Premature Ovarian Insufficiency: Causes, Symptoms, and Management

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

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

Managing Migraine in Relation to Hormonal Factors

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

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

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

It is recommended that all women with a BMI greater than 30 undergo screening for gestational diabetes using an oral glucose tolerance test (OGTT) between 24-28 weeks of pregnancy. Additionally, women who have risk factors for gestational diabetes, such as a family history of diabetes, a previous large baby weighing 4.5 kg or more, or belonging to an ethnic group with a high prevalence of diabetes, should also be offered an OGTT during this time. If a woman has previously had gestational diabetes, she should be offered an OGTT as soon as possible after booking and again at 24-28 weeks if the first test is normal. Alternatively, early self-monitoring of blood glucose may be offered as an option.

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.

To manage gestational diabetes, insulin should be started if the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis. Therefore, commencing insulin is the correct answer. Offering a trial of diet and exercise changes or commencing metformin only would not be appropriate in this case. Referral for an oral glucose tolerance test to confirm the diagnosis is not necessary as a patient can be diagnosed with gestational diabetes based on their fasting plasma glucose level or 2-hour plasma glucose level. However, discussing diet and exercise changes with the patient may be helpful in managing the condition.

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.

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.

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.

Nancy can be advised that she doesn’t need contraception for up to 21 days after giving birth. According to the Faculty of Sexual and Reproductive Healthcare Guideline on Postnatal Sexual and Reproductive Health, contraceptive protection is not necessary before Day 21 postpartum. However, if Nancy wants to avoid pregnancy after Day 21, she should use a contraceptive method as ovulation may occur as early as Day 28 in non-breastfeeding women. Breastfeeding women who want to prevent pregnancy should also use a contraceptive method, although any method will be more effective due to reduced fertility. Fully breastfeeding women may rely on the lactational amenorrhoea method (LAM) alone until breastfeeding decreases or other LAM criteria are no longer met.

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.

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.

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

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

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

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

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

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.

No action is required as she has missed only one pill. For more details, please refer to the FSRH guidelines.

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 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.

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.

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.

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

Sodium Valproate: Uses and Adverse Effects

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

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

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

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

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

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

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

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

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.

When treating nipple candidiasis during breastfeeding, it is recommended to use miconazole cream for the mother and nystatin suspension for the baby. This is likely to be nipple thrush, and it’s important to treat both mother and baby simultaneously to prevent re-infection, even if the baby shows no signs of infection. It’s worth noting that while miconazole gel can also be used for babies over 4 months, it’s not licensed for those under 4 months due to concerns about choking on the gel. Parents should be carefully informed about the risks and how to administer it safely if it’s prescribed.

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.

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.

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.

If a woman is fully or almost fully breastfeeding, under 6 months postpartum, and not experiencing periods yet, lactational amenorrhoea can be a highly effective form of contraception. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) recommends that if these conditions are met, there may be no need for an alternative contraceptive method at this time.

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 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®.

Understanding Postpartum Depression

Postpartum depression is a common condition that affects many new mothers. It typically occurs within a year of childbirth and is characterized by a range of symptoms, including feelings of sadness, anxiety, and hopelessness. While some women may experience a short-lived reaction known as the baby blues, postnatal depression typically begins within two to three months of giving birth and can last for several months or even longer.

If you are experiencing symptoms of postpartum depression, it is important to seek help from a healthcare professional. Treatment options may include therapy, medication, or a combination of both. With the right support and treatment, it is possible to overcome postpartum depression and enjoy a healthy, happy life with your new baby.

Pregnant women should steer clear of soft cheese as it may pose a risk of Listeria infection.

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.

Contraceptive Options for Postpartum Women

Postnatally, it is important for women to undergo a risk assessment for venous thromboembolism before considering their contraceptive options. Women with risk factors for venous thromboembolism within 6 weeks of childbirth, such as immobility, postpartum haemorrhage, and pre-eclampsia, should not use combined hormonal contraception. This applies to women who are breastfeeding and not breastfeeding, as the risk of venous thromboembolism is the same for both groups. However, the risk reduces quickly over the first three weeks postpartum, and the UKMEC advises that women who breastfeed should wait until six weeks postpartum before using combined hormonal contraception. Studies have shown that early initiation of combined hormonal contraception may have inconsistent effects on breastfeeding performance and conflicting data on infant outcomes, but overall, there is no negative impact on infant outcomes when initiated from six weeks postpartum.

Anti-D Injection for Rhesus Antibody Sensitisation

Rhesus antibody sensitisation is a condition that requires careful consideration when deciding whether or not to administer anti-D injection. According to NICE guidelines, women should be given the option to discuss the need for this injection. If a woman has decided not to have any further children, immunisation with anti-D may not be necessary as long as she is sure her family is complete. However, it is important to note that patients often change their minds, and this needs to be discussed.

