Other important bits n bobs Flashcards
1
Q
Conditions/specifics to ask about as a general cover in the history
A
Heart disease
Stroke
VTE
HTN
Headache/migraine
Epilepsy
Liver disease
Bowel disorders
Diabetes
Cancer
HIV
Smoker?
BMI?
2
Q
What fhx specifically ask about
A
breast ca (BRCA carriers - UKMEC 3 for CHC and 2 for others)
VTE (if first deg fam <45 then = UKMEC 3 CHC, if >45 = UKMEC 2)
3
Q
General history
A
Remind confidential
Personal history
Family history
PMHx
Social hx incl smoking, alcohol, domestic abuse, alcohol/drugs
Meds hx
Sexual hx
Obstetric hx (thinking about breast feeding)
Gynae hx (incl LMP, regularity, lenth, pain, HMB, endo, fibroids)
Cervical screening
4
Q
Criteria to be a migraine
A
2 or more of:
- photophobia
- headache impairs ability to function
- nausea
5
Q
criteria to be aura
A
visual aura rating scale (VARS)
Visual aura lasts between 5-60 mins = 3 points
Aura symptom develops gradually over 5-60 mins = 2 points
Presence of dark/ blank spot = 2 points
Presence of zigzag lines = 2 points
Visual impairement affects same side in both eyes (NB usually unilateral) = 1 point
Migraine with aura if >=5 points
Key to establish length of time symptoms last for. If <5 min wont count.
6
Q
ICHD-3 criteria migraine
A
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
visual
sensory
speech and/or language
motor
brainstem
retinal
C. At least three of the following six characteristics:
- at least one aura symptom spreads gradually over ≥5 minutes
- two or more aura symptoms occur in succession
- each individual aura symptom lasts 5-60 minutes1
- at least one aura symptom is unilateral
- at least one aura symptom is positive
- the aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another ICHD-3 diagnosis.
7
Q
What should a fertility consultation address? [3]
A
- Advice on how to get pregnant and factors affecting pregnancy
- The time frame involved
- Recommendations for seeking medical advice if pregnancy fails to occur
8
Q
How many times a week should women be having sex when trying to conceive?
A
2-3 times a week
9
Q
Should you recommend timing to fertile period
A
No it isnt recommended and there is no need for temperature measurements of ovulation testing kits but it’s acknowledged many women will use these so understanding the principles is important
10
Q
How long before extra fertility tests should be done when a couple is trying?
A
12 months - after 12mo, 80% of couples will have conceived. If fails after regular sex for a year further assessment and ix of woman and man to be done.
Women under the age of 36 are advised to wait 12 months before getting ix.
11
Q
What things decrease fertility?
A
-AGE - massive curve drop off from 31y/o
- Recurrent PID
- Inflammatory bowel disease
12
Q
Modifiable factors affecting female fertility
A
- Smoking
- Alcohol
- Drugs
- Taking folic acid
- Normal BMI
- Stress
- Caffeine
- Exercise- can boost fertility by improving insulin resistance and glucose control. Also helps reduce stress.
Changing these can increase chance of conception, and reduce the risk of pregnancy related complications.
13
Q
Non-modifiable factors affecting female fertility
A
- PCOS
- Age
- Chronic medical conditions such as diabetes - MDT approach to prep for pregnancy
- PID
- IBD
- Delay due to current contraception (DMPA is the only one)
14
Q
What are the pregnancy risks related to being overweight?
A
- Increase miscarriage risk when BMI >30
- Gestational diabetes
- Pre-eclampsia
- Stillbirths
- Baby >4kg
- VTE
15
Q
What are the peripartum risks related to being overweight?
A
- Preterm labour
- Long labour
- Shoulder dystocia
- Postpartum haemorrhage
- Operative/instrumental delivery
- Anaesthetic risks
16
Q
Postpartum risks related to being overweight?
A
- Infections
- VTE
17
Q
What preconception advice should be given to women with high BMI
A
- Weight loss advice
- Increased dose of folic acid (5mg)
- Referral to dietician if BMI >40
- 10mcg vit D following conception
- Advice they might need hospital based antenatal care for raised BMI
- Nutritional advice - no need for extra calories first 2 trimesters, extra 200kcal/day in 3rd trimester, not to diet in pregnancy but to eat healthily
18
Q
What medical problems need special attention w/r to pregnancy?
