Dermoid Cyst of the Ovary

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Dermoid Cyst of the Ovary — Recognise, Assess & Remove Safely

The ovarian dermoid cyst (mature cystic teratoma) is the commonest ovarian tumour in young women. This sheet gives the ultrasound signs, the complications, the warning signs of malignant change, when to watch and when to operate, and the pitfalls, with numbered references.

🎯 AT A GLANCE — OVARIAN DERMOID CYST

A dermoid cyst is a mature cystic teratoma: a benign germ cell tumour with tissue from the three germ layers (skin, hair, fat, teeth) [1]

About 10 to 20% of all ovarian tumours; the commonest ovarian tumour under 20 years [1][3]

Usual age about 30 (range 13 to 76); bilateral in 8 to 15%; more often on the right [1][2]

About 20% are found by chance; acute pain in 5 to 10%, often from torsion [1]

Ultrasound is the main test; a dermoid plug is strong evidence [1][2]

Slow growth, about 1 to 2 mm a year [2][3]

Malignant change in about 1 to 2%, mostly squamous cell carcinoma in women over 40 [1][2]

Most are benign and can be removed with the ovary preserved; the main dangers are torsion, rupture and a missed malignancy.

🚨 ACT URGENTLY OR REFER IF…

Sudden severe pelvic pain with vomiting — torsion; urgent surgery [1][3]

Peritonitis, or fatty fluid seen under the diaphragm — rupture with chemical peritonitis [1][3]

Blood flow inside the mass on Doppler — work up for malignancy [3]

Enhancing solid component, irregular wall or spread outside the capsule — refer to oncology [1][2]

Over 10 cm, age over 40 or postmenopausal — higher suspicion; MRI and tumour markers [1][3]

Young woman with new psychiatric symptoms, seizures or confusion — think of anti-NMDA receptor encephalitis [1]

Fever and a tender mass — infected dermoid (about 1%) [2]

🧭 FROM THE SCAN TO A PLAN

STEP 1 · RECOGNISE — what it is and what is inside

🧬 PATHOLOGY IN BRIEF

Feature	Detail
Share of tumours [1]	About 11% of ovarian tumours; 69% of germ cell tumours; 95% of teratomas
Size and shape [1][3]	Mean about 7 cm; unilocular in 88%; usually under 10 cm
Contents [1][2]	Skin and sebaceous material in almost all; fat in over 93%; teeth in about 31%
Thyroid tissue [1]	In about 15%; struma ovarii if over 50% of the tumour
Symptoms [1]	None in about 20%; pressure or a mass if large; acute pain in 5 to 10%

STEP 2 · IMAGE — the signs that make the diagnosis

🔬 ULTRASOUND SIGNS

Sign	What you see [2][3]
Dermoid plug (Rokitansky nodule)	Echogenic mural nodule with shadowing; the most typical finding
Dot-dash sign (dermoid mesh)	Bright lines and dots from hair; positive predictive value 98%
Tip of the iceberg	Bright near surface with dense shadow hiding the rest; can be mistaken for bowel gas
Fat-fluid level	Not specific alone; counts when another sign is present
Floating balls	Mobile globules with no blood flow; uncommon
Doppler	No internal blood flow; flow inside needs work-up

CT: detects fat with 93 to 98% sensitivity; also teeth and calcification; not routine because of radiation [2][3]

MRI: for difficult cases; fat is bright on T1 and drops on fat-suppressed images [2][3]

A palpable mass not seen on scan may be a dermoid hidden as “bowel gas” [2]

Markers (SCC antigen, CA-125, CA19-9, CEA, AFP) may rise with malignancy; they do not diagnose a benign dermoid [1]

STEP 3 · KNOW THE RISKS — complications and malignant change

⚠️ COMPLICATIONS

Complication	Reported rate
Torsion [2][3]	About 3 to 16%; the commonest
Rupture [1][2]	About 1 to 4%; chemical peritonitis
Malignant transformation [1][2]	About 1 to 2% (0.5 to 3%); squamous cell carcinoma in 80 to 85%
Infection [2]	About 1%
Autoimmune haemolytic anaemia [2]	Under 1%
Anti-NMDA receptor encephalitis [1][3]	Rare; may appear before the tumour is found
Recurrence after cystectomy [1]	4 to 5%

Signs of malignant change: enhancing solid nodule, obtuse angle with the cyst wall, thick wall or septa, necrosis, growth through the capsule [1][2]

Size does not exclude it: of 173 malignant cases with a recorded size, 27% were under 10 cm; every described solid component was over 1 cm [4]

STEP 4 · MANAGE — watch, remove or refer

🛠️ MANAGEMENT BY SITUATION

Situation	Plan
Small, typical, no symptoms [3]	Yearly ultrasound under 7 cm to check growth
Premenopausal, about 5 cm or more [1][3]	Surgery is generally recommended; one source advises removal beyond 7 cm
Operation of choice [1]	Laparoscopic cystectomy, preserving the ovary
Postmenopausal [1]	Oophorectomy is standard; remove even smaller cysts
Children and adolescents [1]	Observation of small cysts is debated; preserve ovarian tissue
Pregnancy [1]	About 10.5% of patients are pregnant; no evidence that pregnancy raises infection, rupture or malignancy risk
Malignant change found [1]	Manage as ovarian cancer; fertility-sparing surgery possible in young women