It is also important to consider the benefits and risks of anti-D injection. All preparations of anti-D carry a small risk of allergic reaction, as with the use of all medicines. The risk of D sensitisation is greatest during the first pregnancy and increased in ante-partum haemorrhage, third trimester miscarriage, termination, and with chorionic villus sampling. Therefore, it is crucial to weigh the potential benefits and risks of anti-D injection before making a decision.

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.

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

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

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

Understanding Postpartum Mental Health Problems

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

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

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

In case of suspected rubella during pregnancy, it is important to consult with the local Health Protection Unit for guidance on appropriate investigations. If the mother is found to be non-immune to rubella, the MMR vaccine should be administered after delivery. However, the risk of transmission to the fetus in this scenario is uncertain. If transmission does occur, particularly later in the pregnancy, it can cause significant harm to the developing fetus. Hospitalization is not necessary at this point.

Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, rubella is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

The risk of damage to the fetus is as high as 90% in the first 8-10 weeks of pregnancy, but damage is rare after 16 weeks. Congenital rubella syndrome can cause a range of features, including sensorineural deafness, congenital cataracts, congenital heart disease, growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It is important to note that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is crucial to check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the postnatal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

The FSRH has updated its guidance on missed contraceptive pills. If a woman misses two or more pills, she should continue taking the rest of the pack as usual and use an additional form of contraception for the next seven days. Condoms should be used or sexual activity avoided until seven consecutive active pills have been taken. This advice may be overly cautious in the second and third weeks, but it serves as a backup in case more pills are missed. If the woman has a new partner, it is recommended to consider STI screening after a suitable period. For more information, refer to the FSRH guidelines.

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.

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.

Diagnosis of Gestational Diabetes

Gestational diabetes is a common condition that affects pregnant women. It is important to be familiar with the threshold levels of plasma glucose for diagnosing gestational diabetes using both a fasting and 75g 2-hour oral glucose tolerance test. The diagnosis of gestational diabetes is different from that of non-pregnant or male patients.

To diagnose gestational diabetes, a woman should have either a fasting plasma glucose level of 5.6 mmol/litre or above or a 2-hour plasma glucose level of 7.8 mmol/litre or above. For non-pregnant or male patients, the figures are 7 mmol/l and 11.1 mmol/l.

It is recommended that patients should be offered a 75 g 2-hour OGTT if they have risk factors for diabetes or if they had gestational diabetes in a previous pregnancy. In 2015, NICE offered new advice that glycosuria of 2+ or above on one occasion or of 1+ or above on two or more occasions detected by reagent strip testing during routine antenatal care may indicate undiagnosed gestational diabetes. If this is observed, further testing should be considered to exclude gestational diabetes.

HELLP Syndrome: A Dangerous Condition in Pregnant Women

HELLP syndrome is a serious condition that can occur in pregnant women who have pre-eclampsia or eclampsia. It is characterized by liver damage and abnormalities in blood clotting, which can lead to serious complications for both the mother and the baby.

The symptoms of HELLP syndrome include hypertension, right upper quadrant/epigastric pain, sickness/vomiting, and oedema. Haemolysis can cause anaemia and increase bilirubin levels, while elevated liver enzymes and low platelet counts are also common.

It’s important to note that even mild elevations in blood pressure can lead to HELLP syndrome in some cases. Pregnant women with a diastolic BP of 90 or more should be evaluated for a hypertensive disorder of pregnancy. Additionally, changes in blood pressure should be monitored closely, as a significant rise in diastolic or systolic BP can be a warning sign of HELLP syndrome.

Overall, early detection and treatment of HELLP syndrome is crucial for the health and safety of both the mother and the baby. If you are pregnant and experiencing any of the symptoms associated with HELLP syndrome, it’s important to seek medical attention right away.

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.

When a pregnant woman reports reduced fetal movements, it is important to investigate the cause as it can indicate a risk of stillbirth and fetal growth restriction. The first step in this investigation should be to use a handheld Doppler to confirm the presence of a fetal heartbeat.

If a fetal heartbeat is detected with the handheld Doppler and the pregnancy is over 28 weeks gestation, a CTG should be used to monitor the fetal heart rate for at least 20 minutes to assess for any fetal compromise.

The guidelines recommend assessing fetal movements based on the subjective perception of the mother. If a mother reports reduced fetal movements, there is no need for further counting of fetal movements.

If no fetal heartbeat is detected with the handheld Doppler, an immediate ultrasound should be offered. If there is still concern about reduced fetal movements despite a normal CTG, an urgent ultrasound can be used to assess abdominal circumference or estimated fetal weight and amniotic fluid volume measurement, rather than ultrasound with Doppler.

Understanding Reduced Fetal Movements

Reduced fetal movements can indicate fetal distress and are a cause for concern as they can lead to stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency. Fetal movements usually start between 18-20 weeks gestation and increase until 32 weeks gestation, after which the frequency of movement tends to plateau. Multiparous women may experience fetal movements sooner, from 16-18 weeks gestation. Fetal movements should not reduce towards the end of pregnancy.

There is no established definition for what constitutes reduced fetal movements, but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment. Reduced fetal movements are a fairly common presentation, affecting up to 15% of pregnancies. Risk factors for reduced fetal movements include posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size.

