SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

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

Clinician Reference Infographic

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.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Pruritus in Pregnancy

Itching in pregnancy is common, but one cause threatens the baby. This guide covers how to sort the itch, intrahepatic cholestasis of pregnancy, the pregnancy skin diseases, tests, safe symptom relief, and timing of birth, using the ITCH approach.

🎯 AT A GLANCE — PRURITUS IN PREGNANCY

Itching affects many pregnant women and is usually harmless, but generalised itch without a rash can be intrahepatic cholestasis of pregnancy (ICP), which raises the risk of preterm birth and stillbirth

Look at the skin first: no primary rash (only scratch marks) means test the liver; a rash points to a skin cause

ICP: itch of palms and soles, worse at night, usually after 28 weeks; diagnosed by raised serum bile acids (10 µmol/L or more) and often raised liver enzymes

Treat ICP with ursodeoxycholic acid, monitor bile acids and liver tests weekly, and plan birth by the bile acid level

Skin causes (polymorphic eruption of pregnancy, atopic eruption, scabies) are treated with emollients, topical steroids, and antihistamines; pemphigoid gestationis needs a specialist

Itch with no rash in pregnancy: test bile acids and liver enzymes the same week — a normal result today does not exclude ICP, so repeat if the itch persists

🚨 ACT NOW IF

Itch with jaundice, dark urine, pale stools, or abdominal pain — acute hepatitis (including hepatitis E), gallstones, or acute fatty liver of pregnancy

Itch with high blood pressure, headache, or upper abdominal pain — pre-eclampsia or HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)

Reduced fetal movements — same-day assessment with cardiotocography and ultrasound

Bile acids 100 µmol/L or more, or itch with prolonged clotting — senior review and planned early birth

Tense blisters or large urticarial plaques around the navel — pemphigoid gestationis: dermatology referral

🗺️ THE PATHWAY AT A GLANCE

1 · AskWhere it itches, when it started, gestation, night itch, jaundice, drugs, contacts, previous pregnancy

2 · LookIs there a primary rash, or only scratch marks?

3 · TestBile acids, liver enzymes, blood count, kidney and thyroid, and urine

4 · DiagnoseCholestasis, a skin condition, or another cause

5 · TreatUrsodeoxycholic acid, emollients, antihistamines, or topical steroids

6 · MonitorWeekly tests, kick counts, growth scans, and timed birth

STEP 1 · SORT THE ITCH — rash or no rash

🔬 FIRST QUESTION: IS THERE A RASH?

Feature	Points
How common	Itching affects roughly one in five pregnant women (estimates vary); dry skin and stretching of the abdominal skin are common reasons
Pregnancy-specific causes	Intrahepatic cholestasis (liver), polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis
Other causes	Scabies, urticaria, drug reactions, fungal infection, anaemia, thyroid disease, diabetes, kidney disease, and viral hepatitis

STEP 2 · CHOLESTASIS OF PREGNANCY — the one that matters most for the baby

🫘 ICP: DIAGNOSIS AND RISKS

Topic	Details
Features	Itch starting on the palms and soles, spreading to the whole body; worse at night; no primary rash; usually after 28 weeks (can start earlier); dark urine or pale stool are uncommon
Diagnosis	Serum bile acids 10 µmol/L or more (non-fasting is acceptable); liver enzymes (ALT, AST) often raised; bilirubin mildly raised in a minority; exclude other liver disease
Rule out	Hepatitis A, B, C, and E, Epstein–Barr virus, cytomegalovirus, gallstones, autoimmune liver disease, pre-eclampsia, and acute fatty liver of pregnancy with a liver ultrasound and viral serology
Risk factors	Previous ICP, family history, twins, IVF pregnancy, hepatitis C, gallstones; recurrence in later pregnancies is common (about 40–70%)
Risks to the baby	Spontaneous preterm birth, meconium-stained fluid, respiratory problems, and stillbirth (risk rises with bile acids of about 100 µmol/L or more)
Risks to the mother	Sleep loss and distress, fat malabsorption and vitamin K deficiency (rare), and postpartum haemorrhage if clotting is abnormal
Severity	Mild: bile acids 10–39; moderate: 40–99; severe: 100 µmol/L or more (cut-offs follow RCOG)

