Maternity and Reproductive Health Flashcards
When to treat with PO iron in pregnancy?
- If pt at risk of iron deficiency anaemia and serum ferritin is <30.
- If anaemic (booking Hb <110 or <105 in 2nd or 3rd trimester)
need 180-200mg elemental iron daily
if 2nd bullet point met should also receive 400mcg of folic acid daily and recheck Hb in 2-3/52-if no improvement then check Vit B12, ferritin and folate.
Most common cause of thrombocytopenia in pregnancy?
Gestational thrombocytopenia-secondary to increased blood volume, increased PLT activation and then clearance.
When should FBC be checked in pregnancy?
At booking (8-12 wks) and again at 28 wks.
Why should women not abruptly stop breastfeeding if they develop mastitis?
increased risk of abscess formation
Why should opioids be used with caution in breastfeeding women?
their presence in breast milk can cause neonatal lethargy, poor feeding, bradycardia and resp depression
*codeine no longer recommended, dihydrocodeine may be used as a safer alternative
What is required for lactational amenorrhoea to be reliable for contraception?
mother must be <6 months post partum
completely amenorrhoeic
almost exclusively on-demand breastfeeding
When can contraception be started after birth?
- immediately after-all except COCP
- POP, progesterone injection and progesterone implant can be started at any time
- Cu coil and mirena can be inserted within 48hrs of birth, if not then after 4 weeks
- COCP UKMEC 4 if breastfeeding and less than 6 weeks post partum. After 6 weeks-UKMEC2, then 1 from 6 months.
- COCP if not breastfeeding, <3 weeks post partum UKMEC 4 if VTE RFs and UKMEC 3 if no other VTE RFs, from week 3 UKMEC 2 if no other VTE RFs, UKMEC 3 if RFs. From 6 weeks post partum not breastfeeding UKMEC 1.
if commenced before 3/52 post partum no additional precautions are required
Which drugs should always be avoided in breastfeeding women?
lithium clozapine retinoids cytotoxic drugs e.g. MTX tetracyclines, ciprofloxacin, chloramphenicol, sulphonamides aspirin carbimazole sulfonylureas amiodarone
If a patient on the COCP misses a pill, when would emergency contraception be required?
if patient has had UPSI in the 1st week of pill taking or in the pill free interval
(2 pills must have been missed)
For how long after a miscarriage, ectopic pregnancy or abortion are women not at risk of pregnancy?
5 days
Cautions/contraindications to Cu-IUD for emergency contraception?
48hrs-4 weeks post partum
distortion of uterine cavity
active infection e.g. PID (if previous PID the Cu-IUD is ok to use)
note higher risk of uterine perforation if breastfeeding
should NOT be inserted if woman may already be pregnant
Cautions/contraindications to ulipristal (single oral 30mg dose) for emergency contraception? (acts to delay ovulation)
severe asthma managed with PO steroids
recent use of PO medication containing progesterone (within last 1 week)
may be less effective if raised BMI or on liver enzyme inducers/PPIs (ulipristal NOT recommended if on liver enzyme inducers)
if breast feeding should bottle feed for 1 week after taking ulipristal
regular hormonal contraception must be delayed by 5 days after taking ulipristal
Cautions/contraindications to levonorgestrel for emergency contraception? (acts to inhibit ovulation) (single 1.5mg dose)
possibly less effective if raised BMI (>26 or weight >70kg) or on liver inducers (use double dose- 3mg)
What is “quick start” hormonal contraception?
starting regular hormonal contraception at any time other than the start of a normal menstrual cycle
regular hormonal contraception can be started immediately after levonorgestrel EC but must be delayed by 5 days after ulipristal
Why must regular hormonal contraception be delayed by 5 days after uliprsital emergency contraception?
because ulipristal interacts with progesterone
When are extra precautions needed if starting regular hormonal contraception?
if started after the first 5 days of the menstrual cycle (or started after 7 days for the mirena)
extra precautions for 2 days if starting POP after first 5 days of menstrual cycle
for 7 days if COCP, progesterone only implant/injection, and mirena
Age of consent to sexual activity as stated by law?
16 years
children 12 years and younger cannot legally consent to any form of sexual activity
How should a woman with lactational mastitis be managed if no sx improvement after 48 hours on flucloxacillin but pt stable (+no signs of breast abscess)?
switch to BS antibiotics e.g. co-amoxiclav or cephalexin
if still not improved after 10-14/7 of Abx then r/f urgently to breast surgeon to r/o breast abscess
Tx of candidates mastitis?
