SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Medicolegal, PCPNDT and Bioethics in Obstetrics

Obstetric practice sits inside law and ethics. This guide covers consent and confidentiality, the PCPNDT Act, the MTP Act, other legal duties, negligence and records, and bioethical dilemmas, using the ETHICAL approach.

🎯 AT A GLANCE — MEDICOLEGAL, PCPNDT AND BIOETHICS

Good obstetric practice is safe practice: informed consent, honest communication, careful records, and working within the law protect the woman and the doctor

Four laws shape daily work in India: the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act (sex selection), the Medical Termination of Pregnancy (MTP) Act, the Protection of Children from Sexual Offences (POCSO) Act, and the law of negligence and consumer protection

Four ethical principles: respect for autonomy, beneficence, non-maleficence, and justice — in pregnancy the woman's autonomy comes first, and the fetus is cared for through her

Most claims arise from communication failure and poor records, not only from clinical error

Never reveal the sex of the fetus, never treat consent as a signature alone, and never alter a record after the event

🚨 LEGAL RED LINES

Revealing or hinting at the fetal sex, or doing a scan to find it — a criminal offence under the PCPNDT Act

Terminating a pregnancy outside the MTP Act (wrong gestation, unqualified provider, unapproved facility), except to save her life

Pregnancy in a girl under 18 — report the sexual offence under POCSO; treat her first and protect her identity

Refusing emergency care to a woman — including a survivor of sexual assault — for lack of payment, papers, or police formalities

Altering, back-dating, or destroying records after a complication

🗺️ HOW TO PRACTISE SAFELY

1 · ConsentExplain, check understanding, record; consent for the woman, not her family

2 · ComplyPCPNDT forms, MTP certification, POCSO reporting

3 · DocumentTimed, signed, legible, contemporaneous notes; never alter

4 · ProtectConfidentiality, dignity, chaperone, privacy

5 · EscalateSecond opinion, senior help, ethics or legal advice in a dilemma

6 · LearnDisclose errors honestly, report incidents, review maternal deaths

STEP 1 · CONSENT AND CONFIDENTIALITY — the woman decides

✍️ INFORMED CONSENT IN OBSTETRICS

Topic	Details
What makes it valid	Capacity, adequate information (nature, benefits, material risks, alternatives, and what happens if she declines), voluntary, in a language she understands, recorded — a signature on a form is evidence, not the consent itself
Who consents	The adult woman herself; no spousal, in-law, or family consent is required for treatment, caesarean, MTP, or sterilisation; family is involved only with her permission
Minors and persons who lack capacity	Guardian's consent (the MTP Act requires a guardian's written consent for a girl under 18 or a mentally ill woman); still involve the girl and respect her views
Emergencies	Treat to save life or prevent serious harm when she cannot consent and no one can be reached; record why (good-faith emergency principle)
Additional or extended procedures	Do not extend an operation beyond what she agreed unless delay would endanger her life (Samira Kohli v Prabha Manchanda, Supreme Court, 2008); discuss hysterectomy, tubal ligation, or other likely extensions beforehand
Refusal	A competent woman may refuse any treatment, including a caesarean or blood, even if the fetus is at risk; explain the risks, record the refusal, keep caring
Intimate examinations	Explicit consent for vaginal and rectal examinations, for examination under anaesthesia, and for trainees to observe or examine; offer a chaperone
Sterilisation and ART	Separate written consent (see the Female Sterilisation sheet); never at the time of labour pain or sedation

🔒 CONFIDENTIALITY AND ITS LIMITS

Duty to keep her information private (privacy is a fundamental right, Puttaswamy v Union of India, 2017); do not discuss her condition, HIV status, abortion, or sexual history with relatives without her permission

Legal exceptions that require disclosure: POCSO (sexual offence involving a child), court orders, notifiable diseases, maternal death reporting, and some medico-legal cases

MTP: the woman's name and particulars must not be revealed except to a person authorised by law; breach is punishable

HIV: the HIV and AIDS (Prevention and Control) Act, 2017 requires informed consent for testing, confidentiality, and no discrimination; disclosure to a partner is allowed only in narrow circumstances after counselling and when she will not disclose and the partner is at significant risk

Her records belong to her in practice: give copies when asked (Indian Medical Council regulations expect indoor patient records to be provided within 72 hours)

