Atypical Endometrial Cells: Significance and Associated Risks

Diagnosis of atypical endometrial cells is of clinical significance as it may indicate the presence of significant uterine disease. In fact, more than one-third of women with histological follow-up have been found to have such conditions. Atypical endometrial cells may be associated with various conditions such as endometrial polyp, chronic endometritis, intrauterine contraceptive device (IUCD), endometrial hyperplasia, and endometrial carcinoma. The risk of carcinoma is particularly concerning, and patients should be referred to a gynaecologist for further investigation. Urgent referral is recommended, and patients should be seen within two weeks of referral to ensure timely diagnosis and treatment.

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.

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.

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.

Implications of Unintended Pregnancy and Contraceptive Efficacy

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

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

Management of Lower Urinary Tract Infection

Guidance from SIGN1 recommends that in cases of lower urinary tract infection (UTI), a dipstick test is not necessary if typical symptoms are present. However, if minimal symptoms or signs are present, a dipstick test should be performed. If the test is positive for leukocytes and nitrites, treatment should be commenced. If it is negative, clinical judgement should be used to determine whether to offer empirical treatment and/or send a mid-stream urine (MSU) sample.

In cases where there are signs or symptoms of upper UTI infection, such as loin pain and systemic symptoms, admission should be considered. Non-pregnant women of any age with symptoms or signs of acute LUTI should be treated with a three-day course of trimethoprim or nitrofurantoin.

By following these guidelines, healthcare professionals can effectively manage lower UTIs and provide appropriate treatment to patients. Proper management can help prevent the spread of infection and improve patient outcomes.

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

NICE doesn’t recommend routine auscultation for the fetal heart, but if the mother requests it, it may provide reassurance.

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

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

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

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

Immediate initiation of insulin is recommended due to the high blood glucose levels and presence of macrosomia. Additionally, it is advisable to consider administering aspirin as there is an elevated risk of pre-eclampsia.

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.

Hepatitis B and Pregnancy: Screening and Prevention

During pregnancy, all women are offered screening for hepatitis B. If a woman is found to be chronically infected with hepatitis B or has had acute hepatitis B during pregnancy, her baby should receive a complete course of vaccination and hepatitis B immunoglobulin. Studies are currently being conducted to evaluate the effectiveness of oral antiviral treatment, such as Lamivudine, in the latter part of pregnancy.

There is little evidence to suggest that a caesarean section reduces the transmission rates of hepatitis B from mother to baby. It is important to note that hepatitis B cannot be transmitted through breastfeeding, unlike HIV. Therefore, mothers with hepatitis B can safely breastfeed their babies without fear of transmission.

Overall, screening for hepatitis B during pregnancy and taking appropriate preventative measures can greatly reduce the risk of transmission from mother to baby. It is important for healthcare providers to educate pregnant women about the importance of screening and prevention to ensure the health and safety of both mother and baby.

Disorders of Sex Development: Common Conditions and Characteristics

Disorders of sex development refer to a group of conditions that affect the development of an individual’s reproductive system. The most common disorders are androgen insensitivity syndrome, 5-α reductase deficiency, male and female pseudohermaphroditism, and true hermaphroditism. Androgen insensitivity syndrome is an X-linked recessive condition that results in end-organ resistance to testosterone, causing genotypically male children to have a female phenotype. 5-α reductase deficiency, on the other hand, is an autosomal recessive condition that results in the inability of males to convert testosterone to dihydrotestosterone, leading to ambiguous genitalia in the newborn period. Male and female pseudohermaphroditism are conditions where individuals have testes or ovaries but external genitalia are female or male, respectively. Finally, true hermaphroditism is a very rare condition where both ovarian and testicular tissue are present. Understanding the characteristics of these conditions is crucial in providing appropriate medical care and support for affected individuals.

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.

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.

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

Chickenpox Exposure in Pregnancy: Risks and Management

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

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

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

During pregnancy, fibroid degeneration can occur and may cause symptoms such as low-grade fever, pain, and vomiting. If an ultrasound scan shows no signs of inflammation in the appendix, it is unlikely that the patient has appendicitis. Given the presence of fibroids in the uterus, the patient is at risk of experiencing fibroid degeneration, particularly red degeneration, which can cause fever, pain, and vomiting. The absence of vaginal bleeding makes it unlikely that the patient is experiencing a threatened miscarriage. Ovarian torsion typically presents with pain and vomiting, but it is usually associated with risk factors such as ovarian cysts or enlargement.

Understanding Fibroid Degeneration

Uterine fibroids are non-cancerous growths that can develop in the uterus. They are known to be sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days. It is important to note that fibroid degeneration is a common occurrence and doesn’t necessarily indicate a serious underlying condition.

The mother’s behavior suggests that she may be experiencing puerperal psychosis and requires immediate admission for psychiatric assessment.

Although not all psychotic symptoms are present, there are several indications of significant mental health issues, such as the mother’s unusual lack of interaction with her baby, incoherent speech about the future, and expressing concern that the baby has been born into a troubled world.

Therefore, it is crucial that the mother receives prompt psychiatric evaluation.

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.