Topical miconazole 2% cream-applied to affected nipple after every feed
Combine with topical hydrocortisone if severely inflamed
Can also combine with topical Abx especially if nipple fissures
If persistent infections and spread into ductal system consider oral fluconazole.
Baby treated with PO nystatin suspension or miconazole 1.25ml gel QDS after feeds
Statin management with regards to pregnancy?
should be stopped in women 3 months prior to conception due to risk of congenital defects
Why is COCP not advised to be used in women taking lamotrigine montherapy?
risk of reduced seizure control
Up to how many days post partum is contraception not required irrespective or any other criteria?
20 days
Which contraceptive methods should not be used for women with unexplained PV bleeding?
Cu-IUD or LNG-IUS if initiating contraception
sterilization
What constitutes UKMEC4 with regards to COCP use for a woman based on age+smoking status?
if age 35 or older and smoking 15 cigarettes or more daily
other UKMEC 4 for COCP:
current breast Ca
breastfeeding and <6 weeks post partum
(UKMEC 3 if <3 weeks post partum and NOT breastfeeding, if >3weeks post partum and not breastfeeding can offer if no other risks for VTE)
How long should non-hormonal contraception, combined hormonal and progestogen-only injectable be continued for at the menopause?
-non-hormonal: if aged under 50 contraception should be continued for 2 years after LMP
If 50 and over it should be continued for 1 year after LMP
-Combined hormonal contraception and progestogen-only injectable should be stopped at age 50 and switched to non-hormonal method to continue for 2 years after LMP or POP/implant/mirena and follow advice for these.
How long should POP and progesterone implant be continued for contraception at the menopause?
- if NOT amenorrhoeic continue over age of 55 until been amenorrhoeic for 1 year
- if amenorrhoeic either check FSH twice 6 weeks apart if over age of 50 and if both FSH more than 30 stop contraception after a further year OR continue until age of 55.
How long should LNG-IUS be continued for around menopause?
if fitted age 45 or over for contraception or HMB can retain until menopause if amenorrhoeic (then test for menopause with FSH) and remove once confirmed
if NOT amenorrhoeic can use for 7 years if bleeding pattern acceptable
What UKMEC category would a woman with BMI >35 in relation to combined hormonal contraception be?
3
Relationship between topical steroid use in pregnancy and birth weight?
Association has been found with using high doses of potent or very potent topical steroids in pregnancy and low birth weight
UKMEC criteria when considering COCP if pt has 1st degree relative with VTE <45yrs of age?
3
if 1st degree relative over 45 with VTE then UKMEC 2
any personal history of VTE or known thrombogenic mutations=UKMEC 4
Management of patient who has 2 consecutive (within 3 months) inadequate samples during cervical screening?
colposcopy
Risks to baby if non-immune pregnant woman develops infection with parvovirus-B19?
fetal anaemia
hydrops fetalis
fetal death
- therefore if a pregnant lady comes into contact with child with this infection she needs to have a blood test to check for immunity-can be reassured if specific IgG detected and specific IgM not detected
- if neither detected woman not immune and should have rpt blood test in 1 month or sooner if develops sx-if both still negative can be reassured but remains susceptible to infection
- if specific IgM detected irrespective of IgG result rpt test as soon as possible and r/f for specialist obstetric assessment.
How long should cervical screening be delayed for after delivery?
12 weeks
When should FSH be considered in making a diagnosis of the menopause?
- if aged 40-45 with menopausal sx, including a change in menstrual cycle
- if under 40 in whom POI suspected
- if aged over 45 with atypical sx
- if over the age of 50 and using progestogen only contraception
should NOT be used if taking combined hormonal contraception or HRT
When can women be given continuous combined HRT?
if not had a period for at least 1 year or have been on sequential combined HRT for at least 1 year
with continuous, woman should not have any more periods but initial breakthrough bleeding can occur in the first 3 months
Breast cancer risk with oestrogen only vs combined HRT?
oestrogen only-NO increased risk
combined HRT in woman under the age of 51-NO increased risk
combined over the age of 51-excess risk is no more than 1 extra case per 1000 women per year beyond the average age of the menopause
micronised progesterone better for less risk of breast cancer
with any HRT-NO effect on risk of dying of breast cancer
How is diagnosis of premature ovarian insufficiency made?
in women aged <40 yrs (NOT on CHC) with:
- menopausal sx including no or infrequent periods AND
- elevated FSH (>30) on 2 blood samples taken 6 weeks apart
these women NEED to receive HRT until average age of menopause to reduce risk of CVD, osteoporosis and dementia, unless contraindications
HRT in these women does not have risks-these are only relevant to women over 51 years of age
these patients need r/f to gynae
Contraindications to HRT?