STEP 2 · PCPNDT ACT — prohibiting sex selection

⚖️ THE PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES ACT, 1994

Provision	What it requires
Purpose	To ban sex selection before or after conception and misuse of prenatal diagnostic techniques for sex determination; the 2003 amendment brought in ultrasound and pre-conception techniques
Allowed uses (section 4)	Prenatal diagnostic techniques only to detect chromosomal abnormalities, genetic metabolic diseases, haemoglobinopathies, sex-linked genetic diseases, congenital anomalies, or other conditions the Central Supervisory Board specifies
Indications (section 4)	One or more of the following, recorded in writing: maternal age over 35; two or more spontaneous abortions or fetal losses; exposure to teratogens; family history of mental retardation or physical deformities; other conditions the Board specifies
Consent and explanation (section 5)	Explain side and after effects; written consent in the prescribed form, in a language she understands; give her a copy
Sex of the fetus (sections 5 and 6)	No one may communicate the sex of the fetus to the woman, her relatives, or anyone else by words, signs, or any other manner; no sex determination and no sex selection
Registration	Genetic counselling centres, genetic laboratories, genetic clinics, and ultrasound clinics must be registered with the Appropriate Authority (usually the Civil Surgeon or district health officer); display the registration certificate and the notice that sex determination is a punishable offence
Records	Complete every field of Form F for each ultrasound in a pregnant woman; keep records and consent forms (about 2 years, or until legal proceedings end); submit monthly reports
Penalties	First offence: up to 3 years' imprisonment and a fine up to Rs 10,000; repeat: up to 5 years and Rs 50,000; the doctor's name goes to the State Medical Council (suspension while charges are pending, removal from the register on conviction); people who seek sex selection are also punishable; incomplete Form F is itself an offence
Other bans	Advertising sex selection or prenatal sex determination; selling ultrasound machines to unregistered users; unregistered mobile ultrasound

Treat every scan as a legal record: Form F complete, indication stated, consent signed, no comment on sex — if a relative asks, say the law forbids it

✅ DO AND DON'T — PCPNDT IN DAILY PRACTICE

Do	Don't
Check the clinic's registration, Form F, and signage	Never mention sex, gender, or 'boy or girl' in notes, reports, or words
Write the indication for each scan (dating, growth, anomaly, placenta, liquor)	Never use codes, signs, or colour hints for sex
Counsel couples that sex determination is illegal and that daughters have equal value	Never refer to or accept referrals from centres that reveal sex
Report suspected violations to the Appropriate Authority	Never keep ultrasound without registration, nor leave scans to unsupervised staff
Record the genetic indication and consent for any invasive test	Never test for sex in an abortion or a termination request

STEP 3 · MTP ACT — abortion law

📜 THE MEDICAL TERMINATION OF PREGNANCY ACT, AS AMENDED IN 2021

Topic	Details
Up to 20 weeks	One registered medical practitioner (RMP), in good faith, if continuing risks her life or causes grave injury to her physical or mental health, or the child would be seriously handicapped; contraceptive failure is a ground (woman or her partner); mental anguish from rape is presumed grave injury
20 to 24 weeks	Opinion of two RMPs for specified categories: survivors of rape or incest, minors, change of marital status during the pregnancy, women with physical disability, mental illness, or intellectual disability, fetal malformation, and women in humanitarian settings or disasters
Beyond 24 weeks	Only for substantial fetal abnormalities, on the opinion of a State-level Medical Board (gynaecologist, paediatrician, radiologist or sonologist, and other members)
Emergency	One RMP may terminate at any gestation if immediately necessary to save her life
Unmarried women	The 2021 Act refers to 'a woman'; the Supreme Court in 2022 (X v Union of India) held that unmarried women are eligible for the 20 to 24 weeks category and that marital rape counts as sexual assault for MTP
Consent	The woman's own consent; no husband's or parent's consent for an adult; guardian's written consent for a girl under 18 or a woman with mental illness
Minors and POCSO	Provide the abortion and report the offence; the Supreme Court has held that the doctor need not give the minor's identity in the police report if she or her guardian does not wish it
Where and who	An approved or government facility, an RMP with training in obstetrics and gynaecology (as the rules specify); no one else may perform it
Records and confidentiality	Maintain the admission register and consent forms (kept for 5 years); section 5A: do not reveal her name or particulars except as the law allows
Offences	Unqualified persons, unapproved places, or terminations outside the Act are offences under the Bharatiya Nyaya Sanhita (earlier the Indian Penal Code sections 312 to 316) and the MTP Act; breach of confidentiality can bring up to 1 year's imprisonment