Investigations for reduced fetal movements are dependent on gestation at onset. If past 28 weeks gestation, handheld Doppler should be used to confirm fetal heartbeat. If no fetal heartbeat is detectable, immediate ultrasound should be offered. If fetal heartbeat is present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm the presence of fetal heartbeat. If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

While reduced fetal movements can be a cause for concern, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Therefore, it is important for expectant mothers to be aware of their baby’s movements and seek medical attention if they notice a decrease in fetal movements.

In the case of treating Chlamydia during pregnancy, erythromycin would be the most appropriate option among the listed antibiotics. Amoxicillin, azithromycin, or erythromycin can be used to treat Chlamydia during pregnancy. However, since the patient is allergic to penicillin, amoxicillin is not suitable. Doxycycline, which is the first-line treatment for uncomplicated Chlamydia in non-pregnant individuals, is not recommended during pregnancy due to its teratogenic effects. Co-amoxiclav is also not appropriate for treating Chlamydia and is contraindicated in this patient due to their penicillin allergy.

Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

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.

No additional contraception is necessary if the Kyleena® IUS is inserted within the first seven days of a patient’s menstrual cycle. This form of intrauterine contraception contains a lower dose of levonorgestrel than the Mirena® IUS and is approved for use for up to five 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®.

Screening tests for Down syndrome are not always accurate, as they can miss detecting the condition in a significant number of babies. If a patient receives a low-risk result, they will not be offered any further testing for Down syndrome.

However, if a patient receives a higher risk result, meaning their baby has a risk greater than 1 in 150, they will be offered a diagnostic test to confirm whether or not their baby has Down syndrome. It is ultimately up to the patient to decide whether or not to undergo the diagnostic test.

Diagnostic tests for Down syndrome include chorionic villus sampling and amniocentesis.

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

Understanding Menopause and Hormone Replacement Therapy

The menopause is a natural biological process that marks the end of a woman’s reproductive years. It is defined as the cessation of normal menstruation, which typically occurs around the age of 51 in the UK. However, the climacteric, a period of gradually declining ovarian function, can begin years before and last years after menopause itself. This perimenopausal period can be characterized by irregular periods and occasional menorrhagia.

To be considered postmenopausal, a woman must have gone without menstruation for at least 12 months. However, it is important to note that a woman can still potentially become pregnant for up to two years after her last period if she is under 50, and one year if over 50. Therefore, contraception should be discussed with healthcare providers.

While hormone replacement therapy (HRT) can be used to alleviate symptoms of hypo-oestrogenism, it is not always necessary or appropriate. Routine hormone testing is not recommended unless there is diagnostic doubt. Women who are considering HRT should discuss the potential risks and benefits with their healthcare provider, as well as any pre-existing medical conditions that may affect their suitability for treatment.

Patients who experience problematic bleeding within the first 3 months of starting a new combined hormonal contraceptive pill, without any concerning symptoms, can be reassured and monitored. It is common for bleeding to improve after this initial period. A physical examination is typically not necessary for these patients, as long as they are participating in cervical screening and have not experienced more than 3 months of problematic bleeding.

A transvaginal ultrasound scan is not recommended at this stage.

However, if bleeding persists beyond 3 months or if there are other symptoms that suggest an underlying cause, such as abdominal pain, dyspareunia, abnormal vaginal discharge, heavy bleeding, or postcoital bleeding, a per vaginal and speculum examination should be considered.

If problematic bleeding continues, a higher dose of ethinylestradiol in a combined hormonal contraceptive pill can be tried, up to a maximum of 35 micrograms. While there is no evidence that changing the dose of progestogen improves cycle control, it may be beneficial on an individual basis.

There is no need for gynaecology referral at this stage.

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.

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.

All pregnant women are now advised to take 10mcg of vitamin D throughout their pregnancy. Additionally, low dose folic acid is recommended for the first 12 weeks of pregnancy for all women. However, those with pregnancies at a higher risk of neural tube defects should take 5mg of folic acid during the first 12 weeks. This includes couples where either partner has a neural tube defect or a family history of such defects, those who have had a previous pregnancy affected by a neural tube defect, or women with coeliac disease, diabetes mellitus, sickle-cell anaemia, or who are taking antiepileptic medication.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

Emergency Contraception after Childbirth

Levonorgestrel and ulipristal acetate are safe options for emergency contraception after childbirth, regardless of whether a woman is breastfeeding or not. Levonorgestrel has been shown to have no adverse effects on breastfeeding or infant outcomes, so women can continue to breastfeed after taking it.

However, ulipristal acetate is excreted in breast milk, and its effects on infants are not fully understood. Therefore, it is recommended that women do not breastfeed for seven days after taking it. To maintain lactation, women should express and discard breast milk during this time. Overall, emergency contraception is a viable option for women after childbirth, and healthcare providers can help them make informed decisions about which method to use.

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

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.

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.

Bacterial vaginosis is a condition characterized by the excessive growth of mainly bacteria.

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.

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.