- current, past or suspected breast cancer
- known or suspected oestrogen dependent cancer
- current VTE or previous idiopathic VTE if pt NOT on anticoagulant tx
- active liver disease with abnormal LFTs
- active or recent arterial thromboembolic disease e.g. angina or MI
- undiagnosed PV bleeding
- untreated endometrial hyperplasia
- pregnancy
- thrombophilic disorder
How can women with diabetes reduce their risk of having a baby with a neural tube defect?
take high dose folic acid (5mg per day) from pre conception until 12 weeks of pregnancy
Monitoring of blood glucose that should be offered by GPs to women with diabetes planning a pregnancy?
offer up to monthly measurement of HbA1c-advise to aim to keep HbA1c below 48
offer blood glucose meters for self monitoring
offer blood ketone testing strips and ketometer to women with T1DM
Plasma glucose targets for women with T1DM planning a pregnancy?
aim for normal capillary plasma glucose targets:
5-7 on waking
4-7 before meals at other times of the day
When should women with diabetes who are planning a pregnancy have a retinal assessment?
offer at their first appointment if seeking pre conception care (unless they’ve had a retinal assessment in the last 6 months)
should be offered after 1st antenatal clinic appointment and again at 28 weeks, if diabetic retinopathy present at initial assessment further one should be offered at 16-20 weeks
Which women with diabetes should be referred to a nephrologist when planning a pregnancy?
serum creatinine 120 or greater
ACR>30
total protein excretion exceeds 0.5g/day, if proteinuria >5g/day consider thromboprophylaxis
Which women should be offered testing for gestational diabetes in pregnancy?
If any of the below RFs: previous GDM FH of diabetes in 1st degree relative an ethnicity with high prevalence of DM-South Asia, Black Caribbean, Middle Eastern previous macrosomic baby-4.5kg or more BMI>30
consider further testing to exclude gestational diabetes if woman found to have glycosuria-2+ or above on 1 occasion, or 1+ or above on 2 or more occasions
How should women be tested for GDM in pregnancy?
offer OGTT at 24-28 weeks if any RFs for gestational diabetes
if previous GDM, offer OGTT as soon as possible after booking and a rpt at 24-28wks if 1st test was negative, OR offer early self monitoring of blood glucose
At what glucose level can gestational diabetes be diagnosed?
fasting plasma glucose of 5.6 or greater OR
2hr plasma glucose level of 7.8 or greater
woman should be offered a review in joint diabetes and antenatal clinic within 1 week of diagnosis
Pharmacological management of women with gestational DM who has a fasting plasma glucose of 7 or above at diagnosis?
offer immediate tx with insulin with/without metformin AND diet and exercise changes
consider the above when fasting plasma glucose 6-6.9 but complications e.g. macrosomia or hydramnios
if initial plasma glucose less than 7 start with diet and exercise changes only but if no improvement after 1-2 weeks offer metformin
After 20 week fetal anomaly scan how should fetal growth and wellbeing for women with diabetes in pregnancy be monitored?
US monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks
Pharmacological management of gestational DM after birth of baby?
STOP blood-glucose lowering therapy
if pre-existing T2DM and breastfeeding can continue or resume metformin immediately after birth but should avoid other oral blood glucose lowering therapy whilst breastfeeding
Follow up of women with gestational diabetes after birth whose blood glucose levels returned to normal after birth?
offer lifestyle advice
offer fasting plasma glucose test at 6-13 weeks
after 13 weeks offer fasting plasma glucose test if not done earlier, or HbA1c if fasting plasma glucose test not possible
offer referral into NHS diabetes prevention programme if eligible
If negative postnatal test for diabetes how should women with gestational diabetes be monitored in primary care?
offer an annual HbA1c test
Which women should be advised to take high dose (5mg) folic acid pre conceptually and up to 12 weeks of pregnancy?
Patient or their partner has NTD FH of NTDs in either patient or their partner Previous pregnancy affected by NTD On anti-epileptics Malabsorption state e.g. coeliac disease DM Sickle Cell Disease, thalassaemia (throughout pregnancy) BMI 30 or higher
Further management of pregnant woman after Abx treatment for a UTI?
urine culture at 7 days after finishing Abx as a test of cure
What is a miscarriage?
spontaneous loss of pregnancy before 24 weeks gestation, early if less than 13 weeks gestation
3 or more consecutive pregnancies lost before 24 weeks=recurrent miscarriage
1st line management to be offered in an incomplete or missed miscarriage?
