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Obstetrics & Gynaecology — Clinical Protocols

Evidence-based treatment protocols · Mandatory investigations · Periodic screening schedules

OB/GYN Module

🤰 Obstetrics (ANC)

🔬 Gynaecology

📅 Screening Schedule

📋 Quick Reference

ANC Visit Schedule

Mandatory Investigations

High-Risk Pregnancy

Intrapartum & Postnatal

Antenatal Care (ANC) Visit Schedule

ℹ️WHO minimum 8 ANC contacts. MoHFW/FOGSI guideline ≥8 visits for uncomplicated singleton pregnancy.

Booking Visit — Ideally <10 Weeks

First Contact

Clinical: Full obstetric history · LMP → EDD · BP, weight, BMI · Uterine size
Mandatory Investigations ALL
FBC · Blood group & Rhesus · Antibody screen · Rubella IgG · VDRL/RPR (syphilis) · HBsAg · HIV (4th gen) · anti-HCV · Thalassaemia screen (Hb electrophoresis) · Urine C&S · FBG / HbA1c · TSH · Toxoplasma IgG/IgM · Varicella IgG · Pap smear (if due)

11–13+6 Weeks

First Trimester Screening

Mandatory: Combined FTS (NT USS + PAPP-A + free β-hCG) · Uterine artery Doppler (PE risk) · NIPT/cfDNA offered
BP · weight · urine dipstick · CVS if high-risk (10–13 wks)
Counsel: Down/T18/T13 risk · PE aspirin prophylaxis 150mg nocte if risk ≥1:100

16 Weeks

Second Trimester — Early Contact

BP · weight · urine dipstick · SFH · FHR auscultation
Quad screen (if NIPT not done): AFP, hCG, uE3, inhibin-A
Review prior investigations · Iron/folate adherence check

18–22 Weeks

Anomaly / Morphology Scan

Mandatory USS: Detailed anomaly scan (4-chamber, LVOT, RVOT, head, spine, abdomen, kidneys, limbs, lips, placenta, liquor) · Cervical length (TVS if ≤25mm) · Placental localisation
FBC (anaemia) · BP · urine dipstick · SFH

24–28 Weeks

Glucose Challenge — Critical Screen

Mandatory: 75g OGTT (2hr) — GDM screen (WHO 2013: F≥5.1, 1hr≥10.0, 2hr≥8.5 mmol/L)
FBC · Anti-D 500IU IM at 28wks (Rh-negative) · Indirect Coombs (Rh-neg) · BP · urine protein · SFH · FHR

⚠️GDM diagnosed → refer Endocrinology + Dietitian. SMBG. Repeat USS biometry every 4 weeks.

28–32 Weeks

Third Trimester — Growth Assessment

Growth USS (BPD, HC, AC, FL) + AFI · Umbilical artery Doppler
Presentation · SFH · FHR · BP · urine protein · weight
FBC if prior anaemia · Anaemia treatment review

34–36 Weeks

Pre-Term Planning

Mandatory: GBS swab (low vaginal + anorectal, 35–37wks) · Repeat FBC · Coag screen if PE suspected
Repeat HIV/HBsAg/syphilis (high-risk — FOGSI/NMC recommendation) · BP · urine dipstick
Birth plan · ECV counselling if breech · Breastfeeding counselling

38–40 Weeks

Term — Labour Readiness

Mandatory: FBC · Coagulation (PT/aPTT) · LFT · RFT · Uric acid · Group & Screen/Crossmatch · Urine protein (24hr if dipstick ≥2+) · Non-stress test (CTG ≥40wks) · BPP if post-dates · Cervical assessment (Bishop score) · USS — position, placenta, liquor · GBS result → IV Penicillin G if positive

🔴Offer induction at 41+0 weeks. Do not proceed beyond 42 weeks without senior obstetric review.

Postnatal — 6 Weeks

Postnatal Review

BP · weight · wound/perineum · FBC (postnatal anaemia)
75g OGTT (if GDM — 6–12 wks postpartum) · TSH (if gestational thyroid dysfunction)
Edinburgh Postnatal Depression Scale (EPDS) · Contraception · Pap smear if due · MMR if rubella non-immune
Anti-D within 72hrs (Rh-negative + Rh-positive baby)

Mandatory Investigations — Full Matrix by Trimester

ℹ️M = Mandatory all patients (NMC/FOGSI). C = Conditional on risk factors.