A
- Diabetes
- Epilepsy
- VTE
- Mental health issues
- Renal
- Cardiac
- HTN
- Severe asthma
- AI conditions
- HIV
Consider preconception referral to maternal fetal medicine.
18
Q
Risks around preg assoc with diabetes
What women should do prior to conception
A
- poor control is accoc with inc risk of congenital malformation, miscarriage, stillbirth & neonatal death
prior to conceiving:
- pre-preg specialist review, esp if underlying microvascular disease
- optimise diabetic control and reduce their hba1c <48
- eye screening
- women with t2dm may need to switch to insulin
good glycaemic control reduces risks
19
Q
What women with epilepsy be advised w/r to conception
A
They need specialist pre-conception counselling to review and ADJUST THEIR AEDS
Meds such as valproate and carbamazepine together with other multidrug regimes = inc risk of congenital malf and LT neurodevelopmental probs
Women on valproate should be on a pregnancy prevention programme
DO NOT STOP MEDS UNTIL SPECIALIST REVIEW. Continue contraception.
20
Q
What is the leading cause of maternal death in the UK?
A
VTE!!
21
Q
What are significant RFs for VTE in pregnancy? If women have any of these RFs what should be done?
A
- Personal or Fhx
- Thrombophilia
- High BMI
- Increased maternal age
MDT preconception counselling needed involving HAEM AND OBSTETRICS. Some women may need to change anticoag - WARFARIN = TERATOGENIC. Or start prophylactic treatment
22
Q
What needs to be done around mental health w/r to pre-conception?
A
- Screen for undiagnosed MH issues
- Pre-existing MH issues may be exacerbated by pregnancy and a new baby. Some psychotropics are teratogenic and need specialist review. e.g. carbamazepine, valproate, lithium, lamotrigine, paroxetine. CONTINUE CONTRACEPTION until review.
23
Q
Who is usually involved with pregnancy planning for women who have physical or learning disabilities?
A
Holistic consultation needed
Extensive input usually required from carers, social services and support workers
24
Who do you refer same sex couples wanting to conceive to?
Fertility specialist and counselling
What is available depends on the region
25
What psychosexual issues might affect fertility? Approach?
Persistent issues , despite counselling, such as severe vaginismus or erectile dysfunction and who are unable to conceive a child naturally should be referred for fertility treatment
26
Women wants to conceive but amenorrhoeic / oligo?
early fertility referral should be considered to exclude endocrine dysfunction e.g. PCOS, prolactinoma
27
Approach to women with cancer / cancer treatment in past of child bearing age
Advise to discuss fertility prospects with a specialist even if preg isnt an imminent issue. Women undergoing cancr treatment can often have discussion with specialist prior to starting and eggs can be collected.
28
Aside from advice around conceiving, what should ALWAYS be explored and asked about in a fertility consult?
DOMESTIC ABUSE
it is more common during pregnancy and women are more likely to die when pregnant.
Consider involving adult AND child safeguarding.
29
What are the additional risks to the baby for overweight mothers
- increased risk of fetal abnormalities and neural tube defects
- risk of obesity and diabetes later in life
- neonatal hypoglycaemia
- increased perinatal mortality
30
What screening tests can be done in the preconception period?
The pre-conception period provides an opportunity to perform relevant screening tests, either to reduce risk of complications during pregnancy e.g undiagnosed STI or to maximise disease prevention, e.g. cervical screening
- Ensure cervical screening up to date. (NB should be avoided when actually pregnant)
- CT screening - untreated genital CT can lead to neonatal pneumonia and conjuctivitis
- Rubella screening - can cause fetal loss or congenital rubella syndrome. If not had, or had less than 2 doses of MMR vaccine, then is to have two doses 1 month apart and then not get pregnant for 1 month after.
