Obstetrics and Gynaecology Flashcards

Question

A woman presents to have a Nexplanon (etonogestrel) inserted. Where is the most appropriate place to insert the implant? ``` Subcutaneous, buttock Subdermal, non-dominant arm Subcutaneous, non-dominant arm Intradermal, non-dominant arm Subdermal, buttock ```

Answer 1

Implantable contraceptives Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are: the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus. Key points highly effective: failure rate 0.07/100 women/year long-acting: lasts 3 years doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc can be inserted immediately following a termination of pregnancy Disadvantages include the need for a trained professional to insert and remove device additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle Adverse effects irregular/heavy bleeding is the main problem 'progestogen effects': headache, nausea, breast pain Interactions enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment Contraindications UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies** UKMEC 4**: current breast cancer * proven risks generally outweigh the advantages * *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3 * **a condition which represents an unacceptable risk if the contraceptive method is used

Answer 2

Sterilisation Male sterilisation - vasectomy failure rate: 1 per 2,000* simple operation, can be done under LA (some GA), go home after a couple of hours doesn't work immediately semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks) complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men) the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years Female sterilisation failure rate: 1 per 200* usually done by laparoscopy under general anaesthetic generally done as a day case many different techniques involving clips (e.g. Filshie clips) , blockage, rings (Falope rings) and salpingectomy complications: increased risk of ectopic if sterilisation fails, general complications of GA/laparoscopy the current success rate of female sterilisation reversal is between 50-60% *source = Royal College of Obstetricians and Gynaecologists

Answer 3

Injectable contraceptives Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions** The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning. Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months) Adverse effects irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time *Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks **the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community

Answer 4

Cervical ectropion On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix The term cervical erosion is used less commonly now This may result in the following features vaginal discharge post-coital bleeding Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Answer 5

Combined oral contraceptive pill increased risk of breast and cervical cancer protective against ovarian and endometrial cancer The combined oral contraceptive pill has actually been shown to reduce the risk of ovarian cancer Combined oral contraceptive pill: advantages/disadvantages ``` Advantages of combined oral contraceptive pill highly effective (failure rate ```

Answer 6

B. Anti-D is still required following delivery even if the mother received routine antenatal ant-D prophylaxis Subsequent pregnancies are most at risk following the sensitising event of the first childbirth. Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis - once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations: delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling Tests all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant ``` Affected fetus oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy ```

Answer 7

IUD - Previous ectopic pregnancy is not a contraindication to intrauterine device insertion. Intrauterine systems (Mirena) cannot be used for emergency contraception. Emergency contraception There are two methods currently available in the UK: Emergency hormonal contraception There are now two methods of emergency hormonal contraception ('emergency pill', 'morning-after pill'); levonorgestrel and ulipristal, a progesterone receptor modulator. Levonorgestrel should be taken as soon as possible - efficacy decreases with time must be taken within 72 hrs of unprotected sexual intercourse (UPSI)* single dose of levonorgestrel 1.5mg (a progesterone) mode of action not fully understood - acts both to stop ovulation and inhibit implantation 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 2 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated Ulipristal a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle is not recommended breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel Intrauterine device (IUD) must be inserted within 5 days of UPSI, or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period *may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Answer 8

Cervical cancer screening 25-49 years: 3-yearly 50-64 years: 5-yearly The question is specific to England as there are some variations in practice across the UK Cervical cancer screening The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening Who is screened and how often? A smear test is offered to all women between the ages of 25-64 years 25-49 years: 3-yearly screening 50-64 years: 5-yearly screening How is performed? There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid. Advantages of LBC includes reduced rate of inadequate smears increased sensitivity and specificity It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS. In Scotland women from the ages of 20-60 years are screened every 3 years.

Answer 9

Mefenamic acid - Tranexamic acid would not treat the dysmenorrhoea. Menorrhagia: management Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive. Prior to the 1990's many women underwent a hysterectomy to treat heavy periods but since that time the approach has altered radically. The management of menorrhagia now depends on whether a women needs contraception. Investigations a full blood count should be performed in all women further investigations are based upon the history and examination findings Does not require contraception either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period if no improvement then try other drug whilst awaiting referral Requires contraception, options include intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill long-acting progestogens Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Answer 10

Refer for external cephalic version Breech presentation In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity Risk factors for breech presentation uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation) Cord prolapse is more common in breech presentations Management if

Answer 11

C. Proteinuria suggests pre-eclampsia Hypertension in pregnancy NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include: hypertensive disease during previous pregnancies chronic kidney disease autoimmune disorders such as SLE or antiphospholipid syndrome type 1 or 2 diabetes mellitus The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy: blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks after this time the blood pressure usually increases to pre-pregnancy levels by term Hypertension in pregnancy in usually defined as: systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Answer 12

Polycystic ovarian syndrome is extremely common, affecting between 5-20% of women of reproductive age Polycystic ovarian syndrome: features and investigation Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome. Features subfertility and infertility menstrual disturbances: oligomenorrhea and amenorrhoea hirsutism, acne (due to hyperandrogenism) obesity acanthosis nigricans (due to insulin resistance) Investigations pelvic ultrasound: multiple cysts on the ovaries FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes check for impaired glucose tolerance

Answer 13

Topical oestrogens Menopause: management Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women's Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis. Management options for hot flushes or night sweats lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing hormone replacement therapy: most effective tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea selective serotonin reuptake inhibitors: only small trials have been completed to date Vaginal atrophy topical oestrogens

Answer 14

Tibolone Menopause: management Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women's Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis. Management options for hot flushes or night sweats lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing hormone replacement therapy: most effective tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea selective serotonin reuptake inhibitors: only small trials have been completed to date Vaginal atrophy topical oestrogens

Answer 15

Clonidine Menopause: management Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women's Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis. Management options for hot flushes or night sweats lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing hormone replacement therapy: most effective tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea selective serotonin reuptake inhibitors: only small trials have been completed to date Vaginal atrophy topical oestrogens

Answer 16

Genital wart treatment multiple, non-keratinised warts: topical podophyllum solitary, keratinised warts: cryotherapy Cryotherapy is also acceptable as an initial treatment for genital warts (see below) Genital warts Genital warts (also known as condylomata accuminata) are a common cause of attendance at genitourinary clinics. They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer. Features small (2 - 5 mm) fleshy protuberances which are slightly pigmented may bleed or itch Management topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy imiquimod is a topical cream which is generally used second line genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

Answer 17

Chickenpox exposure in pregnancy - if not immune give VZIG The negative IgG indicates no previous exposure to chickenpox Chickenpox exposure in pregnancy Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome Fetal varicella syndrome (FVS) risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities Management of chickenpox exposure if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

Answer 18

Contraceptives - time until effective (if not first day period): instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS Intrauterine contraceptive devices Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia Effectiveness both the IUD and IUS are more than 99% effective Mode of action IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions) IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening Counselling IUD is effective immediately following insertion IUS can be relied upon after 7 days Potential problems IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 19

