The patient should be informed that their future fertility is not impacted by the abortion and there is no association with placenta praevia, ectopic pregnancy, stillborn or miscarriage. However, they should also be made aware of the potential complications that may arise from the procedure. These include severe bleeding, uterine perforation (surgical abortion only), and cervical trauma (surgical abortion only). The risks of these complications are lower for early abortions and those performed by experienced clinicians. In the event that one of these complications occurs, further treatment such as blood transfusion, laparoscopy or laparotomy may be required. Additionally, infection may occur after medical or surgical abortion, but this risk can be reduced through prophylactic antibiotic use and bacterial screening for lower genital tract infection.

Termination of Pregnancy in the UK

The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, although in emergencies, only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise. The method used to terminate pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone followed by prostaglandins is used, while surgical dilation and suction of uterine contents are used for pregnancies less than 13 weeks. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion is used. The 1967 Abortion Act outlines the conditions under which a person shall not be guilty of an offense under the law relating to abortion. These limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.

Missed Birth Control Pills

When a woman misses three or more birth control pills in the third week of her cycle, she should complete the third week but skip the pill-free period and start a new pack immediately. This advice is according to the Faculty of Sexual and Reproductive Healthcare (FSRH). It is also recommended to use barrier contraception for seven days. On the other hand, if only one pill is missed, the woman can maintain the pill-free week. It is not usually necessary to extend the pill-free period beyond seven days. However, emergency contraception may be necessary depending on when the pills were missed. It is important to review the latest FSRH guidance before taking any exams.

Premature Ovarian Insufficiency: Causes, Symptoms, and Management

Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flashes, night sweats, infertility, secondary amenorrhoea, and elevated FSH and LH levels. Hormone replacement therapy or a combined oral contraceptive pill is recommended until the age of the average menopause, which is 51 years. It is important to note that HRT doesn’t provide contraception in case spontaneous ovarian activity resumes.

While the use of combined oral contraceptive pills (COCP) may be restricted for obese patients, all other contraceptive options are considered safe with a UK Medical Eligibility Criteria (UKMEC) rating of 1. It has been established that Depo-Provera may lead to weight gain, but there is no indication that the dosage of progestogen-only pills or other forms of contraception needs to be altered for obese patients.

Contraception for Obese Patients

Obesity can increase the risk of venous thromboembolism in women who take the combined oral contraceptive pill (COCP). Therefore, it is recommended that patients with a BMI of 30-34 kg/m² should use the COCP with caution (UKMEC 2), while those with a BMI of 35 kg/m² or higher should avoid it altogether (UKMEC 3). Additionally, the combined contraceptive transdermal patch may be less effective in patients who weigh over 90kg.

It is important to note that all other methods of contraception have a UKMEC of 1, meaning they are considered safe for use in obese patients. However, patients who have undergone gastric sleeve/bypass/duodenal switch surgeries cannot use oral contraception, including emergency contraception, due to its lack of efficacy.

In summary, obese patients should be cautious when using the COCP and consider alternative methods of contraception. It is important to discuss contraceptive options with a healthcare provider to determine the best course of action based on individual needs and medical history.

Breastfeeding women who follow a vegan diet may require a B12 supplement as this vitamin is primarily present in meat and dairy products. Vegans can obtain vitamin B12 from fortified breakfast cereals and yeast extracts like Marmite. Additionally, the NHS recommends that all breastfeeding women, regardless of their dietary preferences, should take a daily vitamin D supplement of 10 mcg to promote bone health for themselves and their baby. Women who are eligible for Healthy Start vouchers may receive free supplements, and their Health Visitor can provide guidance on this matter.

Vitamin B12 is a type of water-soluble vitamin that belongs to the B complex group. Unlike other vitamins, it can only be found in animal-based foods. The human body typically stores enough vitamin B12 to last for up to 5 years. This vitamin plays a crucial role in various bodily functions, including acting as a cofactor for the conversion of homocysteine into methionine through the enzyme homocysteine methyltransferase, as well as for the isomerization of methylmalonyl CoA to Succinyl Co A via the enzyme methylmalonyl mutase. Additionally, it is used to regenerate folic acid in the body.

