Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

1. National and Unified Obstetric and Newborn care Guidelines and Protocols Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

2. National and Unified Obstetric and Newborn care Guidelines and Protocols

3. Guidelines • Normal delivery • Breastfeeding • Normal care to the newborn • High risk cases (1 : medical conditions) • High risk cases (2 obstetrical conditions) • Obstetrical Emergencies • Newborn High Risk and Emergencies • Obstetrical procedures • Neonatal procedures • Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols

4. Guidelines • Normal delivery • Breastfeeding • Normal care to the newborn • High risk cases (1 : medical conditions) • High risk cases (2 obstetrical conditions) • Obstetrical Emergencies • Newborn High Risk and Emergencies • Obstetrical procedures • Neonatal procedures • Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols

5. High Risk Cases 1st SECTION : The Mother and Foetus Topic 4: High risk cases Part 1 Medical conditions Part 2 Obstetrical conditions National and Unified Obstetric and Newborn care Guidelines and Protocols

6. High Risk Cases : medical conditions 1st SECTION : Mother and foetus Topic 4: High risk cases Part 1 Medical conditions Anemia in Pregnancy Diabetes Heart disease Bronchial Asthma Antiphodpholipid Syndrome Epilepsy Prophylaxis against thrombo-embolism Patients with viral hepatitis or HIV Management of sepsis in obstetrics National and Unified Obstetric and Newborn care Guidelines and Protocols

7. High Risk Cases : medical conditions Anemia in Pregnancy 1 Topic 3 High Risks Sub topic 1 Anemia in pregnancy Women with haemoglbin concentration less than 11 g/dl Care group: Pregnant/labouring women with low haemoglobin concentration ·Mild anemia: Hb 9- <11 g/dl ·Moderate Hb 8- <9 g/dl. Standard statement: All patients with anaemia needs active management of third stage of labour (i.v. oxytocin and/or ergometrinat delivery of anterior shoulder followed by controlled cord traction-CCT): ·Severe: Hb <8 g/dl. Definition: National and Unified Obstetric and Newborn care Guidelines and Protocols

8. High Risk Cases : medical conditions Anemia in Pregnancy 1 The Physician must be informed about all cases of mild, moderate & severe anemia Treat & consult with Medical Specialist/Haematologistif any knwon case of oHaemolytic anaemia oAplastic anaemia oAnaemia of chronic disease, oAuto immune anaemia, oAnaemia with SLE oand Anaemia due to haemoglobinpathies National and Unified Obstetric and Newborn care Guidelines and Protocols

9. High Risk Cases : medical conditions Anemia in Pregnancy 1 • Assessment of anaemia severity and management • Check complete Blood Count (CBC) at booking antenatal visit. • Recheck FBC at 30 weeks gestation and  • If Hb is > 11 g/dl No further Hb check is required. • If Hb concentration < 11 g/dl and FBC indices refer to nutritional anemia  treat according to degree of anaemia and gestational age. (Iron supplementation)  • If Severe anaemia (< 8 g/dl ) at any gestational age needs : Blood transfusion and further iron/folate supplementation. National and Unified Obstetric and Newborn care Guidelines and Protocols

10. High Risk Cases : medical conditions Anemia in Pregnancy 1 ALGORITHM : Anaemia 1st visit : Check Hb > 11 g 8 - 11 g < 8 g Iron Folate Blood transfusion + Iron / folate Re –check At 30 weeks Re –check After 2-4 wks Hb increase No Hb increase  If Hb > 11 No further check. Intolerance ? Non-compliance ? Next slide National and Unified Obstetric and Newborn care Guidelines and Protocols

11. High Risk Cases : medical conditions Anemia in Pregnancy 1 ALGORITHM : Anaemia Intolerance ? Non-compliance ? Intolerance No compliance Good Tolerance Good compliance Change Iron preparation Increase Iron dose Re –check after 2-4 wks Hb increase No Hb increase Refer National and Unified Obstetric and Newborn care Guidelines and Protocols

12. High Risk Cases : medical conditions Diabetes 2 Topic 3 High Risk Cases Sub topic 2 Obstetrical Management of patient with Diabetes in pregnancy Care group Established DM/GDM women in pregnancy Standard statement DM complicating pregnancy, put the mother and her baby at increased risk. Definition Diabetes complicates ~4 / 1000 pregnancies, the majority of which is pre-existing insulin-dependent diabetes mellitus National and Unified Obstetric and Newborn care Guidelines and Protocols

