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Y4 Obs and Gynae > Gynaecology: Contraception and Abortion > Flashcards

Gynaecology: Contraception and Abortion Flashcards

1
Q

Why is contraception important?

A
  • Reduces high risk pregnancies

- Allows for family planning/spacing which in turn reduced infant mortality, reduced impact of low SES

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2
Q

What are some important barriers to achieving adequate contraception to be aware of?

A
  • Lack of knowledge
  • Poor communication from health care providers
  • Poor quality of service from HCPs
  • Improper use
  • Fear of side effects
  • Cultural or religious opposition
  • Language barriers
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3
Q

What is the most commonly prescribed method of contraception in the UK?

A

Combined Hormonal Contraception.

Most commonly a second gen COCP pill (e.g. Levonorgestrel), but can give 1st/3rd/4th gen if bad reactions to past pills, can also give rings or patches but rare in UK.

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4
Q

What are some health risks associated with CHC?

A

Rare, but can cause increased risk of:

  • Breast cancer
  • Cervical cancer
  • VTE (however effect is mediated by other RFs, little to no increased risk if normal BMI, BP etc)
  • CVD and stroke
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5
Q

What are some crucial contraindications for CHC?

A

UK MEC category 4:

  • Cardiovascular disease (IHD, Stroke)
  • Multiple RFs for arterial disease e.g. over 35+ smoking
  • Hypertension (160/95)
  • VTE current or past
  • Major surgery w/ prolonged immobilisation
  • Complicated valvular and congenital heart disease
  • Migraine with aura
  • SLE

Also important to know drugs which can react with CHC:

  • Anti-epileptics
  • Rifampicin
  • HIV drugs
  • Lamotrigine
  • UPA
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6
Q

Outside of contraception, what are some benefits from CHC?

A

Reduces:

  • Menstrual bleeding
  • Menstrual pain
  • PID risk
  • Ovarian, endometrial and colorectal cancer risk
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7
Q

What is the most commonly given POP and how does it work?

A

Cerazette.

Cervical mucus alteration AND inhibits ovulation

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8
Q

In what conditions is the POP safe but the COCP unsafe?

A

Women with:

  • Migraine
  • DVT
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9
Q

What are some side effects of the POP?

A
  • Headaches
  • Breast pain
  • Acne
  • Nausea
  • Changes in libido
  • Changes in bleeding patterns are reasonably common
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10
Q

What is the most important UKMEC category 4 contraindication for the POP?

A

Current breast cancer!

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11
Q

Give an example of a progesterone only injectable?

A

Depo Provera, given IM in GP clinics every 3 months.

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12
Q

When can progesterone injections be given when COCP or POP may not?

A

If the patient is on a complex drug regimen (e.g. TB or HIV), effectiveness is not affected by enzyme inducing drugs

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13
Q

What are some downsides to the Depo injection contraception?

A
  • Delayed return to fertility (can take up to a year)
  • Weight gain!!!
  • Can cause a small loss in Bone Mass Density, but no evidence of increased fracture risk (still best to avoid in peeps with osteoporosis risk e.g. FH or wheelchair bound)
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14
Q

What is the main contraindication for depo injections AND subdermal infections according to UKMEC?

A

Current breast cancer!

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15
Q

What is an aternative to the depo injection in terms of long term progesterone contraception?

A

Nexplanon subdermal implant. Effective for 3 years (4 in Covid).

Implanted in the skin above the tricep of the non dominant arm.

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16
Q

What are the benefits to the subdermal implant?

A
  • Long acting reversible contraception
  • No adverse effect on BP, VTE risk, CV disease
  • No effect on bone mass density (issue with depo)
  • Rapid return to ovulation and fertility following removal
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17
Q

What are some drawbacks to the implant as a method of contraception?

A

Risks associated with insertion: Infection, Bledding, Bruising, Scarring, Deep implant and subsequent difficulty with removal.

Bleeding issues: Irregular for first 3 months, long term some get amenorrhoea, some get infrequent periods and some get prolonged bleeding.

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18
Q

What are the main forms of Intrauterine Contraception?

A
  • Copper bearing IUD

- Levonorgestrel releasing IUS (e.g. Mirena)

19
Q

What is the most effective form of emergency contraception?

A

Copper IUD, but only really used in situations when pills are not appropriate.

20
Q

What are some benefits of the Copper IUD?

A
  • Very low failure rate
  • Effective for 5-10 years
  • If a woman is in her 40s she can have one device until menopause.
21
Q

How does the Mirena coil work?

A
  • Releases oestrogens into the womb
  • This keeps the womb lining thin
  • Preventing implantation
  • Effective for 3 or 5 years
22
Q

What checks need to be made prior to insertion of Intra uterine contraception?

A
  • No chance of pregnancy

- No risk of infection (ask about recent unprotected sex, consider testing and consider prophylactic antibiotics)

23
Q

What are some risks associated with IUC?

A
  • Pain and discomfort on insertion
  • Infection or PID
  • Bleeding
  • Perforation is rare but possible
  • Expulsion is more common
  • Slight risk of failure and ectopic pregnancy

Copper coil can cause HMB, painful periods.

Mirena can cause acne, breast tenderness, irregular bleeding

24
Q

What are some contraindications for intrauterine contraception?

A
  • Pregnancy
  • PID, NG, CT
  • Pelvic TB
  • Postpartum sepsis
  • Shouldn’t give in women with unexplained vaginal bleeding due to risk of cervical or endometrial cancer
25
Q

When is emergency contraception indicated?

