Ectopic Pregnancy and Contraception

According to the FSRH, a previous ectopic pregnancy is not an absolute contraindication to the use of intrauterine methods of contraception. In fact, the overall risk of ectopic pregnancy is reduced with the use of IUC when compared to using no contraception. However, if pregnancy does occur with an intrauterine method in situ, the risk of an ectopic pregnancy occurring is increased. In some studies, half of the pregnancies that occurred were ectopic.

It is important to note that older editions of an Australian primary care textbook list an ectopic pregnancy as a contraindication. However, the latest FSRH advice is the reference on which the RCGP is likely to base their answers. Therefore, healthcare professionals should follow the most up-to-date guidelines when considering contraception options for patients with a history of ectopic pregnancy.

Frequent feeding in a breastfed baby doesn’t necessarily indicate low milk supply in the mother. It is uncommon for a mother to have low milk supply, and if the baby is growing well and producing enough urine, it is a good sign that the milk supply is sufficient. In fact, frequent feeding or cluster feeding is normal in the early weeks and helps to establish a good milk supply. Breastfeeding mothers should be encouraged to seek support from local and national breastfeeding groups and consult with a trained professional to ensure proper infant positioning and latch.

There is no need to refer the baby to a pediatrician at this stage. It is not recommended to supplement breastfeeding with formula, especially in the early weeks, as this can decrease milk supply. It is important to feed the baby on demand to stimulate milk production. If milk is not removed from the breast, milk production will decrease.

While maternal prolactin deficiency is a rare cause of low milk supply, testing for it is not necessary in this scenario. If there are signs of low milk supply, such as a baby failing to thrive or becoming dehydrated, and after addressing positioning and latch issues, maternal prolactin deficiency may be considered. Factors that increase the likelihood of this condition include a history of maternal thyroid disorder, eating disorder, hypoplastic breasts, or breast surgery.

For more information on breastfeeding problems, refer to the NICE clinical knowledge summary.

Breastfeeding Problems and Management

Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

The Faculty of Sexual and Reproductive Healthcare recommends that an intrauterine contraceptive can be inserted right after the evacuation of the uterine cavity following a surgical abortion, provided that it is the woman’s preferred method of contraception.

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.

Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is equal to or greater than 7 mmol/L at the time of gestational diabetes diagnosis. Glibenclamide may be considered for women who cannot tolerate metformin or do not achieve glucose targets with metformin but decline insulin therapy. If the fasting plasma glucose level is less than 7 mmol/L, lifestyle interventions such as a low glycemic index diet and exercise should be attempted first. If glucose targets are not achieved within 1-2 weeks of lifestyle measures, metformin may be initiated.

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.

For women who have had gestational diabetes, it is recommended to offer a fasting plasma glucose test at 6 weeks after giving birth to rule out diabetes. This is in line with NICE guidelines, which suggest testing between 6-13 weeks postpartum. Testing at 10 days or 2 weeks is not sufficient to accurately assess the risk of developing type 2 diabetes. After 13 weeks, HbA1c testing can be used instead of fasting plasma glucose, but testing at 20 weeks or later is not recommended.

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.

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.

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.

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.

When it comes to treating infertility in PCOS, clomifene is usually the first choice. Metformin can also be used, but only after anti-oestrogens like clomifene have been tried.

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.

Statin therapy should not be used during pregnancy due to potential risks. However, paracetamol is considered safe for use during pregnancy. Lamotrigine is preferred over other anti-epileptics due to a lower risk of neurodevelopmental effects on the foetus, but all pregnant women on anti-epileptics should take 5mg folic acid before conception and during the first trimester. Metformin and insulin are commonly used to treat diabetes during pregnancy. It is important to note that all statins should be avoided during pregnancy as they have been associated with congenital anomalies.

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.

Patients on insulin are not always required to inform the DVLA, except for those on temporary treatment for less than three months or those with gestational diabetes who are taking insulin for less than three months after delivery. If a patient falls under these exceptions, they can continue driving but must follow the guidelines for insulin-taking patients, which include checking their blood glucose two hours before driving and every two hours during the journey. It is incorrect to assume that a patient can continue driving as normal without any stipulations, even if they do not need to inform the DVLA.

DVLA Regulations for Drivers with Diabetes Mellitus

The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

The first-line management for nausea and vomiting in pregnancy/hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral antiemetics or fluids, symptoms are not controlled with primary care management, or hyperemesis gravidarum is suspected. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.

Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, preterm birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

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.

To reduce the risk of neural tube defects, women who are trying to conceive and up to 12 weeks into their pregnancy are recommended to take 400 mcg of folic acid. If there are additional risk factors, such as diabetes or a personal or family history of neural tube defects, a higher dose of 5mg is recommended. For bone health, a daily supplement of 10mcg of vitamin D is advised throughout pregnancy and breastfeeding. If a woman chooses to take a multivitamin during pregnancy, she should ensure that it doesn’t contain high doses of vitamin A (retinol) as it can cause birth defects.

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.

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.

The most appropriate course of action for gestational diabetes is to commence insulin immediately if the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis. While lifestyle changes and co-prescribing metformin should also be discussed, starting insulin is the priority. This is in line with NICE guidelines, which recommend immediate insulin initiation (with or without metformin) and lifestyle advice for glucose levels between 6 and 6.9 mmol/L, especially if there are complications such as macrosomia or hydramnios.