STEP 4 · OTHER LEGAL DUTIES — know the wider law

🧾 OTHER LAWS THAT TOUCH OBSTETRIC PRACTICE

Law	Key points
POCSO Act, 2012	Any sexual activity with a person under 18 is an offence, even if she consents; doctors must report to the Special Juvenile Police Unit or local police (section 19); failure to report is punishable (section 21); examine with a trusted person present and a female doctor for a girl; do not delay treatment for the report
Sexual assault survivors	Hospitals must give free first aid and treatment and tell the police; refusing treatment is an offence (Criminal Law (Amendment) Act, 2013); obtain her consent for the medico-legal examination; collect and preserve evidence
Medico-legal cases	Sexual assault, criminal abortion, injuries and domestic violence, poisoning, burns, suicide attempts, and unnatural or suspicious deaths: register as medico-legal, inform police, document findings objectively
Medical negligence — civil	Consumer Protection Act, 2019: medical services are covered; complaints within 2 years of the cause of action; compensation for deficiency in service
Medical negligence — criminal	Jacob Mathew v State of Punjab (2005): criminal liability needs gross negligence or recklessness; a credible medical opinion should come before prosecution; doctors should not be arrested routinely; Bharatiya Nyaya Sanhita section 106: death by negligence, with a lighter maximum for registered medical practitioners
Disability and sterilisation	Rights of Persons with Disabilities Act, 2016: no forced sterilisation or procedures that cause infertility without her free and informed consent
Assisted reproduction and surrogacy	ART (Regulation) Act and Surrogacy (Regulation) Act, 2021: registered clinics, consent, records, no sex selection, altruistic surrogacy only
Maternal deaths	Notify every maternal death within 24 hours (Maternal Death Surveillance and Response); facility review, then district review; blame-free learning
Maternity benefit	Maternity Benefit Act as amended in 2017: paid maternity leave of 26 weeks for the first two children — issue timely medical certificates

STEP 5 · NEGLIGENCE AND RECORDS — protect the woman and yourself

📋 NEGLIGENCE, DOCUMENTATION AND DISCLOSURE

Topic	Details
Elements of negligence	Duty of care, breach of that duty (measured against what a reasonably competent practitioner would do — Bolam test), harm, and causation; res ipsa loquitur may apply to retained swabs and wrong-site injuries
Common obstetric claims	Delay in caesarean for fetal distress, birth asphyxia and cerebral palsy, shoulder dystocia, postpartum haemorrhage, retained swab or instrument, bladder, ureter, or bowel injury, failed sterilisation, missed anomaly, anaesthesia events, unrecognised ectopic pregnancy
What a good record contains	Date and time of every entry, name and designation, history, examination, findings, reasoning, plan, and advice; consent discussion and refusals; partograph, CTG, drug chart, operation and anaesthesia notes, swab and instrument counts; who was called and when
How to write it	Contemporaneous, legible, objective, signed; correct with a single line and countersign; never overwrite, back-date, or add later without labelling it as a late entry
Retention	Indoor patient records should be kept for at least 3 years (Indian Medical Council regulations), longer for MTP (5 years), PCPNDT, and where a case is pending; safe, secure, retrievable
After a complication	Tell her and her family honestly and early, explain what is known, apologise for the outcome, offer support; report the incident internally; preserve the records; inform the insurer
Protecting yourself	Professional indemnity cover, follow written protocols, seek a second opinion in difficult cases, refer when beyond your skill or facility, handover clearly

STEP 6 · BIOETHICS — principles and dilemmas

🧭 PRINCIPLES AND THE MATERNAL–FETAL RELATIONSHIP

Autonomy: her informed decision decides; beneficence: act for her good and, through her, the fetus's; non-maleficence: avoid harm; justice: fair access and no discrimination by sex, caste, religion, or poverty

The pregnant woman is the patient; the fetus has no separate legal right to override her; court-ordered or forced treatment is not accepted practice

Persuade, do not coerce: use time, information, and support; involve a senior colleague or ethics committee when conflict persists

Conscientious objection: a doctor may decline to take part in a procedure, but must say so early, refer without delay, and always treat emergencies (FIGO ethics guidance)

🧩 COMMON ETHICAL DILEMMAS

Dilemma	Approach
Refusal of caesarean or blood transfusion	Confirm capacity and understanding; explore the reasons; offer alternatives (cell salvage, iron, tranexamic acid); document; honour a competent refusal
Periviable birth (around 22 to 25 weeks)	Joint counselling with the neonatal team on local survival and disability; shared decision on resuscitation; comfort care is valid
Fetal anomaly and termination	Non-directive counselling; respect either choice within the MTP Act; use the Medical Board beyond 24 weeks; support for continuing (perinatal palliative care)
Adolescent pregnancy	Treat with confidentiality and dignity; explore consent, coercion, and abuse; report under POCSO; involve a guardian as the law requires
HIV and partner notification	Encourage her to disclose; offer to help; breach only within the narrow legal exceptions after counselling and documented attempts
Pressure for sex selection	Refuse firmly, counsel the family, document, and report where the law requires
Violence and coercion at home	Ask privately, offer safety planning and referral, do not confront the partner, respect her pace, document findings
Research and trainees	Ethics committee approval and written consent (ICMR guidelines); no pressure to join, and care is unaffected if she declines
Scarce resources	Allocate by clinical need and fair criteria, not by payment, status, or sex; explain openly
Pregnant woman who is brain-dead	Complex: seek the family's views, an ethics committee, and legal advice; decide by her known wishes and best interests

⚠️ COMMON PITFALLS

Consent taken by a junior, in labour, or as 'sign here'

Taking consent from the husband or in-laws instead of the woman

Letting a hint about the baby's sex slip, or an incomplete Form F

Delaying care for a minor or a rape survivor while waiting for the police

Poor, late, or altered records, and no honest explanation after a complication

Treating ethics as paperwork instead of a conversation with the woman

Memory Aid

ETHICAL

Seven habits for lawful, ethical obstetric care.