expectant management-last 7-14 days
should not be offered if pt at increased risk of bleeding, has an infection, had previous traumatic pregnancy or at increased risk from effects of haemorrhage
if bleeding and pain resolve within the 7-14 days pt should rpt UPT at 3/52 and return if positive
Which women following a miscarriage require anti-D Ig?
if rhesus -ve and had surgical procedure to manage miscarriage
Anti-D also needed for rhesus -ve women who have had surgical tx of ectopic
Tx in pregnancy if antiphospholipid syndrome to reduce risk of miscarriage?
aspirin and LMWH
Which women can self refer in to an EPAU?
if hx of recurrent miscarriage
previous ectopic
previous molar pregnancy
Expectant management to women presenting at less than 6 weeks gestation with painless PV bleeding and no RFs for ectopic pregnancy?
pt to rpt a UPT at 7-10/7 and to return if positive, also to return if bleeding continues or pain develops
advise that if UPT is negative then the woman has miscarried
Medical management of a missed or incomplete miscarriage?
vaginal misoprostol
if incomplete miscarriage-600mcg misoprostol, 800 if missed
When should MTX be offered for management of an ectopic pregnancy?
no significant pain AND unruptured tubal EP with adnexal mass <35mm with no visible heartbeat AND serum beta hCG <1500 AND no IUP AND can return for f/u.
after MTX should have beta HCG checked at 4 and 7 days then 1 per week until negative
If RFs for infertility what surgical management should be offered for an ectopic?
salpingotomy
HCG at 7 days post surgery then weekly until -ve
if salpingectomy then UPT at 3 weeks
Definition of severe HTN in pregnancy?
systolic BP 160 or greater and/or diastolic 110 or greater
Definition of significant proteinuria in pregnancy?
urinary protein:creatinine ratio of 30mg/mmol or ACR of at least 8mg/mmol
High risk factors for pre eclampsia?
T1 or T2DM
CKD
chronic HTN
autoimmune conditions e.g. SLE or antiphospholipid syndrome
hypertensive disease in a previous pregnancy
any 1 of these factors puts patient at high risk of pre eclampsia
Moderate risk factors for pre eclampsia?
First pregnancy Multiple pregnancy Pregnancy interval of more than 10 years Age 40 or over BMI 35 or over at first visit FH of pre eclampsia
2 or more of these factors puts patient at high risk of pre eclampsia
Management of pregnant women at high risk of pre eclampsia?
- refer for consultant led care at booking visit
- ensure aspirin 75-150mg is started from 12 weeks of gestation until birth
- offer advice about healthy lifestyle
Management of women presenting with severe HTN in pregnancy to primary care?
hospital admission
Risk of patient with chronic HTN developing superimposed pre eclampsia during pregnancy?
25%
Antihypertensive drug tx recommended in pregnancy?
labetalol is 1st line if not contraindicated
consider nifedipine if labetaolol not suitable
consider methyldopa if both of the above are not suitable
Target BP following antihypertensive tx in pregnancy?
135/85
if chronic uncomplicated HTN the aim for pregnant women is to keep BP below 150/100
When should a working diagnosis of UTI be made in women in pregnancy who have proteinuria but no HTN after 20 weeks of pregnancy?
if 1+ protein on dipstick and either sx of UTI or also nitrites on dipstick or leucocytes and blood on dipstick
send an MSU
Management of patient with 2+ or more protein on urine dipstick in pregnancy after 20 weeks gestation with normal BP?
urgent secondary care assessment
Management of pregnant woman more than 20 weeks gestation presenting with 1+ proteinuria on dip with normal BP and no e/o UTI and no sx of pre-eclampsia?
F/u and reassess in 1 week:
- advise to seek urgent medical attention if sx of pre eclampsia in that period
- dipstick urine and measure BP, use ACR or PCR to quantify persistent proteinuria
- if significant proteinuria (ACR 8mg/mmol or PCR of 30mg/mmol) seek specialist obstetric advice-also if any other concerns or uncertainty.
Post partum, what is the required BP for patients with pre eclampsia to be transferred to primary care?
150/100 or lower
Use of methyldopa for HTN post partum?
should be stopped within 2 days due to risk of depression
1st line tx for HTN in women post partum if the woman wishes to breastfeed?
enalapril
if afro caribbean origin consider nifedipine 1st line (or amlodipine if previously used)
How long is abstinence required to provide a semen sample for investigation of infertility?
minimum of 48 hours, max of 7 days
need to deliver sample to lab within 1 hour
if abnormal, rpt at 3 months
rpt sooner (after 2-4 weeks) if man very anxious and prefers test earlier or severe oligospermia or azoospermia. if 2 abnormal samples, r/f to secondary care.
