This document summarizes changes to guidelines and classifications for preeclampsia and abnormal uterine bleeding. For preeclampsia, proteinuria is no longer required for diagnosis and mild and severe classifications have been eliminated. Treatment indications now include magnesium sulfate for more cases and later termination dates. For abnormal uterine bleeding, a new PALM-COEIN classification system has been adopted that defines bleeding types and replaces older systems. Physicians are encouraged to follow such changes to stay up to date and provide standardized care.

1. Be ready !!!
The basics are changing
Dr/ Mahmoud Abdel-Aleem
Assistant Professor of Obstetrics and
Gynecology

3. INTRODUCTION

4. • Human mind is always scrutinizing and
searching for new information.
• Science is always changing and evolving.
– Meticulous research is being done.
– More new types of research.
– Better assessment methods.

5. What do we need to discuss?
Major changes in our basic practice involving
common day-to day problems

6. FOR WHOM IS THIS PRESENTATION?

7. • For guidelines developers: adopt the recent change
to be up-to-date.
• For academics: lecture preparation
• For specialists: application and standardization of
new knowledge and practice.
• For postgraduate students: preparation for an exam
• For undergraduate students: preparation for an exam
• For researchers: for conducting and publishing
research.

8. IT LOOKS LIKE AN “ORANGE AND
PEACHES PRESENTATION”

9. Selected Hot Topics
• Pregnancy:
– Pre-eclampsia.
– Diabetes mellitus during pregnancy.
• Normal labour
– First stage.
– Second stage.
– Third stage.
Common.
Practical.
Recent Major changes.
• Venous Thromboembolism during pregnancy and
labour.
• Gynecology: Abnormal uterine bleeding.

10. Hypertensive disorders during
pregnancy

11. Increasing
incidence
Why
important?
Contribution
to
prematurity
Less than
optimal care
Contribution
to near-miss
cases
Contribution
to maternal
mortality

12. • ACOG Task Force on Hypertension in Pregnancy.
• A 99-page report.
• Published on November 2013.
• Inclusive of the diagnosis and management of
preeclampsia.
• Culmination of two years of hard work by
the 16-member ACOG task force.

13. Classification
• Pre-eclampsia / Eclampsia
• Chronic HT.
• Chronic HT with superimposed PE.
• Gestational HT.

14. A changing paradigm !!!
• The problem is that many patients with
preeclampsia don't have enough proteinuria
to meet the former criteria, so their diagnosis
and treatment are delayed.

15. Starting by definition
Was Now
No longer requires the detection of proteinuria.
Persistent HT that develops during pregnancy or
during the postpartum period that is associated
with:
Proteinuria
OR
New development of thrombocytopenia.
hepatic or renal dysfunction.
Pulmonary edema.
Signs of brain trouble such as seizures and/or
visual disturbances.
Hypertension
Plus
Proteinuria

16. Next: types
Was Now
Preeclampsia
Preeclampsia with severe features.
Mild
severe
Preeclampsia is a dynamic disease:
We don’t know
When
or at Which rate
or in Whom
it will change from mild to severe

17. IUGR is eliminated. Not a feature of severity

18. Hypertension
• As it is; no change
• 140/90 mmHg or more on 2 readings 6 hours
apart at bed rest unless anti-HT drugs were
given.
• 160/110 mmHg or more on single reading at
bed rest unless anti-HT drugs were given.

19. Proteinuria
• Proteinuria: 300 mg/protein in a 24-hr urine
collection.
• A protein/creatinine 0.3
• Dipstick is not recommended because of wide
variability. It is only to be used if other methods
aren’t available. Proteinuria 1+ = diagnosis.
• Massive proteinuria > 5gm. Not to be used.

20. Protein dipstick grading
Designation
Approx. amount
Concentration[6] Daily[7]
Trace 5–20 mg/dL
1+ 30 mg/dL Less than 0.5 g/day
2+ 100 mg/dL 0.5–1 g/day
3+ 300 mg/dL 1–2 g/day
4+ More than 300 mg/dL More than 2 g/day

21. Then: treatment
Was Now
Prophylactic magnesium
sulphate is used in:
BP 160/110 or more.
BP 140/90-159/109 PLUS
symptoms.
Prophylactic Magnesium
sulphate was used in
Severe PE with symptoms
Termination is at:
37 weeks: no severe features
34 weeks: associated severe
features
Termination is at:
38 weeks: mild cases
34 weeks: severe cases

22. Last of All: Prevention of PE
• Vitamin C: no role
• Vitamin E: no role.
• Calcium:
– Normal takers: no role.
– Low takers: reduces the severity of PE.
• Aspirin: 60-80 mg/day.
– Low risk: no value
– High risk: slight decrease in PE and adverse
perinatal outcome.

23. Take home message
• Don’t wait proteinuria to diagnose PE.
• On diagnosis of new onset HT: do platelet
count, liver enzymes, serum creatinine, ask for
visual symptoms.
• There is no method to predict, to prevent PE.
The only way to help women is early diagnosis
and early treatment.
• Use low dose aspirin only in high risk women.

24. Abnormal Uterine Bleeding
FIGO classification.

25. High
incidence
Why
important?
Contribution
to anemia
Lowering the
effective
woman load
weight in
society
Contribution
Contribution
to increasing
surgical
interventions
to low
quality of life

26. • The Federation Internationale de Gynecologie
et d’Obstetrique (FIGO)
• Date: November 2010.
• The causes of AUB in the reproductive years.
• A collaborative, international group consisting
of reproductive clinicians, haematologists,
basic scientists.
• The group had representation from six
continents

27. Normal values for menstrual flow

28. Definitions adopted
• Acute AUB: an episode of bleeding in a woman of
reproductive age, who is not pregnant, that is of
sufficient quantity to require immediate
intervention to prevent further blood loss.
• Chronic AUB: bleeding from the uterus that is
abnormal in frequency, duration and/or volume
and has been present for the majority of the
previous six months.

29. • Inter-menstrual bleeding (IMB): bleeding
between clearly defined cyclic and predictable
menses and includes random episodes as well
as predictable episodes occurring at the same
time each month.

30. Definitions abolished

31. PALM-COEIN SYSTEM

32. Take home message II
• The PALM-COEIN system is readily applicable.
• Let us try to use the new classification system
for abnormal uterine bleeding as regards the
norms, definitions, classification.

33. And So !!!

34. Do we have to follow the changes ?
• We should be in accordance with changes as the
scientific society is now “A small village”.
• Although the changes may look both few and little,
they are of great value in defining, standardizing,
diagnosing and treating diseases.
• We were already following older recommendations,
and once they change, we have to apply the changes
especially if these are simple and not sophisticated.