Re-checking the glucose level in two weeks is not appropriate as uncontrolled hyperglycaemia can be dangerous for both the mother and the unborn child.

Starting exenatide is not recommended during pregnancy as there is insufficient data on its safety. Studies in mice have shown adverse effects on fetal and neonatal growth and skeletal development.

Starting metformin alone is not sufficient if the fasting glucose level is greater than 7 mmol/L. However, metformin can be prescribed in combination with insulin.

A trial of lifestyle changes alone is not appropriate if the fasting glucose level is already above 7 mmol/L. If the level is below 7 mmol/L, lifestyle changes can be tried for 1-2 weeks, and if glucose targets are not met, metformin can be offered.

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.

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.

Due to the increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy, induction of labour is typically recommended at 37-38 weeks gestation. Therefore, a normal labour is not appropriate for this patient. Ursodeoxycholic acid is used to treat the intense pruritus associated with this condition. While a caesarean section may be necessary on an emergency basis, it is not currently indicated at 37-38 weeks. Similarly, a caesarean section at 40 weeks is not currently necessary. Induction of labour at 40 weeks is later than the recommended timeline and may increase the risk of stillbirth.

Understanding Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, early diagnosis and management of this condition is crucial for the health and well-being of both the mother and the baby.

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.

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.

Managing Epilepsy in Pregnancy

During pregnancy, it is important to manage epilepsy carefully to ensure the safety of both the patient and fetus. Uncontrolled seizures pose a greater risk than any potential teratogenic effect of the therapy. However, total plasma concentrations of anticonvulsants may fall during pregnancy, so the dose may need to be increased. It is important to explain the potential teratogenic effects of carbamazepine, particularly neural tube defects, and provide the patient with folate supplements to reduce this risk. Screening with alpha fetoprotein (AFP) and second trimester ultrasound are also required. Prior to delivery, the mother should receive vitamin K. Switching therapies is not recommended as it could precipitate seizures in an otherwise stable patient. It is important to note that both phenytoin and valproate are also associated with teratogenic effects.

A lower occurrence of hyperemesis gravidarum is linked to smoking.

Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, preterm birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

Pros and Cons of the Combined Oral Contraceptive Pill

The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than one per 100 woman years. It is a convenient option that doesn’t interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

However, there are also some disadvantages to consider. One of the main drawbacks is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections, so additional precautions may be necessary. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side effects such as headache, nausea, and breast tenderness may also be experienced.

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

The patient is protected for the next 7 days as she had taken the pill for 7 days in a row previously. According to the FSRH guidelines, emergency contraception is not required after taking seven consecutive pills. However, the guidelines suggest using condoms for the next 7 days in this scenario. Please refer to the provided link for more information.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

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.

For men with infertility, NICE suggests that the first primary care investigations should include semen analysis and chlamydia screening using a first void urine sample. Additionally, a clinical examination should be conducted to check for any indications of hypogonadism, cryptorchidism, or scrotal masses. It is recommended that a semen sample be produced after abstaining for at least 2 days but no more than 7 days. However, NICE doesn’t recommend screening for antisperm antibodies.

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.

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.

Contraceptive Methods and Timing

The timing of contraceptive methods is crucial to their effectiveness. The copper-bearing intrauterine device can be used at any time during the menstrual cycle, as long as pregnancy has been reasonably excluded. It doesn’t require any additional contraception. However, if a woman starts taking the combined oral contraceptive pill on day six or later of her menstrual cycle, she needs to use additional contraception or avoid sexual intercourse for seven days. The same applies to the Mirena coil if it is inserted from day eight onwards of the menstrual cycle. The progesterone-only pill and implant also require additional contraception or avoidance of sexual intercourse if started from day six onwards of the menstrual cycle. It is important to understand the timing requirements of each contraceptive method to ensure their effectiveness in preventing pregnancy.

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.

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.

Pre-eclampsia is characterized by a new-onset blood pressure of 140/90 mmHg or higher after 20 weeks of pregnancy, along with either proteinuria or organ dysfunction. In this case, the patient has both high blood pressure and proteinuria, indicating a need for immediate evaluation by the obstetric team in secondary care. Hospitalization and Antihypertensive treatment may be necessary, and delivery may need to be expedited to resolve the condition and prevent complications such as eclamptic fits, coagulation problems, and liver dysfunction.

Given the potential for rapid deterioration, it is not appropriate for the patient to wait for a routine review with her midwife. While labetalol is commonly used to control blood pressure in women with pregnancy-induced hypertension or pre-eclampsia, it should only be initiated and managed under the direction of a specialist. Bisoprolol is not typically used in the treatment of pre-eclampsia.

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.

The recommended initial treatment for migraines during pregnancy is paracetamol, which is likely to be effective for this patient experiencing a pulsating headache on one side. Aspirin and ibuprofen should be avoided in the third trimester due to the risk of fetal ductal arteriosus closure. Sumatriptan is not considered first-line and should only be used if the potential benefits outweigh the risks, according to the manufacturer’s advice.

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.

Levonorgestrel dosage should be increased for individuals with a BMI greater than 26 or a weight exceeding 70 kg.

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.