- Other STI and BBV screen
- Sickle cell/ thalassaemia screen
- Vit D screen
- Varicella screen
31
What preconception nutrition and vitamin supplementation advice should be given incl doses, when to take, and who applies to
1. Folic acid - reduces neural tube defects eg spina bifida, anencephaly, cleft palate. Foods naturally high in it = brussels, beans, oranges, yeast. Dose: 400mcg OD. Higher dose of 5mg for women who have h/o or fhx neural tube defects, DM/coeliac dis, BMI>30, sickle cell/ thalassaemia, twins, on AEDs ***** or enzyme inducers, partner with spina bifida. Take when trying to conceive and for 12w gestation. No SEs.
2. Vitamin D - helps prevent rickets in the child and osteoporosis in the adult. Take 10mcg/day. Particularly recommened in: darker skin, BMI >30, little exposure to sun
3. Vitamin C - as it helps iron absorption
32
What foods should people trying to conceive AVOID
- Any supplement containing vitamin A
- High dose multivitamins
- Fish liver oil supplements
- Unpasteurised cheeses
- Uncooked meats and raw or lightly cooked eggs
- Peanuts
- Certain fish such as swordfish, and restrict tune (mercury poisoning)
- Foods high in fat and sugar
33
To summarise - what should be discussed in a pre-conception consultation:
1. Factors affecting fertility incl modifiable
2. STI screening
3. Cervical cytology screening
4. Supplements - folic acid, vit D, vit C and foods to avoid
5. Full PMH and drug hx
6. Domestic abuse
7. Full history in general
8. MH
34
How long will it take to get an abortion when I want one? What if I need time to think about it?
- assessment within 1 week
- then abortion within 1 week of assessment
- may choose to wait longer however the implications should be explained - risks and complications increase with increasing gestation
35
I want an abortion - what is my gestation?
- Estimate gestation based on the first day of LMP, provided has regular cycle.
The gestational age is based on the date of the last period, not the date of conception.
So count the weeks from the first day of LMP.
- USS is usually done to confirm gestation prior to abortion
36
What is considered to be a 'very early gestation' for an abortion, what are the issues with abortions at this time and how are these mitigated?
PT may confirm before visibility on USS (appearance of fetus ~5-6w).
Abortions can still be carried out provided that:
1. No sx of ectopic
2. Woman aware of small ectopic risk and f/u appts may be needed
3. 24h emergency contact info provided
37
What is the gestational limit for most abortions in the UK? What are caveats to this?
23+6. ALL elements of abortion must be completed by then.
Caveats = fetal defects, risk to mothers life
38
What is used for a medical abortion and how is it done? Latest can have it?
Oral mifepristone 200mg followed by 800mcg misoprostol (buccal, sublingual or vaginal) 24-48h later
10 WEEKS IF AT HOME. If >10w done in hospital. If >10w in hosp, repeated doses of misoprostol til preg passes
39
What does mifepristone do
Blocks progesterone receptors directly = endometrial degeneration, cervical softening and dilatation, release of endogenous prostaglandins, and an increase in the sensitivity of the myometrium to the contractile effects of prostaglandins.
40
What does mifepristone do
Blocks progesterone receptors directly = endometrial degeneration, cervical softening and dilatation, release of endogenous prostaglandins, and an increase in the sensitivity of the myometrium to the contractile effects of prostaglandins. Causes embryo to detach from uterine wall.
41
What does misoprostol do
Misoprostol dilates the cervix and induces muscle contractions which clear the uterus.
42
Surgical abortion - what happens? talk me through the weeks and how it varies
Cervix is prepared no matter when done
If <14w misoprostol is used to prep the cervix
>14w osmotic dilators are placed into the cervix hours or day before
Then suction tube used to evacuate. Half a day procedure if <19w. If >19w then cervix prepared D1 and procedure done D2
Can be LA/ GA / sedation.
43
What follow up is needed after abortion?
BASICALLY IF AT HOME - DO A PT AT 2W, OTHERWISE NOTHING
Depends on the abortion
1. Early medical at home: low sensitivity urinary pregnancy test no sooner than 2w after
2. For other medical abortions if done at home then same as above but none needed if visible passage of preg in hospital.
3. Surgical - none needed.
No need for any other types of abortion
44
What needs to be considered about abortion at home vs hospital
- womens pref
- medical and social factors:
support at home
distance from hospital
age - if under 16 should be in hosp or clinic
45
Complications of abortion [3] and how likely these are
- haemorrhage - rare, increases with gestation. Higher risk if surgical. 1-70/1000
- cervical trauma / uterine perf - only related to surgical abortions.