Spillage at laparoscopy is reported in 0 to 100% of cases across studies [1]; use a retrieval bag and wash the pelvis thoroughly (from memory)

Torsion: untwist and conserve the ovary where viable, then remove the cyst (from memory)

In pregnancy, elective surgery is usually timed in the second trimester (from memory)

🗣️ COUNSELLING AND FOLLOW-UP

It is benign in about 98 to 99 of 100 women [1][2]

Fertility: cystectomy keeps the ovary; discuss ovarian reserve if both sides are operated (from memory)

If watching: return at once for sudden pain or vomiting; scan every year [3]

After surgery: 4 to 5% recur, and the other ovary can develop one; scan if symptoms return [1]

Histology: collect and review the report for every specimen

⚠️ COMMON PITFALLS

Mistaking the dermoid for bowel gas and reporting a normal scan [2]

Mistaking a haemorrhagic cyst for a dermoid; fibrin strands mimic the dot-dash sign [2]

Not scanning the other ovary [1]

Oophorectomy in a young woman when cystectomy is possible [1]

Trusting size alone to exclude malignancy [4]

Ignoring internal blood flow or a solid part in an older woman [3]

Spilling contents without thorough lavage

Memory Aid

DERMOID

Seven points for every dermoid cyst.

D

Dermoid plug — the key ultrasound sign

E

Echogenic with shadow — beware the tip of the iceberg

R

Right and left — check both ovaries; 8 to 15% are bilateral

M

Malignant change — 1 to 2%; older age, solid part, blood flow

O

Ovary-sparing cystectomy — in women before menopause

I

Intact removal — bag it, avoid spillage, wash well

D

Do follow up — histology, recurrence 4 to 5%

Remember: a dermoid is usually benign and slow; torsion is the emergency, and the older woman is the one to worry about.

🔤 ABBREVIATIONS USED

Abbreviation	Meaning
AFP	Alpha-fetoprotein
CA-125, CA19-9	Cancer antigens 125 and 19-9; blood tumour markers
CEA	Carcinoembryonic antigen
CT	Computed tomography
MCT	Mature cystic teratoma; the pathological name for a dermoid cyst
MRI	Magnetic resonance imaging
NMDA	N-methyl-D-aspartate; a brain receptor attacked by antibodies in a rare encephalitis
O-RADS	Ovarian-Adnexal Reporting and Data System
SCC antigen	Squamous cell carcinoma antigen
T1	An MRI sequence on which fat appears bright
doi	Digital object identifier of a paper

📚 REFERENCES

[1] Cong L, Wang S, Yeung SY, Lee JHS, Chung JPW, Chan DYL. Mature cystic teratoma: an integrated review. Int J Mol Sci 2023;24(7):6141. doi:10.3390/ijms24076141.

[2] Sahin H, Abdullazade S, Sanci M. Mature cystic teratoma of the ovary: a cutting edge overview on imaging features. Insights Imaging 2017;8(2):227-241. doi:10.1007/s13244-016-0539-9.

[3] Radiopaedia. Mature cystic ovarian teratoma. radiopaedia.org (online reference article; accessed November 2026).

[4] Jordan H, Low G, Wilson MP. Size threshold as a risk for malignant transformation in typical ovarian dermoid lesions: a scoping review. Published 21 December 2024 (abstract read; journal details not shown on the page).

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

Clinician-facing summary. Pages opened and read: [1] Cong 2023 and [2] Sahin 2017 (first 100,000 characters of each), [3] Radiopaedia reference article, [4] abstract of Jordan 2024. PubMed Central and StatPearls pages were blocked, so no StatPearls, RCOG or ACOG guidance was read. The sources give different size thresholds for surgery (about 5 cm in [1]; 7 cm in [3]) and different torsion rates (16% in [2]; 3 to 16% in [3]); the sheet shows the ranges. Items marked “from memory” (retrieval bag and lavage, detorsion with conservation, second-trimester surgery in pregnancy, ovarian reserve) were not checked. Sources are from outside India: follow your local protocol.

Adenomyosis

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Adenomyosis — Recognise, Image & Treat

Adenomyosis is a common, benign cause of heavy and painful periods and of reduced fertility. This sheet gives who gets it, the ultrasound and MRI signs, medical treatment, procedures, fertility and pregnancy outcomes, and the pitfalls, with numbered references.

🎯 AT A GLANCE — ADENOMYOSIS

Adenomyosis is endometrial glands and stroma within the myometrium; it is benign [1]

Found in 20.9% of symptomatic clinic patients on ultrasound, and in 10 to 35% of hysterectomy specimens [1]

Peak age 41 to 45, but it is now diagnosed more often in younger and infertile women [1]

Heavy menstrual bleeding in 40 to 60%; dysmenorrhoea in 15 to 30%; up to one-third have no symptoms [1]

Fibroids coexist in up to 50%, and endometriosis in about 11% [1]

Transvaginal ultrasound is the first test; MRI confirms when it is unclear [1]

The LNG-IUS is the first-line medical treatment; hysterectomy is the only definitive cure [1][2]

The plan depends on three things: her main symptom, her age and whether she wants a pregnancy.

