Obstetric ICU

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Obstetric ICU — Care of the Critically Ill Mother

The obstetric ICU and HDU bring skilled, early care to women with life-threatening complications. This guide follows the Government of India (MoHFW) guidelines on unit design, staffing, admission, monitoring, protocols, discharge, and referral, with organ support in pregnancy and the CRITICAL approach.

🎯 AT A GLANCE — THE OBSTETRIC ICU

An obstetric high-dependency unit (HDU) and intensive care unit (ICU) care for women with life-threatening complications of pregnancy, childbirth, or the puerperium — "when things go wrong in obstetrics, they go wrong fast"

HDU = step-up and step-down care for single-organ or no-organ support; ICU = multi-organ failure or advanced support (ventilation, inotropes, dialysis), led by an intensivist

The main reasons for admission are haemorrhage, hypertensive disorders (eclampsia, HELLP), sepsis, heart disease, respiratory failure, and acute kidney or liver failure

Pregnancy changes everything: airway, oxygenation, blood pressure targets, drug choice, and the fetus — treat the mother first, because a stable mother is the best treatment for the baby

Early transfer saves lives: do not wait for the woman to deteriorate; the right level of care, at the right time, by trained staff

🚨 MOVE FROM HDU TO ICU IF (MoHFW)

Pulmonary oedema, acute respiratory distress syndrome (ARDS), or oxygen need that rises despite treatment

Systemic inflammatory response (SIRS), septic shock, or poor cardiac output despite fluids

Disseminated intravascular coagulation (DIC) or multi-organ failure

Need for ventilation, inotropes, or dialysis, or a falling level of consciousness

🗺️ THE PATHWAY AT A GLANCE

1 · RecogniseEarly-warning score triggers; senior review without delay

2 · TriageWard, HDU, or ICU; obstetrician and intensivist decide together

3 · StabiliseAirway, oxygen, circulation, left tilt, treat the cause

4 · SupportOrgan support, fetal plan, thromboprophylaxis, nutrition

5 · MonitorHourly observations in the acute phase; protocols and records

6 · Step downDischarge criteria, follow-up, counselling, case review

STEP 1 · THE UNIT — design, staff, and equipment (MoHFW guidelines)

🏥 HDU AND ICU — SPACE, STAFF AND EQUIPMENT

Topic	Details (Ministry of Health and Family Welfare)
HDU versus ICU	HDU: between the labour ward and the ICU; single-organ or no-organ support; usually not for ventilated or multi-organ failure patients; ICU: multi-organ failure or advanced support, led by an intensivist
Number of beds	Up to 250 deliveries a month: 4 beds; 250–500: 8 beds; over 500: increase in proportion; one isolation room (about 150 sq ft) for infectious cases
Space and location	About 120–130 sq ft per HDU bed and 130–150 per ICU bed; next to the labour room and theatre, near the ICU, laboratory, radiology, and blood bank; one entry, emergency exits
Staff	Nurse-to-patient ratio 1:2 in HDU and 1:1 in ICU; HDU headed by a full-time obstetrician; 8-bed HDU: 4 nurses and 2 emergency obstetric care medical officers per shift; 4-bed ICU: 4 nurses and an intensivist; anaesthetist present 24 hours; on-call physician, paediatrician, surgeon, radiologist
Equipment	Bedside monitors (oxygen saturation, blood pressure, ECG, respiration, temperature), infusion and syringe pumps, ultrasound with colour Doppler, cardiotocography, defibrillator and crash cart, transport and non-invasive ventilators, arterial blood gas machine, blood warmer, eclampsia box, Bakri balloon, intubation equipment
Per bed	At least 2 oxygen, 1 air, and 2 suction outlets and about 10 power points; backup power, fire safety, biomedical waste management, ambulance with newborn transport support
Training	Orientation for nurses and medical officers; 3 months of ICU posting for medical officers; emergency drills every 3 months; emergency trolley checked daily; everyone trained in CPR

STEP 2 · ADMISSION AND TRIAGE — who needs which level of care

🚪 WHO SHOULD BE ADMITTED

Level	Typical conditions
HDU (MoHFW list)	Severe anaemia, haemorrhage, pre-eclampsia, eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), sepsis, DIC, placental problems; cardiac disease, thyroid disorders, diabetic complications, dengue, malaria, asthma; surgical or trauma cases; or clinical judgement
ICU (physiological thresholds)	Very low or very high blood pressure, low Glasgow coma score, abnormal electrolytes or pH, low oxygen despite oxygen therapy, need for ventilation or inotropes, DIC, ARDS, multi-organ failure (use the national tables for exact values)
Common triggers (general)	Respiratory rate over 30 or under 10, saturation under 90% on oxygen, systolic pressure under 90, urine under 0.5 mL/kg/hour for 2 hours, lactate over 4, seizures or coma, platelets under 50,000 with bleeding
Who decides	Obstetrician with the intensivist or anaesthetist; ICU referral only after ICU admission is assured; a mother's baby moves with her if already delivered