However, there are several causes of vitamin B12 deficiency, including pernicious anaemia, Diphyllobothrium latum infection, and Crohn’s disease. When the body lacks vitamin B12, it can lead to macrocytic, megaloblastic anaemia and peripheral neuropathy. To prevent these consequences, it is important to ensure that the body has enough vitamin B12 through a balanced diet or supplements.

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.

If a woman has a history of STI, it is advisable to refer her to secondary care earlier. For women under 36 years of age, referral for further assessment and management should be considered if they have not conceived after one year, and their history, examination, and investigations are normal. However, if the woman is 36 years or older, has amenorrhea or oligomenorrhea, previous abdominal or pelvic surgery, previous pelvic inflammatory disease, abnormal pelvic examination, or a known reason for infertility, earlier referral should be considered. Similarly, for men, referral should be considered earlier if they have a history of previous genital pathology, urogenital surgery, STI, varicocele, significant systemic illness, abnormal genital examination, or a known reason for infertility.

Understanding Infertility: Initial Investigations and Key Counselling Points

Infertility is a common issue that affects approximately 1 in 7 couples. However, it is important to note that around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

To determine the cause of infertility, basic investigations are typically conducted. These include a semen analysis and a serum progesterone test, which is done 7 days prior to the expected next period. The interpretation of the serum progesterone level is as follows: if the level is less than 16 nmol/l, it should be repeated and if it consistently remains low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

In addition to these investigations, there are key counselling points that should be addressed. These include advising the patient to take folic acid, aiming for a BMI between 20-25, and having regular sexual intercourse every 2 to 3 days. Patients should also be advised to quit smoking and limit alcohol consumption.

By understanding the initial investigations and key counselling points for infertility, healthcare professionals can provide their patients with the necessary information and support to help them conceive.

Obstetric cholestasis is the primary cause of itch during pregnancy that is not accompanied by a rash. To diagnose obstetric cholestasis, doctors should look for symptoms such as itchiness that begins in the third trimester, starts on the palms and soles before spreading upwards, worsens at night, and causes severe scratching that leads to excoriation marks. Additionally, patients may report anorexia, malaise, and abdominal pain, which are also associated with obstetric cholestasis.

If a woman displays any of these symptoms, it is recommended that she be admitted to the hospital or referred to an obstetrician on the same day. In secondary care, liver function tests are conducted to confirm the diagnosis, and treatment may include ursodeoxycholic acid and sedating antihistamines.

Jaundice During Pregnancy

During pregnancy, jaundice can occur due to various reasons. One of the most common liver diseases during pregnancy is intrahepatic cholestasis of pregnancy, which affects around 1% of pregnancies and is usually seen in the third trimester. Symptoms include itching, especially in the palms and soles, and raised bilirubin levels. Ursodeoxycholic acid is used for symptomatic relief, and women are typically induced at 37 weeks. However, this condition can increase the risk of stillbirth.

Acute fatty liver of pregnancy is a rare complication that can occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea, vomiting, headache, jaundice, and hypoglycemia. ALT levels are typically elevated. Supportive care is the initial management, and delivery is the definitive management once the patient is stabilized.

Gilbert’s and Dubin-Johnson syndrome may also be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for Haemolysis, Elevated Liver enzymes, Low Platelets, can also cause jaundice during pregnancy. It is important to monitor liver function tests and seek medical attention if any symptoms of jaundice occur during pregnancy.

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.

Criteria for Determining Pregnancy Status in Starting Contraception

Health professionals can determine with reasonable certainty whether a woman is pregnant or not before starting contraception. This is important to ensure the safety and effectiveness of the chosen contraceptive method. According to CKS NICE, the following criteria can be used to determine pregnancy status:

– The woman has not had sexual intercourse since the last normal menses.
– The woman has used a reliable method of contraception correctly and consistently.
– The woman is within the first 7 days of the onset of a normal menstrual period.
– The woman is within 4 weeks postpartum for non-breastfeeding women.
– The woman is within the first 7 days post-termination of pregnancy or miscarriage.
– The woman is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
– A pregnancy test is performed no sooner than 3 weeks since the last episode of unprotected sexual intercourse (UPSI) and is negative.

By following these criteria, health professionals can ensure that women are not inadvertently exposed to the risks of contraceptive methods during pregnancy. It is important to note that if there is any doubt about pregnancy status, a pregnancy test should be performed before starting contraception.