Management of women post partum who had pre eclampsia but did not require antihypertensive tx?
BP should be measured at least once in first 3-5 days, if abnormal then measure on alternate days until normalises
Target BP <140/90
if BP 150/100 or higher then to start antihypertensive tx
Management of women post partum who had pre eclampsia and required antihypertensive tx?
Continue tx
Measure BP every 1-2 days for up to 2 weeks after t/f to community until tx no longer needed and no HTN
When should women on antihypertensive tx post partum be offered a medical review?
2 weeks after t/f to community care
Follow up of women postpartum who had chronic HTN or gestational HTN during pregnancy?
BP measurement daily for 1st 2 days then at least once between days 3 and 5, then as clinically indicated
for those with gestational HTN who did not take tx, antihypertensive tx should be started post partum if BP 150/100 or higher
How long can the copper coil (IUD) be left in for if inserted at age 40 or over?
can remain in situ until 1 year after the LMP in women age 50 and over, or 2 years after the LMP in women age below 50
What 2 variables should be checked when examining a woman suspected of being menopausal/perimenopausal/POI?
BP and BMI
What can be used 2nd line for urogenital sx of menopause in women in whom low dose vaginal oestrogen is not tolerated or contraindicated?
oral ospemifene (SERM), if moderate to severe symptoms and no contraindications
From what age does HRT increase the risk of CVD?
from age of 60
only combined HRT increases the risk
Non-hormonal treatments and non-drug options for vasomotor sx in menopause?
- SSRIs and SNRIs e.g. fluoxetine 20mg OD
- clonidine (alpha 2 agonist)-licensed for tx of hot flushes
- gabapentin
- CBT, also consider for mood disorders
When is emergency contraception required for patients who have missed their POP?
if they have had UPSI after missing the pill or within 48 hours of restarting it
When is the whooping cough vaccine offered in pregnancy?
after 20 weeks (NICE state from 16 weeks) and ideally before 32 weeks, but if missed can have it up until labour
pregnant women should also be offered the seasonal influenza vaccine (October-January)
combined vaccine is given (diphtheria, pertussis, polio, tetanus)
Number of routine antenatal appointments in an uncomplicated pregnancy?
10 if nulliparous
7 if multiparous
Routine US scans in an uncomplicated pregnancy?
- dating scan-10-13 weeks
- anomaly scan-18-20 weeks
When is the combined test offered in pregnancy to screen for Downs syndrome?
combined test-nuchal translucency plus serum beta HCG and PAPPA
offered at 11-13+6 weeks of pregnancy
if booked later, triple or quadruple test should be offered between 15 and 20 weeks-beta HCG, unconjugated oestriol, alpha fetoprotein, inhibin A
in all of these tests, risk of downs is calculated using the results combined with maternal factors e.g. smoking, weight, age.
Which infections is a mother routinely screened for in pregnancy?
HIV
Hepatitis B
Syphilis
asymptomatic bactriuria
if woman under the age of 25 give her advice about the National Chlamydia screening programme
Duration of free prescriptions for pregnant women?
throughout pregnancy and for 1 year after birth
Duration of baby blues?
starts at days 2-3 after birth and resolves by the 5th day
affects up to 80% of women
Time scale of psychological treatment after referral for women with depression in pregnancy?
should be seen within 2 weeks of referral and seen ideally within 1 month of assessment for treatment
Management of women presenting with mild features of depression in pregnancy with history of severe depression?
- Consider a TCA, SSRI or SNRI
- if presents with moderate or severe depression can consider referral for high intensity psychological intervention or start medication or both.
SSRIs of choice in breastfeeding women?
sertraline and paroxetine
How to manage persistent sub threshold depressive sx or mild to moderate depression in woman presenting first time postnatally?
consider referral for facilitated self help
if woman had a hx of severe depression consider an anti depressant
Management of reduced fetal movements beyond 28 weeks gestation?
1st line-handheld doppler to confirm fetal hearbeat
if not present then immediate ultrasound required
if present then continuous CTG for 20 mins, if still concern then urgent ultrasound within 24hrs-abdo circumference, estimate fetal weight and amniotic fluid volume
if fetal movements have never been felt by 24 weeks of gestation need referral to fetal medicine specialist, movements normally felt by 18-20 weeks, sometimes earlier (16 weeks) if multiparous women
What should be considered to be used in the assessment of N+V in pregnancy?
validated questionnaire e.g. pregnancy-unique quantification of emesis (PUQE)
If an anti-emetic is started for N+V in pregnancy when is reassessment required?
after 24 hours
if response if good then continue tx and reassess every week