Pathogens and Pregnancy: What You Need to Know

Although various pathogens can colonize and infect the vagina during pregnancy, only syphilis is routinely tested for. Adequate treatment of syphilis before 18 weeks of pregnancy can prevent infection of the fetus, while treatment after 18 weeks can cure an infected fetus. Failure to treat syphilis can result in congenital syphilis, which can have long-term consequences.

herpesvirus is not routinely screened for during pregnancy, but if a woman contracts genital herpes for the first time during the first trimester, there is a small risk of miscarriage. If first infection occurs later in the pregnancy, a caesarean section may be offered to prevent the baby from coming into contact with active sores. The risk of passing on a newly caught infection to the baby during vaginal birth is about 4 in 10, but neonatal herpes is very rare in the UK, affecting only 1-2 in every 100,000 babies born.

Strep B is not routinely tested for during pregnancy, but about one in five pregnant women in the UK carry group B Streptococci bacteria. While most pregnant women who carry these bacteria have healthy babies, there is a small risk that infection can pass to the baby during childbirth. Group B Strep infection in newborn babies can cause serious complications that can be life-threatening, and even with the best medical care, one in 10 babies diagnosed with early-onset infection will die.

HPV and gonorrhea are not routinely tested for during pregnancy. It is important for pregnant women to discuss any concerns about sexually transmitted infections with their healthcare provider to ensure the best possible outcomes for themselves and their babies.

Using combined hormonal contraceptive pills (CHC) can be beneficial for women in their 40s and beyond. It can reduce menstrual bleeding and pain, as well as alleviate menopausal symptoms. CHC with levonorgestrel or norethisterone are recommended as they have a lower risk of venous thromboembolism compared to other progestogens. However, it is important to note that there are risks associated with CHC use, and women should be informed of these before deciding to use it. The Faculty of Sexual and Reproductive Health advises that CHC can be used until age 50, but after that, women should switch to non-hormonal methods as the risks of CHC generally outweigh the benefits. Women who wish to continue using CHC after age 50 should be assessed on an individual basis. Extended or continuous CHC regimens can also be used for contraception and to manage menstrual or menopausal symptoms. Additionally, CHC is associated with a reduced risk of ovarian and endometrial cancer that can last for several decades after stopping use. Finally, CHC may help maintain bone mineral density during the perimenopause compared to not using hormones.

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.

According to NICE guidelines, women who are at high risk of VTE and are seeking HRT should be referred to a haematologist before starting any treatment, even if it is transdermal. While the risk of VTE associated with HRT is higher for oral preparations than transdermal ones, the risk for transdermal HRT at standard therapeutic doses is not greater than the baseline risk. However, for women with a significant baseline risk, such as those with a strong family history of VTE or a hereditary thrombophilia, referral to a haematologist for assessment is recommended before considering HRT. Therefore, all options that suggest prescribing HRT are incorrect, with oral prescription being the most problematic. It is not enough to advise this woman to manage her symptoms conservatively, as there is clear guidance to refer her to a specialist for additional help.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Pregnant women should not take warfarin and are typically prescribed low-molecular weight heparin instead throughout their pregnancy.

Prescribing Considerations for Pregnant Patients

When it comes to prescribing medication for pregnant patients, it is important to exercise caution as very few drugs are known to be completely safe during pregnancy. Some countries have developed a grading system to help guide healthcare professionals in their decision-making process. It is important to note that the following drugs are known to be harmful and should be avoided: tetracyclines, aminoglycosides, sulphonamides and trimethoprim, quinolones, ACE inhibitors, angiotensin II receptor antagonists, statins, warfarin, sulfonylureas, retinoids (including topical), and cytotoxic agents.

In addition, the majority of antiepileptics, including valproate, carbamazepine, and phenytoin, are potentially harmful. However, the decision to stop such treatments can be difficult as uncontrolled epilepsy poses its own risks. It is important for healthcare professionals to carefully weigh the potential risks and benefits of any medication before prescribing it to a pregnant patient.

An appropriate substitute would be mefenamic acid in oral form.

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.

Sterilisation as a Permanent Contraceptive Method

Sterilisation is a permanent contraceptive method with an overall failure rate of approximately 1 per 200. However, the individual failure rate may be lower depending on the method used. It is important to note that sterilisation should be considered permanent, even though reversal is possible. This is because it is an operation performed with the intention of being permanent and reversal cannot be guaranteed.

The proportion of women expressing regret after undergoing sterilisation varies between different studies and different countries but tends to range from 3% to 10% in the United Kingdom. Sterilisation is usually done laparoscopically, although methods involving a vaginal approach are possible.

It is crucial to counsel patients about the effectiveness of other contraceptive methods that are as effective as sterilisation. Patients may not be aware of this, and it may alter their decision. For some, a long-acting form of contraception such as the intrauterine system (Mirena) may be more acceptable and preferable. Therefore, it is essential to discuss all available options with patients to help them make an informed decision about their contraceptive choices.

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.

Initiation of Combined Hormonal Contraception Postpartum

Combined hormonal contraception can be safely started by eligible women 21 days after giving birth, provided they have no other risk factors for venous thromboembolism and are not breastfeeding. However, women who breastfeed and want to use combined hormonal contraception should wait until six weeks postpartum, regardless of whether they have additional risk factors for VTE. Studies have shown conflicting effects of combined oral contraception on breastfeeding, with some indicating less weight gain in infants of users compared to non-users when started at or before six weeks postpartum. No study has demonstrated an effect on infant weight gain when initiated after six weeks postpartum. It is important for healthcare providers to consider individual patient factors and preferences when discussing contraceptive options postpartum.

