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.

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.

Hormone Replacement Therapy (HRT) Options for Women

Women who have had a hysterectomy can use unopposed oestrogens, but those with a uterus must use regimens with both oestrogen and progestogen to avoid the risk of endometrial hyperplasia and potential malignant transformation. Postmenopausal women can use combined continuous regimens, while those still having periods can use cyclical HRT. Urogenital symptoms can be treated with topical oestrogens or non-hormonal vaginal moisturisers. Low dose combined pills may be an option for under 50s, but careful patient selection is necessary due to contraindications and cautions. It is important to discuss the risks and benefits of each option with a healthcare provider to determine the best course of treatment.

Infertility Management and Referral Criteria

Infertility is a common issue that affects many couples. According to the Clinical Knowledge Summaries, if a couple has been having regular unprotected sexual intercourse for one year and are without comorbidities that affect fertility, investigation into the cause of infertility should be initiated. If no cause is found, the couple should be referred for specialist input.

The referral criteria for infertility may vary between health authorities, so it is important to refer to local guidelines. However, in general, if the woman is younger than 36 years and history, examination, and investigations are normal in both partners, referral should be considered if the couple has not conceived after one year. If the woman is aged 36 years or older, referral should be considered after six months. Earlier referral may be necessary if there is a known cause for infertility, a history of factors that predispose to infertility, or if treatment is planned that may result in infertility.

It is important to ensure that the couple has been offered counselling before, during, and after investigation and treatment, regardless of the outcome. Infertility and its investigation and treatment can cause psychological stress, and infertility counsellors are provided by all licensed clinics in the UK through the British Infertility Counselling Association.

Understanding Contraception: A Basic Overview

Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

Barrier methods, such as condoms, act as a physical barrier and can help protect against sexually transmitted infections (STIs). However, their success rate is relatively low, particularly when used by young people. Daily methods include the combined oral contraceptive pill, which inhibits ovulation but increases the risk of venous thromboembolism and certain types of cancer. The progesterone-only pill thickens cervical mucous, but irregular bleeding is a common side effect.

LARCs include implantable contraceptives, injectable contraceptives, and intrauterine devices (IUDs). The implantable contraceptive and injectable contraceptive both inhibit ovulation and thicken cervical mucous, with the implant lasting up to three years and the injection lasting 12 weeks. The IUD decreases sperm motility and survival, while the intrauterine system (IUS) prevents endometrial proliferation and thickens cervical mucous, with irregular bleeding being a common side effect.

In summary, understanding the different types of contraception available and their methods of action can help individuals make informed decisions about their reproductive health.

The Risks of Warfarin Use During Pregnancy

Warfarin, a commonly used anticoagulant, is contraindicated during pregnancy due to its ability to cross the placental barrier and cause bleeding in the fetus. Its use during the first trimester, particularly between the sixth and ninth weeks, can lead to skeletal abnormalities such as nasal hypoplasia, limb abnormalities, and calcification of the vertebral column, femur, and heel bone. Other potential complications include low birthweight, developmental disabilities, and an increased risk of spontaneous abortion, stillbirth, neonatal death, and preterm birth. However, unfractionated heparin or low-molecular-weight heparin can be used as safer alternatives. While warfarin is not known to cause neural tube defects or cleft lip and palate, it is important to be aware of the potential risks associated with its use during pregnancy.

Mastitis is a common condition that affects breastfeeding women, typically occurring six weeks after giving birth. It can be difficult to distinguish between an engorged breast, blocked duct, non-infectious mastitis, and infected mastitis. Milk accumulation in breast tissue can cause an inflammatory response, leading to bacterial growth and resulting in a painful breast with fever, malaise, and a tender, red, swollen, and hard area of the breast.

If symptoms do not improve or worsen after 12-24 hours despite effective milk removal, or if a nipple fissure is infected, infectious mastitis should be suspected. Breast milk culture is not routinely required unless mastitis is severe, there has been no response to antibiotics, or this is recurrent mastitis.

Management of mastitis involves relieving pain with simple analgesia and warm compresses, and ensuring complete emptying of the breast after feeding. Breastfeeding should be continued as it improves milk removal and prevents nipple damage. If pain prevents breastfeeding, expressing breast milk by hand or pump is recommended until breastfeeding can be resumed.