There is increasing evidence that metformin is safe during pregnancy Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.5 kg or above. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) Screening for gestational diabetes if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes NICE issued guidelines on the management of diabetes mellitus in pregnancy which were updated in 2008 Management of pre-existing diabetes weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Management of gestational diabetes responds to changes in diet and exercise in around 80% of women oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check

Answer 20

Initially irregular bleeding later followed by light menses or amenorrhoea Intrauterine contraceptive devices Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia Effectiveness both the IUD and IUS are more than 99% effective Mode of action IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions) IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening Counselling IUD is effective immediately following insertion IUS can be relied upon after 7 days Potential problems IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 21

3 Years Implantable contraceptives Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are: the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus. Key points highly effective: failure rate 0.07/100 women/year long-acting: lasts 3 years doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc can be inserted immediately following a termination of pregnancy Disadvantages include the need for a trained professional to insert and remove device additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle Adverse effects irregular/heavy bleeding is the main problem 'progestogen effects': headache, nausea, breast pain Interactions enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment Contraindications UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies** UKMEC 4**: current breast cancer * proven risks generally outweigh the advantages * *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3 * **a condition which represents an unacceptable risk if the contraceptive method is used

Answer 22

Hepatitis B and pregnancy Basics all pregnant women are offered screening for hepatitis B babies born to mothers who are chronically infected with hepatitis B or to mothers who've had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy there is little evidence to suggest caesarean section reduces vertical transmission rates hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 23

Trichomonas vaginalis Trichomonas vaginalis is a highly motile, flagellated protozoan parasite Features vaginal discharge: offensive, yellow/green, frothy vulvovaginitis strawberry cervix pH > 4.5 in men is usually asymptomatic but may cause urethritis Investigation microscopy of a wet mount shows motile trophozoites Management oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Answer 24

Updated guidance from the FSRH states the following after a woman has missed two pills: 'If you have missed two or more pills (i.e. more than 48 hours late), anywhere in the pack continue taking the rest of the pack as usual and use an extra method of contraception for the next 7 days' For further information please consult the link to the FSRH guidelines. As this was a new partner consideration should be given to STI screening after an appropriate interval. According to the FSRH emergency contraception does not need to be given in this scenario. Depo-Provera is a long-acting contraceptive. It should not be used for emergency contraception and not given unless there is no chance of pregnancy. Combined oral contraceptive pill: missed pill The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol If 1 pill is missed (at any time in the cycle) 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 needed If 2 or more pills missed take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception* if pills are missed in week 3 (Days 15-21): 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 7 days on, 7 days off

Answer 25

It should be noted that whilst NICE define infertility as 'failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology' they advise that investigations are offered after 1 year Infertility Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years ``` Causes male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15% ``` Basic investigations semen analysis serum progesterone 7 days prior to expected next period ``` Key counselling points folic acid aim for BMI 20-25 advise regular sexual intercourse every 2 to 3 days smoking/drinking advice ```

Answer 26

Endometriosis Preterm birth Preterm birth is defined as delivery of an infant before 37 weeks gestation. It occurs in around 5-10% of pregnancies (6% of singletons, 45% of twins) ``` Causes unexplained (30-40%) multiple pregnancies (20-30%) congenital abnormalities antepartum haemorrhage pre-eclampsia cervical incompetence diabetes mellitus polyhydramnios uterine abnormalities infections e.g. Pyelonephritis ```

Answer 27

The majority of pathologists believe that uterine leiomyosarcomas which may initially present as 'fibroids' are probably de novo lesions rather than a transformation of existing fibroids Uterine fibroids Fibroids are benign smooth muscle tumours of the uterus. They are through to occur in around 20% of white and around 50% of black women in the later reproductive years Associations more common in Afro-Caribbean women rare before puberty, develop in response to oestrogen, don't tend to progress following menopause ``` Features may be asymptomatic menorrhagia bloating urinary symptoms, e.g. frequency, may occur with larger fibroids subfertility ``` Management medical: symptomatic management e.g. with combined oral contraceptive pill. GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment surgery is sometimes needed uterine artery embolization Complications red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Answer 28

Turner's syndrome causes primary rather than secondary amenorrhoea. Amenorrhoea Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer). ``` Causes of primary amenorrhoea Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital tract ``` Causes of secondary amenorrhoea (after excluding pregnancy) hypothalamic amenorrhoea (e.g. Stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis* Initial investigations exclude pregnancy with urinary or serum bHCG gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) prolactin androgen levels: raised levels may be seen in PCOS oestradiol thyroid function tests *hypothyroidism may also cause amenorrhoea

Answer 29

Irregular vaginal bleeding Progestogen only pill: advantages/disadvantages Advantages highly effective (failure rate = 1 per 100 woman years) doesn't interfere with sex contraceptive effects reversible upon stopping can be used whilst breast-feeding can be used in situations where the combined oral contraceptive pill is contraindicated e.g. in smokers > 35 years of age and women with a history of venous thromboembolic disease Disadvantages irregular periods: some users may not have periods whilst others may have irregular or light periods. This is the most common adverse effect doesn't protect against sexually transmitted infections increased incidence of functional ovarian cysts common side-effects include breast tenderness, weight gain, acne and headaches. These symptoms generally subside after the first few months

Answer 30

Gardasil, rather than Cervarix, has the advantage of offering protection against genital warts. Human papilloma virus vaccination It has been known for a longtime that the human papilloma virus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic. There are dozens of strains of HPV. The most important to remember are: 6 & 11: causes genital warts 16 & 18: linked to a variety of cancers, most notably cervical cancer ``` HPV infection is linked to: over 99.7% of cervical cancers around 85% of anal cancers around 50% of vulval and vaginal cancers around 20-30% of mouth and throat cancers ``` It should of course be remembered that there are other risk factors important in developing cervical cancer such as smoking, combined oral contraceptive pill use and high parity. Testing for HPV has now been integrated into the cervical cancer screening programme. If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV if HPV negative the patient goes back to routine recall if HPV positive the patient is referred for colposcopy Immunisation A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 & 18 but not 6 & 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 & 18. Girls aged 12-13 years are offered the vaccine in the UK the vaccine is normally given in school information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy Injection site reactions are particularly common with HPV vaccines.