13. High Risk Cases : medical conditions Diabetes 2 Abbreviations or Acronyms National and Unified Obstetric and Newborn care Guidelines and Protocols

14. High Risk Cases : medical conditions Diabetes 2 Patients with established DM or GDM  refer them to Medical Specialist/Endocrinologist for detailed assessment. National and Unified Obstetric and Newborn care Guidelines and Protocols

15. High Risk Cases : medical conditions Diabetes 2 • Pre-pregnancy assessment and counseling: • Counsel and advise women if planning a pregnancy. • Improved pre-pregnancy glycaemic control will reduce risk of congenital anomalies • Non-insulin dependent diabetics should change therapy to insulin • Counsel about the demands of antenatal diabetes control and the potential effects on the woman’s work / family life • Continue contraception until disease is well controlled • Detect and treat medical complications of DM: Retinopathy, Nephropathy, and neuropathy • Commence folic acid supplementation : 5 mg once daily • Life-style advice including smoking / dietary advice • Check rubella status and immunise if not immune National and Unified Obstetric and Newborn care Guidelines and Protocols

16. High Risk Cases : medical conditions Diabetes 2 Antenatal Screening and Diagnosis: Screen all patients for DM/Gestational DM (GDM) by any of the following methods 1. A timed blood sugar monitoring: Check Fasting Blood Sugar (FBS), one hour and two hours Post Prandial Blood Sugar (PPBS) Repeat screening at 24-28 weeks if the booking was before 20 weeks 2. A 50 g oral glucose load at 24–28 weeks of gestation. Check glucose level 1 hour later. A glucose level of > 7.8 mmol/l (>140 mg/dl) or more is classified as impaired glucose tolerance (IGT). Any patient who have impaired glucose tolerance (IGT) should have a formal 75 g Oral Glucose Tolerance Test OGTT: National and Unified Obstetric and Newborn care Guidelines and Protocols

17. High Risk Cases : medical conditions Diabetes 2 Normal < 6 mmol/l ( < 110 mg/dl) Impaired < 7 mmol/l (< 125 mg/dl) < 6 mmol/l ( < 110 mg/dl) > 6 mmol/l ( >110 mg/dl) > 7 mmol ( > 125 mg/dl) > 6 mmol/l ( > 110 mg/dl) FBS and RBS National and Unified Obstetric and Newborn care Guidelines and Protocols

18. High Risk Cases : medical conditions Diabetes 2 FBS Two hours after 75 g Oral glucose Normal <110 mg/dl <6 mmol/l <145 mg/dl <8 mmol/l Impaired 110-144 mg/dl 6-8 mmol/l 145-195 mg/dl 8-10.9 mmol/l Diabetic >144 mg/dl >8 mmol/l >195 mg/dl >10.9 mmol/l FBS and OGTT National and Unified Obstetric and Newborn care Guidelines and Protocols

19. High Risk Cases : medical conditions Diabetes 2 Patients with these risk factors may have OGTT directly 1) Personal history (P/H) of GDM 2) P/H of unexplained stillbirth or neonatal death. 3) Weight >90 Kg 4) P/H of big baby weight >4Kg. 5) Patients with polyhydramnios, Preeclampsia or macrosomic fetus 6) Patients on steroids treatment 7) Strong family history (1st Siblings). National and Unified Obstetric and Newborn care Guidelines and Protocols

20. High Risk Cases : medical conditions Diabetes 2 Indications for admission: 1) Patients with abnormal blood sugar screening levels as mentioned above. 2) Patients who are newly diagnosed. 3) Patients with complication. National and Unified Obstetric and Newborn care Guidelines and Protocols

21. High Risk Cases : medical conditions Diabetes 2 1st visit Risk factors ALGORITHM : Diabetes No risks +ve Risk factors Fasting Blood Sugar Normal < 110 mg/dl Abnormal > 110 mg/dl 24-28 sem weeks Oral glucose load Abnormal > 140 mg/dl OGTT Normal < 140 mg/dl Normal < 145 mg/dl Abnormal 145-195 mg/dl Abnormal > 195 mg/dl Follow-up Diet control Refer National and Unified Obstetric and Newborn care Guidelines and Protocols

