The increase in body temperature after ovulation is utilized in certain cases of natural family planning.

Phases of the Menstrual Cycle

The menstrual cycle is a complex process that can be divided into four phases: menstruation, follicular phase, ovulation, and luteal phase. During the follicular phase, a number of follicles develop in the ovaries, with one follicle becoming dominant around the mid-follicular phase. At the same time, the endometrium begins to proliferate. This phase is characterized by a rise in follicle-stimulating hormone (FSH), which results in the development of follicles that secrete oestradiol.

During ovulation, the mature egg is released from the dominant follicle and triggers the acute release of luteinizing hormone (LH). This phase occurs on day 14 of the menstrual cycle. Following ovulation, the luteal phase begins, during which the corpus luteum secretes progesterone. This hormone causes the endometrium to change into a secretory lining. If fertilization does not occur, the corpus luteum will degenerate, and progesterone levels will fall.

The cervical mucus also changes throughout the menstrual cycle. Following menstruation, the mucus is thick and forms a plug across the external os. Just prior to ovulation, the mucus becomes clear, acellular, and low viscosity. It also becomes ‘stretchy’ – a quality termed spinnbarkeit. Under the influence of progesterone, it becomes thick, scant, and tacky.

Basal body temperature is another indicator of the menstrual cycle. It falls prior to ovulation due to the influence of oestradiol and rises following ovulation in response to higher progesterone levels. Understanding the different phases of the menstrual cycle can help individuals track their fertility and plan for pregnancy.

According to NICE guidelines, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, or mefenamic acid should be the first-line treatment for primary dysmenorrhoea, unless contraindicated. Combined oral contraceptives (COCs) containing ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are also recommended for women who do not wish to conceive. However, for a non-sexually active woman, a non-hormonal drug would be more appropriate. Paracetamol can be prescribed if NSAIDs are not tolerated or contraindicated. Tranexamic acid is useful for menorrhagia, not dysmenorrhoea. The diagnosis of primary dysmenorrhoea is likely if menstrual pain starts 6-12 months after menarche, before menstruation, and lasts up to 72 hours, with non-gynaecological symptoms present, and a normal pelvic examination.

When women experience postmenopausal bleeding (PMB), it is important to rule out the possibility of endometrial cancer. The first step is to conduct a speculum examination to check for any visible abnormalities. For women over 40 years old, an endometrial biopsy and hysteroscopy should be performed to diagnose endometrial cancer. Risk factors for this type of cancer include advanced age, never having given birth, using unopposed estrogen therapy, starting menstruation at an early age and experiencing menopause later in life, being overweight, and having submucosal fibroids that typically calcify after menopause.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. Progestogen therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

Placenta praevia is a condition where the placenta is located in the lower part of the uterus, either partially or completely. If the placenta covers the internal cervical os, it is classified as major praevia, while it is considered minor or partial if it does not. Bleeding can occur spontaneously, due to trauma, or during labor as the cervix opens.

The Royal College of Obstetricians and Gynaecologists recommends considering placenta praevia in all cases of vaginal bleeding after 20 weeks of pregnancy. Symptoms that increase suspicion of this condition include painless bleeding, a high presenting part, and abnormal fetal lie. A definitive diagnosis usually requires an ultrasound to determine the position of the placenta.
(RCOG Green-top Guideline No. 27)

In this case, the absence of pain makes placental abruption unlikely, and the normal appearance of the cervix rules out cervical trauma, cervical neoplasm, and inevitable miscarriage as the cause.

Understanding Placenta Praevia

Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.

There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.

Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.

In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.

Postpartum haemorrhage caused by uterine atony can be treated with various medical options such as oxytocin, ergometrine, carboprost and misoprostol.

Uterine atony is the primary cause of postpartum haemorrhage, which occurs when the uterus fails to contract fully after the delivery of the placenta, leading to difficulty in achieving haemostasis. This condition is often associated with overdistension, which can be caused by multiple gestation, macrosomia, polyhydramnios or other factors.

In addition to the standard approach for managing PPH, including an ABC approach for unstable patients, the following steps should be taken in sequence:

1. Bimanual uterine compression to stimulate contraction manually
2. Intravenous oxytocin and/or ergometrine
3. Intramuscular carboprost
4. Intramyometrial carboprost
5. Rectal misoprostol
6. Surgical intervention such as balloon tamponade

(RCOG Green-top Guideline No. 52)

Understanding Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

Injectable Contraceptives: Depo Provera

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

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

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

The copper intrauterine device is the recommended form of contraception for individuals with breast cancer. Hormonal forms of contraception are not recommended and are rated as a Category 4 risk, which is deemed unacceptable for the patient’s health.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

The diagnosis that needs to be ruled out first is obstetric cholestasis, as it can heighten the chances of premature birth and fetal death. The condition is identified by abnormal liver function tests and itching without any skin rash. Unlike uric acid, it is the bile acids that are elevated in obstetric cholestasis.

Liver Complications During Pregnancy

During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

To prevent neural tube defects in the foetus, it is crucial to consume folic acid. It is advised that women who are planning to conceive should take a supplement of 400 micrograms of folic acid daily. This dose should be continued until the 12th week of pregnancy. If there is a family history or a previous pregnancy affected by neural tube defects, the recommended dose should be increased.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

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

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.