💊 ICP: TREATMENT AND MONITORING

Topic	Details
Ursodeoxycholic acid	10–15 mg per kg per day in divided doses (for example 500 mg twice daily) until birth; relieves itch for many women and improves liver tests; safe in pregnancy; evidence that it prevents stillbirth is limited
Symptom relief	Emollients, cool compresses, loose cotton clothes, and a sedating antihistamine at night; no effect on the cause
Vitamin K	Oral vitamin K if the clotting is prolonged or fat malabsorption is suspected; give the baby vitamin K at birth as for all
Tests	Bile acids and liver tests at diagnosis, then about weekly (more often if severe); clotting if bilirubin is raised or itch is severe
Fetal surveillance	No test reliably predicts stillbirth; teach kick counting and offer growth scans; a normal cardiotocogram does not remove the risk
Timing of birth (varies by guideline)	Bile acids 100 µmol/L or more: about 35–36 weeks; lower levels: discuss between about 36 and 40 weeks; earlier for other obstetric reasons, worsening results, or intolerable symptoms; senior decision
After birth	Itch usually settles within days; repeat liver tests at about 10 days and again at 6 weeks; if still abnormal, refer to a hepatologist
Future	Counsel on recurrence and that oestrogen-containing contraceptives may bring it back; use a progestin-only or non-hormonal method if she had ICP with them

STEP 3 · THE SKIN CAUSES — recognise the pattern

🩹 PREGNANCY SKIN DISEASES THAT ITCH

Condition	Pattern and treatment
Polymorphic eruption of pregnancy (PUPPP)	First pregnancy, third trimester; urticarial papules and plaques that begin inside the abdominal stretch marks and spare the navel; benign, settles after birth; treat with emollients, a moderate topical steroid, and an antihistamine
Atopic eruption of pregnancy	The commonest; eczema or prurigo-type papules on the limbs, trunk, and flexures, often with earlier eczema; emollients, topical steroid, and antihistamine
Pemphigoid gestationis	Intensely itchy urticarial plaques and then tense blisters, starting around the navel; autoimmune; may recur and is linked to small babies and preterm birth; needs dermatology, skin biopsy, and often oral steroids
Scabies	Night itch, burrows between fingers and wrists, and itchy contacts; permethrin 5% cream is safe in pregnancy: apply from neck down and repeat in 7 days; treat the household
Urticaria and drug rash	Wheals that come and go, or a rash after a new drug; stop the drug and give a non-sedating antihistamine
Dry skin and stretch itch	Itch with no rash on the abdomen or limbs; emollients and cool, short bathing (but do not dismiss itch of the palms and soles)

STEP 4 · INVESTIGATE — what to order

🧪 TESTS FOR PRURITUS

Test	Why
Serum bile acids	Confirm cholestasis; if the result takes days, do not wait to treat symptoms
Liver tests (ALT, AST, bilirubin, alkaline phosphatase)	Raised in ICP, hepatitis, HELLP, and fatty liver (alkaline phosphatase rises normally in pregnancy)
Blood count and ferritin	Anaemia, iron deficiency, and low platelets
Kidney, thyroid, and blood glucose	Systemic causes of itch
Viral serology	Hepatitis A, B, C, and E; other viruses as indicated
Urine for protein and BP	Pre-eclampsia
Liver ultrasound	Gallstones and bile duct disease
Skin scraping or biopsy	Scabies; or blisters for immunofluorescence in suspected pemphigoid

STEP 5 · SYMPTOM RELIEF — safe options in pregnancy

🧴 WHAT YOU CAN USE

Option	Notes
Emollients and soap substitutes	Apply several times a day; keep them cool; short lukewarm baths
Cooling agents	Menthol 0.5–1% in aqueous cream or calamine
Topical corticosteroids	Mild to moderate potency for short courses is considered safe; avoid long use of very potent steroids over large areas
Oral antihistamines	Chlorphenamine (sedating, useful at night), and loratadine or cetirizine (non-sedating) are widely used
Avoid	Scratching and hot water, tight synthetic clothing, and unproven herbal or oral remedies
Mental health	Itch and sleep loss cause distress; ask about mood and support

⚠️ COMMON PITFALLS

Dismissing itch of the palms and soles in the third trimester as dry skin

Treating without testing the liver when there is no rash

Relying on one normal bile acid result when the itch continues (repeat after a week)

Missing viral hepatitis, pre-eclampsia, and fatty liver of pregnancy

Thinking a normal cardiotocogram excludes the risk of stillbirth in ICP

Not checking the liver again after birth

Missing scabies and not treating the family

Memory Aid

ITCH

Four steps for every pregnant woman with itching.

I

Inspect the skin — is there a primary rash or only scratch marks?

T

Test — bile acids, liver enzymes, blood count, and viral serology

C

Cholestasis first — treat with ursodeoxycholic acid and monitor

H

Hasten the plan — weekly tests, kick counts, and timed birth

Remember: itch with no rash needs a liver test, and a normal skin does not mean a normal pregnancy.

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

Clinician-facing summary drawn from memory of Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline on obstetric cholestasis, Society for Maternal-Fetal Medicine (SMFM), American College of Obstetricians and Gynecologists (ACOG), and dermatology reviews; no source was read for this sheet. No Government of India document was read. Bile acid cut-offs, ursodeoxycholic acid dose, monitoring intervals, 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.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Preterm Birth Prevention

Preterm birth is the leading cause of newborn and child deaths, and some of it can be prevented. This guide covers risk factors, prevention for all women, cervical length screening, progesterone and cerclage, care when birth threatens, and counselling, using the PREVENT approach.