22. High Risk Cases : medical conditions Diabetes 2 • Antenatal Management: • All patients with established DM and/or screen positive for GDM should be referred for hospital booking as early as possible. • Those patients already diagnosed as GDM and/or known Diabetic with FBS> 110and/or PP>145 will be advised for admission • Teach recognition of Hypoglycaemia, teach how to use glucagon to woman and her family. • Women should have a written information and contact telephone • Perform a baseline dating Ultrasound at booking as assessment of foetal growth and timing of delivery • Mark the Expected Date of Delivery EDD National and Unified Obstetric and Newborn care Guidelines and Protocols

23. High Risk Cases : medical conditions Diabetes 2 • Antenatal Management: • A second anomaly scan should be performed at 18-20 weeks including cardiac scan. A third scan at 28 (with measurement of AC), and fourth one between 34-36 weeks as minimum. • The Insulin dose should be clearly written • Measure HbA1c monthly • Antenatal visits of two weeks interval from 20 weeks till 34 with FBS, PPBS, then weekly till delivery. • Consultant should decide about mode & time of delivery National and Unified Obstetric and Newborn care Guidelines and Protocols

24. High Risk Cases : medical conditions Diabetes 2 • Hospital Management • Patients admitted for control should started on diabetic diet and Blood Sugar Profile (BSP). • Fasting blood Sugar, preprandial (Pre lunch, pre supper, and pre-bed snacks) (FBS, I2 pm, 6 PM, 11:30 PM) • When Insulin is required, has to be given in the morning and/or evening to keep the FBS <100 mg /dl ( < 5.5 mmol/l) and the Pre Prandial at around 125 mg/dl (< 7 mmol/l). • Sliding scale is a good option for known diabetic patients who need to be shifted from oral hypoglycaemic to Insulin and those with very high levels and receive no Insulin (to avoid hyperglycemic coma). This help to calculate the average daily dose National and Unified Obstetric and Newborn care Guidelines and Protocols

25. High Risk Cases : medical conditions Diabetes 2 Blood Sugar Sub cutaneous Regular Insulin < 150 mg/ dl No Insulin 150 - 200 mg/dl 4 Units 201 - 250 mg/dl 8 Units 251 - 300 mg/dl 12 Units 301 - 350 mg/dl 16 Units Level of > 350 mg/dl you need to consult Physician Sliding Scale National and Unified Obstetric and Newborn care Guidelines and Protocols

26. High Risk Cases : medical conditions Diabetes 2 DETECTIONS OF COMPLICATIONS 1. Hypoglycemia (perspiration, headache, tachycardia, tremor) Always keep a juice beside the patient 2. Ketoacidosis (drowsy, stupor or coma). Acidotic breathing, dehydration, urine sugar & ketones). • Seek senior & medical help • Correct dehydration with normal saline (N/S) • Urgent serum glucose, bicarbonate, U&E, ABG & urine for sugar and ketones • Insulin & Bicarbonate dose depends on the degree of ketoacidosis. National and Unified Obstetric and Newborn care Guidelines and Protocols

27. High Risk Cases : medical conditions Diabetes 2 • SPECIAL NOTES IN RAMADAN • InRamadan, patients on insulin should be advised not to fast. • In Ramadanand for those who insist to keep their fasting, BSP profile would be altered to: • Before evening breakfast (Fatour) for FBS, • I l PM, for 12 mid day • 3am for 6 pm • and 9am. for 11:30 pm • Insulin morning dose to be given before the fasting break • (Maghreb-Fatour- time) • Evening Dose to be given before sahour time National and Unified Obstetric and Newborn care Guidelines and Protocols

28. High Risk Cases : medical conditions Diabetes 2 • MANAGEMENT during DELIVERY • Time of delivery : • At 40 weeks • For patients on diet alone andthose with good control and with no complications. • At 38weeks • Diabetes with complications • Poor diabetic control • Previous stillbirth • previous history of macrosomia or shoulder dystocia • Any time before 38 if any other obstetric indication arise. National and Unified Obstetric and Newborn care Guidelines and Protocols