When a pregnant woman is exposed to Chickenpox, it can lead to serious complications for both her and the developing fetus. To prevent this, the first step is to check the woman’s immune status by testing for varicella antibodies. If she is found to be non-immune, she should receive varicella-zoster immune globulin (VZIG) as soon as possible for post-exposure prophylaxis (PEP).

It is important to note that the management and organization of the blood test can be arranged by the GP, although the midwife should also be informed. If the woman is less than 20 weeks pregnant and non-immune, VZIG should be given immediately, but it may still be effective up to 10 days after exposure.

For pregnant women who develop Chickenpox after 20 weeks of gestation, oral aciclovir or an equivalent antiviral should be started within 24 hours of rash onset. However, if the woman is less than 20 weeks pregnant, it is recommended to seek specialist advice.

It is crucial to take action and not simply provide reassurance in cases where the woman is found to be non-immune to varicella, as both she and the fetus are at risk.

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.

Anorexia Nervosa and its Associated Hormonal Changes

Anorexia nervosa is a serious eating disorder that affects many individuals. It is characterized by a distorted body image and an intense fear of gaining weight. Patients with anorexia often experience hormonal changes that can have significant effects on their health.

One of the most common hormonal changes associated with anorexia is functional hypogonadotrophic hypogonadism. This condition is characterized by low levels of follicle-stimulating hormone (FSH) and luteinising hormone (LH). Despite this, plasma testosterone levels are typically normal in females with anorexia.

Cortisol levels may also be affected in patients with anorexia. While they may be within the normal range, they may fail to suppress with dexamethasone. Additionally, basal levels of T3 may be depressed, while thyroxine (T4) and TSH levels may be normal. Finally, ferritin levels are often low in a state of malnutrition.

Overall, anorexia nervosa can have significant effects on a patient’s hormonal balance. It is important for healthcare providers to be aware of these changes and to monitor patients accordingly.

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.

The effectiveness of hormonal contraception may be reduced by EllaOne. To ensure proper contraception, individuals using the pill, patch, or ring should wait 5 days after taking Ulipristal before starting or restarting their contraception. During this period, it is recommended to use barrier methods.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

During the booking visit for prenatal care, healthcare providers typically test for sexually transmitted infections (STIs) that can have serious consequences for the mother and/or the developing fetus. These include syphilis, hepatitis B, and HIV. Testing for hepatitis C is usually only done for women who are at high risk, such as those who use intravenous drugs. Other STIs, such as chlamydia, gonorrhea, trichomonas, bacterial vaginosis, genital herpes, and genital warts, are not routinely tested for during pregnancy unless the patient has symptoms or is considered to be at risk. It is important to identify and treat STIs during pregnancy to prevent adverse outcomes for both the mother and the baby.

Antenatal care is an important aspect of pregnancy, and the National Institute for Health and Care Excellence (NICE) has issued guidelines on routine care for healthy pregnant women. The guidelines recommend 10 antenatal visits for first pregnancies and 7 visits for subsequent pregnancies, provided that the pregnancy is uncomplicated. Women do not need to see a consultant if their pregnancy is uncomplicated.

The timetable for antenatal visits begins with a booking visit between 8-12 weeks, where general information is provided on topics such as diet, alcohol, smoking, folic acid, vitamin D, and antenatal classes. Blood and urine tests are also conducted to check for conditions such as hepatitis B, syphilis, and asymptomatic bacteriuria. An early scan is conducted between 10-13+6 weeks to confirm dates and exclude multiple pregnancies, while Down’s syndrome screening is conducted between 11-13+6 weeks.

At 16 weeks, women receive information on the anomaly and blood results, and if their haemoglobin levels are below 11 g/dl, they may be advised to take iron supplements. Routine care is conducted at 18-20+6 weeks, including an anomaly scan, and at 25, 28, 31, and 34 weeks, where blood pressure, urine dipstick, and symphysis-fundal height (SFH) are checked. Women who are rhesus negative receive anti-D prophylaxis at 28 and 34 weeks.

At 36 weeks, presentation is checked, and external cephalic version may be offered if indicated. Information on breastfeeding, vitamin K, and ‘baby-blues’ is also provided. Routine care is conducted at 38 weeks, and at 40 weeks (for first pregnancies), discussion about options for prolonged pregnancy takes place. At 41 weeks, labour plans and the possibility of induction are discussed. The RCOG advises that either a single-dose or double-dose regime of anti-D prophylaxis can be used, depending on local factors.