🚨 DO NOT LABEL IT “ADENOMYOSIS” AND STOP IF…

Bleeding after menopause, or between periods after 45 — sample the endometrium first (from memory)

Severe anaemia or haemodynamic compromise — admit, transfuse or give iron, then treat the cause (from memory)

A rapidly growing uterus or mass — exclude malignancy; get MRI and senior review (from memory)

Positive pregnancy test — exclude pregnancy complications (from memory)

Infertility — refer early; adenomyosis lowers IVF success [1][2]

Pregnancy after adenomyosis surgery — higher uterine rupture risk; plan the delivery in a hospital [2]

🧭 FROM SYMPTOMS TO A PLAN

STEP 1 · RECOGNISE — who has it and how it presents

👩 WHO AND HOW

Feature	Detail [1]
Risk factors	Increasing age, parity, previous uterine procedures (caesarean, dilation and curettage)
Typical patient	Multiparous, over 40, previous uterine surgery
Newer group	Under 40, infertility, dysmenorrhoea or abnormal bleeding
Symptoms	Heavy bleeding (40 to 60%), dysmenorrhoea (15 to 30%); less often dyspareunia and chronic pelvic pain
Examination	Enlarged, tender, boggy uterus; no classic sign or laboratory test
Coexisting disease	Fibroids up to 50%; endometriosis 11%; adenomyosis in 25 to 70% of women with endometriosis

Bleeding severity follows the depth of myometrial invasion [1]

STEP 2 · IMAGE — ultrasound first, MRI to confirm

🔬 ULTRASOUND AND MRI

MUSA 2022 sign	Type [2]
Myometrial cysts	Direct
Hyperechogenic islands	Direct
Echogenic subendometrial lines and buds	Direct
Globular uterus; asymmetric walls	Indirect
Fan-shaped shadowing	Indirect
Irregular or interrupted junctional zone	Indirect
Translesional vascularity	Indirect

Indirect signs alone leave the diagnosis uncertain [2]

Severity by myometrial involvement: mild under 25%, moderate 25 to 50%, severe over 50% [2]

Doppler: diffuse vessels through an adenomyotic lesion; a ring of flow around a fibroid [2]

Test	Sensitivity	Specificity
Transvaginal ultrasound	72 to 79% [2]; 83.8% [1]	78 to 81% [2]; 63.9% [1]
MRI	77 to 78% [1][2]	88 to 93% [2]; 89% [1]

MRI shows a thickened junctional zone and bright foci of haemorrhage [3]; use it when ultrasound is unclear or before conservative surgery

Histology is still the definitive diagnosis [3]

STEP 3 · TREAT MEDICALLY — first choice for most women

💊 MEDICAL OPTIONS

Option	Evidence and place
NSAIDs [1][2]	Help dysmenorrhoea; the main option while trying to conceive
Tranexamic acid	Reduces heavy bleeding in general; not covered in the sources read (from memory)
LNG-IUS [1][2][3]	First-line; reduces bleeding, pain and uterine volume; haemoglobin comparable to hysterectomy at 6 and 12 months; 72% satisfied at 3 years
Dienogest [2][3]	Reduced pain and improved quality of life in a placebo-controlled trial; no standard protocol
Combined pill, other progestins [1]	Commonly used off-label; watch thromboembolic risk with the combined pill
GnRH agonists [1][2][3]	Reduce pain and uterine size; short term only because of low-oestrogen effects and bone loss
GnRH antagonists (elagolix, linzagolix) [3]	Case-level evidence so far
Aromatase inhibitors (letrozole) [2][3]	Comparable to GnRH agonists in one trial; specialist use

No medicine is licensed specifically for adenomyosis; all are used off-label, and symptoms return when treatment stops [1] (from memory)

STEP 4 · PROCEDURES — when medicines fail

🛠️ INTERVENTIONAL AND SURGICAL OPTIONS

Procedure	What the reviews report [2]
Uterine artery embolisation	83.1% symptom improvement (30 studies, 1049 patients); not advised if she wants a pregnancy
Radiofrequency ablation	94.7% symptom relief in one systematic review; mainly focal disease
HIFU	Reduces pain and lesion size; in 557 women trying to conceive, pregnancy 53.4% and live birth 35.2%
Adenomyomectomy	Of 364 women trying to conceive: 35% conceived; uterine rupture 0.8%
Recurrence after conservative surgery	9% complete excision; 19% partial; 32.5% non-excisional
Hysterectomy [1]	Definitive; for women past childbearing when other treatment fails

Conservative resection carries a higher rupture risk in a later pregnancy than myomectomy or caesarean [2]

Endometrial ablation was not covered in the sources read; deep disease may respond poorly (from memory)

STEP 5 · FERTILITY AND PREGNANCY — counsel honestly

🤰 FERTILITY AND OBSTETRIC OUTCOMES

IVF: a meta-analysis found a 28% lower chance of clinical pregnancy [1]