- incomplete or failed abortion - 1% in medical abortion, 0.5% surgical
- infection - lowest for early abortions, <1/100
46
What prophylaxis should be considered in abortion, and in who?
1. Abx - in all surgical abortions and in medical ones where high risk of STI
2. Anti-D prophylaxis - offer to all surgical abortions, and med abortions >10w
3. VTE prophylaxis - assess individual risk
47
If patient is younger and wants abortion what needs to be considered
Additional safeguarding considerations for young people (incl those under 16) and vulnerable adults
48
Outline general pre-abortion consultation (9)
1. Patient details, contact information and relevant permissions
2. Is she happy for info to be shared with GP
3. Feelings about pregnancy - when find out, anyone else know, reasons for requesting abortion, capacity to consent
4. Assessment of gestation: LMP, menstrual cycle, USS findings, any bleeding or pain
5. Previous gynae and obstetric hx, contraception, prev pregnancies and outcomes incl complications
6. PMH, drug hx, allergies. CONSIDER VTE prophylaxis
7. Social history and partner info
8. Safeguarding: Domestic violence, young person risk assessment
9. Other: STI/HIV risk ax. Contraception - return to fertility is quick so DISCUSS THIS. Can actually have LARC fitted at abortion
49
What should she expect if doing medical abortion at home
- bleeding and cramping which will start soon after misoprostol is taken and continue for several hours
- the bleeding will become heavier like a very heavy period until the pregnancy passes
- there may be light bleeding for up to 2 weeks following the procedure
- take para
- if little or no bleeding after 4 hours, redose with misoprostol
50
What percentage of women in early pregnancy have a miscarriage
20% - 1 in 5
51
Symptoms of early pregnancy
Breast tenderness
Morning sickness
Missed period / abnormal bleeding
Urinary frequency
Lethargy
Mild cramps
Constipation
Change in discharge
Aversion to certain foods/drinks
52
What does hcg do
It's produced by placental cells at around 5d of pregnancy. Its main role is to support and maintain corpus luteum to make progesterone necessary to enrich the uterine lining and sustain a healthy fetus
53
How long is hcg around for during a healthy pregnanct
levels double every 2-3d and peak in week 9. Once development of the placenta is complete ~12w, this takes over progesterone production from corpus luteum
54
How long could a hcg test remain positive for after a first trimester miscariage or abortion
What tests to use
4 weeks
Use low sensitity hCG test (detects 1000-2000 mIU/ml instead of high senstivitiy 20-35 mIU/ml tests)
55
Causes of false positive pregnancy tests [3]
1. hCG secreting tumours e.g. ovarian
2. Gestational trophoblastic disease
3. Certain medications e.g. prochlorperazine, chlorpromazine
56
What gestation is the first scan usually done, and what level of hcg should sonographers be able to see a viable intrauterine pregnancy on scan?
12 weeks
1500 of hcg - should be able to see, if not then could indicate a failing pregnancy
57
What are the 3 potential complications of early pregnancy? What are signs of this?
1. Miscarriage
2. Ectopic
3. Gestational trophoblastic disease
Signs/Symps: vaginal bleeding, pain
58
RFs ectopics
1. H/o ectopic
2. PMHx STIs/ PID
3. IUC
4. Previous IVF
5. Previous abdominal surgey where tubal damage or adhesions are possible
59
Symptoms of ectopics - common/ uncommon
Common:
- Pain and bleeding
Uncommon:
- Shoulder tip pain
- Dizziness
- Rectal pain / pain on defacation
- GI sx
- Urinary sx
- Breast tenderness
60
What signs seen in ectopic
- pelvic, abdo, adnexal tenderness
- sign of peritonism on abdo exam
- cervical excitation
- tachycardic/hyotensive/tachypnoeic
61
What ix done in ectopic
- USS --> no evidence of intrauterine pregnancy on USS - can see 'bagel sign' in fallopian tube.