Investigation	Booking <13wks	13–28wks	28–36wks	36–40wks	Notes / Threshold
HAEMATOLOGY
Full Blood Count (FBC)	✅ M	✅ 28wks	✅ 34wks	✅ M	Hb <10 g/dL → treat. Plt if pre-eclampsia.
Blood Group & Rhesus	✅ M	—	—	✅ G&S	Repeat G&S at delivery.
Antibody Screen (Indirect Coombs)	✅ M	Rh-neg only	Rh-neg only	✅ M	Anti-D 500IU IM at 28wks for Rh-negative.
HbA1c	✅ M	—	—	—	≥6.5% → pre-existing DM, refer Endocrine.
Thalassaemia Screen (Hb electrophoresis)	✅ M	—	—	—	UAE mandatory. Partner testing if carrier.
INFECTION SEROLOGY
Hepatitis B (HBsAg)	✅ M	—	—	High-risk repeat	HBsAg+ → neonatal HBIg + vaccine at birth.
Hepatitis C (anti-HCV)	✅ M	—	—	—	Positive → HCV RNA + Hepatology referral.
HIV (4th gen Ag/Ab)	✅ M	—	High-risk	✅ M	Reactive → confirm + PMTCT. ART within 2wks.
Syphilis (VDRL/RPR + TPHA)	✅ M	—	—	✅ M	Positive → Penicillin G + partner treatment.
Rubella IgG	✅ M	—	—	—	Non-immune → MMR postpartum (not in pregnancy).
Toxoplasma IgG/IgM	✅ M	—	—	—	IgM+ → avidity test. Low avidity → spiramycin.
GBS swab (vaginal + rectal)	—	—	✅ 35–37wks	—	Positive → IV Penicillin G in labour.
BIOCHEMISTRY & ENDOCRINE
TSH (±FT4)	✅ M	—	Sx/at-risk	—	TSH >2.5 T1 → Levothyroxine. >3.0 T2/T3.
75g OGTT (Gestational DM)	—	✅ 24–28wks	—	—	WHO 2013: F≥5.1, 1hr≥10.0, 2hr≥8.5 → GDM.
LFT, RFT, Uric Acid, LDH	—	High-risk PE	PE suspected	✅ M	ALT >70 or Plt <100 → HELLP workup.
Coagulation (PT, aPTT)	—	—	PE/abruption	✅ M	Mandatory pre-delivery / pre-regional anaesthesia.
24hr Urinary Protein / PCR	—	Dipstick ≥2+	Dipstick ≥2+	✅ if BP↑	>300 mg/24hr → pre-eclampsia criterion.
PAPP-A + free β-hCG	✅ 11–13wks	—	—	—	Combined first trimester screen (FTS).
ULTRASOUND
Dating / Viability USS	✅ <13wks	—	—	—	CRL for EDD if LMP uncertain.
NT + FTS USS	✅ 11–13+6wks	—	—	—	NT ≥3.5mm → genetics counselling.
Uterine Artery Doppler	✅ 11–13wks	✅ 20–24wks	—	—	PI >95th centile → high PE risk; aspirin 150mg.
Anomaly / Morphology Scan	—	✅ 18–22wks	—	—	Mandatory structural survey.
Cervical Length (TVS)	—	✅ 20–24wks	—	—	CL <25mm → progesterone / cerclage.
Growth Biometry + Doppler	—	—	✅ 28,32,36wks	Post-dates	AC <5th centile → SGA protocol, weekly Doppler.
Non-Stress Test (CTG)	—	—	High-risk	✅ ≥40wks	Non-reactive → BPP or delivery per gestation.