A

Contraception failure:

  • Condom not used or condom accident
  • Missed COCP (2+ pills)
  • Late POP (more than 36 hours)
  • Late Depo (more than 14 weeks since last injection)
  • Impalpable implant or more than 3 years since insertion
  • IUD expulsion, lost threads
26
Q

What are the three most common methods of emergency contraception?

A

EllaOne

  • Selective progesterone receptor modulator
  • 30mg single dose
  • Up to 120 hours after UPSI or contraceptive failure

Levonelle

  • Progesterone
  • 1.5mg single dose
  • Up to 72 hours since UPSI or contraceptive failure LICENCED
  • UNLICENCED up to 120 hours

Copper coil

  • Copper is toxic to sperm and ovum
  • Has to be after 5 days of USPI AND within 5 days from earliest estimated day of ovulation
  • 99% effective
27
Q

What counselling should be given to women after taking emergency contraception?

A
  • Know it can fail
  • Should consider pregnancy test in 3 weeks if abnormal periods
  • Nausea, headaches, breast tenderness, abdominal pain al common
  • Small number will vomit and must repeat dose
  • Reiterate importance of contraception
  • Take drug history; if on liver inducers need double dose.
28
Q

Define abortion?

A

Abortion is the removal or expulsion of an embryo or foetus from the uterus before viability, be it spontaneous or medically induced.

29
Q

What does the Abortion Act of 1967 state?

A

Under UK law, an abortion can be carried out during the first 24 weeks of pregnancy as long as certain criteria are met.

A pregnancy can be terminated by a medical practitioner if TWO medical practitioners feel that:

  • Continuation of the pregnancy would involve risk to the physical or mental health of the woman
  • Continuation of the pregnancy involves a risk to the life of the woman
  • There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
30
Q

What are the two methods of performing an abortion?

A

Medical:

  • Mifepristone (an anti-progesterone) and Misoprostol (a prostaglandin)
  • If 22 weeks or beyond, add Fetocide agent such as Potassium Chloride

Surgical:

  • Suction evacuation (1st trimester)
  • Dilatation and evacuation (2nd trimester)
31
Q

What are some benefits of medical abortion?

A
  • Avoids surgery

- If early can be performed in the home (9 weeks or earlier)

32
Q

What are some drawbacks of medical abortion?

A
  • Takes time (hours to days)
  • Women experience bleeding and cramping, potentially nausea and vomiting
  • May require more clinic visits and therefore actually more time with HCP than surgery
33
Q

What are some benefits of surgical abortion?

A
  • Quick procedure
  • Complete abortion is easily verified
  • Takes place in a healthcare facility
  • Sterilisation/long term contraception ca be inserted at the same time.
34
Q

What are some drawbacks of surgical abortion?

A
  • Requires instrumentation of the uterus

- Small risk of uterine or cervical injury

35
Q

In what cases would you always recommend medical abortion over surgical?

A
  • Very obese women
  • Uterine malformation or fibroids
  • If the woman wants to avoid surgical intervention
  • If a pelvic examination is not feasible or unwanted
  • Contraindications for anaesthetic
36
Q

What medical abortion regime is recommended for a woman at 9 weeks pregnancy (63 days gestation)?

A

Mifepristone 200mg orally, can be taken at home.

24-48 hour delay

Misprostol 800 micrograms given vaginaly, or sublingually.

37
Q

What medical abortion regime would you recommend for a woman beyond 9 weeks but before 14 weeks gestation

A

Mifepristone 200mg orally

24-48 hour delay

Micoprostol 800 micrograms given vaginally, or sublingually.

Followed by an additional 400 micrograms of Micoprostol every 3 hours until abortion occurs.

38
Q

What surgical abortion regime would you recommend for a woman below 14 weeks gestation?

A

Manual or vacuum aspiration

39
Q

What medical abortion regime would you recommend for a woman beyond 14 weeks gestation?

A

Above 14 weeks should always be done in a medical facility.

Mifepristone 200mg orally, 12-48 hours later, Misoprostol 800 micrograms vaginally, then again 400mg every 3 hours

If no abortion after 24 hours repeat entire cycle again

40
Q

What surgical abortion regime would you recommend for a woman beyond 14 weeks gestation?

A

Vacuum aspiration using large bore cannulae

OR

Dilatation and evacuation (rarer, tend to be in specialised centres)

41
Q

What form of abortion do women in the second trimester tend to get?

A

Medical, surgical becomes notably more difficult in the second trimester whereas medical remains as effective.

42
Q

What are the common complications of abortion?

A
  • Failure to end pregnancy (1-2%)
  • Need for further intervention to complete the procedure
  • Haemorrhage requiring transfusion
  • Uterine rupture (second trimester medical abortions)

Surgical TOP:

  • Cervical trauma
  • Uterine perforation
43
Q

What after care advice is offered to women post abortion?

A
  • How much bleeding to expect in the next few days and weeks
  • How to recognise potential complications
  • How to recognise signs of ongoing pregnancy
  • When they can resume normal activities (including sexual intercourse)
  • How and where to seek help if needed
  • Women who want to conceive again soon should be advised to have at least one normal period before getting pregnant again (multiple if anaemic)
  • Give Anti-D if appropriate
  • Offer contraception, method of their choice.

Y4 Obs and Gynae (13 decks)

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