Extra precautions are not necessary when taking antibiotics with the progestogen-only pill.

Counselling for Women Considering the Progestogen-Only Pill

Women who are considering taking the progestogen-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. It is important to note that the POP should be taken at the same time every day, without a pill-free break, unlike the combined oral contraceptive (COC).

When starting the POP, immediate protection is provided if commenced up to and including day 5 of the cycle. If started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a COC, immediate protection is provided if continued directly from the end of a pill packet.

In case of missed pills, if the delay is less than 3 hours, the pill should be taken as usual. If the delay is more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours.

It is important to note that antibiotics have no effect on the POP, unless the antibiotic alters the P450 enzyme system. Liver enzyme inducers may reduce the effectiveness of the POP. In case of diarrhoea and vomiting, the POP should be continued, but it should be assumed that pills have been missed.

Finally, it is important to discuss sexually transmitted infections (STIs) with healthcare providers when considering the POP. By providing comprehensive counselling, women can make informed decisions about whether the POP is the right contraceptive choice for them.

Meera’s condition has progressed to pre-eclampsia, indicated by her blood pressure exceeding 140/90 mmHg and the presence of proteinuria at a level of 1+ or higher. As per NICE guidelines, it is imperative that she is promptly admitted to an obstetric unit for close observation and potential intervention.

Hypertension during pregnancy is a common condition that can be managed effectively with proper care. In normal pregnancy, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, if a pregnant woman develops hypertension, it is usually defined as a systolic blood pressure of over 140 mmHg or a diastolic blood pressure of over 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from booking readings can also indicate hypertension.

After confirming hypertension, the patient should be categorized into one of three groups: pre-existing hypertension, pregnancy-induced hypertension (PIH), or pre-eclampsia. PIH, also known as gestational hypertension, occurs in 3-5% of pregnancies and is more common in older women. If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker for pre-existing hypertension, it should be stopped immediately, and alternative antihypertensives should be started while awaiting specialist review.

Pregnancy-induced hypertension in association with proteinuria, which occurs in around 5% of pregnancies, may also cause oedema. The 2010 NICE guidelines recommend oral labetalol as the first-line treatment for hypertension during pregnancy. Oral nifedipine and hydralazine may also be used, depending on the patient’s medical history. It is important to manage hypertension during pregnancy effectively to reduce the risk of complications and ensure the health of both the mother and the baby.

If a woman is diagnosed with gestational diabetes and her fasting glucose level is equal to or greater than 7 mmol/l, immediate insulin (with or without metformin) should be initiated.

In this scenario, the patient’s fasting glucose level is above 7 mmol/L, indicating the need for immediate insulin therapy (with or without metformin). The diagnosis of gestational diabetes is based on a fasting plasma glucose level of > 5.6 mmol/L or a 2-hour plasma glucose level of >/= 7.8 mmol/L.

While dietary advice is an essential aspect of diabetes management, it is not sufficient in this case due to the elevated fasting glucose level.

Gliclazide is not a suitable option for gestational diabetes treatment because sulfonylureas are not recommended during pregnancy due to the risk of neonatal hypoglycemia.

Metformin may be used in the management of gestational diabetes, but in cases where the fasting glucose level is equal to or greater than 7 mmol/L, insulin is the preferred treatment option. Insulin and metformin can be used together to manage gestational diabetes.

Since both the fasting glucose and 2-hour glucose levels are elevated, there is no need to repeat the test as the diagnosis of gestational diabetes is conclusive.

Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

The use of the combined oral contraceptive pill could potentially alleviate certain symptoms experienced during perimenopause and help preserve bone mineral density.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

UK Medical Eligibility Criteria for Contraception

The UK medical eligibility criteria for contraception categorizes contraceptive methods into four categories. Category 1 indicates that there are no restrictions for use, while Category 4 indicates that use poses an unacceptable health risk. For patients with a BRCA gene mutation, the combined contraceptive pill has a UK Category rating of 3 and should definitely not be used. All of the other options are rated a UK Category 2, so will still need careful follow-up. The intrauterine copper coil is the only method that is rated a UK Category 1, making it the safest option to use here. There is no restriction on the use of this method for this condition. It is important to consider the UK medical eligibility criteria when choosing a contraceptive method to ensure the safety and effectiveness of the chosen method.

