

Stress, urge, mixed, overflow and functional are the types; mixed is the commonest overall, and you treat the more bothersome symptom

Classify the leak before choosing treatment

First-line treatment for all types is conservative and has no major harms: weight loss, fluid and caffeine changes, bladder training and pelvic floor muscle training

Up to 38% of women with stress incontinence alone are cured after at least 3 months of pelvic floor training

Drugs for urge give modest benefit and cure is rare; combining a drug with behavioural therapy works better than either alone

Systemic oestrogen can make incontinence worse

Ask every woman about leakage, because most will not mention it; name the type; exclude red flags and reversible causes; then start with training before any drug or operation.

🚨 DO NOT JUST TREAT THE LEAK — INVESTIGATE OR REFER IF…

There is gross haematuria, recurrent urinary infection or pain — exclude stones and bladder cancer

She has new retention, a high post-void residual or kidney dysfunction

Leakage is constant, or began after surgery, radiotherapy or a difficult delivery — suspect a vesicovaginal or other fistula (from memory)

There are nerve signs, such as weakness, numbness or faecal incontinence with a neurological deficit

A pelvic mass, or a prolapse that bulges outside the vagina

Conservative treatment has failed, or she prefers a procedure — refer to a urogynaecologist

STEP 1 · RECOGNISE AND ASSESS — name the type and look for a cause

🔍 THE TYPES

Type	She leaks when	Typical woman
Stress	She coughs, sneezes, laughs or exerts herself	Younger women; second most common in older women
Urge	There is a sudden strong desire to pass urine; often frequency and nocturia	Most common in older women; caused by detrusor overactivity
Mixed	Both stress and urge	The most common overall
Overflow	The bladder is full and dribbles	Drugs with anticholinergic effect, or nerve disease
Functional	She cannot reach the toilet in time	Limited mobility, memory or mood

🩺 ASSESSMENT

Ask about triggers, urgency, frequency, nocturia, pad use, a bulge, bowel symptoms, pain, blood in the urine, deliveries and operations, drugs, and how much it bothers her

Look for reversible causes: urinary infection, constipation, vaginal atrophy, drugs such as diuretics and sedatives, poor mobility, and confusion (from memory)

Ask her to keep a bladder diary and fill in a symptom questionnaire

Examine the abdomen, nervous system and pelvis; try to show stress leakage with a cough; check for prolapse and for atrophy

Send a urinalysis and measure the post-void residual when indicated

Before surgery, objectively demonstrate stress leakage and check bladder emptying; do urodynamics when the diagnosis is unclear (from memory)

STEP 2 · TREAT — conservative care first, then step up

🧭 FROM THE LEAK TO THE TREATMENT

💊 TREATMENT OPTIONS

Option	What to do	Notes
Lifestyle	Lose weight if overweight (stress); cut fluids, caffeine and fizzy drinks; treat constipation; stop smoking	Useful for all types
Pelvic floor muscle training	3 sets of 8 to 10 contractions, each held 6 to 8 seconds, 3 to 4 times a week, for 15 to 20 weeks; extend the hold to 10 seconds	Most effective for stress incontinence; supervised teaching helps
Bladder training	Suppress the urge, then extend the interval by 30 to 60 minutes; aim to pass urine every 3 to 4 hours	For urge; scheduled or prompted voiding if memory is poor
Vaginal pessary or devices	A pessary for stress incontinence if she is pregnant, unfit for surgery or after failed surgery; tibial nerve stimulation for urge	Urethral plugs carry a high risk of infection
Drugs for urge	An antimuscarinic for 4 to 8 weeks (long-acting and selective if possible), or mirabegron	Avoid antimuscarinics in dementia, narrow-angle glaucoma and retention, and with caution in older women; mirabegron raises blood pressure
Vaginal oestrogen	Low-dose, for atrophy and sometimes urge	Systemic oestrogen may worsen incontinence
Duloxetine for stress	Off-label	Reduces leakage but does not cure; 45% stop because of side effects
Botulinum toxin, sacral neuromodulation	For urge that does not respond to drugs	Botulinum lasts 3 to 6 months; neuromodulation is an implant
Stress surgery	Midurethral sling (TVT is the most common), Burch colposuspension, bulking agents	Only after conservative care fails; risks include new urgency, voiding difficulty, prolapse and repeat surgery; bulking cures or improves 18 to 40%

Say: “Pelvic floor exercises work best if you do them every day for months, so we shall check you are doing them correctly.” Review at 4 to 8 weeks before adding a drug.

STEP 3 · COUNSEL — what she needs to hear

🗣️ WHAT TO TELL HER

Leaking urine is common and treatable; she is not alone and need not feel ashamed

Start with exercises and bladder habits; they work, and have no harm

Drinking less does not cure it: pass urine about every 3 to 4 hours, and avoid caffeine, fizzy drinks and drinking late at night (from memory)

Treat constipation and a chronic cough, because they strain the pelvic floor (from memory)

Medicines can dry the mouth and constipate; the benefit is modest

Surgery is for stress leakage that has not improved; discuss goals, risks and future pregnancy first

⚠️ COMMON PITFALLS

Not asking, so she suffers in silence

Starting a drug before classifying the leak

Giving an antimuscarinic to a woman with retention, dementia or glaucoma

Expecting drugs to treat stress incontinence

Operating without demonstrating stress leakage or measuring emptying

Missing a fistula in a woman who leaks constantly after delivery or surgery (from memory)

Prescribing systemic oestrogen for leakage

Teaching pelvic floor exercises once and not following up

Memory Aid

LEAKS

Five steps for urinary incontinence.

L

Label the type — stress, urge, mixed, overflow, functional

E

Exclude red flags — blood, retention, fistula, nerve signs

A

Advise first — weight, fluids, bladder training, pelvic floor

K

Keep a diary — and review at 4 to 8 weeks

S

Step up — drugs, devices, then surgery

Remember: most women improve with training alone; drugs and surgery come after it.

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

Clinician-facing summary. Checked against: the AAFP article “Clinical Management of Urinary Incontinence in Women” (2013): types, prevalence, lifestyle, bladder training, pelvic floor training schedule, devices, drugs, procedures and surgery; and a summary of the ACOG and AUGS practice bulletins (assessment, classification, referral and red flags). The AAFP article is from 2013, so newer guidance may differ. I could not read the NICE NG123 text. Items marked “from memory” (reversible causes, fistula, urodynamics, counselling) were not checked. Drug doses are not given here; availability and protocols differ in India: follow local practice.