Antibiotics are only recommended if necessary, and the first line antibiotic is flucloxacillin for 14 days (erythromycin if penicillin allergic). Intravenous antibiotics are rarely needed, but urgent referral to breast surgeons for drainage may be necessary if a breast abscess is suspected.

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.

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

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. THF plays a crucial role in transferring 1-carbon units to essential substrates involved in DNA and RNA synthesis. Green, leafy vegetables are a good source of folic acid. However, certain medications like phenytoin and methotrexate, pregnancy, and alcohol excess can cause folic acid deficiency. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

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

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

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.

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

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

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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.

Women can begin using hormonal contraception right away after taking levonorgestrel (Levonelle) for emergency contraception. However, if ulipristal acetate was used instead, it may affect the effectiveness of hormonal contraception and women should use barrier methods or refrain from sex for 5 days before resuming hormonal contraception.

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.

Rhesus negative mothers can develop anti-D IgG antibodies if they deliver a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis at 28 and 34 weeks. Anti-D should also be given in various situations, such as delivery of a Rh +ve infant or amniocentesis. Tests include cord blood FBC, blood group, direct Coombs test, and Kleihauer test. Affected fetuses may experience oedema, jaundice, anaemia, hepatosplenomegaly, heart failure, and kernicterus, and may require transfusions and UV phototherapy.

Understanding Hirsutism and its Common Causes

Hirsutism is a condition characterized by excessive hair growth in women, often in areas where hair is typically absent or minimal. The most common cause of hirsutism is polycystic ovary syndrome (PCOS), which accounts for 95% of cases. This condition is often accompanied by obesity and amenorrhea, which are indicative of insulin resistance.

Biochemically, patients with PCOS have a reversed luteinising hormone:follicle-stimulating hormone (LH:FSH) ratio and elevated androstenedione with a low sex-hormone-binding globulin (SHBG). It is important to rule out other potential causes of hirsutism, such as androgen-producing tumors of the adrenal gland or ovary, Cushing’s syndrome, or congenital adrenal hyperplasia.

In summary, hirsutism is a common condition in women, with PCOS being the most common cause. Proper evaluation and diagnosis are crucial to ensure appropriate treatment and management.

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

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

Folic Acid Supplements for Women

Taking folic acid supplements before conception can be beneficial for women. It is important to note that the correct dose for women without risk factors is 400mcg, not 5mg. While 400mcg tablets are available over the counter, 5mg tablets require a prescription. Women should continue taking the supplements until 12 weeks of pregnancy. It is important to start taking folic acid before becoming pregnant to reap the benefits.

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

Chickenpox Exposure in Pregnancy: Risks and Management

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

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

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

The BNF recommends against the use of quinolones during pregnancy due to the risk of arthropathy observed in animal studies. While there have been reports of a potential increase in the risk of necrotizing enterocolitis with the use of co-amoxiclav during pregnancy, the evidence is not conclusive. The BNF states that co-amoxiclav is currently considered safe for use during pregnancy, and provides links to both the BNF and the UK teratology information service for further information.

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.

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.

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.

Starting and Maintaining the Combined Oral Contraceptive Pill

The Combined Oral Contraceptive Pill (COC) can be started at any point during the menstrual cycle, as long as the woman is not pregnant. Once established on the COC, it is reasonable to give a 12-month prescription.

According to the latest guidance from the Faculty of Sexual and Reproductive Healthcare (FSRH), additional precautions are no longer required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with the COCP for durations of 3 weeks or less. However, if the antibiotics or illness cause vomiting or diarrhea, the usual additional precautions relating to these conditions should be observed.

If seven COC pills have been taken, ovulation is suppressed for a further seven days, and emergency contraception is not required.

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.

If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced as the next step. This is in accordance with current NICE guidelines, which recommend offering insulin if metformin is not suitable for the patient or contraindicated.

For pregnant women with any form of diabetes, it is important to maintain plasma glucose levels below the following target values:

– Fasting: 5.3 mmol/L
– One hour after a meal: 7.8 mmol/L
– Two hours after a meal: 6.4 mmol/L

Commencing anti-emetic medications is not the correct answer, as this will not address the gestational diabetes and is therefore not the most relevant option.