High-Risk Pregnancy Protocols

Pre-Eclampsia / Hypertensive Disorders

BP ≥140/90 after 20 weeks

🔴 Investigations

FBC, platelets, LFT (ALT/AST), LDH, uric acid, RFT, coagulation
24hr urine protein or PCR (protein:creatinine ratio)
USS — biometry, liquor, umbilical artery Doppler
CTG twice weekly (severe / inpatient)
Repeat labs every 48hrs if stable; daily if severe

💊 Management

Aspirin 150mg nocte from <16wks if PE risk ≥1:100
Antihypertensives: Labetalol 200mg BD or Nifedipine LA 30mg (1st line)
Target BP ≤135/85
Severe (≥160/110): IV Labetalol / Hydralazine + MgSO₄
MgSO₄ seizure prophylaxis: 4g IV load → 1g/hr infusion
Delivery: ≥37wks mild PE; ≥34wks severe/HELLP

🔴HELLP = Haemolysis + Elevated LFTs + Low Platelets → immediate delivery regardless of gestation

Gestational Diabetes Mellitus (GDM)

WHO 2013 / IADPSG Criteria

🔬 Monitoring

SMBG: fasting + 1hr post-meal (4× daily minimum)
HbA1c at diagnosis, then 4-weekly
Fetal biometry USS every 4 weeks from diagnosis
CTG from 38wks (weekly diet-controlled; twice weekly on insulin)

💊 Treatment Ladder

Step 1: Medical nutrition therapy (MNT) + 30 min exercise daily
Step 2 (if targets not met in 2wks): Metformin 500mg BD → max 2g/day
Step 3: Insulin (NPH nocte + pre-meal actrapid)
Targets: Fasting <5.3, 1hr <7.8, 2hr <6.7 mmol/L
Delivery: 38+0 (diet-controlled); 37+0 (insulin/macrosomia)

📅 Postnatal

75g OGTT at 6–12 weeks postpartum
Annual HbA1c/FBG for life — 50% develop T2DM within 10 years

Preterm Labour (PTL) / Threatened PTL

<37 weeks with regular contractions

🔬 Investigations

Cervical length (TVS) — <25mm = high risk
Fetal fibronectin (fFN) — negative = 99% no delivery in 7 days
HVS + GBS swab + MSU · FBC, CRP · CTG monitoring

💊 Tocolysis & Neuroprotection

Tocolysis 24–33+6wks: Nifedipine 20mg oral → 10–20mg 4–6hrly
Corticosteroids 24–34+6wks: Betamethasone 12mg IM × 2 doses 24hrs apart
MgSO₄ neuroprotection <32+0wks: 4g IV → 1g/hr × 24hrs
GBS prophylaxis if positive/unknown: IV Penicillin G

IUGR / SGA

EFW or AC <10th centile

🔬 Surveillance

Umbilical artery Doppler weekly (2× weekly if AREDF)
MCA Doppler — CPR <1.0 = compromise
Ductus venosus Doppler if UA AREDF · BPP twice weekly <32wks
CTG daily if venous Doppler abnormal

⚡ Delivery Timing

Normal Doppler → deliver ≥37+0 wks
UA PI >95th → deliver ≥34–36 wks
Absent/reversed EDF → deliver ≥32 wks after steroids
Abnormal DV + CTG changes → immediate delivery

Intrapartum Care Protocol

🏥 Admission Assessment

BP, HR, Temperature, SpO₂, BMI
FHR auscultation / CTG · Abdominal palpation — presentation, engagement
VE — cervical dilation, effacement, station, membranes
GBS result → IV Penicillin G if positive
FBC, coagulation, G&S / crossmatch · Urine dipstick · IV access 16G

📊 Intrapartum Monitoring

Low-risk: Intermittent auscultation q15min (1st), q5min (2nd stage)
High-risk / Oxytocin / Epidural: Continuous CTG
FBS if CTG pathological + delivery not imminent
Partograph — cervicogram, BP q1hr, urine, temperature q4hr
VE q4hr active labour (q2hr if augmenting)

🔴AMTSL (Active Management 3rd Stage): Oxytocin 10IU IM within 1 min of delivery + controlled cord traction + uterine massage. Reduces PPH risk by 60%.