- BhCG --> suboptimal rise in consecutive serum BhCG levels taken 48h apart
62
Management options for ectopic - medical, surg, conservative
Refer to A&E or early preg assessment service
Medical- methotrexate -stops the pregnancy developing any further. It then gets resorbed by the body or passed in next period. Contraception recommended for minimum of 3mo after.
Surgical - salpingectomy - removal of fallopian tube or salpingotomy - incision
Conservative - watch and wait, rare.
63
What is the risk of recurrence of ectopic
18.5%
64
Causes of miscarriage
Baby:
- genetic abnormalities
Mother:
- Age
- Hormonal problems eg thyroid
- Uterine abnormalities
- Cervical abnormalities
- Chronic medical conditions eg diabetes, rubella
Environment:
- Medications
- Toxins: smoking, drugs, alcohol, pollution
65
How do you diagnose a miscarriage and what are the different management options depending on gestation?
You need an USS and often need 2. If unable to find fetal heart beat, get them to return in 7 days for another scan (if baby is larger then can get a second opinion rather than bringing them back)
<6w gestation - if bleeding but no pain then advise to return if bleeding continues or pain develops & repeat PT in 7d. If +ve return, if -ve = miscarriage.
Threatened miscarriage - bleeding but has fetal heart beat. Return if bleeding worsens or persists beyond 14d. Continue antenatal care if bleeding stops.
6w or more and confirmed miscarriage - depends on whether stable or not, evidence of infection and PMH. Options:
- Expectant mx - 7-14d
- Medical mx - misoprostol
- Surgical - manual vacuum
66
Complications of miscarriage
- Incomplete --> can lead to infection
- Infection
- Bleeding or blood loss
67
Gestational trophoblastic disease - types and features
- Complete molar pregnancy - duplication of single sperm following fertilisation of empty ovum or 2 sperm (dispermic) fertilisation of an empty ovum
- Partial molar preg - same as above but is not an empty ovum
- Trophoblastic tumours
Features:
- irreg bleeding
- hyperemesis
- excessive uterine enlargement
- very high hCG levels
68
Management of gestational trophoblastic disease
- Give written info
- Refer to trophoblastic screening centre
- If molar preg - evacuation
- If neoplasia - chemo
- Women are followed up for 6mo from uterine evac or from normal hCG levels
- Women advised to notify the centre when planning future pregnancies as risk of recurrence
- Preg should be avoided during treatment and follow up
- All contraceptions fine apart from IUC
69
Talk me through the biopsychosocial causes of sexual dysfunction. Give 4 in each
BIOLOGICAL
- Menopause
- Pelvic surgery
- Vulval dermatoses
- STIs
- Candida
- Iatrogenic eg chemo
- Endocrine diseases
- Low testosterone
- Chronic conditions e.g. DM, CVD, Ca, Renal failure
PSYCHOLOGICAL
- Low mood / anxiety
- PTSD / trauma
- Psychosis
- Living with HIV
- Infertility
- Substance and alcohol misuse
SOCIAL
- Domestic violence
- Prev. sexual trauma
- Negative cultural attitudes towards sex
- Unemployment
- Poverty
NB many can fit into more than one category
70
Name 4 medication groups that can have negative effects on sexual functioning?
Antideps
AEDs
Antipsychotics
Chemo
Diuretics
Antihypertensives
Statins
Opioids
PD meds
Sedatives
Medications used in context of gender transitioning e.g. oestrogens, testosterone, finasteride, spironolactone
71
Causes of painful sex
Anogenital causes:
- STIs
- Candida
- PID
- Prostatitis
- Anal fissures or haemorrhoids
Gynae/ urological causes:
- FGM
- Endo
- Anatomical abnormality - imperforate hymen
- Postpartum scar tissue
- Menopausal atrophic vaginitis
- Hernia
- Pelvic cancer
Psychosexual causes:
- Previous trauma
- Anxiety
- Fear of pregnancy
- Prev difficult childbirth
- Prev STIs
72
What is vaginismus? Primary vs secondary
sexual pain penetration disorder - persistent difficulties with penetration despite a persons express wish for this
Cause debated but for many people = involuntary spasm of vaginal musculature. Can be generalised - all circumstances, or situational - eg can for tampons, cant for partner finger
Primary = always had
Secondary = develops when have prev had penetration eg after sexual trauma or childbirth
73
Treatment for vaginismus
Combination of:
- psychosexual therapy
- pelvic floor exervises
- graded dilators
to overcome cycle of pain anticipation and vaginal spasm
- if elements of vulvodynia/ vestibulodynia (persistent burning pain) then topical lidocaine or oral amitriptyline/gabapentin may help
- if post menopausal atrophic vaginitis - topical oestrogen, moisturises or HRT
74
What would you recommend to help people struggling with arousal and orgasm?