Managing Low Libido in Menopausal Women

Lubricants can provide temporary relief for menopausal women experiencing low libido, but they require frequent application and may not address the underlying issue. Measuring testosterone levels is not a reliable method for diagnosing low libido in menopausal women. While testosterone patches can benefit naturally menopausal women, they are currently only licensed for use in women who have had their ovaries removed. However, it is important to note that the postmenopausal ovary does produce testosterone. Tibolone is a medication that has been shown to improve low libido in postmenopausal women. It is important for women experiencing low libido to discuss their symptoms with their healthcare provider to determine the best course of treatment.

Treatment Options for Urinary Incontinence

Bladder training is a highly effective treatment for urge or mixed incontinence. It has fewer adverse effects and lower relapse rates compared to antimuscarinic drugs, which are the next line of treatment. On the other hand, pelvic floor muscle training is recommended as the first line of treatment for stress incontinence symptoms.

Duloxetine is only recommended for stress incontinence and may be offered as a second-line treatment for women who prefer pharmacological treatment over surgery. However, modification of fluid intake is not routinely recommended. It is only recommended if fluid intake is high or low and in cases of urinary incontinence or overactive bladder.

In summary, there are various treatment options available for urinary incontinence, depending on the type and severity of the symptoms. It is important to consult with a healthcare professional to determine the most appropriate treatment plan.

Antiphospholipid Syndrome and Pregnancy: Risks and Management

Antiphospholipid syndrome is a condition that increases the risk of both venous and arterial blood clots, recurrent miscarriage, and low platelet count. It can occur as a primary disorder or as a secondary condition to other illnesses, such as systemic lupus erythematosus. When a woman with antiphospholipid syndrome becomes pregnant, there are several potential complications that may arise, including pre-eclampsia, placental abruption, and preterm delivery.

To manage these risks, low-dose aspirin is typically prescribed as soon as the pregnancy is confirmed through a urine test. Once a fetal heartbeat is detected on ultrasound, low molecular weight heparin is added to the treatment plan. This medication is usually discontinued at 34 weeks gestation. These interventions have been shown to increase the live birth rate by seven-fold. It is important for women with antiphospholipid syndrome to work closely with their healthcare provider to ensure the best possible outcome for both mother and baby.

Extra precautions should be taken during the first 7 days of starting the combined oral contraceptive pill as it doesn’t provide immediate protection when initiated on day 6 of the menstrual cycle. Women over the age of 35 who smoke should not use this form of contraception.

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on various aspects. This includes the potential benefits and harms of the COC, such as its high effectiveness rate of over 99% when taken correctly, but also the small risk of blood clots, heart attacks, strokes, and increased risk of breast and cervical cancer. Additionally, advice on taking the pill should be provided, such as starting it within the first 5 days of the cycle to avoid the need for additional contraception, taking it at the same time every day, and considering tailored regimens that eliminate the pill-free interval. It is also important to discuss situations where efficacy may be reduced, such as vomiting or taking liver enzyme-inducing drugs. Finally, counselling should include information on STIs and the use of concurrent antibiotics, which may no longer require extra precautions except for enzyme-inducing antibiotics like rifampicin.

Overall, women should receive comprehensive counselling on the COC to make informed decisions about their reproductive health. This includes discussing the potential benefits and harms, advice on taking the pill, and situations where efficacy may be reduced. By providing this information, women can make informed decisions about their contraceptive options and reduce the risk of unintended pregnancies.

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®.

The license for using Mirena as endometrial protection for women on oestrogen-only HRT is limited to 4 years. Similarly, intrauterine contraceptives are licensed for a duration of 3 years.

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®.

If a person misses two pills between days 8-14 of their cycle while taking the combined oral contraceptive pill (COCP) correctly for the previous seven days, emergency contraception is not necessary. This is the case for a patient who is currently in the second week of taking the pill and has had unprotected sex during this time. However, they should use additional precautions for the next seven days. Emergency contraception would only be necessary if the patient had unprotected sex during the first week of taking the pill or during the pill-free week, or if they had not taken at least seven consecutive pills prior to the episode of unprotected sex. It is important to use additional precautions for seven days, rather than restarting the pill as normal or with only two days of additional precautions. The pill-free interval doesn’t need to be omitted if the patient misses pills only during the second week of taking the pill.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

Couples, including those with fertility issues, have a 15-20% chance of conceiving naturally within a year through regular unprotected sexual intercourse. However, this patient’s PCOS condition, which causes ovulation insufficiency, may prolong the process. Hence, a referral is necessary for assistance, and treatment with clomifene to stimulate ovulation would be suitable.

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.

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.

Having a short inter-pregnancy interval of less than 12 months between childbirth and conceiving again can lead to a higher likelihood of preterm birth, low birthweight, and small for gestational age babies. Women should be informed of this risk, and it is currently recommended by the World Health Organisation to wait at least 24 months after childbirth before getting pregnant again. It is important to note that the risk associated with a short inter-pregnancy interval is still relatively low.

After giving birth, women need to use contraception after 21 days. The Progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first 2 days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the Combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than 6 weeks postpartum. If breastfeeding is between 6 weeks to 6 months postpartum, it is UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk postpartum. After day 21, additional contraception should be used for the first 7 days.

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks. Meanwhile, the Lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than 6 months postpartum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

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.

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.