Frozen transfer cohort (3503 women, 140 with adenomyosis): live birth adjusted OR 0.46 (0.27 to 0.75); clinical pregnancy 0.62 (0.39 to 0.98) [2]

Miscarriage is more frequent, linked to junctional zone involvement and severity [2]

Freeze-all is the preferred IVF strategy [2]

GnRH agonist before transfer: the reviews disagree; one reports the best rates after pre-treated frozen transfer [3], the other found no proven benefit [2]

In pregnancy: higher risk of pre-eclampsia and small-for-gestational-age babies [2]; book as high risk

⚠️ COMMON PITFALLS

Calling every bulky uterus a fibroid; the treatment and the surgery differ

Diagnosing on indirect ultrasound signs alone [2]

Skipping endometrial assessment in older women with abnormal bleeding

Offering hysterectomy first without a trial of the LNG-IUS

Long GnRH agonist courses without bone protection

Uterine artery embolisation in a woman who wants a pregnancy [2]

Not warning about uterine rupture after adenomyomectomy [2]

Memory Aid

BULKY

Five points for the bulky, tender uterus.

B

Bleeding and pain — heavy, painful periods are the usual story

U

Ultrasound first — look for direct MUSA signs; MRI if unclear

L

LNG-IUS — first-line when no pregnancy is wanted

K

Keep fertility in mind — NSAIDs, early referral, freeze-all IVF

Y

Years and family complete — hysterectomy only after other options

Remember: adenomyosis is benign and common; match the treatment to the woman, not to the scan.

🔤 ABBREVIATIONS USED

Abbreviation	Meaning
COC	Combined oral contraceptive pill
FET	Frozen embryo transfer
GnRH	Gonadotrophin-releasing hormone
HIFU	High-intensity focused ultrasound
IVF	In vitro fertilisation
LNG-IUS	Levonorgestrel-releasing intrauterine system
MRI	Magnetic resonance imaging
MUSA	Morphological Uterus Sonographic Assessment; a consensus on ultrasound terms
NSAID	Non-steroidal anti-inflammatory drug
OR	Odds ratio
RFA	Radiofrequency ablation
UAE	Uterine artery embolisation
PMID / doi	PubMed identifier / digital object identifier of a paper

📚 REFERENCES

[1] Schrager S, Yogendran L, Marquez CM, Sadowski EA. Adenomyosis: diagnosis and management. Am Fam Physician 2022;105(1):33-38.

[2] Selntigia A, Molinaro P, Tartaglia S, Pellicer A, Galliano D, Cozzolino M. Adenomyosis: an update concerning diagnosis, treatment, and fertility. J Clin Med 2024;13(17):5224. doi:10.3390/jcm13175224. PMID 39274438.

[3] Moawad G, Youssef Y, Fruscalzo A, et al. The present and the future of medical therapies for adenomyosis: a narrative review. J Clin Med 2023;12(19):6130. doi:10.3390/jcm12196130. PMID 37837773.

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

Clinician-facing summary. Pages opened and read: [1] Schrager 2022, [2] Selntigia 2024 (first 100,000 characters), [3] Moawad 2023 (first 100,000 characters). No drug doses are given because the sources read did not give them. The reviews report different ultrasound accuracy figures; both are shown. They also disagree on GnRH agonist pre-treatment before embryo transfer. Items marked “from memory” (the red-flag list, tranexamic acid, endometrial ablation, symptom return after stopping treatment) were not checked. No formal society guideline was read; an ESHRE/ESGE/WES good-practice paper exists but was not opened. Sources are from the USA and Europe: follow your local protocol and drug availability.

Biomarker-Guided Pre-eclampsia Care

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Biomarker-Guided Pre-eclampsia Care — Select, Interpret & Act

PlGF and the sFlt-1/PlGF ratio can rule out pre-eclampsia for a week with high confidence, but they do not diagnose it or time delivery. This sheet gives who to test, the assay cut-offs, how to read and act on the result, the key trials, guideline positions and the pitfalls, with numbered references.

🎯 AT A GLANCE — BIOMARKER-GUIDED PRE-ECLAMPSIA CARE

Two placental markers are used: PlGF (falls) and sFlt-1 (rises); they are read as PlGF alone or as the sFlt-1/PlGF ratio (from memory)

The best-proven use is to rule out pre-eclampsia in a woman with suspected disease between 20 and 36+6 weeks [1][2]

A ratio of 38 or less has a negative predictive value of 99.3% for 1 week [2]

A high result means higher risk, not a diagnosis; the positive predictive value is only 36.7% at 4 weeks [2]

Revealed PlGF testing cut the time to diagnosis from 4.1 to 1.9 days and reduced severe maternal outcomes [4]

The tests add to clinical assessment; they do not replace BP, urine and blood tests [1][2]

Do not use a biomarker result to decide on planned early birth [1].