Gonorrhea: Symptoms, Treatment, and Complications

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

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

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

When using Ellaone, it is recommended to wait for 5 days before starting the combined contraceptive pill and to use barrier contraception for 7 days. This is because taking progestogen within 5 days of using Ulipristal may reduce its effectiveness as an emergency contraceptive. Waiting for this period and avoiding further unprotected sexual intercourse ensures that Ellaone is as effective as possible in preventing pregnancy. When starting the combined contraceptive pill, patch, or ring, or the progesterone-only implant or injection, barrier contraception should be used for 7 days. For Qlaira contraceptive pill, barrier contraceptives should be used for 9 days, and for the progesterone-only pill, for 2 days after starting the method.

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.

Cardiac arrest cannot be listed as the sole cause of death on a death certificate as it is a method of dying and requires further clarification.

While the use of old age is discouraged, it may be listed on a death certificate for patients over the age of 80 if specific criteria are met (refer to the provided link).

The only acceptable abbreviations for HIV and AIDS should be used on a death certificate.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

The most appropriate management option for this patient is to offer the progestogen-only implant, as it can be safely inserted immediately after delivery and provides a long-term contraception option. Advising her that she doesn’t require contraception is not appropriate, as she is using a top-up formula and not exclusively breastfeeding. Offering the Mirena coil or restarting the combined oral contraceptive pill immediately are also not appropriate options, as they have specific timing requirements and potential risks for postpartum women.

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.

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.

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.

The Kyleena intrauterine system (IUS) is approved for use as a contraceptive for a period of 5 years. It contains 19.5mg of levonorgestrel (LNG) and is a relatively new option in the UK. Compared to the Mirena IUS, it has a smaller frame and insertion tube. The Mirena IUS, which contains 52mg of LNG, is also approved for 5 years of use as a contraceptive. The Jaydess IUS, which contains 13.5mg of LNG, is approved for 3 years of use. Copper coils typically have a contraceptive license for a period of 5 years or less.

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 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.

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.

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.

Treatment Options for Menopausal Symptoms

Systemic oestrogens remain the most effective treatment for hot flashes during menopause, according to available evidence. However, hormone profiling is only useful in uncertain cases, and clonidine effectiveness in treating hot flashes is not yet conclusive. Loss of libido is often caused by a decrease in circulating androgens, but tibolone has been shown to improve libido. On the other hand, counselling efficacy in treating menopausal symptoms is still uncertain, and phyto-oestrogens are no more effective than a placebo, according to BMJ Clinical Evidence. In summary, systemic oestrogens and tibolone are the most promising treatments for menopausal symptoms, while other options require further research.

Contraception is still necessary after menopause. Women who are over 50 years old should use contraception for at least 12 months after their last period, while those under 50 years old should use it for at least 24 months after their last period.

Understanding Menopause and Contraception

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It typically occurs when a woman reaches the age of 51 in the UK. However, prior to menopause, women may experience a period known as the climacteric. During this time, ovarian function starts to decline, and women may experience symptoms such as hot flashes, mood swings, and vaginal dryness.

It is important for women to understand that they can still become pregnant during the climacteric period. Therefore, it is recommended to use effective contraception until a certain period of time has passed. Women over the age of 50 should use contraception for 12 months after their last period, while women under the age of 50 should use contraception for 24 months after their last period. By understanding menopause and the importance of contraception during the climacteric period, women can make informed decisions about their reproductive health.

Implants are considered a UKMEC 2 option for contraception in patients with epilepsy. However, there are also UKMEC 1 options available.

Contraception for Women with Epilepsy

Women with epilepsy need to consider several factors when choosing a contraceptive method. The effectiveness of anti-epileptic medication can be affected by the contraceptive, and vice versa. Additionally, if a woman becomes pregnant while taking anti-epileptic medication, there is a risk of teratogenic effects on the fetus. To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends the consistent use of condoms in addition to other forms of contraception.

For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends using the combined oral contraceptive pill (COCP) or progestogen-only pill (POP) with a UK Medical Eligibility Criteria (UKMEC) rating of 3. The implant has a UKMEC rating of 2, while the Depo-Provera injection, intrauterine device (IUD), and intrauterine system (IUS) have a UKMEC rating of 1.

For women taking lamotrigine, the FSRH recommends using the COCP with a UKMEC rating of 3 or the POP, implant, Depo-Provera injection, IUD, or IUS with a UKMEC rating of 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol.

In summary, women with epilepsy should carefully consider the potential interactions between their anti-epileptic medication and their chosen contraceptive method. Using condoms consistently in addition to other forms of contraception can help reduce the risk of unintended pregnancy and potential teratogenic effects on the fetus.

Starting Hormonal Contraception After Emergency Contraception

When starting hormonal contraception after taking progesterone-only emergency contraception, it is important to advise the use of additional contraception until contraceptive efficacy is established. If there is still a risk of pregnancy, the woman should express her preference for contraception immediately and be aware of the theoretical risk of fetal exposure to hormones, although evidence indicates no harm. A pregnancy test should be suggested at least three weeks after the last episode of unprotected sexual intercourse.

After taking progesterone-only emergency contraception, it is recommended to use condoms or avoid sex for seven days before starting most hormonal contraception. However, if ulipristal emergency contraception is taken, its effectiveness could be reduced if progestogen is taken in the following five days. Therefore, the quick start of suitable hormonal contraception should be delayed for five days (120 hours) after ulipristal.