Chapter 6 Obstetrics gynaecology NATIONAL DEPARTMENT OF HEALTH

Chapter 6: Obstetrics & gynaecology NATIONAL DEPARTMENT OF HEALTH AFFORDABLE MEDICINES ESSENTIAL MEDICINES PROGRAMME PRIMARY HEALTHCARE GUIDELINES 2018 1

EVIDENCE Please access the National Essential Medicines List Committee (NEMLC) report for detailed evidence (including rationale, references and costings) informing decision-making on medicine addition, amendments and deletions: http: //www. health. gov. za/index. php/standard-treatment-guidelines-andessential-medicines-list/category/285 -phc DISCLAIMER This slide set is an implementation tool and should be used alongside the most recently published STG available on the EML Clinical Guide Application. This information does not supersede or replace the STG itself. 2

Termination of pregnancy (TOP) DESCRIPTION Termination of pregnancy for pregnancies where gestation ≤ 12 weeks and 0 days, on request. CHANGES • Section on management of TOP for gestation ≤ 12 weeks (and 0 days) for accredited sites, ADDED. • Medical TOP limited to those < 9 weeks as ultrasound in primary care not mandatory. REASON To improve access to safe TOPs at primary level of care. 3

Antenatal supplements DESCRIPTION Supplements before and during pregnancy and lactation can help to prevent, or lessen the effect of, a number of conditions or complications associated with pregnancy like anaemia and preeclampsia in mothers and neural tube defects in the developing fetus. CHANGES – new section • Prevention of neural tube defects REASON • Clarify use of folate supplementation. Previously given to prevent megaloblastic anaemia. • Encourage preconception use of supplements. - Folic acid, oral, 5 mg daily, ADDED • Prevention of anaemia - Iron (Ferrous sulphate or ferrous fumarate), AMENDED • Prevention of pre-eclampsia - Calcium, elemental, 1 g daily (given as calcium carbonate, oral 12 hourly, AMENDED 4

Anaemia in pregnancy DESCRIPTION Anaemia in pregnancy is a haemoglobin (Hb) < 11 g/d. L. CHANGES • Folic acid, oral, for prevention of megaloblastic anaemia, DELETED (folic acid added as routine supplement see section 6. 4. 1: Antenatal supplements) • Dosing of ferrous, oral, AMENDED from 8 hourly to 12 hourly REASON • Fortification of foods to supply >400 mcg/day folate means that additional folate to prevent anaemia not needed. 5

Urinary tract infection in pregnancy DESCRIPTION Cystitis: infection of lower urinary tract infection: lower abdominal pain, frequency of micturition and/or dysuria Pyelonephritis: infection of upper urinary tract infection, temperature ≥ 38°C, renal angle tenderness, vomiting, tachypnoea, tachycardia, hypotension, confusion CHANGES REASON • New section • Cystitis: nitrofurantoin, oral, 100 mg 6 hourly for 7 days, ADDED • Pyelonephritis: pre-referral dose of ceftriaxone, IV, 1 g as a single dose, ADDED • Common conditions presenting in pregnancy • Need for clarification of safe antibiotic choice in pregnancy, addressing the penicillin allergy 6

Puerperal sepsis DESCRIPTION • Infection that develops within six weeks of delivery. • Presents with temperature ≥ 38°C (≥ 2 days), offensive vaginal discharge (lochia) and/or abdominal pain within the first 10 days postpartum. CHANGES REASON • New section • Pre-referral dose of ceftriaxone, IV, 1 g as a single dose, ADDED • To increase awareness and pre-referral treatment of a common, potentially lifethreatening condition 7

Prevention of vertical transmission of hepatitis B DESCRIPTION Babies born to mothers with acute hepatitis B infection at the time of delivery or to mothers who are HBs. Ag-positive or HBe. Ag-positive ADDITIONS Infants should receive: • Hepatitis B immunoglobulin, IM • Hepatitis B vaccine, IM Both should be given within 12 hours of delivery REASON Alignment with Paediatric (2017) and Adult Hospital (2015) STGs and EML 8

HIV In pregnancy DESCRIPTION HIV- infected pregnant mother - prophylaxis against cryptococcal meningitis. CHANGES REASON • Fluconazole for Cr. Ag+ patients AMENDED: restricted to 2 nd trimester onwards • Restricted to 2 nd trimester onwards due to safety concerns. • Women Cr. Ag+ in 1 st trimester are referred for management. 9

Maternal mental health DESCRIPTION This includes antenatal and postnatal depression, as well as postpartum psychosis. CHANGES New sections added with descriptions, general measures and referral criteria REASON To increase recognition and improve management of these conditions as there is potential for significant negative impact on the mother’s ability to carry the pregnancy to term and to care for her baby. 10

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