E

Explain and obtain consent — from her, not her family; record it

T

Tell no one the fetal sex — PCPNDT; complete Form F; give the indication

H

Honour confidentiality — with the legal exceptions understood

I

Inform and report — POCSO, medico-legal cases, maternal deaths

C

Chart carefully — timed, signed, contemporaneous; never alter

A

Act within the MTP Act — gestation, certification, facility, consent

L

Learn and disclose — honest communication, incident review, second opinions

Remember: her autonomy, her dignity, honest records, and the law.

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

General information for clinicians, not legal advice. PCPNDT Act sections 4 to 6 were read from a copy of the Act and a legal explainer, and the MTP (Amendment) Act, 2021 provisions from a published summary of the Act. Everything else, including PCPNDT penalties and registration details, Form F retention, MTP Rules and Medical Board procedure, POCSO, the Bharatiya Nyaya Sanhita, Supreme Court judgments, the Consumer Protection Act, record-retention rules, and the ethics guidance, is from memory; laws and rules change and vary by state, so confirm with the current statute, your state notifications, your hospital's legal adviser, and your indemnity provider; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and consult a legal adviser in any contested case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Placenta Accreta Spectrum

Placenta accreta spectrum is a major cause of life-threatening bleeding that can be anticipated. This guide covers definitions and grades, risk factors, ultrasound and MRI diagnosis, antenatal planning, the planned operation, and the unexpected case and aftercare, using the ACCRETA approach.

🎯 AT A GLANCE — PLACENTA ACCRETA SPECTRUM

Placenta accreta spectrum (PAS) is an abnormally adherent or invasive placenta because the decidua is deficient, so the placenta grows into or through the uterine wall and cannot separate normally after birth

The leading cause of massive obstetric haemorrhage, peripartum hysterectomy, and maternal intensive care admission

The main risk factor is a previous caesarean section with a placenta previa or low-lying placenta; incidence is rising with the caesarean rate

Prenatal diagnosis by expert ultrasound (with MRI when needed) lets the team plan: a planned caesarean hysterectomy at about 34–36 weeks in a centre with blood, intensive care, and a multidisciplinary team gives far better outcomes than an unplanned emergency

The cardinal rule: do not try to pull out an adherent placenta

Think of it in every woman with a previous caesarean and a low or anterior placenta — ask the sonologist to look specifically

🚨 ACT NOW IF

Previous caesarean (especially two or more) with placenta previa or a low anterior placenta — refer for expert PAS ultrasound and a specialist centre

Antepartum bleeding in a woman with suspected PAS — admit, cross-match, call the senior team, and arrange transfer

Placenta does not separate after birth, or heavy bleeding when removal is attempted — stop pulling, call for help, and resuscitate

Haematuria, abdominal pain, or a bulging bladder area — suspect bladder invasion

Uterine scar pregnancy in the first trimester (gestational sac low in the scar) — early specialist referral

🗺️ THE PATHWAY AT A GLANCE

1 · SuspectPrevious caesarean or uterine surgery with a low or anterior placenta

2 · ScanExpert ultrasound at 18–24 weeks, repeat at about 28–32 weeks, MRI if unclear

3 · ReferTo a centre with a PAS team, blood bank, and intensive care

4 · PrepareCorrect anaemia, counsel, plan blood and cell salvage, steroids

5 · DeliverPlanned caesarean hysterectomy at about 34–36 weeks (earlier if bleeding)

6 · RecoverIntensive care, clot prevention, counselling, contraception

STEP 1 · WHAT IT IS — the spectrum and the grades

🔬 DEFINITIONS AND GRADES

Term	Details
Placenta accreta (FIGO grade 1)	Villi attach to the myometrium without invading it (no decidua between them); the commonest type
Placenta increta (grade 2)	Villi invade into the myometrium
Placenta percreta (grade 3)	Villi penetrate the serosa (3a), invade the bladder (3b), or other pelvic organs and tissues (3c)
Why it happens	Scar tissue, a thin lower segment, or damaged endometrium means poor decidua, so trophoblast invades deeper
How common	Rare before the 1980s (about 1 in 2,500) and now reported at roughly 1 in 300–700 deliveries, rising with caesarean rates; Indian figures vary by centre