Bacterial vaginosis during pregnancy can lead to various pregnancy-related issues, such as preterm labor. In the past, it was advised to avoid taking oral metronidazole during the first trimester. However, current guidelines suggest that it is safe to use throughout the entire pregnancy. For more information, please refer to the Clinical Knowledge Summary provided.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

Breastfeeding is generally safe with most anti-epileptic drugs, including the commonly prescribed Lamotrigine. This drug is often preferred for women as it doesn’t affect their ability to bear children. However, Carbimazole and Diazepam’s active metabolite can be passed on to the baby through breast milk and should be avoided. Isotretinoin’s effect on breastfed infants is not well studied, but oral retinoids should generally be avoided while breastfeeding.

Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important to aim for monotherapy and to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, with sodium valproate being associated with neural tube defects, carbamazepine being considered the least teratogenic of the older antiepileptics, and phenytoin being associated with cleft palate. Lamotrigine may be a safer option, but the dose may need to be adjusted during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn. It is important to seek specialist neurological or psychiatric advice before starting or continuing antiepileptic medication during pregnancy or in women of childbearing age. Recent evidence has shown a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate, leading to recommendations that it should not be used during pregnancy or in women of childbearing age unless absolutely necessary.

The lactational amenorrhea method is most effective for women who are less than 6 months postpartum, fully breastfeeding, and not experiencing menstrual periods. However, if the baby is receiving formula at night, this method may not be completely reliable. Additionally, ulipristal, a medication used for emergency contraception, is excreted in breast milk for up to 5 days after use, so it is recommended to avoid breastfeeding for a week after taking it, which could significantly impact a woman’s ability to breastfeed.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

Understanding Contraception: A Basic Overview

Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

Barrier methods, such as condoms, act as a physical barrier and can help protect against sexually transmitted infections (STIs). However, their success rate is relatively low, particularly when used by young people. Daily methods include the combined oral contraceptive pill, which inhibits ovulation but increases the risk of venous thromboembolism and certain types of cancer. The progesterone-only pill thickens cervical mucous, but irregular bleeding is a common side effect.

LARCs include implantable contraceptives, injectable contraceptives, and intrauterine devices (IUDs). The implantable contraceptive and injectable contraceptive both inhibit ovulation and thicken cervical mucous, with the implant lasting up to three years and the injection lasting 12 weeks. The IUD decreases sperm motility and survival, while the intrauterine system (IUS) prevents endometrial proliferation and thickens cervical mucous, with irregular bleeding being a common side effect.

In summary, understanding the different types of contraception available and their methods of action can help individuals make informed decisions about their reproductive health.

Pregnant women with bacterial vaginosis can still use oral metronidazole as it has been found to be safe during pregnancy. Bacterial vaginosis can increase the risk of premature birth and miscarriage. There is no evidence of any harmful effects on the fetus during the first trimester of pregnancy. The guidelines suggest treating symptomatic patients at any stage of pregnancy. While both metronidazole and oral clindamycin can enter breast milk, breastfeeding women are advised to use clindamycin intravaginal gel.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

If a pregnant woman who is not immune to Chickenpox has been exposed to the virus before 20 weeks of pregnancy, the recommended course of action is to administer VZIG. Ganciclovir is not typically used to treat Chickenpox, but may be used for acute herpetic keratitis or cytomegalovirus. However, it should be avoided during pregnancy unless the benefits outweigh the risks. General advice is not appropriate for pregnant women with symptoms of Chickenpox due to the risk of fetal varicella syndrome. If the pregnant woman had already developed Chickenpox, oral aciclovir may be prescribed within 24 hours of the onset of the rash.

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.

Infertility Management and Referral Criteria

Infertility is a common issue that affects many couples. According to the Clinical Knowledge Summaries, if a couple has been having regular unprotected sexual intercourse for one year and are without comorbidities that affect fertility, investigation into the cause of infertility should be initiated. If no cause is found, the couple should be referred for specialist input.

The referral criteria for infertility may vary between health authorities, so it is important to refer to local guidelines. However, in general, if the woman is younger than 36 years and history, examination, and investigations are normal in both partners, referral should be considered if the couple has not conceived after one year. If the woman is aged 36 years or older, referral should be considered after six months. Earlier referral may be necessary if there is a known cause for infertility, a history of factors that predispose to infertility, or if treatment is planned that may result in infertility.