Could you please tell me if you or anyone in your household smokes? If yes, how many cigarettes do they smoke per day? Additionally, may I examine your fingers for any signs of tar-staining?

Smoking cessation is the process of quitting smoking. In 2008, NICE released guidance on how to manage smoking cessation. The guidance recommends that patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion, and that clinicians should not favour one medication over another. These medications should be prescribed as part of a commitment to stop smoking on or before a particular date, and the prescription should only last until 2 weeks after the target stop date. If unsuccessful, a repeat prescription should not be offered within 6 months unless special circumstances have intervened. NRT can cause adverse effects such as nausea and vomiting, headaches, and flu-like symptoms. NICE recommends offering a combination of nicotine patches and another form of NRT to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

Varenicline is a nicotinic receptor partial agonist that should be started 1 week before the patient’s target date to stop. The recommended course of treatment is 12 weeks, but patients should be monitored regularly and treatment only continued if not smoking. Varenicline has been shown in studies to be more effective than bupropion, but it should be used with caution in patients with a history of depression or self-harm. Nausea is the most common adverse effect, and varenicline is contraindicated in pregnancy and breastfeeding.

Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist that should be started 1 to 2 weeks before the patient’s target date to stop. There is a small risk of seizures, and bupropion is contraindicated in epilepsy, pregnancy, and breastfeeding. Having an eating disorder is a relative contraindication.

In 2010, NICE recommended that all pregnant women should be tested for smoking using carbon monoxide detectors. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services. The first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing, or structured self-help and support from NHS Stop Smoking Services. The evidence for the use of NRT in pregnancy is mixed, but it is often used if the above measures fail. There is no evidence that it affects the child’s birthweight. Pregnant women

Hormone Therapy Contraindicated in Breast Cancer Patient

Hormone therapies are not an option for a woman with a history of breast cancer due to contraindications. This rules out all hormone therapy options. Additionally, fluoxetine, which inhibits the enzyme that converts tamoxifen to its active metabolite, should not be used in this case. This is because it reduces the amount of active drug that is released.

The most appropriate treatment option for low mood in the absence of depression is cognitive behavioral therapy (CBT). While it may not help with menopausal flashes, it is recommended by NICE and is the best choice from the list of options provided.

Overall, it is important to consider a patient’s medical history and any contraindications before prescribing any treatment options. In this case, hormone therapy and fluoxetine are not suitable, and CBT is the recommended course of action.

AEDs and their effect on oral contraceptive pill efficacy

The metabolism of oestrogen and progestogen is increased by anti-epileptic drugs (AEDs) that induce cytochrome P450. These drugs can be strong inducers, such as carbamazepine, or weaker inducers, such as topiramate. Phenytoin is a strong enzyme inducer. It should be noted that women using lamotrigine should be advised that seizure frequency may increase when initiating the oral contraceptive pill. Additionally, lamotrigine side effects may increase in the pill-free interval or when discontinuing the oral contraceptive pill. Therefore, it is important to consider the potential effects of AEDs on the efficacy of the oral contraceptive pill.

Implications of Unintended Pregnancy and Contraceptive Efficacy

The risk of unintended pregnancy varies among different contraceptive methods. The Progestogen implant has the lowest failure rate at 0.05% in the first year of use, while the COCP has a failure rate of 9%. However, the implications of an unintended pregnancy for an individual patient must be considered when advising on contraception. In this case, the patient’s FEV1 and BMI suggest that the consequences of an unintended pregnancy would be very serious.

Furthermore, while the COCP may not be a suitable option for this patient due to its high failure rate, her potential risk factors for developing VTE should also be taken into account. Despite having a negative personal and family history, normotension, non-smoking status, and BMI <30 kg/m2, her frequent hospital admissions and indwelling intravenous catheters may increase her risk of developing VTE. Therefore, careful consideration is necessary when selecting a contraceptive method for this patient.