STEP 2 · WHO IS AT RISK — find the woman before the bleeding

⚠️ RISK FACTORS

Factor	Details
Previous caesarean with previa	Risk of PAS rises with the number of caesareans: about 3% after one, 11% after two, 40% after three, and over 60% after four or more (classic series, from memory)
Placenta previa or low-lying placenta	Even without a scar, previa carries a small risk; an anterior placenta over a scar is the highest-risk site
Other uterine surgery	Myomectomy, dilatation and curettage, hysteroscopic surgery, endometrial ablation, previous manual removal, and uterine infection; Asherman syndrome
Other factors	Assisted reproduction (IVF), advanced maternal age, high parity, smoking, short interval after caesarean, hypertensive disease
Previous PAS	High risk of recurrence (reported around 20–30%, from memory)

Every unnecessary primary caesarean raises the risk of PAS in later pregnancies — the best prevention is a safe vaginal birth where possible

STEP 3 · DIAGNOSIS — scan in the right woman, by the right person

📡 ULTRASOUND AND MRI

Tool	Signs and notes
Who to scan	Anyone with a previous caesarean or uterine surgery and a low or anterior placenta; assess the placental site at every anomaly scan
Best time	First-trimester scan for a scar pregnancy; detailed scan at 18–24 weeks, repeat in the third trimester; use transabdominal and transvaginal views
Grey-scale signs	Loss of the clear retroplacental zone, thinned or absent myometrium (under 1 mm), irregular placental lacunae ('Swiss cheese'), bulging of the placenta into the bladder, interrupted bladder wall
Colour Doppler signs	Marked hypervascularity between the placenta and bladder, bridging vessels crossing the myometrium, turbulent lacunar flow
Accuracy	Good in expert hands (sensitivity around 90% in reported series); a normal scan reduces but does not remove the risk
MRI	Adds information when ultrasound is unclear, for posterior placentas, or to map parametrial and bladder invasion; gadolinium is not needed
Cystoscopy	Only if bladder invasion is suspected, by a urologist
Do not	Do a vaginal examination in a woman with previa; use serum markers (such as alpha-fetoprotein) alone to diagnose PAS

STEP 4 · ANTENATAL PLANNING — get her to the right place with the right supplies

🏥 PLAN THE BIRTH

Topic	Details
Refer early	To a centre with a multidisciplinary PAS team: senior obstetrician, gynaecological surgeon, urologist, anaesthetist, intensive care, blood bank, neonatologist, and interventional radiology
Counsel	Explain the risk of haemorrhage and hysterectomy, the loss of fertility, the blood transfusion, the chance of a preterm baby; document consent for hysterectomy
Optimise	Treat anaemia with iron (oral or intravenous); aim for a haemoglobin of at least 11 g/dL; stop smoking
Avoid	Sexual intercourse and vaginal examination (if previa); travel far from the centre in late pregnancy
Admission	Consider admission or staying near the hospital from about 32–34 weeks, especially with a history of bleeding or living far away
Antenatal steroids	Betamethasone or dexamethasone if birth is planned before 37 weeks (per local protocol)
Timing	Planned delivery at about 34 0/7 to 35 6/7 weeks (American guidance) or 35 to 36+6 weeks (UK guidance) when stable; earlier for bleeding, contractions, or rupture of membranes
Blood	Valid group and screen, cross-match of at least 4–6 units with plasma, platelets, and cryoprecipitate on standby; cell salvage if available; massive transfusion protocol ready

STEP 5 · THE OPERATION — one planned attempt, done well

🔪 CAESAREAN HYSTERECTOMY

Step	Details
Set-up	Daytime, fully staffed theatre; two large intravenous lines, arterial line, warming, tranexamic acid, antibiotics; regional or general anaesthesia by the anaesthetist
Incision	Midline vertical skin incision for access; consider ureteric stents or placing balloon catheters where the team and equipment are available
Uterine incision	Through the fundus or the upper segment, away from the placenta (not through it); locate the placenta with ultrasound before opening
Deliver the baby	Hand the baby to the neonatal team; clamp the cord; do not remove the placenta and do not give routine oxytocin until it is clear the placenta will not be removed
Hysterectomy	Leave the placenta in place; close the uterine incision and proceed to hysterectomy (total, if the lower segment or cervix is involved); dissect the bladder carefully; divide the vessels early
Control of bleeding	Pelvic devascularisation (uterine and internal iliac artery ligation), balloon occlusion of the internal iliac or aorta (interventional radiology), packing, tamponade balloon, damage-control surgery if unstable
Injuries	Bladder, ureter and bowel injuries are common in percreta; involve the urologist and repair them
Alternatives in selected women	Leave the placenta in place and follow up (risk of bleeding, infection, and clots; hysterectomy later may be needed), or a one-step conservative operation (such as the triple-P procedure) in expert centres; methotrexate is not recommended