Postnatal Mandatory Assessments

Timepoint	Clinical Checks	Investigations	Actions
1–2 hrs	BP q15min×4, uterine tone, PV loss, perineum, urine output	—	AMTSL complete; oxytocin infusion 40IU/500ml × 4hrs
12–24 hrs	BP, HR, temperature, lochia, wound, urination, breastfeeding	FBC if PPH >500ml	Anti-D if Rh-neg + Rh-pos baby (within 72hrs)
Day 2–5	BP, jaundice, lochia, wound	Neonatal blood spot · Hearing screen	Iron if Hb <10. EPDS screening.
6–8 Weeks	BP, weight, wound, pelvic floor, emotional health	75g OGTT (if GDM) · TSH · FBC	Contraception · Pap smear if due · MMR if Rubella non-immune

PCOS

Endometriosis

Fibroids

Menopause

STI / PID

AUB

PCOS — Rotterdam Criteria (2 of 3)

ℹ️≥2 of: (1) Oligomenorrhoea/anovulation (2) Clinical/biochemical hyperandrogenism (3) Polycystic ovaries on USS (≥20 follicles/ovary or volume >10ml)

Initial Investigations (All Mandatory)

Day 2–5: FSH, LH, E2 (LH:FSH typically >2:1 in PCOS)
Total testosterone, free androgen index, DHEAS
Prolactin, TSH — exclude other causes
Fasting insulin, FBG, 75g OGTT (if BMI >25)
Fasting lipid profile (cholesterol, TG, HDL, LDL)
AMH — typically elevated in PCOS
Pelvic USS — antral follicle count, ovarian volume, endometrial thickness

Periodic Monitoring — Mandatory Recall

Every 6 months: BP, weight/BMI, waist circumference
Every 12 months: FBG/HbA1c, fasting lipids
Every 12–24 months: Pelvic USS — endometrial thickness
Endometrial biopsy if amenorrhoea >3 months + ET >10mm
Depression/anxiety screening (PHQ-9, GAD-7) annually
Sleep study if BMI >35 or snoring (PCOS + OSA)

Treatment Protocol

Menstrual Irregularity

COCP 1st line — cycle regulation + androgen suppression
Progesterone withdrawal q3 months if COCP contraindicated
Metformin 500mg BD–2g/day if insulin resistant

Hirsutism / Hyperandrogenism

COCP with anti-androgenic progestogen (Drospirenone/Cyproterone)
Spironolactone 100mg/day (2nd line; contraception mandatory)

Infertility (Anovulation)

Weight loss ≥5% — ovulation may resume spontaneously
Letrozole 2.5–7.5mg Days 3–7 (1st line — follicle tracking USS from Day 10)
Clomiphene 50–150mg Days 2–6 (alternative)
Metformin adjunct if insulin resistant
Gonadotropins / IVF if fails after 6 cycles

Endometriosis — ASRM Classification I–IV

Investigations & Staging

Pelvic USS (TVS) — endometrioma ("chocolate cyst"), POD obliteration
MRI pelvis — deep infiltrating (DIE), bladder/bowel involvement
CA-125 — elevated in stage III–IV; not diagnostic alone
Laparoscopy — gold standard diagnosis + staging + biopsy
CA-125 annually (stage III–IV, to monitor recurrence)
Renal USS if ureteric involvement suspected

Management — ESHRE 2022

Medical (Hormonal Suppression)

COCP (continuous) — 1st line for pain
Dienogest 2mg OD (preferred progestogen)
LNG-IUS (Mirena) — pain + reduced flow
GnRH agonists (Leuprolide 3.75mg IM monthly × 6mo) + add-back HRT

Surgical

Laparoscopic excision (preferred over ablation)
Ovarian cystectomy for endometrioma >4cm
40–50% recurrence at 5 years → continuous medical therapy post-op

Fertility

Early fertility referral if AMH <1.0 ng/mL
AFC (antral follicle count) before any ovarian surgery

Uterine Fibroids (Leiomyoma)

Investigations

Pelvic USS (TVS) — number, size, FIGO subtype (0–8)
MRI pelvis — mapping pre-surgery, rule out sarcoma
FBC + serum ferritin (iron-deficiency anaemia)
Endometrial biopsy if HMB + age >45
Hysteroscopy for submucosal fibroids (FIGO 0–2)
Renal USS if bulk symptoms / ureteric compression (>10cm)
Annual USS surveillance if conservatively managed

Treatment

Medical

Tranexamic acid 1g TDS (Days 1–5) — HMB control
NSAIDs (mefenamic acid) — dysmenorrhoea + reduce HMB
LNG-IUS (submucosal FIGO 1–2 acceptable)
GnRH agonist × 3–6 months pre-op (shrink, correct anaemia)