29. High Risk Cases : medical conditions Diabetes 2 • MANAGEMENT during DELIVERY • Mode of delivery • 1.Vaginal delivery: • For uncomplicated well-controlled diabetes with estimated fetal weight < 4 Kg • Cases induced for obstetric indications at > 38 weeks • Low threshold for CS if no satisfactory progress After 6-8 hours of starting labour • 2. Emergency Caesrean Section:  • Previous CS if the fetus is macrosomic, • Previous difficult delivery • Any added obstetric complication (e.g. malpresentation , Disproportion) • Severe pre-eclampsia. National and Unified Obstetric and Newborn care Guidelines and Protocols

30. High Risk Cases : medical conditions Diabetes 2 • Diabetic Control for vaginal delivery • Immediate Random blood sugar RBS & hourly thereafter, • The result to be obtained urgently • Incorporate 5 units of regular insulin in 500 ml of 5% Dextrose/water (D/W) • Start at a rate dependinding on the RBS & as follows:  • If RBS is 76 -110 (4-6 mmol/l) give 100 ml D/w 5% per hour =1 Unit of insulin /hour • If RBS is > 110 mg/dl (> 6 mmol/l) double the dose 200 ml /hour =2. Units of Insulin per hour. • If RBS is <75mg.dl (<4 mmol/l) half the dose = 50 ml of D/w 5% = 0.5 unit per hour Half the rate of the iv infusion (5%D/W+Insulin) after delivery. National and Unified Obstetric and Newborn care Guidelines and Protocols

31. High Risk Cases : medical conditions Diabetes 2 • Diabetic control for Elective Lower Sement Caesarean Section (ELSCS): • - Communicate with the anaesthetist • - Put 1st in the list, keep fasting from midnight • - omit the morning insulin dose. • Check fasting blood sugar &electrolytes at 6 am. • If blood sugar <100mg /dl, start 5% Dextrose IV (125 ml /hour) • If blood sugar is >I00 mg /dl, discuss with anaesthetist. Post CS start iv fluid with a total of 3L 5% D/W in alternate with N/S in the first 24 hours, Control blood sugar with sliding scale. National and Unified Obstetric and Newborn care Guidelines and Protocols

32. High Risk Cases : medical conditions Diabetes 2 • MANAGEMENT during POST-PARTUM • Continue the sliding scale for 24 hours after normal deliveries & for 48 hours after LSCS then readjust the insulin accordingly. • At postpartum the patient may be reviewed by a Consultant physician or referred to the diabetic clinic if needed National and Unified Obstetric and Newborn care Guidelines and Protocols

33. High Risk Cases : medical conditions Heart disease 3 Topic 3 High Risk Cases Sub topic 3 Management of Heart disease Care group All pregnant women with diagnosed heart disease Standard statement Definition Heart disease in pregnancy is uncommon, affecting less than 1% of pregnant women. However, it is an important cause of maternal death, Rheumatic heart disease is declining, Advances in the medical and surgical treatment of children with congenital heart disease have led to an increase in the number of women surviving into the reproductive age. Heart disease remains one of the major causes of maternal deaths worldwide National and Unified Obstetric and Newborn care Guidelines and Protocols

34. High Risk Cases : medical conditions Heart disease 3 • Woman with heart disease in pregnancy requires a team approach involving: • Consultant obstetrician. • Consultant cardiologist or obstetric physician, • Anaesthetist • and if necessary • the cardiothoracic surgeon, • and ICU Consultant National and Unified Obstetric and Newborn care Guidelines and Protocols

35. High Risk Cases : medical conditions Heart disease 3 • Pre-pregnancymanagement: • Assess the severity of the cardiac lesion and cardiovascular reserve • Discuss maternal and fetal risks • Review drug treatment, particularly potentially teratogenic drugs. • Advice against pregnancy and discuss contraceptive options in women with high risks such as Eisenmenger's syndrome, pulmonary hypertension and Marfan's syndrome with aortic root involvement. • Offer genetic counseling to women with congenital heart disease or heritable conditions. • Commence Folic Acid for prophylaxis. National and Unified Obstetric and Newborn care Guidelines and Protocols

36. High Risk Cases : medical conditions Heart disease 3 • Antenatal Management : First Antenatal Visit: • Pregnant patients with heart disease should be seen at their booking clinic by a Consultant obstetrician. • Take a full history and examination should be performed, to make a provisional diagnosis. • Routine investigations should be requested including C.B.C, urinalysis, and a Dating ultrasound. • A formal referral to cardiologist has to be made • Pregnant patients with cardiac disease should be graded in response to physical activity : • GRADE I No resulting limitation of physical activity • GRADE II Slight limitation of physical activity • GRADE III Marked limitation of physical activity • GRADE IV Inability to carry out any physical activity without discomfort and have orthopnoea. National and Unified Obstetric and Newborn care Guidelines and Protocols