The copper IUD can be used until menopause if inserted at age 40 or over, according to the FSRH. It can remain in place for 1 year after the last menstrual period if the woman is over 50, or 2 years if she is under 50. It should not be left in place indefinitely due to the risk of infection.

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.

Understanding Vulvovaginitis

Vulvovaginitis is a common condition that can have various causes, including lichen sclerosus, VIN, and other dermatological conditions. However, in young women, an inflammatory vulval dermatitis is often the culprit, triggered by factors such as soaps, frequent washing, perfumes, sanitary towels, douching, or candidiasis.

The initial treatment for this condition typically involves a combination of topical steroid and antifungal preparations. While STI screening and specialist referrals are not usually necessary, it’s important to offer a chaperone during same-sex examinations and consider them mandatory for opposite-sex examinations.

It’s worth noting that lack of estrogen is not typically a cause of vulvovaginitis, and vulval biopsy is not usually indicated based on the information available. By understanding the causes and appropriate treatments for vulvovaginitis, healthcare providers can help their patients manage this common condition effectively.

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.

Interpretation of Patient’s Symptoms

This patient is exhibiting symptoms that suggest hypercalcaemia, which is a clinically significant condition. It is important to note that the free T4 level is at the lower end of the normal range, which is common during pregnancy. Therefore, TSH is a better indicator of thyroid function. Additionally, hyperprolactinaemia and detectable urinary human chorionic gonadotrophin are normal findings during pregnancy. It is also typical for serum alkaline phosphatase levels to increase up to four times the normal range due to increased placental production.

Overall, it is essential to consider the patient’s pregnancy status when interpreting their symptoms and laboratory results.

The Jaydess IUS is licensed for 3 years and has a smaller frame and less levonorgestrel than the Mirena coil. The Mirena coil is licensed for 5 years, while the Kyleena IUS has 19.5mg LNG and is also licensed for 5 years. The copper IUD is licensed for 5 years.

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®.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

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.

Causes of Vaginal Discharge in Women

This woman is experiencing occasional vaginal discharge. There are several potential causes of vaginal discharge, including candidiasis, bacterial vaginosis, and physiological discharge. Candidiasis is typically associated with itch and a thick discharge, while bacterial vaginosis is often intermittent and accompanied by a profuse and smelly discharge. However, given the patient’s age and stable relationship, physiological discharge is the most likely cause.

In this case, it may not be necessary to conduct a speculum exam unless the patient specifically requests it. Initially, the patient can be reassured without further investigation. However, if investigation is deemed necessary, a self-taken lower vaginal swab would be a reasonable option.

It is important to note that normality is a common theme in the MRCGP exam, and understanding the various causes of vaginal discharge is an important aspect of primary care.

When pregnant women are exposed to Chickenpox, it is important to inquire about their prior history of the infection. If they are uncertain or have not had it before, it is recommended to test for varicella antibodies. In cases where they are found to be non-immune, varicella immunoglobulin should be considered. This treatment can be administered at any stage of pregnancy and is effective for up to 10 days following exposure.

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.

If a woman has a suspected or personal history of breast cancer or a confirmed BRCA mutation, the safest form of contraception for her is the copper coil. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides guidelines for the choice of contraception, grading non-barrier contraceptives on a scale of 1-4 based on a woman’s personal circumstances. Contraceptive methods that fall under category 1 or 2 are generally considered safe for use in primary care. In this case, all forms of contraception except the combined pill (category 3) can be offered, with the copper coil being the safest option as it falls under category 1.

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.

Typically, cervical screening is postponed until 3 months after giving birth, unless there was a missed screening or previous abnormal results. Smear tests are not conducted while pregnant, and there is no reason to refer for colposcopy based on the patient’s history. It is standard practice to delay smear tests until 3 months after delivery.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Pregnant women can generally fly safely if their pregnancy is progressing well, but it is important to check with the airline and insurance company before traveling. However, most airlines have restrictions on travel after 37 weeks of pregnancy or after 32 weeks for multiple pregnancies. Additionally, women over 28 weeks pregnant may need a letter from their doctor or midwife confirming their due date and good health. It is also recommended to bring along pregnancy notes when traveling.

The CAA has issued guidelines on air travel for people with medical conditions. Patients with certain cardiovascular diseases, uncomplicated myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention may fly after a certain period of time. Patients with respiratory diseases should be clinically improved with no residual infection before flying. Pregnant women may not be allowed to travel after a certain number of weeks and may require a certificate confirming the pregnancy is progressing normally. Patients who have had surgery should avoid flying for a certain period of time depending on the type of surgery. Patients with haematological disorders may travel without problems if their haemoglobin is greater than 8 g/dl and there are no coexisting conditions.

Annual Assessments for Women on Contraceptives

Women who use the combined contraceptive pill or the progesterone only pill should undergo an annual medical assessment to check for any new health issues. For those using the Depo-Provera injection, a review should be conducted every two years to evaluate the risks and benefits of the treatment.

The Mirena, an intrauterine device, can be used for up to seven years (off licence) if inserted when a woman is 45 years or older and if the patient is comfortable with their bleeding patterns. If a woman remains amenorrhoeic after seven years of use, the device can remain in place until menopause. Similarly, a copper coil inserted at the age of 40 years or over can be kept until menopause.

Regular assessments and reviews are crucial to ensure that women are receiving the most appropriate and effective contraceptive treatment for their individual needs. By staying up-to-date with their health status and treatment options, women can make informed decisions about their reproductive health and overall well-being.