Answer 31

Contraceptives - time until effective (if not first day period): instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS Progestogen only pill: counselling Women who are considering taking the progestogen only pill (POP) should be counselled in a number of areas: Potential adverse effects irregular vaginal bleeding is the most common problem Starting the POP if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21) Taking the POP should be taken at same time everyday, without a pill free break (unlike the COC) Missed pills if 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours Other potential problems diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above antibiotics: have no effect on the POP** liver enzyme inducers may reduce effectiveness Other information discussion on STIs *for Cerazette (desogestrel) a 12 hour period is allowed **unless the antibiotic alters the P450 enzyme system, for example rifampicin

Answer 32

Genital warts - 90% are caused by HPV 6 & 11 Types 6 and 11 are responsible for 90% of genital warts cases Genital warts Genital warts (also known as condylomata accuminata) are a common cause of attendance at genitourinary clinics. They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer. Features small (2 - 5 mm) fleshy protuberances which are slightly pigmented may bleed or itch Management topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy imiquimod is a topical cream which is generally used second line genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

Answer 33

Transverse myelitis is not associated with pre-eclampsia Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure ``` Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease ``` Features of severe pre-eclampsia hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 34

BRCA2 gene Ovarian cancer: risk factors relate to increased number of ovulations Ovarian cancer Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin. Risk factors family history: mutations of the BRCA1 or the BRCA2 gene many ovulations: early menarche, late menopause, nulliparity It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies. ``` Clinical features are notoriously vague abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea ``` Diagnosis is difficult and usually involves diagnostic laparotomy

Answer 35

Urinary incontinence - first-line treatment: urge incontinence: bladder retraining stress incontinence: pelvic floor muscle training Urinary incontinence Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females. Causes overactive bladder (OAB)/urge incontinence: due to detrusor over activity stress incontinence: leaking small amounts when coughing or laughing mixed incontinence: both urge and stress overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement Initial investigation bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude cystocele urine dipstick and culture Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant: bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs:antimuscarinic) is first-line surgical management: e.g. sacral nerve stimulation If stress incontinence is predominant: pelvic floor muscle training (for a minimum of 3 months) surgical procedures: e.g. retropubic mid-urethral tape procedures

Answer 36

Nexplanon - main mechanism of action is inhibition of ovulation Implantable contraceptives Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are: the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus. Key points highly effective: failure rate 0.07/100 women/year long-acting: lasts 3 years doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc can be inserted immediately following a termination of pregnancy Disadvantages include the need for a trained professional to insert and remove device additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle Adverse effects irregular/heavy bleeding is the main problem 'progestogen effects': headache, nausea, breast pain Interactions enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment Contraindications UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies** UKMEC 4**: current breast cancer * proven risks generally outweigh the advantages * *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3 * **a condition which represents an unacceptable risk if the contraceptive method is used

Answer 37

Propylthiouracil is traditionally taught as the antithyroid drug of choice in pregnancy. This approach was supported by the 2007 Endocrine Society consensus guidelines. It also has the advantage of being excreted to a lesser extent than carbimazole in breast milk. Despite this some endocrinologists use carbimazole and the BNF states both drugs may be used in pregnancy. Carbimazole has rarely been associated with aplasia cutis of the neonate Pregnancy: thyroid problems In pregnancy there is an increase in the levels of thyroxine-binding globulin (TBG). This causes an increase in the levels of total thyroxine but does not affect the free thyroxine level Thyrotoxicosis Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester Management propylthiouracil has traditionally been the antithyroid drug of choice. This approach was supported by the 2007 Endocrine Society consensus guidelines 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 - helps to determine risk of neonatal thyroid problems block-and-replace regimes should not be used in pregnancy radioiodine therapy is contraindicated Hypothyroidism Key points thyroxine is safe during pregnancy serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum some women require an increased dose of thyroxine during pregnancy breast feeding is safe whilst on thyroxine

Answer 38

Breast cancer 3 years ago Progestogen only pill: contraindications The decision of whether to start a women a particular type of contraceptive is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below: UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk ``` Examples of UKMEC 3 conditions include active liver disease or past tumour liver enzyme inducers breast cancer more than 5 years ago undiagnosed vaginal bleeding ``` Examples of UKMEC 4 conditions include pregnancy breast cancer within the last 5 years

Answer 39

Around 2-3% go on to develop choriocarcinoma Gestational trophoblastic disorders Describes a spectrum of disorders originating from the placental trophoblast: complete hydatidiform mole partial hydatidiform mole choriocarcinoma Complete hydatidiform mole Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin Features bleeding in first or early second trimester exaggerated symptoms of pregnancy e.g. hyperemesis uterus large for dates very high serum levels of human chorionic gonadotropin (hCG) hypertension and hyperthyroidism* may be seen Management urgent referral to specialist centre - evacuation of the uterus is performed effective contraception is recommended to avoid pregnancy in the next 12 months Around 2-3% go on to develop choriocarcinoma In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen *hCG can mimic thyroid-stimulating hormone (TSH)

Answer 40

Laparoscopic findings correlate well with the severity of symptoms and can guide treatment Endometriosis Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Up to 10-15% of women have a degree of endometriosis ``` Clinical features chronic pelvic pain dysmenorrhoea - pain often starts days before bleeding deep dyspareunia subfertility ``` Less common features urinary symptoms e.g. dysuria, urgency dyschezia (painful bowel movements) Investigation laparoscopy is the gold-standard investigation there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms NSAIDs and other analgesia for symptomatic relief combined oral contraceptive pill progestogens e.g. medroxyprogesterone acetate gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels intrauterine system (Mirena) drug therapy unfortunately does not seem to have a significant impact on fertility rates Surgery some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Answer 41

Combined oral contraceptive pill increased risk of breast and cervical cancer protective against ovarian and endometrial cancer Combined oral contraceptive pill: advantages/disadvantages ``` Advantages of combined oral contraceptive pill highly effective (failure rate ```

Answer 42

Spontaneous miscarriage at 10 weeks Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis - once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations: delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling Tests all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant ``` Affected fetus oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy ```

Answer 43

Folic acid should be prescribed for pregnant patients taking proguanil Malaria: prophylaxis There are around 1,500-2,000 cases each year of malaria in patients returning from endemic countries. The majority of these cases (around 75%) are caused by the potentially fatal Plasmodium falciparum protozoa. The majority of patients who develop malaria did not take prophylaxis. It should also be remembered that UK citizens who originate from malaria endemic areas quickly lose their innate immunity. Pregnant women should be advised to avoid travelling to regions where malaria is endemic. Diagnosis can also be difficult as parasites may not be detectable in the blood film due to placental sequestration. However, if travel cannot be avoided: chloroquine can be taken proguanil: folate supplementation (5mg od) should be given Malarone (atovaquone + proguanil): the BNF advises to avoid these drugs unless essential. If taken then folate supplementation should be given mefloquine: caution advised doxycycline is contraindicated It is again advisable to avoid travel to malaria endemic regions with children if avoidable. However, if travel is essential then children should take malarial prophylaxis as they are more at risk of serious complications. diethyltoluamide (DEET) 20-50% can be used in children over 2 months of age doxycycline is only licensed in the UK for children over the age of 12 years

Answer 44

Migraine with aura Combined oral contraceptive pill: contraindications The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below: UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk Examples of UKMEC 3 conditions include more than 35 years old and smoking less than 15 cigarettes/day BMI > 35 kg/m^2* migraine without aura and more than 35 years old family history of thromboembolic disease in first degree relatives 20 years ago is classified as UKMEC 3 or 4 depending on severity *The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.