STEP 3 · ORGAN SUPPORT IN PREGNANCY — what changes at the bedside

🫁 SUPPORT BY SYSTEM — SPECIAL POINTS IN PREGNANCY AND AFTER BIRTH

System	Advice
Airway	Difficult and failed intubation are commoner (oedema, large breasts, obesity); aspiration risk; pre-oxygenate well (desaturates quickly); senior operator, video laryngoscope, smaller tube
Breathing	Target saturation of 95% or more and PaO₂ of 70 or more; lung-protective ventilation (6 mL/kg ideal body weight); avoid high PaCO₂ (above about 45–50) because it acidifies the fetus; normal pregnant PaCO₂ is 28–32 (see the ABG sheet)
Circulation	Left lateral tilt (about 15°) if over 20 weeks; mean arterial pressure of 65 or more; noradrenaline first for septic shock; restrict fluids in pre-eclampsia (pulmonary oedema risk)
Kidney	Hourly urine output; avoid nephrotoxic drugs (NSAIDs, aminoglycosides); dialysis for refractory acidosis, hyperkalaemia, overload, or uraemia
Brain	Seizures: magnesium sulfate for eclampsia (see the neurology sheet); exclude other causes (stroke, cerebral venous thrombosis, hypoglycaemia)
Blood	Massive haemorrhage protocol, tranexamic acid 1 g, correct DIC (fibrinogen above 2 g/L, platelets above 50,000 if bleeding); Bakri balloon for atony
Infection	Cultures and broad-spectrum antibiotics within the first hour; find and remove the source (retained products, abscess, hysterectomy)
Metabolic and nutrition	Avoid hypoglycaemia; early enteral feeding; correct electrolytes; treat ketoacidosis with insulin infusion
Thromboprophylaxis	Low molecular weight heparin (weight-based) and stockings unless bleeding or very low platelets
Analgesia and sedation	Adequate pain relief; avoid over-sedation; check drug safety for breastfeeding

STEP 4 · CONDITION-SPECIFIC CARE — the commonest reasons for admission

🩺 KEY ICU ACTIONS BY CONDITION

Condition	Key actions
Severe pre-eclampsia, eclampsia, HELLP	Treat severe hypertension within 30–60 minutes (labetalol, nifedipine, hydralazine); magnesium sulfate with monitoring of reflexes, respiration, and urine; restrict fluids; deliver after stabilisation; watch for pulmonary oedema, renal failure, liver haematoma
Obstetric haemorrhage and DIC	Haemostatic resuscitation (red cells, plasma, platelets, fibrinogen), tranexamic acid, surgical control, warm the patient, correct calcium
Sepsis and septic shock	Antibiotics within an hour, fluids with caution, noradrenaline for a mean pressure under 65, source control; influenza in pregnancy: oseltamivir at once without waiting for a test
Heart disease	Peripartum cardiomyopathy and valve disease: echocardiography, diuretics, rate control, anticoagulation as indicated; avoid fluid overload
Amniotic fluid embolism	Supportive care, manage the coagulopathy, consider extracorporeal support
ARDS and pneumonia	Lung-protective ventilation, prone positioning is possible, treat the infection, extracorporeal support if refractory
Acute fatty liver and acute liver failure	Deliver, glucose monitoring, correct coagulopathy, liver unit referral (see the liver sheet)
Diabetic ketoacidosis	Insulin infusion, fluids, potassium; can occur at near-normal glucose in pregnancy (see the diabetes sheet)

STEP 5 · MONITORING, FETUS AND DISCHARGE — the whole picture

📈 MONITORING, THE FETUS AND STEP-DOWN

Topic	Details
Monitoring (MoHFW)	Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and urine output at least hourly in the acute phase; fluid and electrolyte balance; treat the cause
The fetus	Continuous cardiotocography when viable; left lateral tilt about 15° and oxygen; corticosteroids if under 34 weeks; magnesium for neuroprotection before 32 weeks; deliver when it helps the mother (pre-eclampsia, chorioamnionitis, abruption, fatty liver) — not simply to improve a mother's lungs or heart
Protocols (MoHFW)	Written SOPs for admission and discharge, resuscitation, major haemorrhage, pre-eclampsia and eclampsia, severe blood pressure disorders, diabetic ketoacidosis, sepsis, difficult intubation, anaesthesia and analgesia, post-dural puncture headache, thromboprophylaxis
Discharge from HDU (MoHFW)	Stable circulation, no need for intensive monitoring, no continuous intravenous drugs or frequent blood tests, no active bleeding or oxygen need, walking; HDU stay is usually 24–72 hours
Records and referral (MoHFW)	History, diagnosis, tests, operative notes, summary, dated and signed entries, consent and family counselling documented; referral slip, emergency drugs, escort with infusions, monitoring, secure airway
Family and follow-up	Daily, honest communication; support for the woman's mental health (depression and post-traumatic stress are common); breastfeeding, contraception, and counselling for future pregnancy; near-miss review of every ICU admission (see the collapse sheet)

⚠️ COMMON PITFALLS

Late recognition and late transfer; treating on the ward what needs the HDU

Using non-pregnant targets (PaCO₂, blood pressure, oxygen) or forgetting left tilt

Fluid overload in pre-eclampsia, or too little fluid in haemorrhage and sepsis

Delivering a very sick mother for the baby's sake before she is stabilised

No thromboprophylaxis, no hourly chart, poor handover, or no record of consent

Forgetting the baby, the family, and the woman's mind after she leaves the unit

Memory Aid

CRITICAL

Eight rules for the critically ill mother.

