Management of Bleeding in Early Pregnancy

When a woman experiences bleeding in early pregnancy, it is important to follow the appropriate management guidelines. According to NICE advice, if bleeding settles before 6 weeks of gestation and the woman is haemodynamically stable and pain-free, a repeat pregnancy test should be done after 7-10 days to determine if a miscarriage has occurred. Follow-up should also be arranged to manage any changes in the clinical situation, with safety netting advice provided.

Immediate referral to hospital is not necessary in this scenario, unless the patient becomes haemodynamically unstable. A serum βHCG test is also not required as a urinary pregnancy test has already been conducted and is positive. It is important to provide follow-up to ensure that the patient’s symptoms do not worsen and to check for a possible miscarriage.

If a woman is less than 6 weeks pregnant and experiences bleeding but no pain, referral to an EPU is only necessary if bleeding continues after 6 weeks gestation or if symptoms of an ectopic pregnancy develop. In this case, the patient’s bleeding has settled, she is haemodynamically stable, and there are no symptoms of an ectopic pregnancy.

Breastfeeding is not recommended while taking Methotrexate.

Breastfeeding Contraindications: Drugs and Other Factors to Consider

Breastfeeding is generally recommended for infants as it provides numerous benefits for both the baby and the mother. However, there are certain situations where breastfeeding may not be advisable. One of the major contraindications is the use of certain drugs by the mother, which can be harmful to the baby. Antibiotics like penicillins and cephalosporins, as well as endocrine medications like levothyroxine, can be given to breastfeeding mothers. On the other hand, drugs like ciprofloxacin, tetracycline, and benzodiazepines should be avoided.

Aside from drugs, other factors like galactosaemia and viral infections can also make breastfeeding inadvisable. In the case of HIV, some doctors believe that the benefits of breastfeeding outweigh the risk of transmission, especially in areas where infant mortality and morbidity rates are high.

It is important for healthcare professionals to be aware of these contraindications and to provide appropriate guidance to mothers who are considering breastfeeding. By doing so, they can help ensure the health and well-being of both the mother and the baby.

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

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

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

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

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

Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

Signs and Symptoms of Hyperprolactinaemia

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

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

Causes of Vaginal Discharge in Women

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

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

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

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

The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.

If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.

Parents are informed and the NHS website states that the daughter can still receive the vaccine even if the parents object.

The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with strains 6 and 11 causing genital warts and strains 16 and 18 linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for developing cervical cancer, such as smoking and contraceptive pill use, HPV vaccination is an effective preventative measure.

The UK introduced an HPV vaccine in 2008, initially using Cervarix, which protected against HPV 16 and 18 but not 6 and 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16, and 18. Initially given only to girls, boys were also offered the vaccine from September 2019. The vaccine is offered to all 12- and 13-year-olds in school Year 8, with the option for girls to receive a second dose between 6-24 months after the first. Men who have sex with men under the age of 45 are also recommended to receive the vaccine to protect against anal, throat, and penile cancers.

Injection site reactions are common with HPV vaccines. It should be noted that parents may not be able to prevent their daughter from receiving the vaccine, as information given to parents and available on the NHS website makes it clear that the vaccine may be administered against parental wishes.

Lactational Amenorrhoea Method (LAM) as a Contraceptive

Breastfeeding can be used as a form of contraception through the lactational amenorrhoea method (LAM). This method works by suppressing ovarian activity, which prevents the return of menstrual periods after childbirth. For LAM to be effective, a woman must engage in full breastfeeding, which includes exclusive or almost exclusive breastfeeding with no other liquids or solids given.

If the frequency or duration of breastfeeding decreases, the risk of menstrual periods and fertility increases. Women who experience bleeding within the first six months after childbirth have a higher risk of pregnancy than those who remain amenorrhoeic. To use LAM as a contraceptive, a woman must meet all three criteria: fully or nearly fully breastfeeding day and night, no long intervals between feeds, and amenorrhoeic and less than six months postpartum.

When the rules of LAM are strictly followed, failure rates are less than 2%. Therefore, LAM can be an effective and natural form of contraception for women who choose to breastfeed their infants.

Pregnant women should not take any tetracyclines. It is important to note that the aforementioned medications may not be the preferred initial treatments.

Prescribing Considerations for Pregnant Patients

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

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

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.