Answer 45

The pain of secondary dysmenorrhoea develops 3-4 days before the onset of the period The treatment of secondary dysmenorrhoea depends on the underlying cause. Dysmenorrhoea Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea. Primary dysmenorrhoea In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible. Features pain typically starts just before or within a few hours of the period starting suprapubic cramping pains which may radiate to the back or down the thigh Management NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production combined oral contraceptive pills are used second line Secondary dysmenorrhoea ``` Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include: endometriosis adenomyosis pelvic inflammatory disease intrauterine devices* fibroids ``` Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. *this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea

Answer 46

Cervical cancer screening detects squamous cell cancer and may miss adenocarcinomas The change to liquid based cytology has unfortunately not improved the detection rate of adenocarcinomas Cervical cancer screening The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening Who is screened and how often? A smear test is offered to all women between the ages of 25-64 years 25-49 years: 3-yearly screening 50-64 years: 5-yearly screening How is performed? There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid. Advantages of LBC includes reduced rate of inadequate smears increased sensitivity and specificity It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS. In Scotland women from the ages of 20-60 years are screened every 3 years.

Answer 47

Periods will tend to be longer, heavier and more painful Intrauterine contraceptive devices Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia Effectiveness both the IUD and IUS are more than 99% effective Mode of action IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions) IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening Counselling IUD is effective immediately following insertion IUS can be relied upon after 7 days Potential problems IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 48

Repeat ultrasound in 12 weeks If the cyst persists after 12 weeks referral should be considered. Ovarian enlargement: management The initial imaging modality for suspected ovarian cysts/tumours is ultrasound. The report will usually report that the cyst is either: simple: unilocular, more likely to be physiological or benign complex: multilocular, more likely to be malignant Management depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation. Premenopausal women a conservative approach may be taken for younger women (especially if

Answer 49

Cerazette inhibits ovulation in around 97-99% of cycles. Progestogen only pill: types Second generation norethisterone levonorgestrel ethynodiol diacetate Third generation desogestrel (Cerazette) Cerazette new third generation type of progestogen only pill (POP) containing desogestrel inhibits ovulation in the majority of women users can take the pill up to 12 hours late rather than 3 hours like other POPs

Answer 50

Given the history of intermenstrual bleeding this patient should be referred to gynaecology to exclude endometrial cancer Endometrial cancer Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection ``` The risk factors for endometrial cancer are as follows*: obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome ``` Features post-menopausal bleeding is the classic symptom pre-menopausal women may have a change intermenstrual bleeding pain and discharge are unusual features Investigation first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (

Answer 51

Breast feeding is acceptable with nearly all anti-epileptic drugs The BNF states 'breast-feeding is acceptable with all antiepileptic drugs, taken in normal doses, with the possible exception of barbiturates' Epilepsy: pregnancy and breast feeding The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication. Other points aim for monotherapy there is no indication to monitor antiepileptic drug levels sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn Sodium valproate The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate. The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Answer 52

Smoking is associated with a decreased incidence of hyperemesis gravidarum Hyperemesis gravidarum Hyperemesis gravidarum describes excessive vomiting during pregnancy. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*. ``` Associations multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity ``` Smoking is associated with a decreased incidence of hyperemesis Management antihistamines should be used first-line (BNF suggests promethazine as first-line) admission may be needed for IV hydration ``` Complications Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth ``` *and in very rare cases beyond 20 weeks

Answer 53

Antiphospholipid syndrome in pregnancy: aspirin + LMWH The ultrasound at 11 weeks gestation would show a fetal heart if the pregnancy was viable. This patient should therefore be taking both aspirin and low-molecular weight heparin. Antiphospholipid syndrome: pregnancy Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE) ``` In pregnancy the following complications may occur: recurrent miscarriage IUGR pre-eclampsia placental abruption pre-term delivery venous thromboembolism ``` Management low-dose aspirin should be commenced once the pregnancy is confirmed on urine testing low molecular weight heparin once a fetal heart is seen on ultrasound. This is usually discontinued at 34 weeks gestation these interventions increase the live birth rate seven-fold

Answer 54

Trichomonas vaginalis Vaginal discharge Vaginal discharge is a common presenting symptom and is not always pathological ``` Common causes physiological Candida Trichomonas vaginalis bacterial vaginosis ``` ``` Less common causes whilst cervical infections such as Chlamydia and Gonorrhoea can cause a vaginal discharge this is rarely the presenting symptoms ectropion foreign body cervical cancer ```

Answer 55

If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV if HPV negative the patient goes back to routine recall if HPV positive the patient is referred for colposcopy

Answer 56

13 The Faculty for Sexual and Reproductive Health state: In England, Wales and Northern Ireland, those under the age of 13 years are considered unable to legally consent to sexual activity. In Northern Ireland, there is no statutory duty under criminal law to report to the police cases of sexual activity involving children under the age of 16 years unless the child is under 13 years or the other party is aged 18 years or over. When the Sexual Offences Scotland Act 2009 comes into force, sexual activity with a male or female aged under 13 years will be 'rape of a young child'. Contraceptive Choices for Young People The Faculty of Sexual and Reproductive Health (FRSH) produced guidelines in 2010 concerning the provision of contraception to young people. Much of the following is based on those guidelines. Please see the link for more details. Legal and ethical issues the age of consent for sexual activity in the UK is 16 years. Practitioners may however provide advice and contraception if they feel that the young person is 'competent'. This is usually assessed using the Fraser guidelines (see below) children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures The Fraser Guidelines state that all the following requirements should be fulfilled: the young person understands the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent Sexual Transmitted Infections (STIs) young people should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI) Choice of contraceptive clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people

Answer 57

Whilst the RCOG guidelines recommend 28-32 weeks the BHIVA suggest a slightly earlier gestation may be suitable depending on individual circumstances. The most suitable answer is therefore 20-32 weeks. HIV and pregnancy With the increased incidence of HIV infection amongst the heterosexual population there are an increasing number of HIV positive women giving birth in the UK. In London the incidence may be as high as 0.4% of pregnant women. The aim of treating HIV positive women during pregnancy is to minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission. Guidelines regularly change on this subject and most recent guidelines can be found using the links provided. ``` Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding) ``` Screening NICE guidelines recommend offering HIV screening to all pregnant women Antiretroviral therapy all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation Mode of delivery vaginal delivery is recommenced if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended a zidovudine infusion should be started four hours before beginning the caesarean section Neonatal antiretroviral therapy zidovudine is usually administered orally to the neonate if maternal viral load is

Answer 58

Intrauterine contraceptive devices do not need to be removed in mild cases of pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix ``` Causative organisms Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis ``` ``` Features lower abdominal pain fever deep dyspareunia dysuria and menstrual irregularities may occur vaginal or cervical discharge cervical excitation ``` Investigation screen for Chlamydia and Gonorrhoea Management due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ' Removal of the IUD should be considered and may be associated with better short term clinical outcomes' Complications infertility - the risk may be as high as 10-20% after a single episode chronic pelvic pain ectopic pregnancy