Antihistamines are the preferred initial treatment for vomiting during pregnancy.

Specific Points for Antenatal Care

Antenatal care is an essential aspect of pregnancy, and NICE has issued guidelines on routine care for healthy pregnant women. Some specific points to consider during antenatal care include nausea and vomiting, vitamin D, and alcohol consumption.

For nausea and vomiting, natural remedies such as ginger and acupuncture on the ‘p6’ point are recommended by NICE. However, antihistamines such as promethazine are suggested as first-line treatment in the BNF.

Vitamin D is crucial for the health of both the mother and the baby. NICE recommends that all women should be informed about the importance of maintaining adequate vitamin D stores during pregnancy and breastfeeding. Women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Women at risk, such as those who are Asian, obese, or have a poor diet, should take particular care.

Alcohol consumption during pregnancy can lead to long-term harm to the baby. In 2016, the Chief Medical Officer proposed new guidelines recommending that pregnant women should not drink alcohol at all. The official advice is to keep risks to the baby to a minimum, and the more alcohol consumed, the greater the risk.

In summary, antenatal care should include specific points such as managing nausea and vomiting, maintaining adequate vitamin D levels, and avoiding alcohol consumption during pregnancy. These guidelines aim to ensure the health and well-being of both the mother and the baby.

Women who have taken ulipristal acetate should wait for at least 5 days before starting regular hormonal contraception, according to current guidelines. This is because ulipristal acetate may decrease the effectiveness of hormonal contraception. Additionally, taking desogestrel hormonal contraception within 5 days of ulipristal acetate can also reduce the efficacy of emergency contraception. It is recommended to use additional precautions until contraceptive cover is re-established, and if desogestrel is being used, this should be after 48 hours. It would be helpful to discuss long-acting reversible contraception options with the patient in this case.

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.

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.

Women who are taking antiepileptic medication and are planning to conceive should be prescribed folic acid 5mg instead of the standard 400 mcg once daily. This high dose of folic acid should be taken from before conception until 12 weeks into the pregnancy to reduce the risk of neural tube defects. It is important to refer these women to a specialist for assessment, but they should continue to use effective contraception until then. It is important to reassure these women that they are likely to have a normal pregnancy and healthy baby. Folic acid should be started as soon as possible, even if the pregnancy is unplanned.

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.

If one COCP pill is missed, the patient should take the last pill as soon as possible, but no additional action is required.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

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.

Folic Acid Requirements for Women During Pregnancy

Most women are advised to take 400 mcg of folic acid daily from before conception until week 12 of pregnancy. However, there are exceptions to this rule. Women who are at a higher risk of neural tube defects, such as those with a history of bearing children with NTDs, or women with diabetes or taking anticonvulsants, should take a higher dose of 5 mg daily from before conception until week 12 of pregnancy.

Another group of women who require a higher dose of folic acid are those with sickle cell disease. They need to take 5 mg of folic acid daily throughout pregnancy, and even when not pregnant, they’ll usually be taking folic acid 5 mg every 1 to 7 days, depending on the severity of their disease. It’s important for women to consult with their healthcare provider to determine the appropriate dose of folic acid for their individual needs during pregnancy.

Rachel began taking the progesterone only pill during the fourth day of her menstrual cycle, which means she will have instant protection since it was before the fifth day of her cycle.

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.

The contraceptive patch regime involves wearing one patch per week for three weeks, followed by a patch-free week. This method is gaining popularity due to its flexibility, as the patch can be changed up to 48 hours late without the need for extra contraception. Additionally, the patch’s transdermal absorption means that it is not affected by vomiting or diarrhea, eliminating the need for additional precautions. Similar to the pill, this method involves three weeks of contraception followed by a one-week break, during which the woman will experience a withdrawal bleed.

How to Use the Combined Contraceptive Patch

The Evra patch is the only combined contraceptive patch approved for use in the UK. It is worn for 3 weeks straight and then removed for a week, during which a withdrawal bleed occurs. If the patch is not changed on time, different rules apply depending on the week of the patch cycle.

If the patch change is delayed at the end of week 1 or week 2, it should be changed immediately. If the delay is less than 48 hours, no further precautions are needed. However, if the delay is greater than 48 hours, a barrier method of contraception should be used for the next 7 days. If unprotected sexual intercourse has occurred during this extended patch-free interval or in the last 5 days, emergency contraception should be considered.

If the patch removal is delayed at the end of week 3, it should be removed as soon as possible and a new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed. If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.

For more information on combined hormonal methods of contraception, please refer to the NICE Clinical Knowledge Summary.

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.

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.

A cervical smear is not a diagnostic test and should only be conducted as a part of a screening program. An 18-year-old’s risk of cervical cancer is already low, and a normal vaginal examination can further reduce it.

If controlling bleeding is the goal, the combined oral contraceptive pill is more effective than the progesterone-only pill.

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 should be noted that the woman already had hypertension before becoming pregnant. Blood pressure issues related to pregnancy, such as pre-eclampsia or pregnancy-induced hypertension, typically do not occur until after 20 weeks of gestation. The fact that her ambulatory blood pressure readings were elevated rules out the possibility of her hypertension being caused by anxiety in a medical setting. It is important to consider the possibility of secondary hypertension, as high blood pressure in a woman of this age is not typical.

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.