C

Choose the right level — ward, HDU, or ICU; obstetrician and intensivist together

R

Recognise early — early-warning score and hourly observations

I

Intervene on the cause — bleeding, blood pressure, sepsis, heart, lungs

T

Tilt and oxygen — left lateral tilt, saturation 95% or more

I

Involve the team — obstetrician, intensivist, anaesthetist, neonatologist, nurse

C

Care for the fetus — monitor, steroids under 34 weeks, deliver when it helps her

A

Audit and record — protocols, signed notes, near-miss review

L

Look after family and follow-up — mental health, contraception, next pregnancy

Remember: recognise early, choose the right level, treat the cause, and care for the whole family.

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

Clinician-facing summary. Unit design, bed numbers, staffing, equipment, admission lists, transfer triggers, hourly monitoring, protocols, training, discharge criteria, and referral and records follow the Ministry of Health and Family Welfare (MoHFW) Guidelines for Obstetric HDU and ICU (nhm.gov.in), as summarised from the document; the exact physiological admission thresholds in its tables were not extracted. The organ-support advice, general triggers, and condition-specific actions are from memory of the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the Surviving Sepsis Campaign guidance. Check the full national guideline and local protocols before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Placenta and Fetal Nutrition

Fetal growth depends on the placenta, the mother's nutrition, and the fetus's own potential. This guide covers placental function, maternal nutrition, placental disorders, growth surveillance and Doppler, management of growth restriction and large babies, and care after birth, using the PLACENTA approach.

🎯 AT A GLANCE — PLACENTA AND FETAL NUTRITION

The placenta is the fetus's lung, gut, kidney, liver, and endocrine gland — it delivers oxygen and nutrients, removes waste, makes hormones, and filters some harmful substances

Fetal growth depends on three things: the mother's nutrition and health, placental function, and the fetus's own genetic potential

Small-for-gestational-age: estimated weight or abdominal circumference below the 10th centile; fetal growth restriction (FGR) is a small fetus that is failing to reach its potential (usually from placental insufficiency) — many small babies are healthy, and some normal-sized fetuses are restricted

Large-for-gestational-age (above the 90th centile) and macrosomia (birth weight 4000 g or more) mostly reflect maternal diabetes, obesity, and excess weight gain

Good nutrition before and during pregnancy, early detection of growth problems, and well-timed delivery reduce stillbirth, neonatal death, and lifelong disease

Check growth, not just size: serial measurements and Doppler separate constitutionally small babies from those at risk

🚨 ACT NOW IF

Reduced fetal movements — assess the same day with cardiotocography and ultrasound; never reassure by phone alone

Estimated weight or abdominal circumference below the 10th centile with abnormal umbilical artery Doppler, or absent or reversed end-diastolic flow

Fundal height lagging by 3 cm or more, oligohydramnios, or early severe pre-eclampsia with a small fetus

Third-trimester bleeding (painless: think placenta previa; with pain and a hard uterus: abruption)

Previous caesarean with an anterior low placenta — exclude placenta accreta

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyNutrition, folic acid, weight, diabetes and anaemia control, stop smoking

2 · First trimesterDating scan, risk assessment, aspirin if high risk

3 · Mid-pregnancyAnomaly scan, placental site, uterine artery Doppler in at-risk women

4 · Third trimesterFundal height, growth scans, fetal movements, Doppler if small

5 · DiagnoseGrowth restriction or overgrowth, find the cause

6 · Deliver and feedTimed delivery, placental examination, early feeding, glucose checks

STEP 1 · THE PLACENTA — structure, transport and hormones

🫘 HOW THE PLACENTA WORKS

Topic	Details
Development	Trophoblast invades the uterine wall and remodels the spiral arteries into wide, low-resistance vessels (complete by about 18–20 weeks); full maternal blood flow into the intervillous space from about 10–12 weeks; poor remodelling underlies pre-eclampsia and growth restriction
At term	Weight about 500 g (about one-sixth of the baby's weight), diameter 15–20 cm; cord about 50–60 cm with 2 arteries and 1 vein
Gas and water	Oxygen and carbon dioxide cross by simple diffusion; fetal haemoglobin binds oxygen more tightly than adult haemoglobin; flow depends on maternal perfusion and fetal circulation
Glucose	Crosses by facilitated diffusion (GLUT1 transporters); the main fetal fuel; fetal glucose follows maternal levels, so maternal hyperglycaemia drives fetal insulin and fat deposition
Amino acids and minerals	Active transport: fetal amino acid levels exceed maternal levels; iron, calcium, and vitamins are transferred actively; calcium transfer peaks in the third trimester
Fats	Free fatty acids and long-chain polyunsaturated fats (including DHA) cross selectively; most fetal fat is laid down in the third trimester
Antibodies	IgG crosses actively (mostly from about 28 weeks), giving passive immunity; preterm babies receive less
Hormones	Human chorionic gonadotrophin, progesterone, oestrogen, human placental lactogen (raises maternal insulin resistance so glucose reaches the fetus), placental growth hormone, corticotrophin-releasing hormone, placental growth factor
Barrier	Not complete: alcohol, nicotine, many drugs, and several infections cross (see the TORCH sheet); the placenta also inactivates some maternal cortisol