🚨 DO NOT WAIT FOR A BIOMARKER IF…

BP 160/110 or more — admit and treat [2]

Symptoms of imminent eclampsia — admit; magnesium sulphate as per protocol [2]

Pulmonary oedema — emergency care [2]

Abnormal liver enzymes or low platelets — manage as severe pre-eclampsia or HELLP [2]

Pre-eclampsia already confirmed — the test is not indicated [2]

A low result with a worsening woman — treat the woman, not the number

🧭 FROM SUSPICION TO ACTION

STEP 1 · SELECT — who to test and who not to

✅ WHEN THE TEST HELPS, AND WHEN IT DOES NOT

Use it	Do not use it
Suspected pre-eclampsia at 20 to 36+6 weeks [1]	Severe features: the test must not delay care [2]
Routine tests negative or unclear [2]	Pre-eclampsia already confirmed [2]
Once per episode of suspicion [1]	Routine screening with no clinical suspicion [2]
Alongside standard clinical assessment [1]	First-half-of-pregnancy prediction with this test [2]
May help most in women of African, Caribbean and Asian family background [1]	Deciding the timing of delivery [1][2]

Repeat testing: not weekly; repeat only if clinical suspicion returns [2]. NICE asks for research on repeat testing and on multiple pregnancy [1]

STEP 2 · INTERPRET — the assay decides the cut-off

🔬 TESTS AND MANUFACTURER CUT-OFFS

Test	Rule out	Rule in / abnormal
Elecsys sFlt-1/PlGF ratio (Roche), diagnosis [1]	33 or less	85 or more before 34 weeks; 110 or more from 34 weeks
Elecsys ratio, short-term prediction, 24 to 36+6 weeks [1]	38 or less: no pre-eclampsia for 1 week	Over 38: possible within 4 weeks
Triage PlGF (Quidel), 20 to 35 weeks [1]	100 pg/mL or more: normal; delivery within 14 days unlikely	12 to 99: abnormal; under 12: highly abnormal
DELFIA Xpress PlGF 1-2-3 (PerkinElmer) [1]	150 pg/mL or more	Under 50 pg/mL
BRAHMS Kryptor ratio (Thermo Fisher) [1][5]	Not stated	Over 85; not recommended by NICE for routine use; FDA-approved in the USA

Never apply one assay’s cut-off to another assay’s result. Write the assay name on the report.

📊 READING THE sFlt-1/PlGF RATIO

Ratio (Elecsys)	Meaning	Suggested response [2]
Under 38	No pre-eclampsia now; NPV 99.3% at 1 week, 97.9% at 2 weeks, 94.3% at 4 weeks	Routine care; reassess if new suspicion
38 to 85 (up to 34 weeks) or 38 to 110 (after 34 weeks)	Higher risk, not confirmed; PPV 36.7%	Closer follow-up
Over 85 (up to 34 weeks) or over 110 (after 34 weeks)	Higher risk of adverse outcomes	Closer maternal and fetal surveillance; possible admission; local protocol

PlGF below 100 pg/mL before 35 weeks: 94.9% sensitivity for pre-eclampsia needing delivery within 14 days [4]

STEP 3 · KNOW THE EVIDENCE — trials and guideline positions

📚 KEY STUDIES

Study	Design	Main finding
PROGNOSIS (Zeisler 2016) [2][6]	Suspected pre-eclampsia; ratio cut-off 38	NPV 99.3% for 1 week; PPV 36.7% for 4 weeks
PARROT (Duhig 2019) [4]	Stepped-wedge trial; 11 UK units; 1023 women before 37 weeks	Diagnosis in 1.9 vs 4.1 days; severe maternal outcomes 4% vs 5% (adjusted OR 0.32); no perinatal difference
PRAECIS (Thadhani 2022) [3]	18 US hospitals; admitted with hypertension at 23 to 35 weeks; cut-off 40	Severe features within 2 weeks: sensitivity 94%, specificity 75%, PPV 65%, NPV 96%, AUC 0.92

PRAECIS: 74.4% with a ratio of 40 or more delivered within 2 weeks, against 32.6% below 40; twins and heparin users were excluded [3]

Cost: UK modelling showed 56% fewer admissions and savings per patient; savings also reported in Brazil; evidence from low- and middle-income settings is limited [2]

🏛️ WHERE THE GUIDELINES STAND

Body	Position
NICE (UK), DG49 [1]	Recommends 4 PlGF-based tests with clinical assessment at 20 to 36+6 weeks to help rule in or rule out
Brazilian guidance (Costa 2022) [2]	Use the ratio when routine tests are negative; not for confirmation, screening or delivery timing
ACOG and SMFM (USA) [5]	Advise against using the markers to diagnose or rule out pre-eclampsia (as reported in 2024)
ISSHP 2021	Counts angiogenic imbalance as evidence of uteroplacental dysfunction (from memory)

Why the caution: cut-offs came from exploratory analyses; meta-analysis cut-offs range from 1.4 to 196; confidence intervals are wide [5]

STEP 4 · APPLY IT SAFELY — limits, pitfalls and local use

⚠️ LIMITS AND PITFALLS

Treating a positive result as a diagnosis; two in three women with a ratio over 38 do not develop pre-eclampsia in 4 weeks [2]

Treating a negative result as lasting; reassurance is strongest for 1 week [2]

Timing delivery by the ratio [1][2]

Mixing assays and cut-offs [1]

Using it in twins without caution; accuracy in multiple pregnancy needs research [1][3]

Chronic hypertension: most false negatives in PRAECIS had it [3]

Skipping BP, urine and blood tests because a biomarker is available [2]

🇮🇳 USING IT IN OUR SETTING

Availability and cost vary; check which assay your laboratory runs and its turnaround time (from memory)

Best value: the woman with unclear findings before 37 weeks, where a low result avoids admission or referral [2]

If the test is not available, standard assessment and the hospital protocol remain the standard of care [2]

First-trimester screening and aspirin are a different pathway; see the Pre-eclampsia Prediction sheet

Document the assay, the value, the gestation and the plan

Memory Aid

RATIO

Five checks before and after the test.