Orlistat is a medication used to treat obesity by inhibiting gastrointestinal lipase and reducing fat absorption from the gut. However, it often causes loose stool or diarrhea unless the patient follows a low-fat diet. It is crucial to assess the suitability of orlistat for patients taking critical medications like antiepileptics and contraceptive pills, as it may decrease their effectiveness by increasing gut transit time. If the patient wants to continue taking orlistat, it is advisable to consider alternative contraception methods that are more reliable.

Obesity can be managed through a stepwise approach that includes conservative, medical, and surgical options. The first step is usually conservative, which involves implementing changes in diet and exercise. If this is not effective, medical options such as Orlistat may be considered. Orlistat is a pancreatic lipase inhibitor that is used to treat obesity. However, it can cause adverse effects such as faecal urgency/incontinence and flatulence. A lower dose version of Orlistat is now available without prescription, known as ‘Alli’. The National Institute for Health and Care Excellence (NICE) has defined criteria for the use of Orlistat. It should only be prescribed as part of an overall plan for managing obesity in adults who have a BMI of 28 kg/m^2 or more with associated risk factors, or a BMI of 30 kg/m^2 or more, and continued weight loss of at least 5% at 3 months. Orlistat is typically used for less than one year.

Tamoxifen Side Effects According to BNF

The British National Formulary (BNF) is often used to set questions for the AKT, and it lists the frequency of side effects for medications. Tamoxifen, for example, has common or very common side effects such as headaches, while all the other options are rare or very rare. Patients taking tamoxifen should be informed about the increased risk of thromboembolism and advised to watch for symptoms of DVT and PE. Additionally, patients should be warned about the increased risk of endometrial cancer and instructed to report any relevant symptoms. It is important for healthcare professionals to be aware of these potential side effects and counsel patients accordingly.

Missed Birth Control Pills

When it comes to missed birth control pills, most of the advice and evidence is based on studies of the 35 mcg oestrogen combined pill. However, it’s important to note that the risk of pregnancy with a missed 20 mcg pill may be higher than with a larger dose pill. Despite this, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women take the missed pill and continue with the pack. Additional contraception is not required in this case.

If two or more pills are missed, it’s recommended to use barrier contraception for around seven days. It’s important to follow the instructions provided with your specific type of birth control pill and to speak with your healthcare provider if you have any concerns or questions.

Signs and Symptoms of Hyperprolactinaemia

This patient is presenting with several signs and symptoms of hyperprolactinaemia, including weight gain, loss of libido, menstrual disturbance, and galactorrhoea. While conditions such as PCOS, depression, and Cushing’s can cause weight gain and menstrual changes, galactorrhoea is only associated with pregnancy, prolactinoma, certain medications, and hypothyroidism.

It is important to note that the patient’s normal abdominal examination after ten months of amenorrhea, with her last sexual encounter occurring nine months prior, rules out pregnancy as a potential cause for her symptoms. Further investigation and testing may be necessary to determine the underlying cause of her hyperprolactinaemia.

Emergency contraception is necessary if unprotected sex occurred within 48 hours of restarting the POP after a missed pill. In this case, the patient missed her second pill by over 12 hours and is within the 48-hour window. A pregnancy test cannot provide reassurance the day after intercourse. It is important to take additional precautions and resume taking the medication at the normal time after a missed pill for 48 hours. If the missed pill is forgotten for 24 hours, taking two pills at once may be necessary, but it is not applicable in this scenario as the missed pill has already been taken.

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.

Cerazette: A Controversial Contraceptive Option

Cerazette is a popular contraceptive pill that has been marketed as having a Pearl Index similar to the combined pill. It is known for its ability to suppress ovulation and is suitable for a range of women. However, whether Cerazette is superior to traditional POPs is a topic of debate. Despite its effectiveness, Cerazette is not recommended as a first-line option due to its cost. It is only available on prescription and has a missed pill window of 12 hours.

Cerazette has a wider time frame for taking the pill than traditional progestogen only pills, but if a pill is missed, the user should take two pills immediately and use additional contraception for two days.

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.

Medication Protocol for Early Pregnancy

As soon as a pregnancy test comes back positive, it is recommended to prescribe aspirin 75 mg. This medication can help prevent blood clots and other complications during pregnancy. Once foetal heart activity is detected on an ultrasound scan, low dose self-administered subcutaneous heparin should be started. This medication can also help prevent blood clots and is especially important for women who have a history of blood clots or other risk factors. It is important to follow this medication protocol to ensure the health and safety of both the mother and the developing foetus.

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.

A family history doesn’t pose any contraindications for COCP use and is classified as UKMEC 1. However, being a known BRCA1/2 gene carrier is classified as UKMEC 3 for COCP use. If a person has a current breast cancer diagnosis, it is classified as UKMEC 4. If the breast cancer diagnosis was more than 5 years ago, it is classified as UKMEC 3.

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

If a person has a BMI over 26 kg/m2 or weighs over 70 kg, the recommended dose of levonorgestrel should be doubled from 1.5 mg to 3 mg, not 6 mg. Ulipristal acetate is contraindicated for those with brittle asthma that is controlled with glucocorticoids. It would be incorrect to inform the patient that she is not at risk of pregnancy as she is still at risk.

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.