Similarly, commencing metformin is not appropriate in this case, as the patient has indicated that it is not acceptable to her. Insulin should be offered instead.

Offering a 2 week trial of diet and exercise changes is not the correct answer, as this patient now requires medication. This approach may be appropriate for patients with a fasting plasma glucose of between 6.0 and 6.9 mmol/L without complications, but medication should be started if blood glucose targets are not met.

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.

During pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG), which causes an increase in the levels of total thyroxine. However, this doesn’t affect the free thyroxine level. If left untreated, thyrotoxicosis can increase the risk of fetal loss, maternal heart failure, and premature labor. Graves’ disease is the most common cause of thyrotoxicosis during pregnancy, but transient gestational hyperthyroidism can also occur due to the activation of the TSH receptor by HCG. Propylthiouracil has traditionally been the antithyroid drug of choice, but it is associated with an increased risk of severe hepatic injury. Therefore, NICE Clinical Knowledge Summaries recommend using propylthiouracil in the first trimester and switching to carbimazole in the second trimester. Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism. Thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation to determine the risk of neonatal thyroid problems. Block-and-replace regimens should not be used in pregnancy, and radioiodine therapy is contraindicated.

On the other hand, thyroxine is safe during pregnancy, and serum thyroid-stimulating hormone should be measured in each trimester and 6-8 weeks postpartum. Women require an increased dose of thyroxine during pregnancy, up to 50% as early as 4-6 weeks of pregnancy. Breastfeeding is safe while on thyroxine. It is important to manage thyroid problems during pregnancy to ensure the health of both the mother and the baby.

Promethazine is the recommended medication for nausea and vomiting in pregnancy, as metoclopramide should not be used for more than 5 days due to the risk of extrapyramidal effects. Therefore, prescribing promethazine is the correct option for this patient who is requesting an antiemetic. Advising a trial of ginger and acupressure bands is not appropriate as there is little evidence to support their effectiveness. Additionally, advising the patient to take time off work is not necessary as she has expressed a desire to continue working.

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.

Preterm labour is a well-known complication for mothers with diabetes during pregnancy.

Complications of Diabetes during Pregnancy

Diabetes during pregnancy can lead to various complications for both the mother and the baby. Maternal complications may include polyhydramnios, which occurs in 25% of cases and may be due to fetal polyuria. Preterm labor is also a common complication, affecting 15% of cases and often associated with polyhydramnios.

Neonatal complications may include macrosomia, although diabetes can also cause small for gestational age babies. Hypoglycemia is another common complication, which occurs due to beta cell hyperplasia. Respiratory distress syndrome may also occur, as surfactant production is delayed. Polycythemia can lead to neonatal jaundice, and malformation rates increase 3-4 fold, including sacral agenesis, CNS and CVS malformations, and hypertrophic cardiomyopathy. Stillbirth, hypomagnesemia, hypocalcemia, and shoulder dystocia (which may cause Erb’s palsy) are also possible complications.

The effectiveness of hormonal contraception may be reduced by EllaOne. To ensure proper contraception, individuals using the pill, patch, or ring should wait 5 days after taking Ulipristal before starting or restarting their contraception. During this period, it is recommended to use barrier methods.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

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

Termination of Pregnancy in the UK

The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, although in emergencies, only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise. The method used to terminate pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone followed by prostaglandins is used, while surgical dilation and suction of uterine contents are used for pregnancies less than 13 weeks. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion is used. The 1967 Abortion Act outlines the conditions under which a person shall not be guilty of an offense under the law relating to abortion. These limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.

For women who have had gestational diabetes in a previous pregnancy, it is recommended that they undergo an OGTT as soon as possible after their initial booking, and then again at 24-28 weeks. If the first test is normal, they may also be offered early self-monitoring of blood glucose as an alternative. Women who have other risk factors for gestational diabetes, such as a BMI over 30 kg/m², a previous macrosomic baby weighing 4.5 kg or more, a first degree relative with diabetes, or a minority ethnic family origin with a high prevalence of diabetes, but no previous history of gestational diabetes, should be offered an OGTT at 24-28 weeks.

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.