Managing Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. Its management is complex due to the unclear cause of the condition. However, it is known that PCOS is associated with high levels of luteinizing hormone and hyperinsulinemia, and there is some overlap with the metabolic syndrome. General management includes weight reduction if appropriate and the use of combined oral contraceptives (COC) to regulate the menstrual cycle and induce a monthly bleed.

Hirsutism and acne are common symptoms of PCOS, and a COC pill may be used to manage them. Third-generation COCs with fewer androgenic effects or co-cyprindiol with an anti-androgen action are possible options. If these do not work, topical eflornithine may be tried, or spironolactone, flutamide, and finasteride may be used under specialist supervision.

Infertility is another issue that women with PCOS may face. Weight reduction is recommended if appropriate, and the management of infertility should be supervised by a specialist. There is an ongoing debate about whether metformin, clomifene, or a combination should be used to stimulate ovulation. A 2007 trial published in the New England Journal of Medicine suggested that clomifene was the most effective treatment. However, there is a potential risk of multiple pregnancies with anti-oestrogen therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS. Metformin is also used, either combined with clomifene or alone, particularly in patients who are obese. Gonadotrophins may also be used.

If a patient misses a progesterone only pill by over 12 hours or a desogestrel pill by over 36 hours, they should take the missed pill as soon as they remember. Only one pill should be taken, even if multiple pills have been missed. The next pill should be taken at the usual time, which may result in taking two pills in one day. To ensure effectiveness, additional contraceptive precautions such as condoms or abstaining from sex should be taken for 48 hours after restarting the pill. Emergency contraception may be necessary if unprotected sex occurred after the missed pill and within 48 hours of restarting it. The desogestrel pill has the advantage of a longer window for taking it, reducing the likelihood of missed pills.

The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.

If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.

Treatment of C. trachomatis Infection in Pregnancy

C. trachomatis infection is becoming more common in the UK and can lead to adverse fetal outcomes such as spontaneous miscarriage, premature rupture of membranes, and intrauterine growth retardation. Therefore, treatment is advised ahead of test results if chlamydia is strongly suspected clinically. Current UK guidelines recommend three different options for pregnant patients: erythromycin, amoxicillin, and azithromycin. However, erythromycin is the most appropriate option as it is the recommended treatment by most guidelines. Doxycycline, co-trimoxazole, and metronidazole are not routinely used in the treatment of chlamydia during pregnancy. It is also important to note that pregnant patients should be tested for cure 5 weeks after completing treatment (or 6 weeks if azithromycin is used).

Mothers experiencing the ‘baby blues’ typically require reassurance, support, and follow-up. This is the correct answer as ‘baby blues’ is a common condition among mothers in the postnatal period, usually starting a week after childbirth and lasting only a few days. It is normal for mothers to feel emotional, anxious, tearful, and low after giving birth due to sudden hormonal changes. Reassurance is usually sufficient to manage this condition.

Cognitive behavioural therapy and starting sertraline are incorrect options as they are suitable for patients with postnatal depression, which tends to start within 1-3 months post-delivery. Symptoms of postnatal depression include those of baby blues, but with additional symptoms such as lack of sleep, appetite changes, anhedonia, and thoughts of hurting themselves and their baby. Symptoms may also come on more gradually and last for a long time. However, in this vignette, the patient only describes feelings related to low mood and anxiety that set in a week after giving birth, making a diagnosis of postnatal depression unlikely.

Referring to psychiatry is also an incorrect option as it is necessary only for severe circumstances where the patient has severe mental health impairment and poses a risk to themselves or others. This vignette suggests that the patient has baby blues, so reassurance would be the most appropriate option.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of over 13 indicates a ‘depressive illness of varying severity’, and the questionnaire includes a question about self-harm. The sensitivity and specificity of this screening tool are over 90%.