STEP 2 · FETAL NUTRITION — what the baby needs and how to supply it

🥗 MATERNAL NUTRITION IN PREGNANCY

Topic	Details
Weight gain (Institute of Medicine)	Underweight (BMI under 18.5): 12.5–18 kg; normal (18.5–24.9): 11.5–16 kg; overweight (25–29.9): 7–11.5 kg; obese (30 or more): 5–9 kg; twins: larger ranges
Energy	No extra energy in the first trimester; about 350 kcal a day more in the second and third trimesters (ICMR–NIN and Institute of Medicine figures differ slightly)
Protein	Extra protein in the second half (about 10–25 g a day more): pulses, milk, eggs, fish, and meat
Folic acid	400 µg daily before conception and in the first 12 weeks; 4–5 mg for a previous neural tube defect, epilepsy drugs, diabetes, or obesity
Iron and folic acid	WHO: 30–60 mg elemental iron daily; India: 100 mg elemental iron with 500 µg folic acid daily for at least 180 days from the second trimester; treat anaemia early
Calcium	WHO: 1.5–2 g daily in populations with low calcium intake to lower pre-eclampsia risk; India recommends about 1 g daily
Other micronutrients	Iodine (about 250 µg daily), vitamin D, vitamin B12 (vegetarians), zinc; avoid excess vitamin A
Balanced energy and protein supplements	WHO suggests them for undernourished women to reduce stillbirth and small babies; not for well-nourished women
Avoid	Alcohol, smoking and smokeless tobacco, caffeine above about 200 mg daily, unpasteurised dairy and undercooked meat or eggs (listeria, toxoplasma), high-mercury fish

The first 1,000 days (conception to age 2) shape adult health: low birth weight is linked to later diabetes, hypertension, and heart disease — nutrition and growth are long-term investments

🔗 WHAT AFFECTS FETAL GROWTH

Group	Examples
Maternal	Undernutrition, short stature, low pre-pregnancy weight, anaemia, hypertension, diabetes, renal or cardiac disease, antiphospholipid syndrome, smoking, alcohol, drug use, high altitude, young or older age
Placental and cord	Poor placentation, infarcts, abruption, placenta previa, accreta, abnormal cord insertion, single umbilical artery, twin-to-twin transfusion
Fetal	Chromosomal and genetic conditions, structural anomalies, and congenital infection (cytomegalovirus, toxoplasma, rubella, syphilis, malaria)
Large babies	Maternal diabetes, obesity, excess weight gain, previous macrosomia, post-dates, male sex, and genetic factors

STEP 3 · PLACENTAL DISORDERS — recognise and act

⚠️ PLACENTAL AND CORD PROBLEMS

Disorder	Key points and action
Placental insufficiency and growth restriction	Small fetus with abnormal Doppler, often with oligohydramnios; see Step 4
Pre-eclampsia	Shallow trophoblast invasion, raised soluble fms-like tyrosine kinase, and low placental growth factor; often with fetal growth restriction; aspirin prevention for high-risk women
Placenta previa	Placenta covering or near the internal os; painless bleeding; no vaginal examination; caesarean at 36–37 weeks if uncomplicated; a low placenta at the anomaly scan needs a repeat scan at about 32 weeks
Placenta accreta spectrum	Risk rises with previous caesareans and previa; plan delivery in a centre with blood, interventional radiology, and a surgical team
Placental abruption	Painful bleeding, tender hard uterus, fetal distress; resuscitate and deliver; watch for coagulopathy (see the haemorrhage sheet)
Vasa praevia and velamentous cord	Fetal vessels over the cervix; bleeding with membrane rupture and fetal bradycardia; elective caesarean at 34–36 weeks when diagnosed
Single umbilical artery	Look for other anomalies and monitor growth
Placental infection and infarcts	Malaria and other infections damage the placenta and cause low birth weight (see the malaria sheet)

STEP 4 · ASSESSING GROWTH — find the baby who needs help

📏 SURVEILLANCE AND DOPPLER

Tool	Details
Symphysis–fundal height	From 24 weeks, measure at each visit and plot on a growth chart; a lag of 3 cm or more, or a static or falling plot, needs a scan; fundal height alone misses many small babies
Ultrasound growth	Estimated fetal weight from head, abdomen, and femur measurements; abdominal circumference is the most sensitive; repeat no sooner than about 2 weeks; accurate dating matters
Umbilical artery Doppler	Pulsatility index above the 95th centile suggests placental resistance; absent or reversed end-diastolic flow signals severe disease
Middle cerebral artery Doppler	Low pulsatility index ('brain sparing') and a low cerebroplacental ratio indicate fetal redistribution, especially in late-onset growth restriction
Uterine artery Doppler	At 20–24 weeks, a high mean pulsatility index or notching identifies women at risk of pre-eclampsia and growth restriction
Ductus venosus	Absent or reversed a-wave is a late sign of cardiac compromise in early-onset growth restriction
Amniotic fluid	Deepest vertical pocket under 2 cm, or amniotic fluid index under 5, is oligohydramnios; often a sign of placental insufficiency
Cardiotocography and biophysical profile	Reduced variation on computerised cardiotocography, a low biophysical score, or decelerations indicate fetal compromise
Placental biomarkers	Placental growth factor and the soluble fms-like tyrosine kinase-1 to placental growth factor ratio help in suspected pre-eclampsia