37. High Risk Cases : medical conditions Heart disease 3 • Termination of pregnancymight be considered in high risk cases such as: • Eisenmenger’s syndrome • Fallots tetralogy • Primary pulmonary hypertension • Uncorrected or complicated • Atrial septal defect • Patent ductus arteriosus • Non rheumatic severe aortic stenosis • Ventricular septal defect • Coarctation of the aorta • Marfans syndrome • Peripartum cardiopathy • Coronary artery disease   National and Unified Obstetric and Newborn care Guidelines and Protocols

38. High Risk Cases : medical conditions Heart disease 3 • Antenatal Management : Subsequent Antenatal Care: • Every two weeks till 32 weeks, and weekly thereafter till delivery • Look for the presence of risk factors for cardiac failure • Infection • Hypertension • Obesity • Anaemia • Multiple pregnancy • Development of arrhythmia or change of grading to worse. • Respiratory disease • Patients with cardiac disease who may go into cardiac failure, needs hospital care • Assess fetal growth and wellbeing clinically and by using serial ultrasound and cardiotocography. National and Unified Obstetric and Newborn care Guidelines and Protocols

39. High Risk Cases : medical conditions Heart disease 3 • Anticoagulation therapy in pregnant women with heart disease: • Consider Anticoagulation (in consultation with cardiologist) in pregnant patients with any of the followings: • Pulmonary hypertension • Artificial valve replacement • Those with or at risk of atrial fibrillation. • Those with increased a risk of thromboembolism. National and Unified Obstetric and Newborn care Guidelines and Protocols

40. High Risk Cases : medical conditions Heart disease 3 If the patient goes into labour while taking Warfarin. 1.Call the Cardiologist urgently 2.Check INR 3 times control. 3.Give vit K injection to the mother. 4.Ask Blood Bank to prepare fresh frozen plasma to be given when needed. 5.Give Vitamin ‘K’ to the baby. 6.After delivery the patient should continue to receive Heparin. Warfarin may be recommenced 2-5 days after delivery. 7.Warfarin is not contra indicated with breast-feeding. National and Unified Obstetric and Newborn care Guidelines and Protocols

41. High Risk Cases : medical conditions Heart disease 3 • Endocarditis prevention • Prophylactic antibiotics should be given in the following conditions: • Those with previous endocardities or at risk • Those who have valve replacement • Those who are going to have operative delivery • Those who delivered following prolonged rupture of membranes National and Unified Obstetric and Newborn care Guidelines and Protocols

42. High Risk Cases : medical conditions Heart disease 3 • Endocarditis prevention : Drug Regimes • 1.Standard Regime • Intravenous Ampicillin 2 gm + Gentamycin (1.5 mg/kg) (not to exceed 120 mg). 30 minutes before procedure (IOL/onset of labour). • A repeat dose of Amoxicillin 1.5 g orally 6 hrs after initial dose can be given. Alternatively the above parenteral regimen may be repeated once 8 hrs after initial dose.  • 2.Alternative Regime: (If allergy to Ampicillin/Amoxicillin) • Intravenous Vancomycin 1.0 g over 1 hr plus intravenous + Gentamycin 1.5mg / kg (not to exceed 120 mg) 1 hr before procedure • Alternative regime is Telcoplanin 400 mg iv + Gentamycin 1.5 mg / kg (not to exceed 120 mg) 1 hr before procedure • The same dose may be repeated once again 8 hrs after initial dose. National and Unified Obstetric and Newborn care Guidelines and Protocols

43. High Risk Cases : medical conditions Heart disease 3 • Management during Labour:General management: • Labour should not be induced. IOL is reserved for obstetric indications. • Caesarean sections are reserved for obstetric indications and specific cardiac conditions. • If IOL is indicated, communicate with cardiologist, • Consultant on duty should review the patient • Commence antibiotic prophylaxis once labour pains ensue. • Communicate with cardiologist and anaesthetist for patients who are at risk. • Be careful with fluid management not to overload her. • Avoid Methergin in 3rd stage if possible. • Keep patient propped up, comfortable and reassured National and Unified Obstetric and Newborn care Guidelines and Protocols