STEP 6 · WHEN IT IS NOT EXPECTED — emergency plan and aftercare

🆘 UNEXPECTED PAS AND AFTERCARE

Situation	Action
Placenta will not separate or bleeds heavily after attempted removal	Stop pulling, call the senior obstetrician, anaesthetist, and blood bank; resuscitate, give uterotonics and tranexamic acid, and start massive transfusion if needed
If bleeding is controlled	Leave the placenta in place, close, and transfer to a PAS centre (with blood and an escort) if the facility lacks resources
If bleeding is severe	Compress the aorta, apply tamponade or packing, and proceed to hysterectomy with the most experienced surgeon available
Intensive care	Watch for haemorrhage, coagulopathy, infection, kidney injury, and fluid overload
Clots and infection	Give antibiotics and low molecular weight heparin when bleeding is controlled; mobilise early
The mother	Counsel on grief and loss of fertility; iron; review before discharge and at 6 weeks
The baby	Often preterm, so neonatal care and early breastfeeding support (see the premature newborn sheet)
Future pregnancy	After conservative management, advise reliable contraception and early specialist care in a future pregnancy

⚠️ COMMON PITFALLS

Not looking for PAS in a woman with a previous caesarean and a low placenta

Relying on a scan by someone not trained in PAS, or assuming a normal scan excludes it

Pulling on the placenta or attempting manual removal

Delivering at night or in a unit without blood, intensive care, or a surgeon when a planned delivery was possible

Waiting for term and meeting the bleeding unprepared

Cutting through an anterior placenta instead of using a fundal or upper segment incision

Missing bladder and ureteric injury

Not counselling or taking consent for hysterectomy beforehand

Memory Aid

ACCRETA

Seven steps for placenta accreta spectrum.

A

Anticipate — previous caesarean plus a low or anterior placenta

C

Confirm — expert ultrasound at 18–24 weeks, MRI if unclear

C

Centre — refer to a unit with blood, intensive care, and a team

R

Ready — correct anaemia, cross-match, cell salvage, tranexamic acid

E

Elective — planned delivery at about 34–36 weeks

T

Team — obstetrician, urologist, anaesthetist, radiologist, neonatologist

A

Avoid pulling — leave the placenta, hysterectomy, or a conservative plan

Remember: suspect early, scan expertly, plan the birth, and never pull the placenta.

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) and Society for Maternal-Fetal Medicine (SMFM), International Federation of Gynecology and Obstetrics (FIGO), and International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidance; no source was read for this sheet. No Government of India document was read. Incidence, risk percentages, scan accuracy, blood requirements, and timing of delivery vary between guidelines and centres; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

Dermatological Problems in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Dermatological Problems in Pregnancy — Safe Treatment

Skin problems in pregnancy range from harmless physiological changes to conditions that endanger the baby, such as cholestasis, pemphigoid gestationis, and pustular psoriasis. This guide covers normal changes, pregnancy-specific dermatoses, common skin diseases, and safe treatment, using the ITCHING approach.

🎯 AT A GLANCE — SKIN AND PREGNANCY

Skin changes occur in nearly every pregnancy; most are harmless physiological changes (pigmentation, stretch marks, vascular spiders, hair and nail changes)

Four pregnancy-specific dermatoses: atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), pemphigoid gestationis (PG), and intrahepatic cholestasis of pregnancy (ICP) — plus pustular psoriasis of pregnancy

Itch is the commonest symptom: itch without a rash (especially palms and soles at night) is ICP until proved otherwise — it is the one that can kill the baby

Two things decide management: is there a primary rash (papules, plaques, blisters)? and is the fetus at risk? (ICP, PG, and pustular psoriasis are; AEP and PEP are not)

Never attribute generalised itch in late pregnancy to 'dry skin' before checking liver function tests and fasting or random bile acids

🚨 ACT AT ONCE

Itch on palms and soles, worse at night, no rash — obstetric cholestasis: bile acids and liver tests the same day; risk of stillbirth

Blisters beginning around the navel — pemphigoid gestationis: skin biopsy with direct immunofluorescence; fetal growth scans

Widespread pustules with fever — pustular psoriasis of pregnancy: admit, check calcium and albumin, fetal surveillance

Rash with fever or palm and sole lesions: exclude syphilis, varicella, measles, rubella, drug eruption

🗺️ THE PATHWAY AT A GLANCE

1 · LookIs there a primary rash? Where did it start? (navel, striae, flexures, palms)

2 · TimeGestation at onset, first or later pregnancy, previous skin disease

3 · TestBile acids and liver tests; biopsy with immunofluorescence for blisters; exclude infection

4 · TreatEmollients, topical steroids, antihistamines; specific drugs by diagnosis