STEP 5 · MANAGEMENT — fetal growth restriction and large babies

🛡️ FETAL GROWTH RESTRICTION

Topic	Details
Definition	Consensus (Delphi 2016): estimated weight or abdominal circumference below the 3rd centile, or below the 10th with abnormal Doppler or a crossing of centiles; early-onset: under 32 weeks, late-onset: 32 weeks or more
Find the cause	Detailed anomaly scan; consider invasive testing or karyotype if early-onset or with anomalies (see the prenatal diagnosis sheet); test for infection (cytomegalovirus, toxoplasma, syphilis, malaria); look for maternal hypertension, renal, or autoimmune disease
What helps	Stop smoking; treat hypertension, anaemia, and infection; improve nutrition; low-dose aspirin (75–150 mg nightly from 12–16 weeks) lowers the risk in high-risk women; bed rest, extra supplements, and sildenafil are not proven
Monitoring	Growth every 2 weeks, Doppler weekly to twice weekly if abnormal, cardiotocography as indicated; daily fetal movement awareness
Timing of delivery (varies by guideline)	Reversed end-diastolic flow: about 30–32 weeks; absent end-diastolic flow: about 34 weeks; abnormal middle cerebral or uterine Doppler with growth restriction: about 36–37 weeks; small with normal Doppler: about 37–39 weeks; earlier for fetal compromise
Before preterm birth	Antenatal corticosteroids (under 34 weeks), magnesium sulfate under 32 weeks, delivery in a unit with newborn intensive care, continuous fetal monitoring in labour and a low threshold for caesarean

📈 LARGE BABIES AND DIABETES

Topic	Details
Screening for diabetes	India (DIPSI test): 75 g oral glucose, non-fasting, with a 2-hour plasma glucose of 140 mg/dL or more diagnostic (test at the first contact and again at 24–28 weeks); WHO and other criteria are also in use
Control	Diet and activity, glucose monitoring, insulin or metformin when targets are missed (fasting about 95 mg/dL or less and 2-hour after meals about 120 mg/dL or less); tight control lowers macrosomia
Suspected macrosomia	Ultrasound weight estimates are imprecise (error up to 15–20%); discuss the risks of shoulder dystocia, birth injury, and caesarean; caesarean is considered for estimated weight of 4500 g or more in diabetes and 5000 g or more without diabetes
Timing	Induction at 38–39 weeks may be offered for diabetes with a large baby; prepare for shoulder dystocia
The baby	Check blood glucose early and feed promptly; watch for hypoglycaemia, polycythaemia, jaundice, and respiratory distress

STEP 6 · AFTER BIRTH — the placenta and the baby

🔬 EXAMINE THE PLACENTA AND FEED THE BABY

Topic	Details
Examine every placenta	Complete? (cotyledons and membranes), weight, size, shape, infarcts, clots, calcification, cord insertion, length, and 3 vessels; placental weight to birth weight is about 1 to 6 at term
Send for histopathology	Stillbirth or neonatal death, fetal growth restriction, severe pre-eclampsia, abruption, preterm birth, severe anaemia in the baby, maternal sepsis, twin discordance, and abnormal placenta or cord
Small-for-gestational-age babies	Early skin-to-skin contact and breastfeeding; keep warm; check glucose in the first hours; watch for polycythaemia; fortify feeds if very small (see the premature newborn sheet)
Catch-up growth	Support exclusive breastfeeding for 6 months; avoid forced overfeeding; monitor weight, length, and head circumference
Mother	Counsel on diet, iron, interpregnancy interval of at least 2 years, and cardiometabolic follow-up after pre-eclampsia, diabetes, or a growth-restricted birth

⚠️ COMMON PITFALLS

Relying on fundal height or palpation alone and missing growth restriction

Labelling every small baby as restricted, or reassuring a restricted baby because the weight is above the 10th centile

Reassuring about reduced movements without cardiotocography and ultrasound

Scanning too often (growth intervals under 2 weeks give unreliable results) or without accurate dating

Not looking for a cause (infection, anomaly, maternal disease) or not using aspirin in high-risk women

Overlooking diabetes and anaemia, or forgetting the newborn's glucose

Discarding the placenta without examining it

Memory Aid

PLACENTA

Eight steps for placental health and fetal nutrition.

P

Perfusion first — aspirin if high risk, treat hypertension, stop smoking

L

Look at growth — fundal height each visit; scans if at risk, 2 weeks apart

A

Assess with Doppler — umbilical, middle cerebral, uterine arteries

C

Counsel on nutrition — energy, protein, iron, folate, calcium, iodine

E

Evaluate the cause — infection, anomaly, maternal disease, diabetes

N

Notice reduced movements — assess the same day

T

Time the delivery — by Doppler, gestation, and fetal state

A

After birth — examine the placenta, feed early, check glucose

Remember: healthy placenta, well-fed mother, measured growth, timely delivery.