🎯 AT A GLANCE — PRETERM BIRTH PREVENTION

Preterm birth is birth before 37 completed weeks; it is the leading cause of death in children under 5 years and affects roughly 1 in 10 births worldwide (estimates for India are similar or higher and vary)

Prevention starts before pregnancy: space births, treat chronic disease, stop smoking, and improve nutrition

Find the women at risk early: a previous preterm birth or late miscarriage, cervical surgery, a short cervix, multiple pregnancy, and infections

Measure the cervix by transvaginal ultrasound at 18–24 weeks in women at risk; vaginal progesterone or a cerclage can lower preterm birth in selected women

Treat infections and give low-dose aspirin to women at risk of pre-eclampsia; bed rest does not prevent preterm birth

If preterm birth still threatens: give antenatal steroids, magnesium sulfate, antibiotics where indicated, and transfer to a unit with newborn intensive care before delivery

🚨 ACT NOW IF (BEFORE 37 WEEKS)

Regular contractions or tightenings (about 4 or more in an hour), period-like cramps, or low back ache — attend the same day

Leaking of fluid, or a gush of watery fluid — suspect preterm rupture of membranes

Vaginal bleeding, increasing pelvic pressure, or a change in discharge (watery, mucus, or blood-stained)

Fever, burning urine, or foul discharge — treat infection

Cervical dilation, shortening, or a bulging membrane — senior review, transfer, steroids, and magnesium

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancySpacing of at least 18–24 months, control of diabetes, BP, thyroid, and anaemia, and stop smoking

2 · BookingRisk assessment, urine culture, infection screen, and aspirin if at risk of pre-eclampsia

3 · 12–16 weeksCerclage if the history indicates

4 · 18–24 weeksCervical length scan; vaginal progesterone if short

5 · 24–34 weeksTeach symptoms; steroids and magnesium if threatened

6 · After birthSkin-to-skin care and early feeding; plan the next pregnancy

STEP 1 · KNOW THE RISKS — who is likely to deliver early

⚠️ RISK FACTORS

Group	Examples
Obstetric history	Previous spontaneous preterm birth (recurrence risk roughly 15–30% after one and higher after two), second-trimester loss, previous preterm rupture of membranes
Cervix and uterus	Short cervix on scan, cone biopsy or loop excision, repeated dilatation, and uterine anomalies or large fibroids
This pregnancy	Twins or more (about half of twins are born before 37 weeks), polyhydramnios, bleeding (previa, abruption), pre-eclampsia, growth restriction, IVF with several embryos
Infections	Urinary infection and asymptomatic bacteriuria, bacterial vaginosis, sexually transmitted infections, malaria, and severe gum disease
Mother	Age under 18 or over 35, short interval (under 6–12 months) since the last birth, low weight or short stature, anaemia, diabetes, hypertension, thyroid disease
Lifestyle and social	Smoking and smokeless tobacco, alcohol and drugs, very heavy physical work, stress, and violence

STEP 2 · BEFORE AND EARLY IN PREGNANCY — primary prevention for every woman

🌱 PREVENTION FOR ALL WOMEN

Action	Details
Space births	At least 18–24 months between a birth and the next pregnancy; offer postpartum contraception
Adolescents	Delay first pregnancy until after 18 years; support schooling and nutrition
Nutrition and anaemia	Balanced diet, iron and folic acid, calcium; treat undernutrition and anaemia
Chronic disease	Control diabetes, hypertension, thyroid, and kidney disease before conception
Stop tobacco, alcohol, and drugs	Counsel at every visit and offer cessation support
Infection control	Screen for and treat syphilis, HIV, urinary infection, and malaria; dental care
Assisted reproduction	Transfer a single embryo wherever possible to avoid twins
Safe work and support	Avoid very heavy or prolonged standing work late in pregnancy; ask about violence and stress and refer

STEP 3 · WOMEN AT RISK — find the short cervix and act

📏 CERVICAL LENGTH AND ACTION

Topic	Details
Who to scan	Women with a previous spontaneous preterm birth or second-trimester loss, cervical surgery, or a uterine anomaly; some units scan all women at the anomaly scan (18–24 weeks)
How	Transvaginal ultrasound with an empty bladder; measure the closed length of the cervical canal, take the shortest of three; look for funnelling and sludge
Short cervix, no previous preterm birth	Cervix of 25 mm or less before 24 weeks (some use 20 mm): vaginal progesterone 200 mg at night (90 mg gel in some regimens) from diagnosis until 34–36 weeks
Previous preterm birth and a short cervix	Cervix under 25 mm before 24 weeks: ultrasound-indicated cerclage (a stitch), with or without progesterone, decided with a senior
Previous preterm birth, normal cervix	Serial cervical length scans every 2 weeks from 16 to 24 weeks and consider vaginal progesterone
Cervical examination in advanced dilation (before 24 weeks)	Physical-examination cerclage after excluding infection and contractions
Twins	Progesterone and routine cerclage do not prevent preterm birth in twins; a cerclage or pessary may help if the cervix is very short (specialist decision)