5 · WatchFetal growth and wellbeing in ICP, PG, and pustular psoriasis

6 · PlanTiming of delivery, postpartum flares, and recurrence advice

STEP 1 · PHYSIOLOGICAL SKIN CHANGES — common, harmless, reassure

🌸 NORMAL SKIN CHANGES OF PREGNANCY

Change	Details
Pigmentation	Darkening of nipples, areola, genitalia, linea nigra; melasma (chloasma) in about 50–70% (face, worse in sun); fades after delivery but may persist — sunscreen with broad-spectrum protection and a hat
Striae gravidarum	Stretch marks in about 80–90% (abdomen, breasts, thighs); risk higher in young women, family history, large weight gain, big babies; no cream is proven to prevent them; fade to silvery lines
Vascular	Spider naevi, palmar erythema, varicose veins, haemorrhoids, oedema; gingival swelling and bleeding; pyogenic granuloma (epulis)
Hair	Hair thicker in pregnancy (longer growth phase); telogen effluvium (diffuse shedding) 1–5 months after delivery, recovers in 6–12 months
Nails and glands	Brittle nails, ridging, separation from the nail bed; acne may flare; increased sweating, and reduced apocrine gland activity

Counsel: these are normal; sun protection limits melasma; avoid hydroquinone and tretinoin in pregnancy; treat melasma after delivery if it persists

STEP 2 · PREGNANCY-SPECIFIC DERMATOSES — know the four, and the fifth

🔴 ATOPIC ERUPTION OF PREGNANCY AND POLYMORPHIC ERUPTION

Condition	Features and management
Atopic eruption of pregnancy (AEP)	Commonest (about half of pregnancy dermatoses); early or mid pregnancy; eczema on flexures (E-type) or itchy papules and nodules (P-type); often a history of atopy; no fetal risk
Treatment of AEP	Emollients, mild to moderate topical steroids, antihistamines (chlorphenamine at night; loratadine or cetirizine by day); narrowband ultraviolet B or short oral prednisolone if severe; treat infection (staphylococcus)
Polymorphic eruption of pregnancy (PEP, PUPPP)	First pregnancy, third trimester, twins; itchy urticarial papules and plaques that start in the stretch marks of the abdomen and spare the navel; spreads to thighs and limbs; no fetal risk
Treatment of PEP	Emollients, moderate to potent topical steroid, antihistamines; oral prednisolone if severe; resolves within days to weeks after delivery; seldom recurs

🫧 PEMPHIGOID GESTATIONIS (PG)

Topic	Details
What it is	Rare autoimmune blistering disease (about 1 in 50,000) with antibodies against BP180, a skin basement membrane protein; linked to HLA-DR3 and DR4, Graves disease, and molar pregnancy
Features	Intense itch, then urticarial papules and plaques around the navel that spread to limbs and trunk and develop tense blisters; second or third trimester; may flare around delivery
Diagnosis	Skin biopsy with direct immunofluorescence (linear C3 along the basement membrane), serum anti-BP180; exclude PEP (which spares the navel and has no antibodies)
Fetal risk	Preterm birth, small-for-gestational-age babies, and stillbirth; 10% of newborns have transient blisters
Treatment	Potent topical steroids and antihistamines; oral prednisolone 0.5 mg/kg daily for blisters, reduce slowly after control
Monitoring	Growth scans and fetal surveillance; delivery at 37–38 weeks if no complications, earlier for fetal concern
Afterwards	Flare after delivery in about 75%, resolves in weeks to months; recurs in later pregnancies, usually earlier and more severe

🟡 INTRAHEPATIC CHOLESTASIS OF PREGNANCY (OBSTETRIC CHOLESTASIS)

Topic	Details
Features	Itch without a primary rash, worse at night and on palms and soles; usually after 28 weeks (can be earlier); excoriations only; dark urine, pale stools, jaundice in a few
Who	About 0.7% in the UK, higher in South Asian women; multiple pregnancy, previous ICP, family history, hepatitis C, gallstones
Tests	Fasting serum bile acids (10 µmol/L or more is abnormal; a non-fasting sample is acceptable) and liver tests (ALT, AST); if normal and the itch persists, repeat weekly; exclude hepatitis, gallstones, pre-eclampsia, HELLP
Fetal risk	Stillbirth, preterm birth, meconium, fetal distress; risk rises with bile acids, with the highest risk at 100 µmol/L or more
Treatment	Ursodeoxycholic acid 10–15 mg/kg daily in divided doses (relieves itch for many; does not clearly prevent stillbirth); emollients, cooling; vitamin K 10 mg daily if prothrombin time is prolonged
Monitoring	Bile acids and liver tests weekly; fetal growth scans; cardiotocography does not predict stillbirth
Delivery	Bile acids 100 or more: consider delivery at 35–36 weeks; 40–99: 36–37 weeks; under 40: by 38–39 weeks (local protocol; earlier for fetal compromise or deranged liver function)
Afterwards	Itch and liver tests settle within 1–2 weeks; repeat liver tests at 6–8 weeks; recurrence about 60–90%; avoid oestrogen-containing contraception until normal