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), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Institute of Medicine, World Health Organization (WHO), and Indian Council of Medical Research–National Institute of Nutrition (ICMR–NIN) guidance; no source was read for this sheet. No Government of India document was read: the Indian iron, folic acid, calcium, and gestational diabetes (DIPSI) recommendations are from memory, so check the Ministry of Health and Family Welfare guidelines. Centile thresholds, Doppler cut-offs, supplement doses, weight-gain ranges, and delivery timing vary between guidelines and units; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

Neurological Disorders in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Neurological Disorders in Pregnancy — Seizures, Stroke & Neuromuscular Disease

Neurological disorders in pregnancy range from benign headache to eclampsia, stroke, and epilepsy. This guide covers seizures, headache, stroke, multiple sclerosis, myasthenia gravis, other conditions, and delivery planning, using the BRAIN approach.

🎯 AT A GLANCE — THE NERVOUS SYSTEM AND PREGNANCY

Neurological symptoms in pregnancy are common; most are benign (headache, carpal tunnel, Bell's palsy), but a few are emergencies — eclampsia, stroke, cerebral venous thrombosis

Pregnancy and the first 6 weeks after delivery raise the risk of stroke, and change the course of epilepsy, migraine, multiple sclerosis, and myasthenia gravis

New seizure, severe headache, or focal deficit with hypertension is eclampsia or posterior reversible encephalopathy (PRES) until proved otherwise

Neurologist and obstetrician together, a planned delivery, and safe drug choices give good outcomes in most women

Do not stop essential medicines (antiseizure drugs, immunosuppressants, pyridostigmine) without specialist advice — uncontrolled disease usually harms the baby more than the drug.

🚨 EMERGENCY — SEIZURE, STROKE OR THUNDERCLAP HEADACHE

Seizure: protect the airway, left lateral position, oxygen; magnesium sulfate if hypertensive or after 20 weeks; IV lorazepam 4 mg if it persists beyond 5 minutes

Sudden severe (thunderclap) headache, neck stiffness, or reduced consciousness — subarachnoid haemorrhage, cerebral venous thrombosis, or meningitis

Face, arm, or leg weakness, speech or visual loss — stroke; code stroke and urgent brain imaging (MRI preferred)

Rapidly ascending weakness, breathlessness, or difficulty swallowing — Guillain–Barré syndrome or myasthenic crisis

🗺️ THE PATHWAY AT A GLANCE

1 · AssessABC, blood pressure, glucose, gestation, and a focused neurological exam

2 · ExcludePre-eclampsia and eclampsia first: BP, urine protein, platelets, liver tests

3 · ImageMRI (without gadolinium) preferred; CT with shielding if urgent

4 · TreatSeizure control, anticoagulation, steroids, or surgery by diagnosis

5 · PlanMedicines, timing and mode of delivery, anaesthesia

6 · Follow upPostpartum relapse watch, newborn care, breastfeeding, and contraception

STEP 1 · SEIZURES — eclampsia and epilepsy

⚡ ECLAMPSIA — SEIZURES WITH PRE-ECLAMPSIA

Topic	Details
Features	Generalised seizure with hypertension and usually proteinuria; headache, visual disturbance, or epigastric pain often come first; up to a third occur postpartum (most within 48 hours)
Magnesium sulfate — Pritchard regimen	4 g IV over 5–10 minutes plus 10 g IM (5 g in each buttock); then 5 g IM every 4 hours in alternate buttocks for 24 hours after the last seizure or delivery
Magnesium sulfate — Zuspan (IV) regimen	4 g IV loading, then 1 g/hour IV for 24 hours (can reach 2 g/hour)
Monitor before each dose	Knee jerks present, respiratory rate at least 16/min, urine output at least 30 mL/hour (100 mL in 4 hours)
Toxicity	Loss of reflexes, respiratory depression: stop magnesium and give calcium gluconate 1 g (10 mL of 10%) IV over 10 minutes
Blood pressure	Labetalol 20 mg IV (then 40, 80 mg), nifedipine 10 mg orally, or hydralazine 5 mg IV; aim for about 140–150/90–100
Delivery	Stabilise first, then deliver; mode by obstetric indication
Do not assume eclampsia if	Focal deficit, onset before 20 weeks, more than 48 hours after delivery, or no hypertension, or seizures recur on magnesium — do neuroimaging (PRES, venous thrombosis, haemorrhage)

🧠 EPILEPSY IN PREGNANCY

Issue	Advice
Seizure frequency	Unchanged in about 60–70%, worse in 15–30% (missed doses, sleep loss, vomiting, falling drug levels); over 90% of women have a normal baby
Before conception	Review the drug, aim for monotherapy at the lowest effective dose; folic acid 5 mg daily (4–5 mg), started before conception
Drug choice	Lamotrigine and levetiracetam have the lowest malformation risk; carbamazepine is moderate; valproate (about 10% malformations, lower IQ, autism) should be avoided; topiramate, phenytoin, phenobarbital carry higher risk
Do not	Stop or switch drugs after conception unless advised by the neurologist
Drug levels	Lamotrigine levels fall by up to 50% (also levetiracetam): check levels or adjust to seizures; reduce the dose again within 2 weeks of delivery
Antenatal care	Detailed anomaly scan at 18–20 weeks; sleep, adherence, and safety advice (bathing, baby care)
Newborn	Vitamin K 1 mg IM at birth (routine); breastfeeding is encouraged with most antiseizure drugs
Seizure in labour	Lorazepam 4 mg IV or diazepam; continue regular drugs; caesarean for obstetric reasons only
Contraception	Enzyme-inducing drugs (carbamazepine, phenytoin, phenobarbital, topiramate) reduce the pill's effect — use intrauterine devices or injectables; oestrogen lowers lamotrigine levels

Status epilepticus (seizure over 5 minutes or repeated): airway, oxygen, IV lorazepam 4 mg, then levetiracetam or fosphenytoin; obstetric review for fetal distress; deliver if unresponsive.