Surgical / Interventional

Hysteroscopic resection — submucosal FIGO 0–1
Laparoscopic / open myomectomy — fertility-preserving
Uterine artery embolisation (UAE) — if not planning pregnancy
Hysterectomy — definitive, completed family

Menopause & Perimenopause Management

Investigations at Diagnosis

FSH ≥30 IU/L + amenorrhoea >12 months (>45 yrs) — no bloods needed
FSH + E2 if <45 yrs (confirm POI / premature menopause)
TSH, FBC, LFT, RFT — baseline before HRT
DEXA scan — mandatory if early menopause; all post-menopausal women >65
Fasting lipids, HbA1c · Mammogram (if due)
Endometrial USS if PMB or considering HRT with intact uterus

Monitoring on HRT — Mandatory Recall

3 months: Review symptoms, BP, compliance, side effects
Every 12 months: BP, weight, breast check, Pap smear (if due), symptom review
Every 2 years: Mammogram (higher risk on HRT)
Every 2–5 years: DEXA repeat
Annual fasting lipids, HbA1c
Discuss HRT risk:benefit every year · TVS if any PMB

HRT Prescribing Protocol

Intact uterus — Combined HRT

Sequential: Estradiol + progestogen 12 days/cycle (perimenopause)
Continuous combined: Estradiol + daily progestogen (post-menopause >1yr)
Local vaginal oestrogen for urogenital symptoms

Post-hysterectomy — Oestrogen only

Estradiol patches 50–100µg/24hr or gel 0.5–1.5mg/day
Absolute CI: breast cancer, active VTE, liver disease, undiagnosed PMB

Osteoporosis (if HRT declined)

Calcium 1200mg + Vit D 800–1000IU daily
Alendronate 70mg weekly or Risedronate 35mg weekly
Denosumab 60mg SC 6-monthly (if bisphosphonate not tolerated)

STI Screening & Pelvic Inflammatory Disease (PID)

STI Investigations

NAAT (PCR) — Chlamydia + Gonorrhoea (HVS/urine)
NAAT — Trichomonas vaginalis, Mycoplasma genitalium
Wet mount — BV (clue cells, whiff test, pH >4.5), Candida
Syphilis serology (VDRL/RPR + TPHA) · HIV 4th gen · HBsAg · anti-HCV
HSV PCR if genital ulcers · HPV typing if LSIL/HSIL on pap

PID Treatment Protocol

Outpatient (mild–moderate)

Ceftriaxone 500mg IM single dose
+ Doxycycline 100mg BD × 14 days
+ Metronidazole 400mg BD × 14 days
Review at 72hrs — no improvement → admit

Inpatient (severe / TOA)

IV Cefoxitin 2g q6h + Doxycycline 100mg BD
OR IV Clindamycin 900mg q8h + Gentamicin (2mg/kg load, 1.5mg/kg q8h)
TOA >5cm or no response 48hrs → surgical drainage
Partner notification + treatment mandatory

Abnormal Uterine Bleeding (AUB) — PALM-COEIN

Cause	Key Investigation	Treatment Summary
Polyp	Hysteroscopy + USS	Hysteroscopic polypectomy
Adenomyosis	MRI pelvis / TVS (thickened junctional zone)	LNG-IUS, GnRH agonist, hysterectomy
Leiomyoma	TVS / MRI · FBC	See Fibroids protocol above
Malignancy	Endometrial biopsy · USS · MRI · CA-125	Oncology referral, staging surgery
Coagulopathy	PT, aPTT, vWF Ag, Factor VIII, platelet function	Tranexamic acid, DDAVP (vWD), Haematology
Ovulatory dysfunction	TSH, prolactin, FSH/LH, testosterone	Treat underlying cause; COCP; progesterone
Endometrial	Endometrial biopsy (exclude hyperplasia)	Progestogens, LNG-IUS
Iatrogenic	Medication review (anticoagulants, SSRIs)	Adjust/switch medication
Not classified	Comprehensive workup	Per findings

Well-Woman Periodic Screening Schedule

✅Schedules follow NABH/NMC/NABH guidelines, WHO recommendations, and ACOG/RCOG evidence. Intervals for average-risk women — high-risk requires individualised schedule.