‘Baby-blues’ are seen in around 60-70% of women and typically occur 3-7 days following birth. This condition is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features of postnatal depression are similar to depression seen in other circumstances.

Puerperal psychosis affects approximately 0.2% of women and usually occurs within the first 2-3 weeks following birth. The features of this condition include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Reassurance and support are important for all these conditions, but admission to hospital is usually required for puerperal psychosis, ideally in a Mother & Baby Unit. Cognitive behavioural therapy may be beneficial, and certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. While these medications are secreted in breast milk, they are not thought to be harmful to the infant. However, fluoxetine is best avoided due to its long half-life. There is around a 25-50% risk of recurrence following future pregnancies.

Treatment options for urge incontinence

Caffeine reduction is the first recommended therapy for patients with significant urge incontinence and a history of excessive caffeine use. If symptoms persist, bladder training is the next step. For those who do not respond to bladder training, oxybutynin may be effective. In postmenopausal women with significant vaginal atrophy, oestrogen cream may also be tried. However, electrical stimulation is not routinely recommended. It is important to consult with a healthcare professional to determine the best treatment plan for individual cases of urge incontinence.

Complications of Diabetes during Pregnancy

Diabetes during pregnancy can lead to various complications for both the mother and the baby. Maternal complications may include polyhydramnios, which occurs in 25% of cases and may be due to fetal polyuria. Preterm labor is also a common complication, affecting 15% of cases and often associated with polyhydramnios.

Neonatal complications may include macrosomia, although diabetes can also cause small for gestational age babies. Hypoglycemia is another common complication, which occurs due to beta cell hyperplasia. Respiratory distress syndrome may also occur, as surfactant production is delayed. Polycythemia can lead to neonatal jaundice, and malformation rates increase 3-4 fold, including sacral agenesis, CNS and CVS malformations, and hypertrophic cardiomyopathy. Stillbirth, hypomagnesemia, hypocalcemia, and shoulder dystocia (which may cause Erb’s palsy) are also possible complications.

The appropriate course of action for a woman exhibiting symptoms of agitation and paranoid delusions after giving birth is to admit her to the hospital for urgent assessment. This is likely a case of postpartum psychosis, which is different from postnatal depression. Prescribing medication to aid in sleep or reassuring the patient that her low mood will improve with time are not appropriate options in this case. Gradual titration of medication would also not manage her acute symptoms and ensure the safety of herself and her baby. Ideally, she should be admitted to a Mother & Baby Unit for proper care.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of over 13 indicates a ‘depressive illness of varying severity’, and the questionnaire includes a question about self-harm. The sensitivity and specificity of this screening tool are over 90%.

‘Baby-blues’ are seen in around 60-70% of women and typically occur 3-7 days following birth. This condition is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features of postnatal depression are similar to depression seen in other circumstances.

Puerperal psychosis affects approximately 0.2% of women and usually occurs within the first 2-3 weeks following birth. The features of this condition include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Reassurance and support are important for all these conditions, but admission to hospital is usually required for puerperal psychosis, ideally in a Mother & Baby Unit. Cognitive behavioural therapy may be beneficial, and certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. While these medications are secreted in breast milk, they are not thought to be harmful to the infant. However, fluoxetine is best avoided due to its long half-life. There is around a 25-50% risk of recurrence following future pregnancies.

Preterm labour is a well-known complication for mothers with diabetes during pregnancy.

Complications of Diabetes during Pregnancy

Diabetes during pregnancy can lead to various complications for both the mother and the baby. Maternal complications may include polyhydramnios, which occurs in 25% of cases and may be due to fetal polyuria. Preterm labor is also a common complication, affecting 15% of cases and often associated with polyhydramnios.

Neonatal complications may include macrosomia, although diabetes can also cause small for gestational age babies. Hypoglycemia is another common complication, which occurs due to beta cell hyperplasia. Respiratory distress syndrome may also occur, as surfactant production is delayed. Polycythemia can lead to neonatal jaundice, and malformation rates increase 3-4 fold, including sacral agenesis, CNS and CVS malformations, and hypertrophic cardiomyopathy. Stillbirth, hypomagnesemia, hypocalcemia, and shoulder dystocia (which may cause Erb’s palsy) are also possible complications.