44. High Risk Cases : medical conditions Heart disease 3 • Management during Labour:First Stage of Labour: • left lateral position • IV infusion of 5% Dextrose (500ml) at a rate of 80 ml / hour. • keep a fluid balance • combined cardiologist/anaesthetist team . • Establish base line readings BP, pulse rate, Temperature stage of lung bases, Hb CBC and urinalysis. • Auscultation of the lung bases • Analgesia is best given as epidural, • Vaginal examination should be limited • Oxygen must be available and should be administrated dyspnoea or cyanosis. • Preparation for cardiac emergency drugs (Digoxin, Lasix, Morphine or Pethidine) and instruments (Endo-tracheal tube, Laryngoscope oxygen source). • Make sure that all the instruments are in working order. National and Unified Obstetric and Newborn care Guidelines and Protocols

45. High Risk Cases : medical conditions Heart disease 3 • Management during Labour: • Second stage of Labour: • In compensated cases; manage second stage routinely, there is no advantage to perform a routine instrumental delivery in a woman who is going to push the baby easily. • Shorten second stage of labour, in patients who are symptomatic where instrumental delivery may be advantageous provided that all conditions are fulfilled • Third stage of Labour: • Manage third stage actively. • Avoid injection of Ergometrine • Inject 5 IU of oxytocin intravenously at delivery of the anterior shoulder. This can be repeated if indicated. National and Unified Obstetric and Newborn care Guidelines and Protocols

46. High Risk Cases : medical conditions Heart disease 3 • Management during Labour: Post Partum Care: • As postpartum period represents an extremely high-risk situation for patients whose grade of disease may deteriorate rapidly, intensive monitoring must continue while the patient in the labour ward. • 2. The patient should be assessed half an hourly by the SHO on duty. • 3. On transfer to the post natal ward continuous care must be ensured by hourly assessment by the nurses. National and Unified Obstetric and Newborn care Guidelines and Protocols

47. High Risk Cases : medical conditions Heart disease 3 • Manage acute pulmonary oedema: • Oxygen by face mask • Put patient in propped up position • Morphine 5-15mg im • Input/output chart. • Frusemide 20-40mg I/v • Digitalis • (in consultation with Cardiologist/Obstetric Medical specialist) • If not yet delivered , expedite delivery. National and Unified Obstetric and Newborn care Guidelines and Protocols

48. High Risk Cases : medical conditions Bronchial Asthma 4 Topic 3 High Risk Cases Sub topic 4 Bronchial Asthma Care group Pregnant / laboring women with bronchial asthma Standard statement Definition Chronic difficulty in breathing, it is the most common chronic disease in young adults, affecting 3% of women of childbearing age. pregnancy may improve, worsen or have no effect on the course of bronchial asthma National and Unified Obstetric and Newborn care Guidelines and Protocols

49. High Risk Cases : medical conditions Bronchial Asthma 4 • Pre-pregnancy counseling and management: • Patient should be referred to medical specialist • Aim to achieve good control of asthma before pregnancy • Severely uncontrolled disease may increase the risk of preterm labour, low birth weight, slight increased congenital anomalies, • all these risks can be minimised by good control of the disease. • Asthmatic drugs are safe in pregnancy • insufficient data to establish whether the recently introduced drug- Leukotriene antagonists are safe in pregnancy. National and Unified Obstetric and Newborn care Guidelines and Protocols

50. High Risk Cases : medical conditions Bronchial Asthma 4 • Management of Asthma in pregnancy: • The Aim is to achieve a freedom from symptoms by Prevention • Reassure the woman that all drugs commonly used are safe • Women on corticosteroids should be monitored carefully (risk of infection, GDM and PIH) • treat these complications and do not discontinue steroids, • Maintain patients with infrequent symptoms on ventolin (<1/day). • Maintain others women on regular inhaled anti inflammatory medications • If symptoms not controlled give high dose inhaled steroids or long acting inhaled B-agonist (Salmetrol) • If symptoms are still not controlled: try either Theophylline, inhaled ipratropium or a course of regular steroid tablets. The most sensitive indicator of inadequate control is breathlessness at night National and Unified Obstetric and Newborn care Guidelines and Protocols