It is important to ensure that the couple has been offered counselling before, during, and after investigation and treatment, regardless of the outcome. Infertility and its investigation and treatment can cause psychological stress, and infertility counsellors are provided by all licensed clinics in the UK through the British Infertility Counselling Association.

Safe Medications for Hypertension in Pregnancy

Beta blockers are considered safe during the third trimester of pregnancy, but they are not commonly used due to concerns about intrauterine growth retardation. Instead, labetalol is often preferred as it has an established track record of safety and efficacy. Magnesium sulphate is a recognized treatment for pre-eclampsia, a condition not mentioned in this context. ACE inhibitors are not recommended for use during pregnancy. Nifedipine may be used as a second-line treatment. Methyldopa is a well-studied medication that has been shown to be both effective and safe for both mother and baby during pregnancy. By carefully selecting the appropriate medication, hypertension in pregnancy can be managed safely and effectively.

CKS recommends using propylthiouracil instead of carbimazole during the first trimester of pregnancy due to the potential risk of congenital abnormalities associated with carbimazole. However, in the second trimester, it is advised to switch back to carbimazole as propylthiouracil has been linked to a slight risk of severe liver damage.

During pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG), which causes an increase in the levels of total thyroxine. However, this doesn’t affect the free thyroxine level. If left untreated, thyrotoxicosis can increase the risk of fetal loss, maternal heart failure, and premature labor. Graves’ disease is the most common cause of thyrotoxicosis during pregnancy, but transient gestational hyperthyroidism can also occur due to the activation of the TSH receptor by HCG. Propylthiouracil has traditionally been the antithyroid drug of choice, but it is associated with an increased risk of severe hepatic injury. Therefore, NICE Clinical Knowledge Summaries recommend using propylthiouracil in the first trimester and switching to carbimazole in the second trimester. Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism. Thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation to determine the risk of neonatal thyroid problems. Block-and-replace regimens should not be used in pregnancy, and radioiodine therapy is contraindicated.

On the other hand, thyroxine is safe during pregnancy, and serum thyroid-stimulating hormone should be measured in each trimester and 6-8 weeks postpartum. Women require an increased dose of thyroxine during pregnancy, up to 50% as early as 4-6 weeks of pregnancy. Breastfeeding is safe while on thyroxine. It is important to manage thyroid problems during pregnancy to ensure the health of both the mother and the baby.

Pregnancy-induced hypertension is typically treated with Labetalol as the initial medication.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, age over 40, high BMI, family history of pre-eclampsia, and multiple pregnancy. To reduce the risk of hypertensive disorders in pregnancy, women with high or moderate risk factors should take aspirin daily. Management involves emergency assessment, admission for severe cases, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

Pregnancies that occur after the first childbirth are at the highest risk of complications if the mother was sensitized during the initial delivery. To mitigate this risk, the BCSH recommends that cord blood be tested for ABO and Rh D typing after birth. If the baby is confirmed to be D positive, all previously non-sensitized women who are D negative should be offered a minimum of 500 IU of anti-D Ig within 72 hours of delivery. Maternal samples should also be tested for FMH, and additional doses of anti-D Ig should be administered as indicated by the FMH test results.

Rhesus negative mothers can develop anti-D IgG antibodies if they deliver a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis at 28 and 34 weeks. Anti-D should also be given in various situations, such as delivery of a Rh +ve infant or amniocentesis. Tests include cord blood FBC, blood group, direct Coombs test, and Kleihauer test. Affected fetuses may experience oedema, jaundice, anaemia, hepatosplenomegaly, heart failure, and kernicterus, and may require transfusions and UV phototherapy.

The patient is experiencing recurrent migraines with classic symptoms such as unilateral and pulsating headache. However, topiramate is not the best option as it can reduce the effectiveness of hormonal contraception, including both the combined oral contraceptive pill and the progestogen-only pill (UKMEC 3 (disadvantages outweigh advantages)). Instead, alternative options such as triptans and NSAIDs can be used as monotherapy or in combination for acute treatment. Propranolol is also a suitable preventative treatment for women who are of childbearing age or those who are on hormonal contraceptives.