Answer 59

Cessation of established, regular menstruation for 6 months or longer Amenorrhoea Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer). ``` Causes of primary amenorrhoea Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital tract ``` Causes of secondary amenorrhoea (after excluding pregnancy) hypothalamic amenorrhoea (e.g. Stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis* Initial investigations exclude pregnancy with urinary or serum bHCG gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) prolactin androgen levels: raised levels may be seen in PCOS oestradiol thyroid function tests *hypothyroidism may also cause amenorrhoea

Answer 60

After 20 weeks, symphysis-fundal height in cm = gestation in weeks Symphysis-fundal height The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Answer 61

Breech presentation risk factors - uterine malformations, placenta praevia, polyhydramnios or oligohydramnios. NOT maternal obesity Breech presentation In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity Risk factors for breech presentation uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation) Cord prolapse is more common in breech presentations Management if

Answer 62

Block-and-replace is preferable in pregnancy compared to antithyroid drug titration Pregnancy: thyroid problems In pregnancy there is an increase in the levels of thyroxine-binding globulin (TBG). This causes an increase in the levels of total thyroxine but does not affect the free thyroxine level Thyrotoxicosis Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester Management propylthiouracil has traditionally been the antithyroid drug of choice. This approach was supported by the 2007 Endocrine Society consensus guidelines 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 - helps to determine risk of neonatal thyroid problems block-and-replace regimes should not be used in pregnancy radioiodine therapy is contraindicated Hypothyroidism Key points thyroxine is safe during pregnancy serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum some women require an increased dose of thyroxine during pregnancy breast feeding is safe whilst on thyroxine

Answer 63

Pelvic inflammatory disease Endometriosis would normally be seen during laparoscopy.

Answer 64

Irritable bowel syndrome

Answer 65

Ovarian torsion The pain of appendicitis is unlikely to be of sudden onset.

Answer 66

No previous pregnancies is a risk factor for pre-eclampsia Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure ``` Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease ``` Features of severe pre-eclampsia hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 67

Cafalexin Amoxicillin is also recommended in this situation. Nitrofurantoin should be avoided near term as it may cause neonatal haemolysis but it may be used earlier in the pregnancy. This lady is highly likely to have a urinary tract infection so advising her just to use cranberry juice is inappropriate. Urinary tract infection in adults: management Lower urinary tract infections in non-pregnant women local antibiotic guidelines should be followed if available 2012 SIGN guidelines recommend trimethoprim or nitrofurantoin for 3 days Pregnant women with symptomatic bacteriuria should be treated with an antibiotic for 7 days. A urine culture should be sent. For asymptomatic pregnant women: a urine culture should be performed routinely at the first antenatal visit if positive, a second urine culture should be sent to confirm the presence of bacteriuria SIGN recommend to treat asymptomatic bacteriuria detected during pregnancy with an antibiotic a 7 day course of antibiotics should be given a further urine culture should be sent following completion of treatment as a test of cure For patients with sign of acute pyelonephritis hospital admission should be considered local antibiotic guidelines should be followed if available the BNF currently recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days

Answer 68

Bacterial vaginosis in pregnancy: still use oral metronidazole Bacterial vaginosis is a risk factor for a number of pregnancy related problems including preterm labour. It was traditionally taught to avoid oral metronidazole in the first trimester but guidelines now recommend its use throughout pregnancy. Please see the Clinical Knowledge Summary link Bacterial vaginosis Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH. Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women. Features vaginal discharge: 'fishy', offensive asymptomatic in 50% Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH > 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour) ``` Management oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate > 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives ``` Bacterial vaginosis in pregnancy results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes

Answer 69

Must be inserted within 5 days of UPSI OR up to 5 days after the likely ovulation date Emergency contraception There are two methods currently available in the UK: Emergency hormonal contraception There are now two methods of emergency hormonal contraception ('emergency pill', 'morning-after pill'); levonorgestrel and ulipristal, a progesterone receptor modulator. Levonorgestrel should be taken as soon as possible - efficacy decreases with time must be taken within 72 hrs of unprotected sexual intercourse (UPSI)* single dose of levonorgestrel 1.5mg (a progesterone) mode of action not fully understood - acts both to stop ovulation and inhibit implantation 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 2 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated Ulipristal a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle is not recommended breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel Intrauterine device (IUD) must be inserted within 5 days of UPSI, or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period *may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Answer 70

Catherine can be informed that there is no evidence of an impact on future fertility and no association with placenta praevia, ectopic pregnancy, still born or miscarriage. The following guidance has been taken from the Royal College of Obstetrics and Gynaecology entitled 'The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7' : Women should be informed of the uncommon complications that may occur and of their possible clinical consequences. These may include: Severe bleeding requiring transfusion: the risk is lower for early abortions, occurring in less than 1 in 1000, rising to around 4 in 1000 at gestations beyond 20 weeks. Uterine perforation (surgical abortion only): the risk is in the order of 14 in 1000 and is lower for early abortions and those performed by experienced clinicians. Cervical trauma (surgical abortion only): the risk of damage to the external os is no greater than 1 in 100 and is lower for early abortions and those performed by experienced clinicians. Women must be informed that, should one of these complications occur, further treatment in the form of blood transfusion, laparoscopy or laparotomy may be required. Women should be informed that infection of varying degrees of severity may occur after medical or surgical abortion and is usually caused by pre-existing infection. Prophylactic antibiotic use and bacterial screening for lower genital tract infection reduces this risk Reference: The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7 https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-guidelineweb1.pdf Termination of pregnancy The current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks* Key points two registered medical practitioners must sign a legal document (in an emergency only one is needed) only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise The method used to terminate pregnancy depend upon gestation less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions less than 13 weeks: surgical dilation and suction of uterine contents more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour') *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 risk of serious physical or mental injury to the woman.

Answer 71

The combination of deep dyspareunia and lower abdominal pain make a diagnosis of endometriosis likely. Initial treatment options such as the combined pill are not an option in a woman trying to conceive. For a definitive diagnosis the patient should ideally have a laparoscopy. A pelvic ultrasound is not the investigation of choice in endometriosis and may be normal with mild-moderate disease Endometriosis Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Up to 10-15% of women have a degree of endometriosis ``` Clinical features chronic pelvic pain dysmenorrhoea - pain often starts days before bleeding deep dyspareunia subfertility ``` Less common features urinary symptoms e.g. dysuria, urgency dyschezia (painful bowel movements) Investigation laparoscopy is the gold-standard investigation there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms NSAIDs and other analgesia for symptomatic relief combined oral contraceptive pill progestogens e.g. medroxyprogesterone acetate gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels intrauterine system (Mirena) drug therapy unfortunately does not seem to have a significant impact on fertility rates Surgery some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Answer 72

Cystic fibrosis Ultrasound in pregnancy A nuchal scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include: Down's syndrome congenital heart defects abdominal wall defects Causes of hyperechogenic bowel: cystic fibrosis Down's syndrome cytomegalovirus infection