- open about sex and expressing desires to help improve arousal. good communication.
- for women - emphasise importance of clitoral stimulation, foreplay and non penetrative sex
75
Treatment approach for low libido
HOLISTIC
- stress reduction
- sensate focus exercises
- mindfulness
- psychosexual or CBT
- treatment of underlying MH problems
- after menopause - HRT or off label testosterone supplement
- NORMALISE LOSS OF LIBIDO for xyz
76
Physical causes of erectile dysfunction - give 6
VASCULAR
- diabetes
- CVD
- smoking
NEUROGENIC
- spinal cord injury
- diabetic
- stroke
- CKD
- prostate surgery
- MS
- PD
- pelvic surg
ANATOMICAL
- Peyronie's disease - inflam dis that = deformity and bending of the penis
- Hypospadias
HORMONAL
- Diabetes
- Hyperprolactinaemia
- Cushing's
- Hypogonadism
IATROGENIC
- Thiazide diuretics
- Beta blockers
- Antidepressants
- Neuroleptics
- Recreational
TRAUMA
- Penile #
- Pelvic #
77
What is the initial work up for ED ix?
Examination:
- Check BP, HR and BMI
- DRE if over 50, if any sx of urinary obstruction, or h/o prostate enlargement
- Genital examination (?small testes / hypogonadism, lesions, deformities)
- Androgenisation - gynaecomastia? reduced body hair?
Bloods:
- HbA1x
- Morning testosterone
- Lipids
- PSA if DRE not normal
If testosterone is borderline, check LH, FSH, prolactin
In hyperprolactinemia, which induces hypogonadism, the excess prolactin interferes with secretion of gonadotropin-releasing hormone, resulting in decreased testosterone and erectile dysfunction. (antipsychotics block dopamine and cause prolactin rise)
78
Treatments for erectile dysfunction
LIFESTYLE
- lose weight, do exercise, eat healthy, reduce stress
- if cycle >3h per week, encourage trial period without cycling to see if helps
MEDICATION
- PDE-5 inhibitors - sildenafil, tadalafil etc. Works by blocking PDE-5, which, in turn, prevents the break down of cGMP, which causes smooth muscle to relax and dilate. Careful in CV disease, may cause big drop in BP if used with other antihypertensives.
- Testosterone supplements if hypogonadism
MECHANICAL/ SURGICAL
- Vacuum erection device
- Insertion of a penile prostheses (eg following spinal trauma)
PSYCHOSEXUAL
- therapy or CBT
79
Treatments for premature ejaculation
BEHAVIOURAL APPROACH
- squeeze technique, or stop start technique, halt sexual activity just before ejaculation. over time control is learned.
TOPICAL ANAESTHETICS
PSYCHOSEXUAL THERAPY
MEDICATION- SSRI short acting PRN, or off label daily SSRIs such as citalopram or sertraline
80
First onset migraine without aura during CHC - UKMEC?
3
81
What is melasma
hyperpigmentation of the skin - more likely in women with darker skin tones, during preg and following exposure to exogenous hormones
assoc with CHC
82
Additional history required in young persons assessment
- Education, how is it
- Employment
- Family relationships
- Involvement with social or mental health services
- Friendships
- Sexual relationships, ages
- Abuse and coercion - partner ever made them feel unsafe, ever made to engage in sex they didnt want, ever been given gifts, money, drugs in exchange for sex
83
When are Fraser guidelines used?