If pre-eclampsia is suspected in a woman, NICE recommends arranging emergency secondary care assessment. This is because pre-eclampsia can be life-threatening and may not present with obvious symptoms. In this case, the patient has high blood pressure and proteinuria, which are signs of pre-eclampsia. While a growth scan may be necessary later, it is not the priority now. Home BP monitoring is also not indicated at this stage. Instead, the patient needs further investigation and management by obstetric specialists. Labetalol may be used to manage her blood pressure, but only after specialist input.

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.

Women who have taken ulipristal acetate should wait for 5 days before beginning regular hormonal contraception. It is crucial to note that the effectiveness of EllaOne decreases if progestogen is used within 5 days after taking it. Therefore, it is essential to start hormonal contraceptives 5 days after taking EllaOne. Starting the combined oral contraceptive pill at the same time or less than 5 days after taking EllaOne would be incorrect. It is a misconception that EllaOne is only effective if the combined oral contraceptive pill has already been started. Taking EllaOne 14 days after the start of the last menstrual period is also incorrect. The copper coil could be inserted as an effective form of contraception 5 days after the expected date of ovulation, but EllaOne must be taken within 5 days of unprotected sexual intercourse.

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.

Monitoring hCG Levels After Molar Pregnancy

After a molar pregnancy, it is important to monitor hCG levels to detect any persistent gestational trophoblastic disease (GTD) that may require treatment. During this monitoring period, women should avoid becoming pregnant as it is difficult to differentiate between hCG levels that are increasing due to a new pregnancy or persistent GTD. The first hCG measurement is taken four weeks after uterine evacuation.

For complete hydatidiform mole, hCG monitoring is required for six months from the first normal hCG level or six months from evacuation of the uterus if the hCG level normalizes by eight weeks after evacuation. On the other hand, partial molar pregnancy has a lower risk of persistent GTD, and hCG follow-up is only necessary until two consecutive monthly levels are normal.

If a woman undergoes chemotherapy for gestational trophoblastic neoplasia, she should avoid pregnancy for at least one year. It is crucial to monitor hCG levels after molar pregnancy to ensure early detection and treatment of any persistent GTD.

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.

Best Time for Cervical Smear

According to the NHS Cervical Screening Programme, the best time for women to have their cervical smear is mid-cycle, usually 14 days from the start of their last period. This timing allows for a clearer background to the sample, as the mucous plug is at its thinnest and the epithelium is at its thickest, resulting in a full range of cells being obtained. However, this is not a strict rule, and women should not be deterred from having their cervical smear if they cannot get an appointment at this time. It is important to seek advice from a doctor or practice nurse if needed.

Breastfeeding women can safely take SSRIs such as sertraline or paroxetine as the amount of antidepressant passed on to the infant through breast milk is very low and not considered harmful. Therefore, it is recommended that women with postnatal depression continue to breastfeed while receiving antidepressant treatment.

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.

Benefits of Breastfeeding

Breastfeeding has been shown to have numerous benefits for both the mother and the baby. According to the National Institute for Health and Clinical Excellence (NICE) Promotion of breastfeeding initiation and duration (2006), breastfeeding can help reduce the incidence of various conditions.

Studies have demonstrated that breastfeeding can reduce the risk of infantile gastroenteritis, urinary tract infections, atopic disease, juvenile insulin-dependent diabetes mellitus, respiratory infections, and otitis media. However, it is important to note that breastfeeding may not necessarily protect against other conditions such as ADHD, intussusception, or rickets.

Overall, breastfeeding is a natural and effective way to promote the health and well-being of both the mother and the baby.

When women use an IUS for endometrial protection as part of their HRT regimen, they need to replace the device every 4 years according to the BNF or 5 years according to the FSRH. The Mirena® IUS is effective in protecting the endometrium from the effects of exogenous estrogen, and the BNF recommends its use for this purpose. However, if the Mirena® IUS is used for contraception and inserted after the age of 45, it can remain in place until menopause, even if the woman is still having periods.

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.

Emergency Contraception Options After Childbirth

Oral levonorgestrel 1.5 mg and ulipristal acetate 30 mg are safe to use 21 days after childbirth, while the copper intrauterine device can be used for emergency contraception from day 28 postpartum. Among the three options, the copper intrauterine device is the most effective, with a pregnancy rate of approximately 1 in 1000.

It is important to note that the copper intrauterine device carries the same contraindications as when used for standard contraception. It can be retained until the next period then removed or kept in situ for ongoing long-term contraception. With these options available, women can make informed decisions about their reproductive health after childbirth.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that Noristerat, another injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks. The BNF gives different advice regarding the interval between injections, stating that a pregnancy test should be done if the interval is greater than 12 weeks and 5 days. However, this is not commonly adhered to in the family planning community.

Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, preterm birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

Effects of Smoking During Pregnancy

Smoking during pregnancy has various effects on both the mother and the developing fetus. One positive effect is that pre-eclampsia, a potentially life-threatening condition characterized by high blood pressure and damage to organs, is less likely to occur in smokers. However, there is an increased rate of spontaneous abortion and intrauterine growth may be retarded. Additionally, smoking increases the risk of prematurity, which can lead to various health complications for the baby. There is also an increase in perinatal mortality over the average, meaning that the risk of the baby dying before or shortly after birth is higher. Furthermore, smoking during pregnancy increases the risk of thromboembolism, a condition where a blood clot forms and blocks a blood vessel, which can be fatal for both the mother and the baby. Therefore, it is highly recommended for pregnant women to quit smoking to ensure the best possible outcomes for both themselves and their babies.