R

Routine tests first — BP, urine, platelets, liver, creatinine

A

Appropriate woman — suspected disease, 20 to 36+6 weeks, no severe features

T

Test once — per episode; name the assay

I

Interpret — 38 or less reassures for a week; over 85 or 110 is high risk

O

Observe and act clinically — never time delivery by the result

Remember: the biomarker is best at saying “not now”; it cannot say “deliver now”.

🔤 ABBREVIATIONS USED

Abbreviation	Meaning
PlGF	Placental growth factor; a placental protein that falls in pre-eclampsia
sFlt-1	Soluble fms-like tyrosine kinase-1; an anti-angiogenic protein that rises in pre-eclampsia
sFlt-1/PlGF ratio	The sFlt-1 value divided by the PlGF value
BP	Blood pressure
NPV	Negative predictive value; the chance that a negative result is truly negative
PPV	Positive predictive value; the chance that a positive result is truly positive
AUC	Area under the curve; overall test accuracy, where 1.0 is perfect
OR	Odds ratio
HELLP	Haemolysis, Elevated Liver enzymes, Low Platelets
pg/mL	Picograms per millilitre
wk	Weeks of gestation; 36+6 means 36 weeks and 6 days
NICE	National Institute for Health and Care Excellence (UK)
DG49	NICE Diagnostics Guidance number 49
ACOG	American College of Obstetricians and Gynecologists
SMFM	Society for Maternal-Fetal Medicine (USA)
ISSHP	International Society for the Study of Hypertension in Pregnancy
FDA	Food and Drug Administration (USA)
NIHR	National Institute for Health and Care Research (UK)
PROGNOSIS, PARROT, PRAECIS	Names of the three key clinical studies
PMID / doi	PubMed identifier / digital object identifier of a paper

📚 REFERENCES

[1] National Institute for Health and Care Excellence. PLGF-based testing to help diagnose suspected preterm pre-eclampsia. Diagnostics guidance DG49. Recommendations and “The diagnostic tests” chapters.

[2] Costa ML, Cavalli RC, Korkes HA, Cunha Filho EVD, Peraçoli JC. Diagnosis and management of preeclampsia: suggested guidance on the use of biomarkers. Rev Bras Ginecol Obstet 2022;44(9):878-883. doi:10.1055/s-0042-1744286. PMID 35468644.

[3] Thadhani R, et al. Circulating angiogenic factor levels in hypertensive disorders of pregnancy. NEJM Evid 2022;1(12). doi:10.1056/EVIDoa2200161. PMID 38319832. (Read through the NephJC summary.)

[4] Duhig K, Myers J, Seed P, et al. Placental growth factor testing to assess women with suspected pre-eclampsia: a multicentre, pragmatic, stepped-wedge cluster-randomised controlled trial. Lancet 2019;393:1807-18. (Read through the NIHR Evidence alert.)

[5] Lala V, Franzese S. Role of sFlt-1/PlGF ratio in diagnosing preeclampsia. Am Fam Physician 2024;109(5):470-471.

[6] Zeisler H, Llurba E, Chantraine F, et al. Predictive value of the sFlt-1:PlGF ratio in women with suspected preeclampsia. N Engl J Med 2016. (As cited in [2]; not opened.)

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

Clinician-facing summary. Pages opened and read: [1] NICE DG49 (two chapters), [2] Costa 2022 (PMC; the paper declares Roche Diagnostics support), [5] Lala 2024. [3] PRAECIS and [4] PARROT were read through secondary summaries (NephJC and the NIHR Evidence alert), not the original papers. [6] Zeisler 2016 was not opened; its figures come through [2]. The Elecsys rule-out cut-off appears as 33 or less for diagnosis and 38 or less for 1-week prediction in [1], and as under 38 in [2]; both are shown. The ACOG/SMFM position is as reported in [5] in 2024 and may have changed. The ISSHP 2021 statement, the marker biology line and the availability note for India are from memory and were not checked. Sources are from the UK, USA and Brazil: follow your local protocol and laboratory.

PIH- Postpartum Care

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Postpartum Care After Pregnancy-Induced Hypertension — Monitor, Treat & Follow Up

Postpartum care after pregnancy-induced hypertension (PIH) decides whether a woman has a safe fourth trimester. This sheet gives the BP schedule, treatment thresholds and drugs, breastfeeding advice, danger signs, follow-up timeline and long-term risk, with numbered references.