Answer 73

Afro-Caribbean ethnicity Post-partum haemorrhage Post-partum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary Primary PPH occurs within 24 hours affects around 5-7% of deliveries most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors ``` Risk factors for primary PPH include*: previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) ``` Management ABC IV syntocinon (oxytocin) 10 units or IV ergometrine 500 mcg IM carboprost other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure Secondary PPH occurs between 24 hours - 12 weeks** due to retained placental tissue or endometritis *the effect of parity on the risk of PPH is complicated. It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor **previously the definition of secondary PPH was 24 hours - 6 weeks. Please see the RCOG guidelines for more details

Answer 74

None of the above The values listed are within the normal reference ranges Semen analysis Semen analysis should be performed after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour ``` Normal semen results* volume > 1.5 ml pH > 7.2 sperm concentration > 15 million / ml morphology > 4% normal forms motility > 32% progressive motility vitality > 58% liver spermatozoa ``` *many different reference ranges exist. These are based on the NICE 2013 values

Answer 75

Immediately Implantable contraceptives Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are: the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus. Key points highly effective: failure rate 0.07/100 women/year long-acting: lasts 3 years doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc can be inserted immediately following a termination of pregnancy Disadvantages include the need for a trained professional to insert and remove device additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle Adverse effects irregular/heavy bleeding is the main problem 'progestogen effects': headache, nausea, breast pain Interactions enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment Contraindications UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies** UKMEC 4**: current breast cancer * proven risks generally outweigh the advantages * *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3 * **a condition which represents an unacceptable risk if the contraceptive method is used

Answer 76

All tetracyclines should be avoided in pregnancy. It should be noted that the above prescriptions are not necessarily the recommended first-line treatments Prescribing in pregnant patients Very few drugs are known to be completely safe in pregnancy. The list below largely comprises of those known to be harmful. Some countries have developed a grading system - see the link. ``` Antibiotics tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies ``` ``` Other drugs ACE inhibitors, angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents ``` The majority of antiepileptics including valproate, carbamazepine and phenytoin are known to be potentially harmful. The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk

Answer 77

Depo Provera (injectable contraceptive) Injectable contraceptives Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions** The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning. Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months) Adverse effects irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time *Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks **the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community

Answer 78

Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy Epilepsy: pregnancy and breast feeding The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication. Other points aim for monotherapy there is no indication to monitor antiepileptic drug levels sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn Sodium valproate The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate. The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Answer 79

Morning sickness and pruritus are common in pregnant women. Intrahepatic cholestasis of pregnancy would not occur in the first trimester. An ALP of 160 U/l is normal in a pregnant woman leaving the only abnormal result being the raised bilirubin (which usually falls in pregnancy). The most likely diagnosis is therefore Gilbert's syndrome. Gilbert's syndrome Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase. The prevalence is approximately 1-2% in the general population ``` Features unconjugated hyperbilinaemia (i.e. not in urine) jaundice may only be seen during an intercurrent illness ``` Investigation and management investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid no treatment required *the exact mode of inheritance is still a matter of debate

Answer 80

Menorrhagia - intrauterine system (Mirena) is first-line Menorrhagia: management Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive. Prior to the 1990's many women underwent a hysterectomy to treat heavy periods but since that time the approach has altered radically. The management of menorrhagia now depends on whether a women needs contraception. Investigations a full blood count should be performed in all women further investigations are based upon the history and examination findings Does not require contraception either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period if no improvement then try other drug whilst awaiting referral Requires contraception, options include intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill long-acting progestogens Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Answer 81

External cephalic version requires anti-D immunoglobulin prophylaxis Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis - once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations: delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling Tests all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant ``` Affected fetus oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy ```

Answer 82

Confirming a DVT is the first step as this may provide indirect evidence of a pulmonary embolism. As both conditions require anticoagulation this may negate the need for further radiation exposure. Pregnancy: DVT/PE investigation Guidelines were updated in 2010 by the Royal College of Obstetricians. Key points include: chest x-ray should be performed in all patients - compression duplex Doppler should be performed if the chest x-ray is normal - this may provide indirect evidence of a pulmonary embolism and negate the need for further radiation exposure the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist Comparing CTPA to V/Q scanning in pregnancy CTPA CTPA slightly increases the lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation V/Q scanning V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA (1/280,000 versus less than 1/1,000,000)

Answer 83

Increased risk in first 20 days then returns to normal Intrauterine contraceptive devices Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia Effectiveness both the IUD and IUS are more than 99% effective Mode of action IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions) IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening Counselling IUD is effective immediately following insertion IUS can be relied upon after 7 days Potential problems IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 84

Jaundice Ovarian hyperstimulation syndrome Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 85

Do oral glucose tolerance test at 16-18 weeks Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.5 kg or above. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) Screening for gestational diabetes if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes NICE issued guidelines on the management of diabetes mellitus in pregnancy which were updated in 2008 Management of pre-existing diabetes weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Management of gestational diabetes responds to changes in diet and exercise in around 80% of women oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check

Answer 86

Chlamydia is common, affecting around 1 in 10 young women Chlamydia Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen. Approximately 1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic Features asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria ``` Potential complications epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome) ``` Investigation traditional cell culture is no longer widely used nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique Screening in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years relies heavily on opportunistic testing Management doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline if pregnant then erythromycin or amoxicillin may be used. The SIGN guidelines suggest considering azithromycin 'following discussion of the balance of benefits and risks with the patient' patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM for men with symptomatic infection all partners from the four weeks prior to the onset of symptoms should be contacted for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Answer 87

The usual rules regarding starting the COC should still be adhered to, i.e. use condoms for 7 days if not started on the first day of next period Combined oral contraceptive pill: special situations Concurrent antibiotic use for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - 'extra- precautions' were advised for the duration of antibiotic treatment and for 7 days afterwards no such precautions are taken in the US or the majority of mainland Europe in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance precautions should still be taken with enzyme inducing antibiotics such as rifampicin Switching combined oral contraceptive pills the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The Clinical Effectiveness Unit of the FSRH have stated in the Combined Oral Contraception guidelines that the pill free interval does not need to be omitted (please see link). The BNF however advises missing the pill free interval if the progesterone changes. Given the uncertainty it is best to follow the BNF

Answer 88

Pelvic floor exercises for 3 months A diagnosis of stress incontinence is obvious from the history, therefore there is no need for a bladder diary or urodynamic studies. Pelvic floor exercises would be the first line management.

Answer 89

Pelvic floor exercises for 3 months Pregnant women should receive instructions as to how to perform pelvic floor exercises during pregnancy as this may help to decrease subsequent risk of stress urinary incontinence.

Answer 90

Bladder diary for 3 days The patient appears to be describing urge incontinence. A bladder diary is needed to establish the baseline frequency of micturition and amounts of urine passed. Then bladder training can be initiated to increase the volume of urine passed at reduced frequencies.