🔬

Cervical Cancer (Pap + HPV)

Cervical cytology & HPV co-test

Age <21 yrsNo screening

21–29 yrsPap every 3 years

30–65 yrsPap + HPV every 5 years OR Pap alone every 3 yrs

Post-hysterectomy (benign)Stop

>65 (adequate prior screens)Stop

HIV+ / immunocompromisedAnnual Pap × 3 then every 3 yrs

⚠️Intermenstrual/post-coital bleeding → immediate colposcopy regardless of recent Pap result.

🩻

Breast Cancer (Mammogram)

Clinical exam & imaging

Self-examMonthly from age 20

Clinical breast examEvery 3 yrs (20–39); annually >40

Mammogram (average risk)Every 2 years from age 40–74

High-risk (BRCA1/2)Annual mammogram + MRI from age 25–30

Dense breast (BI-RADS D3–D4)3D Tomosynthesis preferred + USS adjunct

BRCA genetic testingIf 1st degree relative with breast/ovarian ca <50

🦴

Osteoporosis (DEXA)

Bone mineral density

Age ≥65 (all women)DEXA every 2 years

Premature menopause <45DEXA at diagnosis + every 2 yrs

Prolonged steroids (>3 months)DEXA at start; every 2 years

FRAX scoreAll women >40 with risk factors

On bisphosphonateRepeat DEXA at 2 yrs; drug holiday after 5 yrs

Vit D (25-OH)Annually (target >50 nmol/L)

🩺

Ovarian Cancer

High-risk only

General populationNo routine screening

BRCA1 carriersTVS + CA-125 q6mo from age 30; prophylactic BSO at 35–40

BRCA2 carriersTVS + CA-125 q6mo from age 35; prophylactic BSO at 40–45

Lynch syndromeAnnual TVS + CA-125; consider prophylactic surgery

Postmenopausal pelvic massCA-125, HE4, ROMA score; urgent oncology referral

💉

HPV Vaccination

Primary prevention

9–14 yrs (primary)Gardasil-9: 2 doses (0, 6–12 months)

15–26 yrs (catch-up)Gardasil-9: 3 doses (0, 2, 6 months)

27–45 yrsShared decision (reduced benefit if sexually active)

Post-vaccinationContinue Pap screening per normal schedule

Also vaccinate againstHep B (3 doses if not immunised) · Hep A (2 doses)

📋

Annual Well-Woman Visit

Routine review

Blood pressureEvery visit / annually

Weight / BMI / waistAnnually

FBG / HbA1cEvery 3 yrs (>45 or BMI >25 + risk factors)

Fasting lipidsEvery 5 yrs (>35 yrs); annually if dyslipidaemia

TSHEvery 5 yrs (>35 yrs); annually if symptoms

Depression screening (PHQ-9)Annually

Colorectal (≥45 yrs)FIT test annually OR colonoscopy every 10 yrs

Screening by Age Group — Quick Reference

Test	18–29 yrs	30–39 yrs	40–49 yrs	50–64 yrs	65+ yrs
Pap Smear	Every 3 yrs (from 21)	Pap+HPV every 5 yrs	Pap+HPV every 5 yrs	Pap+HPV every 5 yrs	Stop if ≥3 negative
Mammogram	High-risk only	High-risk from 30	Every 2 years	Every 2 years	To 74 yrs
DEXA	Early menopause	Risk factors	Risk factors	Risk factors	From 65, every 2 yrs
FBG / HbA1c	Risk factors	Risk factors	Every 3 years	Every 3 years	Every 3 years
Fasting Lipids	Risk factors	Every 5 years	Every 5 years	Every 5 years	Every 5 years
STI Screen	Annual (sexually active)	Risk factors	Risk factors	Risk factors	Risk factors
Colorectal	—	—	From 45 yrs	Annual FIT / 10yr scope	To 75 yrs