🎯 AT A GLANCE — POSTPARTUM CARE AFTER PIH

Blood pressure does not always fall at delivery; it often peaks around days 3 to 6 [1]

Eclamptic seizures can occur after birth, usually after day 3; headache or visual disturbance are the usual warnings, and BP may be normal [1]

Treat persistent BP of 150/100 or more with regular oral drugs; urgent treatment at 160/110 or more [1][3]

Most antihypertensives are compatible with breastfeeding; needing treatment does not prevent it [2]

Pre-eclampsia in pregnancy raises later risk of hypertension, ischaemic heart disease, stroke and heart failure [4]

The fourth trimester is the best time to set up lifelong follow-up [5]

Do not discharge a woman with pregnancy-induced hypertension without a BP plan, return advice and a named person for follow-up.

🚨 READMIT AND CALL THE SENIOR IF…

BP 160/110 or more (or MAP above 125) — treat now; admit [1]

Severe headache, visual disturbance or fits — postnatal eclampsia, even with normal BP [1]

Epigastric pain, vomiting, or breathlessness — check platelets, liver tests, creatinine and urine protein [3] (from memory)

BP above target despite two drugs — senior review; look for another cause [3]

Baby on a mother’s antihypertensive is drowsy, pale, cold or feeds poorly — review the drug [1][2]

Still on treatment at 12 weeks — specialist assessment for chronic hypertension [1]

🧭 AFTER DELIVERY: THE PATHWAY

STEP 1 · MONITOR — in hospital and at home

📅 BP MONITORING SCHEDULE

When	What to do
Days 0 to 2 [1]	BP at least once a day
Days 3 to 5 [1]	BP at least once; this is when it peaks
Up to 72 h, then 7 to 10 days [3]	The US algorithm monitors for 72 h, then rechecks at 7 to 10 days
Community [1]	Midwife, day-care unit or GP; home BP can be requested; the care plan states the frequency, target, stopping point and referral criteria
Every 1 to 2 weeks until normal [6]	Review with BP checks; counsel to report symptoms

Teach her to report headache, visual change, epigastric pain, breathlessness or swelling at once; postpartum pre-eclampsia can appear after discharge [6]

STEP 2 · TREAT — targets, drugs and breastfeeding

🎚️ WHEN TO TREAT AND TO WHAT TARGET

BP	Action
160/110 or more (MAP above 125) [1]	Treat; oral agents if stable; IV only rarely
Persistently 150/100 or more [1][3]	Start regular oral treatment; the US algorithm uses 2 readings 4 to 6 h apart
Target [1]	Below 150/100, ideally below 140/90; with kidney disease or diabetes 130/80 or less; chronic hypertension 135/85 or less
Below 130/80 [1]	Reduce the medicine
Below 120/70 [1]	Stop the medicine

💊 DRUG CHOICE

Step	Drug	Notes
First [1][2]	Enalapril	Check creatinine and potassium; preferred ACE inhibitor in breastfeeding
Second [1][2]	Nifedipine or amlodipine, plus enalapril	Once daily where possible
Third [1]	Add or swap to labetalol (or atenolol)	Scotland prefers labetalol in breastfeeding; atenolol has higher milk transfer
Black African or Caribbean origin [1]	Nifedipine first (or amlodipine)	ACE inhibitor or beta-blocker alone is less effective
Nifedipine vs labetalol [5]	Nifedipine lowered BP more and led to fewer readmissions in several studies	2026 review

Starting and maximum daily doses in the US algorithm [3]: nifedipine XL 30 mg (up to 90 to 120 mg); amlodipine 5 mg (10 mg); enalapril 5 mg (20 mg); labetalol 200 mg in 2 doses (2400 mg). The algorithm is guidance, not a standard of care

Avoid: methyldopa after birth (linked to postnatal depression); NSAIDs if BP is hard to control, with oliguria or poor kidney function; diuretics and ARBs while breastfeeding where possible [1][3]

Most drugs pass into breast milk at very low levels; manufacturer warnings often reflect lack of testing, not harm [2]. Check the baby for drowsiness, pallor, cold limbs or poor feeding [1][2].

STEP 3 · LOOK FOR DANGER — postnatal pre-eclampsia

⚠️ IF SYMPTOMS OR SEVERE BP

Work up: CNS and GI symptoms, examination, urine protein/creatinine, and HELLP blood tests [3]

Magnesium sulphate IV for severe features, or new hypertension with headache or blurred vision [3]; 12 to 24 h postpartum [6]

Severe cases: admit and give IV magnesium for 24 hours [6]

Consider other causes of hypertension if it is hard to control [3]

Stop NSAIDs if BP stays high for more than a day; use other analgesics [3]

Usual course: pre-eclampsia that lasts to delivery usually settles in 6 to 12 hours [6]; HELLP needs the HELLP sheet