Answer 91

Hydroxychloroquine is considered safe during pregnancy Rheumatoid arthritis: pregnancy Rheumatoid arthritis (RA) typically develops in women of a reproductive age. Issues surrounding conception are therefore commonly encountered. There are no current published guidelines regarding how patients considering conception should be managed although expert reviews are largely in agreement. Key points patients with early or poorly controlled RA should be advised to defer conception until their disease is more stable RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery methotrexate is not safe in pregnancy and needs to be stopped at least 3 months before conception leflunomide is not safe in pregnancy sulfasalazine and hydroxychloroquine are considered safe in pregnancy interestingly studies looking at pregnancy outcomes in patients treated with TNF-α blockers do not show any significant increase in adverse outcomes. It should be noted however that many of the patients included in the study stopped taking TNF-α blockers when they found out they were pregnant low-dose corticosteroids may be used in pregnancy to control symptoms NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation

Answer 92

Known thrombogenic mutation Combined oral contraceptive pill: contraindications The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below: UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk Examples of UKMEC 3 conditions include more than 35 years old and smoking less than 15 cigarettes/day BMI > 35 kg/m^2* migraine without aura and more than 35 years old family history of thromboembolic disease in first degree relatives 20 years ago is classified as UKMEC 3 or 4 depending on severity *The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.

Answer 93

Amniocentesis: risk of fetal loss is 0.5-1% Amniocentesis Amniocentesis is a procedure used in prenatal diagnosis. It may be offered after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk, for example if > 35 years old. Around 20 ml of fluid is removed by transabdominal needle under ultrasound guidance. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions. Amniocentesis is usually performed at 16 weeks and the risk of fetal loss is 0.5-1%. The karyotype results typically take 3 weeks. It is known the karyotype may be wrong in 1/1000 cases due to maternal cells being present Conditions which may be diagnosed neural tube defects (raised AFP levels in the amniotic fluid) chromosomal disorders inborn errors of metabolism

Answer 94

Progestogen only pill: missed pill The missed pill rules for the progestogen only pill (POP) are simpler than those used for the combined oral contraceptive pill, but it is important not to confuse the two. 'Traditional' POPs (Micronor, Noriday, Nogeston, Femulen) If less than 3 hours late no action required, continue as normal If more than 3 hours late (i.e. more than 27 hours since the last pill was taken) action needed - see below Cerazette (desogestrel) If less than 12 hours late no action required, continue as normal If more than 12 hours late (i.e. more than 36 hours since the last pill was taken) action needed - see below Action required, if needed: take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Answer 95

ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic. Most clinicians would either use methyldopa or labetalol first-line in this situation Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure ``` Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease ``` Features of severe pre-eclampsia hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 96

Polycystic ovarian syndrome Endometrial cancer Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection ``` The risk factors for endometrial cancer are as follows*: obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome ``` Features post-menopausal bleeding is the classic symptom pre-menopausal women may have a change intermenstrual bleeding pain and discharge are unusual features Investigation first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (

Answer 97

Offer vitamin D supplementation Soft-cheese should be avoided during pregnancy due to the risk of Listeria Antenatal care: specific points NICE issued guidelines on routine care for the healthy pregnant woman in March 2008 Nausea and vomiting natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE antihistamines should be used first-line (BNF suggests promethazine as first-line) Vitamin D NICE recommend 'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding' 'women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement'. This was confirmed in 2012 when the Chief Medical Officer advised: 'All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy' particular care should be taken with women at risk (e.g. Asian, obese, poor diet) Alcohol NICE recommend women should avoid alcohol during the first trimester if women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week

Answer 98

With progesterone only injectable contraception there can be a delay in return to natural fertility of up to 12 months. The other methods are not associated with such a delay. See FSRH guidelines. Injectable contraceptives Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions** The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning. Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months) Adverse effects irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time *Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks **the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community

Answer 99

Progestogen only pill: types Second generation norethisterone levonorgestrel ethynodiol diacetate Third generation desogestrel (Cerazette) Cerazette new third generation type of progestogen only pill (POP) containing desogestrel inhibits ovulation in the majority of women users can take the pill up to 12 hours late rather than 3 hours like other POPs

Answer 100

HPV, the causative agent of cervical cancer, can be transmitted during lesbian sex. Lesbian and bisexual women should therefore have cervical screening as normal. Unfortunately the uptake amongst lesbian women is around 10 times worse than the general female population, sometimes as a consequence of incorrect advice from healthcare professionals. Cervical cancer screening The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening Who is screened and how often? A smear test is offered to all women between the ages of 25-64 years 25-49 years: 3-yearly screening 50-64 years: 5-yearly screening How is performed? There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid. Advantages of LBC includes reduced rate of inadequate smears increased sensitivity and specificity It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS. In Scotland women from the ages of 20-60 years are screened every 3 years.

Answer 101

Provides evidence of adequate ovulation Infertility Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years ``` Causes male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15% ``` Basic investigations semen analysis serum progesterone 7 days prior to expected next period

Answer 102

Preterm birth occurs in around 5-10% of pregnancies Preterm birth Preterm birth is defined as delivery of an infant before 37 weeks gestation. It occurs in around 5-10% of pregnancies (6% of singletons, 45% of twins) ``` Causes unexplained (30-40%) multiple pregnancies (20-30%) congenital abnormalities antepartum haemorrhage pre-eclampsia cervical incompetence diabetes mellitus polyhydramnios uterine abnormalities infections e.g. Pyelonephritis ```

Answer 103

Obesity is a risk factor for endometrial cancer but not cervical cancer Cervical cancer The incidence of cervical cancer peaks around the 6th decade. It may be divided into squamous cell cancer (80%) adenocarcinoma (20%) Features may be detected during routine cervical cancer screening abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding vaginal discharge ``` Risk factors human papilloma virus 16,18 & 33 smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status combined oral contraceptive pill* ``` *the strength of this association is sometimes debated but a large study published in the Lancet (2007 Nov 10;370(9599):1609-21) confirmed the link

Answer 104

Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.

Answer 105

The first line management of stress urinary incontinence, in this case arising for pelvic floor trauma is pelvic floor exercises. These will help a proportion of patients. Non responders should have urodynamics performed to confirm the diagnosis.

Answer 106

Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.

Answer 107

Tough question. As the patient had taken the pill for 7 days in a row previously she is protected for the next 7 days. The FSRH guidelines state: 'after seven consecutive pills have been taken there is no need for emergency contraception' - please consult the link. The guidelines also recommend in this situation using condoms for the next 7 days Combined oral contraceptive pill: missed pill The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol If 1 pill is missed (at any time in the cycle) 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 needed If 2 or more pills missed take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception* if pills are missed in week 3 (Days 15-21): 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 7 days on, 7 days off

Answer 108

There is some evidence to suggest that pre-eclampsia is actually less common in smokers Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure ``` Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease ``` Features of severe pre-eclampsia hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 109

Amniocentesis: performed at 16 weeks, karyotype after 3 weeks Some laboratories are now able to detect Down's syndrome using fluorescence in-situ hybridisation (FISH) in 2 days, but full karyotyping takes 3 weeks Amniocentesis Amniocentesis is a procedure used in prenatal diagnosis. It may be offered after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk, for example if > 35 years old. Around 20 ml of fluid is removed by transabdominal needle under ultrasound guidance. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions. Amniocentesis is usually performed at 16 weeks and the risk of fetal loss is 0.5-1%. The karyotype results typically take 3 weeks. It is known the karyotype may be wrong in 1/1000 cases due to maternal cells being present Conditions which may be diagnosed neural tube defects (raised AFP levels in the amniotic fluid) chromosomal disorders inborn errors of metabolism