Topiramate: Mechanisms of Action and Contraceptive Considerations

Topiramate is a medication primarily used to treat seizures. It can be used alone or in combination with other drugs. The drug has multiple mechanisms of action, including blocking voltage-gated Na+ channels, increasing GABA action, and inhibiting carbonic anhydrase. The latter effect results in a decrease in urinary citrate excretion and the formation of alkaline urine, which favors the creation of calcium phosphate stones.

Topiramate is known to induce the P450 enzyme CYP3A4, which can reduce the effectiveness of hormonal contraception. Therefore, the Faculty of Sexual and Reproductive Health (FSRH) recommends that patients taking topiramate consider alternative forms of contraception. For example, the combined oral contraceptive pill and progestogen-only pill are not recommended, while the implant is generally considered safe.

Topiramate can cause several side effects, including reduced appetite and weight loss, dizziness, paraesthesia, lethargy, and poor concentration. However, the most significant risk associated with topiramate is the potential for fetal malformations. Additionally, rare but important side effects include acute myopia and secondary angle-closure glaucoma. Overall, topiramate is a useful medication for treating seizures, but patients should be aware of its potential side effects and contraceptive considerations.

NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The quadruple test should be offered between 15-20 weeks for women who book later in pregnancy. Results of both tests return either a ‘lower chance’ or ‘higher chance’ result. If a woman receives a ‘higher chance’ result, she will be offered a second screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA from placental cells in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities, with private companies offering screening from 10 weeks gestation.

Patients taking sodium valproate must undergo an Annual Acknowledgement of Risk form with a specialist once a year as part of the valproate pregnancy prevention programme. This is crucial as unplanned pregnancies can result in birth defects. To ensure compliance with the programme, the general practitioner should confirm that the patient is using highly effective contraception, have an up-to-date acknowledgement of risk form signed by the specialist and patient, and refer the patient back to the specialist for an annual review. In the event of an unplanned or planned pregnancy, the patient should be urgently referred to the specialist. Highly effective contraception methods include LARC, Cu-IUD, LNG-IUS, IMP, and sterilisation. The progesterone-only implant doesn’t interfere with sodium valproate. Even if the patient is not sexually active, an annual acknowledgement of risk form and highly effective contraception are still required. The form must be signed by the specialist and patient, not the general practitioner or pharmacist.

Sodium Valproate: Uses and Adverse Effects

Sodium valproate is a medication commonly used to manage epilepsy, particularly for generalised seizures. Its mechanism of action involves increasing the activity of GABA in the brain. However, the use of sodium valproate during pregnancy is strongly discouraged due to its teratogenic effects, which can lead to neural tube defects and neurodevelopmental delays in children. Women of childbearing age should only use this medication if it is absolutely necessary and under the guidance of a specialist neurological or psychiatric advisor.

Aside from its teratogenic effects, sodium valproate can also inhibit P450 enzymes, leading to potential drug interactions. It may cause gastrointestinal symptoms such as nausea, as well as weight gain and increased appetite. Alopecia is also a possible side effect, with regrowth often being curly. Ataxia, tremors, and hepatotoxicity are other potential adverse effects. Pancreatitis, thrombocytopaenia, hyponatraemia, and hyperammonemic encephalopathy are also possible, with the latter being treated with L-carnitine.

In summary, while sodium valproate is an effective medication for managing epilepsy, its use during pregnancy is strongly discouraged due to its teratogenic effects. Women of childbearing age should only use this medication if it is absolutely necessary and under the guidance of a specialist neurological or psychiatric advisor. Additionally, potential adverse effects such as gastrointestinal symptoms, weight gain, alopecia, and neurological symptoms should be monitored closely.

Gonorrhea: Symptoms, Treatment, and Complications

Gonorrhea is a sexually transmitted infection caused by the Gram-negative diplococci Neisseria gonorrhoeae. It can affect both males and females, and they may be asymptomatic or have very few symptoms that can go unnoticed. However, some patients may experience cervicitis, a purulent discharge, and fever.

Due to problems with resistance, current treatment guidelines recommend a combination of IM ceftriaxone and azithromycin. Oral Cefixime may be offered if the injection is refused. It is important to treat gonorrhea promptly to prevent complications such as sepsis, arthritis, pharyngitis, and ophthalmia.

In conclusion, gonorrhea is a common sexually transmitted infection that can have serious consequences if left untreated. It is important to practice safe sex and get tested regularly to prevent the spread of the infection.