Starting Contraception: Important Considerations

When starting contraception, it is important for the clinician to ensure that the woman is likely to continue to be at risk of pregnancy or has expressed a preference to begin contraception immediately. Additionally, the woman should be aware that she may be pregnant and that there are theoretical risks from contraceptive exposure to the fetus, although evidence indicates no harm. It is also important to note that pregnancy can only be excluded once a pregnancy test is negative at least three weeks after the last episode of unprotected sexual intercourse. Therefore, the woman should be advised to carry out a pregnancy test at least three weeks after the last episode of unprotected sexual intercourse and advised on additional contraception. While a negative pregnancy test is not required before starting contraception, the clinician should be reasonably sure that the woman is not pregnant or at risk of pregnancy. It is important to keep in mind that this practice may be outside the product licence.

The Kyleena intrauterine system (IUS) has a higher amount of levonorgestrel (LNG) compared to the Jaydess IUS. The Mirena IUS has the highest amount of LNG (52mg) and is approved for use for up to 5 years in this age group. On the other hand, the Jaydess IUS has the lowest amount of LNG (13.5mg) and is approved for use for up to 3 years. The Kyleena IUS contains 19.5mg of LNG and is approved for use for up to 5 years, making it a better option than the Jaydess IUS in terms of LNG content. While the Mirena IUS has the highest amount of circulating LNG, it may have a better bleeding profile than the other options. Additionally, the Jaydess and Kyleena IUS are smaller in size and have smaller insertion tubes, which may make them easier to fit.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Breakthrough Bleeding on Combined Oral Contraceptive

In patients experiencing breakthrough bleeding while on the combined oral contraceptive, it is crucial to check their compliance and potential illness. However, if these factors are not the cause, breakthrough bleeding may indicate an alternative issue and prompt further investigation for gynaecological causes. This is especially true for patients who have been taking the pill for an extended period.

To assess potential gynaecological causes, a pelvic examination and swabs are necessary. It is also important to ensure that the patient’s smear is up-to-date and to take one if overdue. While cervical cancer is rare in this age group, swabs should be taken to check for chlamydial cervicitis, the most common cause of breakthrough bleeding in young sexually active women.

Additionally, it is crucial to consider the possibility of pregnancy and perform a pregnancy test. However, in cases where compliance and regular usage of the combined pill are confirmed, the likelihood of pregnancy is remote. Proper investigation and assessment can help identify the underlying cause of breakthrough bleeding and ensure appropriate treatment.

To diagnose gestational diabetes, the fasting glucose level should be equal to or greater than 5.6 mmol/L or the 2-hour glucose level should be equal to or greater than 7.8 mmol/L. According to NICE guidance, either of these criteria can be used for OGTT diagnosis. Therefore, the correct diagnosis would be a fasting glucose level of 4.8 mmol/L and a 2-hour glucose level of 7.8 mmol/L. The other options are incorrect as they do not meet the diagnostic threshold, and NICE doesn’t consider 1-hour glucose results in their criteria. It is worth noting that SIGN guidance has different diagnostic criteria.

Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

Statin therapy is not recommended during pregnancy due to the risk of congenital anomalies and potential impact on fetal development. Atorvastatin, in particular, is contraindicated during pregnancy and should be avoided three months prior to attempting pregnancy. However, lactulose and nasal steroids are considered safe for use during pregnancy. It is important for pregnant individuals with asthma to continue taking their medication to maintain good symptom control.

Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

Although the progestogen-only pill can be used in combination with HRT, it cannot serve as the sole progestogen component. Women aged 40 and above can use the combined oral contraceptive pill, which is classified as UKMEC2. For women over 45 years, Depo-Provera is also classified as UKMEC2.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

Although HRT is generally considered safe for patients with migraines (with or without aura), it is important to note that in some cases, it may actually worsen migraines. While HRT can improve vasomotor symptoms, it also increases the risk of stroke and breast cancer. However, this doesn’t necessarily mean that HRT should be avoided altogether. Patients should be fully informed of the risks and benefits so that they can make an informed decision. In some cases, a Mirena coil may be used as the progestogen component of HRT, but an estrogen component is still necessary for controlling vasomotor symptoms. Ultimately, while HRT can be prescribed for patients with a history of migraines, it is important to advise them of the potential for worsening migraines.

Managing Migraine in Relation to Hormonal Factors

Migraine is a common neurological condition that affects many people, particularly women. Hormonal factors such as pregnancy, contraception, and menstruation can have an impact on the management of migraine. In 2008, the Scottish Intercollegiate Guidelines Network (SIGN) produced guidelines on the management of migraine, which provide useful information on how to manage migraine in relation to these hormonal factors.

When it comes to migraine during pregnancy, paracetamol is the first-line treatment, while NSAIDs can be used as a second-line treatment in the first and second trimester. However, aspirin and opioids such as codeine should be avoided during pregnancy. If a patient has migraine with aura, the combined oral contraceptive (COC) pill is absolutely contraindicated due to an increased risk of stroke. Women who experience migraines around the time of menstruation can be treated with mefenamic acid or a combination of aspirin, paracetamol, and caffeine. Triptans are also recommended in the acute situation. Hormone replacement therapy (HRT) is safe to prescribe for patients with a history of migraine, but it may make migraines worse.

In summary, managing migraine in relation to hormonal factors requires careful consideration and appropriate treatment. The SIGN guidelines provide valuable information on how to manage migraine in these situations, and healthcare professionals should be aware of these guidelines to ensure that patients receive the best possible care.

Pregnant women with a BMI of ≥30 kg/m² should be prescribed a high dose of 5mg folic acid to help prevent neural tube defects (NTD) in the first trimester of pregnancy. This is in addition to patients with diabetes, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD. Folic acid should ideally be started before conception to further reduce the risk of NTD.

However, a history of asthma, smoking, patient age, and Asian ethnicity are not indications for high-dose folic acid prescribing in pregnancy. Smoking during pregnancy can increase the risk of prematurity, low birth weight, and cleft lip/palate, but there is currently no recommendation for high-dose folic acid prescribing for pregnant smokers. While asthma and extreme maternal age may carry some NTD risk, there is no current recommendation for high-dose folic acid prescribing for these patient groups.

In addition to folic acid, all pregnant patients should take vitamin D 10mcg (400 units) daily throughout their entire pregnancy, according to NICE guidelines.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. THF plays a crucial role in transferring 1-carbon units to essential substrates involved in DNA and RNA synthesis. Green, leafy vegetables are a good source of folic acid. However, certain medications like phenytoin and methotrexate, pregnancy, and alcohol excess can cause folic acid deficiency. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, all women should take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if either partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with antiepileptic drugs or coeliac disease, diabetes, or thalassaemia trait, and those who are obese (BMI of 30 kg/m2 or more) are also at higher risk and should take the higher dose of folic acid.

Acne Medications and Pregnancy: Risks and Precautions

Acne is a common skin condition that affects many people, including pregnant women. However, not all acne medications are safe to use during pregnancy. Here are some important things to know about the risks and precautions of using acne medications during pregnancy.

Isotretinoin is a highly effective medication for reducing sebum secretion, but it is also highly teratogenic. Women who take isotretinoin must have a negative pregnancy test before treatment and use effective contraception during and after the course. Congenital deafness and central nervous system and heart defects may occur in children exposed to isotretinoin in utero.

Topical retinoids, such as topical isotretinoin and topical retinoin, have a very low absorption rate through the skin. However, there are some reports of birth defects associated with their use, so women should avoid using them during pregnancy until more data is collected.