Answer 110

Erythromycin or amoxicillin is currently recommended for pregnant or breast feeding women. The efficacy of amoxicillin, often assumed to be ineffective against Chlamydia, was supported in a recent Cochrane review. A test of cure should be carried out following treatment Chlamydia Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen. Approximately 1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic Features asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria ``` Potential complications epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome) ``` Investigation traditional cell culture is no longer widely used nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique Screening in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years relies heavily on opportunistic testing

Answer 111

Congenital heart defects Ultrasound in pregnancy A nuchal scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include: Down's syndrome congenital heart defects abdominal wall defects Causes of hyperechogenic bowel: cystic fibrosis Down's syndrome cytomegalovirus infection

Answer 112

Need for contraception after the menopause 12 months after the last period in women > 50 years 24 months after the last period in women 50 years 24 months after the last period in women

Answer 113

The intrauterine device may work by inhibiting fertilisation or implantation Emergency contraception There are two methods currently available in the UK: Emergency hormonal contraception There are now two methods of emergency hormonal contraception ('emergency pill', 'morning-after pill'); levonorgestrel and ulipristal, a progesterone receptor modulator. Levonorgestrel should be taken as soon as possible - efficacy decreases with time must be taken within 72 hrs of unprotected sexual intercourse (UPSI)* single dose of levonorgestrel 1.5mg (a progesterone) mode of action not fully understood - acts both to stop ovulation and inhibit implantation 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 2 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated Ulipristal a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle is not recommended breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel Intrauterine device (IUD) must be inserted within 5 days of UPSI, or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period *may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Answer 114

Pelvic inflammatory disease Menorrhagia: causes Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures. Causes dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients anovulatory cycles: these are more common at the extremes of a women's reproductive life uterine fibroids hypothyroidism intrauterine devices* pelvic inflammatory disease bleeding disorders, e.g. von Willebrand disease *this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia

Answer 115

Desogestrel Progestogen only pill: types Second generation norethisterone levonorgestrel ethynodiol diacetate Third generation desogestrel (Cerazette) Cerazette new third generation type of progestogen only pill (POP) containing desogestrel inhibits ovulation in the majority of women users can take the pill up to 12 hours late rather than 3 hours like other POPs

Answer 116

Carbamezepine Epilepsy: pregnancy and breast feeding The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication. Other points aim for monotherapy there is no indication to monitor antiepileptic drug levels sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn Sodium valproate The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate. The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Answer 117

Vague symptoms in an older woman - ?ovarian cancer There are no symptoms which have a high positive predictive value for ovarian cancer. A high index of suspicion is needed to make the diagnosis Ovarian cancer Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin. Risk factors family history: mutations of the BRCA1 or the BRCA2 gene many ovulations: early menarche, late menopause, nulliparity It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies. ``` Clinical features are notoriously vague abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea ``` Diagnosis is difficult and usually involves diagnostic laparotomy

Answer 118

Nancy can be informed that she does not require contraception up to 21 days after giving birth. The following guidance has been taken from the Faculty of Sexual and Reproductive Healthcare Guideline on Postnatal Sexual and Reproductive Health: Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy is to be avoided. Women who are breastfeeding and who wish to avoid pregnancy should be advised to use a contraceptive method. As fertility is reduced, any contraceptive method will be more effective when used by a breastfeeding woman. Those women who are fully breastfeeding may wish to rely on the lactational amenorrhoea method (LAM) alone until breastfeeding reduces or other LAM criteria are no longer fulfilled. Postnatal Sexual and Reproductive Health - Faculty of Sexual & Reproductive Healthcare Clinical Guidance 2009 - http://www.fsrh.org/pdfs/Ceuguidancepostnatal09.pdf Post-partum contraception After giving birth women require contraception after day 21. Progestogen only pill (POP) the FSRH advise 'postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.' after day 21 additional contraception should be used for the first 2 days a small amount of progestogen enters breast milk but this is not harmful to the infant Combined oral contraceptive pill (COC) absolutely contraindicated - UKMEC 4 - if breast feeding

Answer 119

Combined oral contraceptive pill: overview The combined oral contraceptive pill (COC) is one of the most popular methods of contraception currently used in the UK Mode of action main: stops ovulation also: thickens cervical mucus (reducing chance of semen entering uterus) and thins endometrial lining (reducing chance of implantation)

Answer 120

Take pill now and no further action needed The missed pill rules for the progestogen only pill (POP) are simpler than those used for the combined oral contraceptive pill, but it is important not to confuse the two. 'Traditional' POPs (Micronor, Noriday, Nogeston, Femulen) If less than 3 hours late no action required, continue as normal If more than 3 hours late (i.e. more than 27 hours since the last pill was taken) action needed - see below Cerazette (desogestrel) If less than 12 hours late no action required, continue as normal If more than 12 hours late (i.e. more than 36 hours since the last pill was taken) action needed - see below Action required, if needed: take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-es

Answer 121

Start immediately, effective immediately Post-partum contraception After giving birth women require contraception after day 21. Progestogen only pill (POP) the FSRH advise 'postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.' after day 21 additional contraception should be used for the first 2 days a small amount of progestogen enters breast milk but this is not harmful to the infant Combined oral contraceptive pill (COC) absolutely contraindicated - UKMEC 4 - if breast feeding

Answer 122

HRT: adding a progestogen increases the risk of breast cancer This is the rationale behind giving women who've had a hysterectomy oestrogen-only treatment. The BNF states that the stroke risk is the same regardless of whether the HRT preparation contains progesterone. Hormone replacement therapy: adverse effects Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms. Side-effects nausea breast tenderness fluid retention and weight gain Potential complications increased risk of breast cancer: increased by the addition of a progestogen increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously increased risk of venous thromboembolism: increased by the addition of a progestogen increased risk of stroke increased risk of ischaemic heart disease if taken more than 10 years after menopause Breast cancer in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer the increased risk relates to duration of use breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT

Answer 123

Avoid first trimester. If then chooses to drink 1 to 2 units once or twice per week Antenatal care: specific points NICE issued guidelines on routine care for the healthy pregnant woman in March 2008 Nausea and vomiting natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE antihistamines should be used first-line (BNF suggests promethazine as first-line) Vitamin D NICE recommend 'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding' 'women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement'. This was confirmed in 2012 when the Chief Medical Officer advised: 'All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy' particular care should be taken with women at risk (e.g. Asian, obese, poor diet) Alcohol NICE recommend women should avoid alcohol during the first trimester if women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week

Answer 124

Biophysical profile ``` A biophysical profile is an antenatal ultrasound test which assesses: amniotic fluid volume fetal tone fetal activity fetal breathing movements reactivity of the heart ```