💊 OTHER MEASURES THAT HELP

Measure	Notes
Vaginal progesterone	Lowers preterm birth in a short cervix (with or without a previous preterm birth); 17-hydroxyprogesterone caproate injections are no longer recommended in many guidelines
Cervical cerclage	History-indicated at 12–14 weeks after three or more previous losses or births in the second trimester (some guidelines use two); ultrasound- or examination-indicated as above
Cervical pessary	An alternative in some units for a short cervix; evidence is mixed
Low-dose aspirin	75–150 mg nightly from 12–16 weeks in women at risk of pre-eclampsia reduces preterm pre-eclampsia and preterm birth
Treat bacteriuria	Culture urine in early pregnancy and treat asymptomatic bacteriuria
Bacterial vaginosis	Treat if symptomatic; routine screening of low-risk women does not prevent preterm birth
Omega-3 and calcium	Omega-3 supplements may help in women with low intake (evidence varies); calcium reduces pre-eclampsia where intake is low
What does not work	Bed rest, routine hospital admission, and routine home contraction monitoring

STEP 4 · IF IT THREATENS — reduce the harm if birth cannot be stopped

🛡️ THREATENED PRETERM BIRTH

Intervention	Details
Assess	Contractions, membranes, bleeding, infection, fetal condition, and cervical length; fetal fibronectin can help when the cervix is 15–30 mm
Antenatal corticosteroids	Betamethasone 12 mg intramuscularly, 2 doses 24 hours apart (or dexamethasone 6 mg every 12 hours for 4 doses) from 24 to 34 weeks when birth is likely within 7 days; reduces breathing problems and deaths
Magnesium sulfate	Before 32 weeks when birth is imminent: neuroprotection for the baby (loading dose then infusion as per protocol)
Tocolysis	Nifedipine for up to 48 hours to allow steroids and transfer (does not by itself improve outcome)
Antibiotics	For preterm rupture of membranes (erythromycin with ampicillin or amoxicillin), and for group B streptococcus prophylaxis in labour
Transfer	Move the mother before birth to a unit with newborn intensive care whenever possible
At birth	Delayed cord clamping for 30–60 seconds and warmth; skilled newborn resuscitation
After birth	Skin-to-skin kangaroo mother care and breastmilk feeding (see the premature newborn sheet)

STEP 5 · COUNSEL AND FOLLOW UP — teach her what to watch for

💬 COUNSELLING

Topic	Advice
Warning signs	Regular tightenings or cramps, back ache, pelvic pressure, leaking, bleeding, or a change in discharge — come at once, day or night
Daily life	Rest when tired, drink well, avoid heavy lifting and long standing (but strict bed rest is not needed)
Medicines	Take progesterone and aspirin regularly and attend scheduled scans
Plan	Know the hospital with newborn care, transport, and who will go with her
After a preterm birth	Counsel about the next pregnancy: wait 18–24 months, book early, and start the plan at the first visit

⚠️ COMMON PITFALLS

Not asking about previous preterm birth or late miscarriage at booking

Missing the scan window (18–24 weeks) in a woman at risk

Advising bed rest instead of effective measures

Giving progesterone or a cerclage in twins as routine

Dismissing mild cramps, back ache, or watery discharge as normal

Giving steroids too early or repeatedly without a senior’s decision

Delivering a threatened preterm baby in a unit without newborn care when transfer was possible

Memory Aid

PREVENT

Seven steps to prevent preterm birth.

P

Plan — space pregnancies; control chronic disease; stop smoking

R

Risk — ask about previous preterm birth, cervical surgery, twins

E

Examine the cervix — length scan at 18–24 weeks in women at risk

V

Vaginal progesterone — for a short cervix

E

Eradicate infection — treat bacteriuria and symptomatic infections

N

Nurture — nutrition, aspirin where indicated, no tobacco

T

Teach and transfer — warning signs; steroids and magnesium; deliver in a unit with newborn care

Remember: find the risk, measure the cervix, give progesterone or a stitch to the right woman, and be ready if prevention fails.

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

Clinician-facing summary drawn from memory of Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), Federation of Gynaecology and Obstetrics (FIGO), and World Health Organization (WHO) guidance; no source was read for this sheet. No Government of India document was read. Cervical length cut-offs, progesterone regimens, cerclage indications, steroid regimens, and incidence figures 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.