Hormonal Reference Ranges

Hormone	Phase / Status	Reference Range
FSH	Follicular	3.5–12.5 IU/L
FSH	Post-menopausal	>25–30 IU/L
LH	Follicular	2.4–12.6 IU/L
LH	Ovulatory surge	14–95 IU/L
Oestradiol (E2)	Follicular	77–921 pmol/L
Oestradiol (E2)	Post-menopausal	<110 pmol/L
Progesterone	Mid-luteal (confirms ovulation)	>16 nmol/L
Testosterone (total)	Female normal	0.4–2.0 nmol/L
Prolactin	Non-pregnant	102–496 mIU/L
Prolactin — investigate if	Hyperprolactinaemia	>530 mIU/L
AMH — good reserve		1.0–3.5 ng/mL
AMH — low reserve		<1.0 ng/mL
TSH (pregnancy T1)	0–12 wks	0.1–2.5 mIU/L
TSH (pregnancy T2)	13–26 wks	0.2–3.0 mIU/L
TSH (pregnancy T3)	27–40 wks	0.3–3.5 mIU/L

Red Flag Symptoms — Urgent Action

Red Flag	Required Action
🔴 Postmenopausal bleeding (any)	USS endometrium + biopsy within 2 weeks
🔴 Intermenstrual / post-coital bleeding	Colposcopy + Pap smear urgent
🔴 Pelvic mass (new / rapidly enlarging)	USS + CA-125 + urgent gynae referral
🔴 Vulval ulcer / new lesion	Biopsy within 2 weeks
🔴 Obstetric: BP >160/110	IV antihypertensives + MgSO₄ + delivery
🔴 Obstetric: APH	Immediate obs assessment + USS + CTG
🔴 Obstetric: Decreased fetal movements	CTG within 2 hours of presentation
🔴 Obstetric: SROM <37 weeks	Admit, cultures, steroids, antibiotics
🔴 Severe abdo pain in pregnancy	Ectopic/abruption — IV access, USS, surgical review

Key Drug Doses

Drug	Indication	Dose
Folic acid	ANC	400µg/day (5mg high-risk)
Iron (ferrous sulphate)	Anaemia in pregnancy	200mg TDS (60mg elemental)
Aspirin	PE prophylaxis	150mg nocte <16wks
Betamethasone	Fetal lung maturity	12mg IM × 2 doses, 24hrs apart
MgSO₄	Eclampsia / neuroprotection	4g IV 20min → 1g/hr
Oxytocin (AMTSL)	PPH prevention	10IU IM stat after delivery
Tranexamic acid	PPH treatment	1g IV within 3hrs; repeat 1g at 30min
Anti-D	Rh-negative	500IU IM at 28wks; 500IU within 72hrs delivery
Metformin	GDM / PCOS	500mg BD → max 2g/day
Letrozole	Ovulation induction	2.5–7.5mg Days 3–7 (monitored)

Meta4 Technologies - Clinical System

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My Encounters

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User Management

Location Management

Obstetrics & Gynaecology — Clinical Protocols

Pre-Eclampsia / Hypertensive Disorders

Gestational Diabetes Mellitus (GDM)

Preterm Labour (PTL) / Threatened PTL

IUGR / SGA

Initial Investigations (All Mandatory)

Periodic Monitoring — Mandatory Recall

Treatment Protocol

Investigations & Staging

Management — ESHRE 2022

Investigations

Treatment

Investigations at Diagnosis

Monitoring on HRT — Mandatory Recall

HRT Prescribing Protocol

STI Investigations

PID Treatment Protocol

Cervical Cancer (Pap + HPV)

Breast Cancer (Mammogram)

Osteoporosis (DEXA)

Ovarian Cancer

HPV Vaccination

Annual Well-Woman Visit

Demo Credentials

Meta4 Technologies - Clinical System

Encounter Saved!

My Encounters

All Encounters

User Management

Location Management

Obstetrics & Gynaecology — Clinical Protocols

Pre-Eclampsia / Hypertensive Disorders

Gestational Diabetes Mellitus (GDM)

Preterm Labour (PTL) / Threatened PTL

IUGR / SGA

Initial Investigations (All Mandatory)

Periodic Monitoring — Mandatory Recall

Treatment Protocol

Investigations & Staging

Management — ESHRE 2022

Investigations

Treatment

Investigations at Diagnosis

Monitoring on HRT — Mandatory Recall

HRT Prescribing Protocol

STI Investigations

PID Treatment Protocol

Cervical Cancer (Pap + HPV)

Breast Cancer (Mammogram)

Osteoporosis (DEXA)

Ovarian Cancer

HPV Vaccination

Annual Well-Woman Visit