Clindamycin, a topical and systemic antibiotic, has no reported adverse effects in pregnancy. Minocycline and oxytetracycline are less effective for acne treatment but are also less teratogenic. However, tetracyclines can stain bones and teeth, so they should be stopped if pregnancy occurs. Erythromycin is a more suitable antibiotic for pregnant women with acne.

In summary, pregnant women with acne should consult with their healthcare provider before using any acne medication. It is important to weigh the potential risks and benefits of each medication and take appropriate precautions to ensure the safety of both the mother and the fetus.

In the event that a pregnant patient who is not immune is exposed to Chickenpox, it is recommended that she receive VZIG as soon as possible. VZIG can still be effective if administered within 10 days of contact, with the definition of continuous exposure being 10 days from the appearance of the rash in the initial case. If there is another exposure reported and at least 3 weeks have passed since the last dose, a second dose of VZIG may be necessary.

Chickenpox Exposure in Pregnancy: Risks and Management

Chickenpox is caused by the varicella-zoster virus and can pose risks to both the mother and fetus during pregnancy. The mother is at a five times greater risk of pneumonitis, while the fetus is at risk of developing fetal varicella syndrome (FVS) if the mother is exposed to Chickenpox before 20 weeks gestation. FVS can result in skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There is also a risk of shingles in infancy and severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth.

To manage Chickenpox exposure in pregnancy, post-exposure prophylaxis (PEP) may be necessary. If the pregnant woman is not immune to varicella, VZIG or antivirals may be given within 10 days of exposure. Waiting until days 7-14 is recommended to reduce the risk of developing clinical varicella. However, the decision on choice of PEP for women exposed from 20 weeks of pregnancy should take into account patient and health professional preference as well as the ability to offer and provide PEP in a timely manner.

If a pregnant woman develops Chickenpox, specialist advice should be sought. Oral aciclovir may be given if the pregnant woman is ≥ 20 weeks and presents within 24 hours of onset of the rash. However, caution should be exercised if the woman is < 20 weeks. Overall, managing Chickenpox exposure in pregnancy requires careful consideration of the risks and benefits to both the mother and fetus.

Postnatal depression affects approximately 1 in 7 women and its symptoms and effects are just as severe as depression at other times. While hormonal changes may contribute to postnatal depression, it is not the sole cause. Women who are breastfeeding can safely take most tricyclic antidepressants, except for doxepin, as long as their infant is healthy and being monitored. However, the use of St John’s wort is not recommended for breastfeeding mothers with depression.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of over 13 indicates a ‘depressive illness of varying severity’, and the questionnaire includes a question about self-harm. The sensitivity and specificity of this screening tool are over 90%.

‘Baby-blues’ are seen in around 60-70% of women and typically occur 3-7 days following birth. This condition is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features of postnatal depression are similar to depression seen in other circumstances.

Puerperal psychosis affects approximately 0.2% of women and usually occurs within the first 2-3 weeks following birth. The features of this condition include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Reassurance and support are important for all these conditions, but admission to hospital is usually required for puerperal psychosis, ideally in a Mother & Baby Unit. Cognitive behavioural therapy may be beneficial, and certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. While these medications are secreted in breast milk, they are not thought to be harmful to the infant. However, fluoxetine is best avoided due to its long half-life. There is around a 25-50% risk of recurrence following future pregnancies.

It is safe to insert a contraceptive implant after childbirth, even immediately. However, the manufacturer of the most commonly used implant in the UK recommends waiting at least 4 weeks after childbirth for breastfeeding women. While there is no evidence of harm to the mother or baby, it is not recommended to insert an implant during pregnancy due to potential complications. It is important to note that fertility may not return until after the implant is removed.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

It is important to screen pregnant women for bacteriuria as untreated cases may lead to acute pyelonephritis. Therefore, taking no action based on urine results is inappropriate. Trimethoprim is not recommended in the first trimester due to its teratogenic risk, so nitrofurantoin is a better option. Local prescribing guidelines should always be followed. If group B streptococcal bacteriuria is detected, antenatal services must be informed as prophylactic intrapartum antibiotics will be necessary.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.