STEP 2 · HEADACHE AND STROKE — migraine, venous thrombosis and haemorrhage

🤕 HEADACHE IN PREGNANCY

Cause	Clues	Management
Migraine	Throbbing, one-sided, nausea, aura; often improves in the 2nd and 3rd trimester; may flare after delivery	Paracetamol first; metoclopramide; sumatriptan if needed; propranolol or amitriptyline for prevention; avoid NSAIDs after 20 weeks, ergotamine, valproate, topiramate
Tension-type headache	Band-like, no nausea	Paracetamol, rest, hydration, relaxation
Pre-eclampsia or PRES	Headache with hypertension, visual change, seizures	BP control, magnesium sulfate, delivery
Cerebral venous thrombosis	Progressive headache, seizures, focal signs, papilloedema; peak 2–3 weeks postpartum	MRI with venography; therapeutic low-molecular-weight heparin (even with haemorrhagic infarct)
Subarachnoid haemorrhage	Thunderclap headache, neck stiffness	CT, then angiography; neurosurgery or endovascular coiling; nimodipine
Idiopathic intracranial hypertension	Obesity, daily headache, papilloedema, visual loss	Visual fields; weight control; acetazolamide (after the first trimester); therapeutic lumbar puncture
Meningitis, pituitary apoplexy, and others	Fever, rash; or sudden visual loss with hormone failure	Lumbar puncture and antibiotics; endocrine and neurosurgical care

Red-flag headache (SNOOP): Systemic signs, Neurological signs, Onset sudden or after 20 weeks, Older or new pattern, Papilloedema or positional — image, don't just treat.

🧬 STROKE IN PREGNANCY AND THE PUERPERIUM

Topic	Details
Risk	About 3 times higher during pregnancy and the first 6 weeks; highest around delivery and postpartum
Causes	Pre-eclampsia and eclampsia, cerebral venous thrombosis, cardioembolism (peripartum cardiomyopathy, valve disease), reversible cerebral vasoconstriction syndrome, PRES, aneurysm or arteriovenous malformation, antiphospholipid syndrome, sickle cell disease, thrombotic microangiopathy, and drugs
Imaging	MRI (diffusion) and MR venography without gadolinium; CT head is acceptable if urgent (abdominal shielding)
Ischaemic stroke	Alteplase and thrombectomy may be considered in selected women (weigh bleeding risk); aspirin 75–150 mg after haemorrhage is excluded
Haemorrhage	Control blood pressure; neurosurgical review; reverse anticoagulation; deliver for obstetric reasons
Venous thrombosis	Therapeutic LMWH, continue for at least 6 weeks postpartum
Prevention	Control BP, treat pre-eclampsia, thromboprophylaxis where indicated

STEP 3 · NEUROMUSCULAR AND IMMUNE DISEASE — MS, myasthenia, GBS, Bell's palsy

🛡️ MULTIPLE SCLEROSIS AND MYASTHENIA GRAVIS

Condition	In pregnancy	Management
Multiple sclerosis (MS)	Relapses fall by about 70% in the 3rd trimester and rise in the first 3 months postpartum; no effect on fertility or fetal outcome	Acute relapse: IV methylprednisolone 1 g daily for 3–5 days; interferon beta and glatiramer are acceptable; stop teriflunomide (washout), fingolimod, cladribine, mitoxantrone before conception; natalizumab or ocrelizumab only with specialist advice; vaginal delivery and epidural are safe
Myasthenia gravis	Unpredictable: worse in about a third; crisis risk postpartum	Continue pyridostigmine, prednisolone, azathioprine; IVIG or plasma exchange for exacerbation; avoid magnesium sulfate (worsens weakness) — use levetiracetam for eclampsia if needed; avoid aminoglycosides, macrolides, quinolones, beta-blockers; assist the second stage
Neonatal myasthenia	10–20% of babies; onset at 1–4 days, lasts weeks	Neonatal unit monitoring for feeding, breathing, and tone; pyridostigmine if needed
Guillain–Barré syndrome	Ascending weakness, areflexia; often after infection	IVIG or plasma exchange; respiratory and bulbar monitoring; vaginal delivery is possible
Bell's palsy	More common in the 3rd trimester and the first week postpartum	Prednisolone 50 mg daily for 10 days within 72 hours; eye protection; exclude stroke and pre-eclampsia; most recover
Carpal tunnel syndrome	Night hand numbness from fluid retention	Wrist splints; steroid injection if severe; resolves after delivery
Spinal cord injury	Autonomic dysreflexia above T6 (severe hypertension, headache, sweating)	Epidural analgesia prevents it; treat pressure sores and UTI