STEP 4 · DISCHARGE AND FOLLOW-UP — who sees her and when

🗓️ FOLLOW-UP TIMELINE

When	Who / what
At discharge [1]	Tell the consultant if she goes home on drugs; send the discharge letter to the GP
2 weeks after transfer, if still on drugs [1]	GP or medical review
6 to 8 weeks [1][6]	Postnatal review; high BP at 6 weeks suggests chronic hypertension; refer to primary care
12 weeks, still on treatment [1]	Specialist assessment
3 to 6 months [7]	BP, heart rate, BMI, urine, lipids, electrolytes and kidney function; thrombophilia testing only in severe cases (a German guideline summarised in [7]); NICE advises no routine screening [2]

🤱 COUNSELLING AT DISCHARGE

Breastfeeding can continue; treatment is adapted [2]

Contraception: discuss options for every woman with hypertension [3]; avoid oestrogen-containing methods until BP is controlled (from memory)

Weight: advise BMI 18.5 to 24.9 before the next pregnancy [2]

Report symptoms: headache, vision, pain under the ribs, breathlessness, swelling

Home BP: if she has a machine, record morning and evening readings and bring the log (from memory)

STEP 5 · LONG TERM — the next pregnancy and the next decades

🔁 RECURRENCE AND FUTURE RISK

After pre-eclampsia	Relative risk (95% CI) [4]
Hypertension	3.70 (2.70 to 5.05)
Heart failure	4.19 (2.09 to 8.38)
Ischaemic heart disease	2.16 (1.86 to 2.52)
Cardiovascular death	2.21 (1.83 to 2.66)
Stroke	1.81 (1.45 to 2.27)

Recurrence: about 1 in 5 in a future pregnancy [2]

Kidney: relative risk of end-stage kidney disease is higher, but the absolute risk is low [2][7]

Yearly BP and risk review is advised by several cardiology guidelines; one suggests glucose and lipids every 5 years [4]

No guideline gives a validated schedule for women whose BP has normalised [4]

Next pregnancy: pre-pregnancy counselling after pre-eclampsia or birth before 34 weeks [2]; low-dose aspirin for previous pre-eclampsia [6]

⚠️ COMMON PITFALLS

Discharging on day 2 or 3 before the BP peak, with no home or community plan

Waiting for hypertension in a woman with headache or visual symptoms

Using NSAIDs for pain when BP is high

Using methyldopa after delivery

Stopping breastfeeding because of antihypertensive treatment

Leaving the drug running with no taper plan; BP can fall below target

No long-term follow-up once BP has normalised

Memory Aid

REVIEW

Six steps for the fourth trimester.

R

Record BP — daily for 2 days, then once on days 3 to 5

E

Enalapril or nifedipine — if BP stays 150/100 or more

V

Verify symptoms — headache, vision, pain; labs if present

I

Inform her — breastfeeding is fine; avoid NSAIDs and methyldopa

E

Early review — 2 weeks if on drugs; 6 to 8 weeks for all

W

Watch for life — yearly BP and a cardiovascular risk check

Remember: the pregnancy ends at delivery; the hypertension and the risk do not.

📚 REFERENCES

[1] NHS Scotland. Postpartum hypertension: guideline for management (322), version 3. Right Decisions; reviewed 27 Feb 2024.

[2] National Institute for Health and Care Excellence. Hypertension in pregnancy: diagnosis and management (NG133), 2019; sections 1.9 and 1.10 (extract read; some parts not shown).

[3] University of North Carolina School of Medicine. Hypertension, postpartum (new onset): algorithm. Revised 12 May 2015. Hosted at mombaby.org.

[4] Gamble DT, Brikinns B, Myint PK, Bhattacharya S. Hypertensive disorders of pregnancy and subsequent cardiovascular disease: current national and international guidelines and the need for future research. Front Cardiovasc Med 2019;6:55. doi:10.3389/fcvm.2019.00055.

[5] Management of postpartum hypertension. Curr Opin Obstet Gynecol 2026;38(2):72-77. doi:10.1097/GCO.0000000000001085. (Abstract read; authors not shown.)

[6] Dulay AT. Preeclampsia and eclampsia. MSD Manual Professional Edition. Full review March 2024.

[7] Palmrich P, Binder C, Zeisler H, et al. Awareness of obstetricians for long-term risks in women with a history of preeclampsia or HELLP syndrome. Arch Gynecol Obstet 2021;305(3):581-587. doi:10.1007/s00404-021-06181-w.

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

Clinician-facing summary. Pages opened and read: [1] NHS Scotland guideline, [2] NICE NG133 (extract; the postnatal BP schedule and some drug options were not in the text read), [3] UNC algorithm (2015; self-described as not a standard of care), [4] Gamble 2019, [5] abstract of Curr Opin Obstet Gynecol 2026, [6] MSD Manual, [7] Palmrich 2021. The sources differ: Scotland treats persistent 150/100 or more, the US algorithm uses 2 readings above 150/100, MSD uses 160/110 for severe hypertension; the sheet shows each. Scotland prefers labetalol in breastfeeding, while the US algorithm notes a single case of neonatal bradycardia with labetalol in a preterm baby. Drug doses come from [3] only; the Scottish dose table was an image and could not be read. Items marked “from memory” (symptom work-up details, oestrogen-containing contraception, home BP log) were not checked. UK and US sources may not apply to India: follow your local protocol and drug availability.