🟠 PUSTULAR PSORIASIS OF PREGNANCY (IMPETIGO HERPETIFORMIS)

Rare, third trimester: sheets of sterile pustules in flexures and trunk, with fever, malaise, vomiting; low calcium and albumin cause tetany, seizures

Risks: maternal sepsis and collapse, placental insufficiency, stillbirth, and neonatal death

Treat: admit, correct calcium and fluids, oral prednisolone 30–60 mg daily, ciclosporin if needed, antibiotics for infection; deliver if refractory or fetal compromise

Differential: pustular drug eruption, bacterial infection, and generalised pustular psoriasis from steroid withdrawal

STEP 3 · OTHER SKIN PROBLEMS — and safe drug choices

🩹 PRE-EXISTING AND COMMON SKIN DISEASES

Condition	Management in pregnancy
Acne	Topical benzoyl peroxide, azelaic acid, erythromycin or clindamycin; avoid isotretinoin, oral tetracyclines, and topical retinoids
Psoriasis	Emollients, topical steroids, narrowband UVB; ciclosporin or certolizumab for severe disease; avoid methotrexate, acitretin, and PUVA (psoralen with ultraviolet A); may improve in pregnancy, flares after
Atopic eczema	Emollients, topical steroids, sedating antihistamines at night; treat infection
Scabies	Common in India; permethrin 5% cream over the whole body for 8–12 hours, repeat in 7 days; treat contacts; avoid lindane
Fungal infections	Topical clotrimazole or terbinafine; avoid oral griseofulvin and high-dose fluconazole; vaginal candidiasis: clotrimazole pessary for 7 days
Genital warts	Grow faster in pregnancy; trichloroacetic acid or cryotherapy; avoid podophyllin and imiquimod; caesarean only if obstructing
Herpes zoster and varicella	Acyclovir or valacyclovir; see the TORCH sheet for exposure and delivery plans
Urticaria	Non-sedating antihistamines (loratadine, cetirizine); look for a trigger; short oral steroid if severe
Leprosy	Multidrug therapy is considered safe and should continue; reactions and nerve damage may appear in pregnancy and after delivery — refer early
Lupus and syphilis rashes	Lupus: risk of neonatal lupus and heart block; syphilis: palm and sole rash, test and treat (see the dedicated sheet)

💊 SKIN TREATMENTS — SAFE AND TO AVOID

Group	Advice
Generally safe	Emollients, mild to moderate topical steroids, sunscreen, benzoyl peroxide, azelaic acid, permethrin, topical clotrimazole, chlorphenamine, loratadine, cetirizine, oral prednisolone, narrowband UVB
Use with care	Potent or very potent topical steroids (small areas, shortest time; large amounts may lower birth weight), ciclosporin, azathioprine, dapsone (watch for haemolysis), oral fluconazole
Avoid	Isotretinoin, acitretin, topical tretinoin; methotrexate; oral tetracyclines (doxycycline); thalidomide; finasteride and dutasteride; oral minoxidil; lindane; podophyllin; PUVA
Breastfeeding	Emollients, mild steroids, and permethrin are fine; do not apply creams to the nipple before feeds; avoid methotrexate and retinoids

⚠️ COMMON PITFALLS

Treating itch in late pregnancy with antihistamines alone without bile acids and liver tests

Calling a blistering rash 'PUPPP' without checking the navel and doing a biopsy — pemphigoid gestationis carries fetal risk

Normal liver tests on one occasion do not exclude ICP — repeat if the itch persists

Prescribing isotretinoin, tetracyclines, or methotrexate to a woman who may be pregnant

Using potent steroids on large areas for long periods, or calling scabies 'eczema' and missing the household source

Forgetting the postpartum period: PG flares, ICP recurrence advice, and telogen effluvium

Memory Aid

ITCHING

Seven rules for skin disease in pregnancy.

I

Itch without a rash — cholestasis until proved otherwise: bile acids and liver tests

T

Timing and site of onset — navel means pemphigoid; stretch marks mean PEP

C

Care with drugs — emollients, mild steroids, and safe antihistamines first

H

Hospital for pustular psoriasis and severe pemphigoid

I

Insist on fetal surveillance in ICP, pemphigoid, and pustular psoriasis

N

No isotretinoin, acitretin, methotrexate, tetracyclines

G

Give a postpartum plan — delivery timing, flares, and recurrence

Remember: rash or no rash, test the itch, protect the baby, and choose safe drugs.

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

Clinician-facing summary written from memory of the Royal College of Obstetricians and Gynaecologists (RCOG) obstetric cholestasis guideline, the British Association of Dermatologists (BAD) guidance, and published reviews of pregnancy dermatoses; no Government of India protocol for these conditions was found, so none is incorporated. Check current guidance before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.