STEP 4 · OTHER IMPORTANT PROBLEMS — tumours, infections and nutrition

🔍 OTHER NEUROLOGICAL CONDITIONS TO KNOW

Condition	Key points
Brain and pituitary tumours	Meningiomas and prolactinomas can enlarge in pregnancy; visual field checks; cabergoline or bromocriptine for prolactinoma; surgery in the second trimester if needed
Neurocysticercosis (common in India)	New seizures, headache; MRI; antiseizure drugs; delay albendazole until after delivery unless severe; steroids for oedema
Cerebral malaria and meningitis	Fever with altered consciousness; IV artesunate for severe malaria; antibiotics and lumbar puncture for meningitis; tuberculous meningitis treated with standard anti-tuberculosis drugs and steroids
Wernicke encephalopathy	Confusion, ataxia, eye signs with prolonged vomiting (hyperemesis); thiamine 100–500 mg IV before glucose
Hypoglycaemia and eclampsia mimics	Check capillary glucose in every convulsing or unconscious woman
Anaesthesia	Epidural and spinal are safe in most neurological diseases; avoid with raised intracranial pressure or active infection; document the neurological status first

🏥 DELIVERY, NEWBORN AND AFTER BIRTH

Delivery planning: birth in a unit with neurology and neonatal care; mode by obstetric indication in most conditions; shorten the second stage (forceps or ventouse) in myasthenia, raised intracranial pressure, and unclipped aneurysm

Continue antiseizure and immunosuppressive drugs in labour; give them intravenously if she is vomiting or nil by mouth

Newborn: vitamin K; watch for neonatal myasthenia, antiseizure drug withdrawal, and hypoglycaemia

Postpartum: relapse risk (MS, myasthenia), seizure risk with sleep loss, migraine flare, and stroke or venous thrombosis in the first 6 weeks

Breastfeeding: encouraged with most antiseizure drugs, pyridostigmine, prednisolone, azathioprine, and interferon beta; avoid breastfeeding on certain MS drugs

Safety counselling: bathe the baby with someone present, feed sitting down, and keep medicines regular

⚠️ COMMON PITFALLS

Calling every seizure in a pregnant woman 'epilepsy' or 'eclampsia' without checking blood pressure, glucose, and imaging

Using valproate or stopping antiseizure drugs because of pregnancy, or missing the fall in lamotrigine levels

Giving magnesium sulfate to a woman with myasthenia gravis without a plan

Missing cerebral venous thrombosis in a postpartum woman with headache and seizures; withholding heparin for fear of haemorrhage

Ignoring thunderclap headache or treating postpartum headache as a post-dural puncture headache without excluding other causes

Memory Aid

BRAIN

Five rules for neurological disease in pregnancy.

B

Blood pressure first — seizure or headache with hypertension is eclampsia until proved otherwise; give magnesium sulfate

R

Red flags and imaging — thunderclap, focal signs, onset after 20 weeks or after delivery: MRI

A

Antiseizure drugs — lamotrigine or levetiracetam, folic acid 5 mg, no valproate; check levels

I

Immune disease — MS and myasthenia: continue treatment; avoid magnesium in myasthenia; watch postpartum relapse

N

Newborn and next steps — vitamin K, neonatal myasthenia, breastfeeding, contraception, and follow-up

Remember: exclude pre-eclampsia, image early, choose safe drugs, plan delivery, and watch the 6 weeks after birth.

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

Clinician-facing summary based on the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the National Institute for Health and Care Excellence (NICE), the International League Against Epilepsy (ILAE), and the American Academy of Neurology (AAN); written from memory, with no Government of India protocol incorporated; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

Liver and Pancreatic Diseases in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

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

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

🎯 AT A GLANCE — LIVER, GALLBLADDER AND PANCREAS

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

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

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

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

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

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

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

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

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

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

🗺️ THE PATHWAY AT A GLANCE

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

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

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

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

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

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

STEP 1 · KNOW THE NORMAL — liver tests in pregnancy

🔬 LIVER TESTS — WHAT CHANGES IN PREGNANCY

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

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

⚖️ COMPARING THE FOUR PREGNANCY-SPECIFIC LIVER DISEASES

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

🧪 ICP — BILE ACIDS AND DELIVERY TIMING

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

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

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

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

🔴 HELLP AND ACUTE FATTY LIVER — THE EMERGENCIES

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

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

🦠 VIRAL HEPATITIS IN PREGNANCY

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

🏥 INDIA — HEPATITIS B IN PREGNANCY (NVHCP)

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

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

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

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

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

🩺 CHRONIC LIVER DISEASE AND LIVER TRANSPLANT

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

STEP 4 · GALLBLADDER AND PANCREAS — gallstones and pancreatitis

🪨 GALLSTONE DISEASE

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

🔥 ACUTE PANCREATITIS IN PREGNANCY

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

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

⚠️ COMMON PITFALLS

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

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

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

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

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

Memory Aid

LIVER

Five steps for liver and pancreatic disease in pregnancy.

L

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

I

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

V

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

E

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

R

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

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

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

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