Only if person is UNDER 16
84
What information about SARCs and forensic samples is important to be passed on to an individual
Forensic samples can be obtained, medical reports can be compiled
- SARC can offer to obtain and store forensic evidence incase want to report in future
- can do third party anonymous reporting
- clothing, bedding, sanitary towel, toothbrush used after assault, urine and tissue usd to wipe genitals
- don't wash before examination, try not to urinate or defaecate
- vagina + cervix- 7d, anus -3d, mouth- 2d, clothing/bedding- until washed - advise to keep in a plastic bag
85
What to be considered if sexual assault presents to you with 7d of the assault
7 days
- refer to sarc
- spoken to anyone else? may be called as a witness to court if first person
86
What medical support should be offered to patients who disclose sexual assault?
- Emergency contraception
- PEP
- Hep B vaccination
- STI screen
- Encourage attendance to SARC
- Signpost to local therapeutic support eg survivors network
Reiterate confidentiality
87
Holding a domestic violence consultation
Ask - "As violence in the home is so common we now ask everyone about it routinely, do you ever feel threatened or have you ever been hurt?"
Validate "You are not to blame, you are not alone"
Action - ?any children in the home - if so need referral to safeguarding. Be aware of local DV agency.
88
Woman has a positive PT, 3 initial questions you would ask
1. Date of LMP
2. Was LMP normal and at the expected time
3. Any negative PTs
4. Any pregnancy related symptoms like nausea or breast tenderness
5. When did preg sx start
6. Any other symptoms specifically pain or bleeding?
89
Apart from a viable pregnancy, what else could cause a positive PT?
1. Miscarriage or abortion
2. Ectopic preg
3. Failing preg
4. Hormone secreting tumours
5. False positive test as out of date
6. False positive test as read too late
90
Causes of bleeding in early pregnancy
1. Threatened miscarriage
2. Ectopic pregnancy
3. STI
4. Implantation bleed
5. Genital tract pathology
91
Pelvic pain causes in pregnancy
1. Ectopic
2. PID
3. Constipation
4. UTI
5. Ovarian cysts
6. MSK
92
When reviewing any contraceptive, what information needs to be checked at review
1. Sexual health history
2. Any change in family history
3. Review current medication / over the counter medication
4. Lifestyle: smoking/ alcohol
5. Bleeding patterns / periods
93
48/F on POP, no periods for 2y, she thinks she must be menopausal so wants to stop contraception. What 3 things should you tell her?
1. Lack of period on POP is not indicative of menopause
2. She would need to continue contraception until menopause is diagnosed
3. At age of 55 years she can safely stop POP
4. FSH levels should not be checked before the age of 50 years. When >50y, FSH can be checked and if result is >30 menopause can be diagnosed and contraception must be continued for a further year.
94
Symptoms of menopause
Hot flushes/ night sweats
Poor concentration
Forgetfulness
Mood swings/ changes
Vaginal dryness
Reduced libido
Joint pains
Skin or hair dryness or thinning
95
Explain the 5 components of the Fraser guidelines
1. Patient has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
2. She cannot be persuaded to tell her parents or allow the doctor to tell them
3. She is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
4. Her physical or mental health is likely to suffer unless she received the advice or treatment
5. The advice or treatment is in the young persons best interests
96
What 4 things should you advise someone about missed pills (with relation to the desogestrel POP)
1. A missed pill is one taken >36h after the last. You will then need to use condoms until you have taken 2 or more pills correctly.
2. If vomit within 2h of taking pill take another
3. If you have diarrhoea for >24h use condoms until diarrhoea has stopped and then until youve taken 2 pills in a row
4. Discuss use of apps/ leaflet for pill regime
97
What would you do to teach someone putting on a condom
before:
- check expiry
- carefully remove from packet
- DO NOT USE WITH OIL BASED LUBRICANT
putting on:
- make sure not inside out
- squeeze teat
- still holding the teat, roll the condom down to the base of the fully erect penis
after ejaculation
- withdraw penis whilst still erect while holding condom at base. remove condom, check for tears, throw away.
98
Low libido post new baby case - remember to ask/do:
- Post-partum, suggest health visitor chat if struggling
- Specifically ask about post natal depression
- Smears
- STI history
- Normalise libido issues
- Safety netting
99
What is the recommended limit for alcohol intake per week / per day
14/week (bottle wine = 9 units)
Daily: no more than 2-3 units/day - 1 glass wine / 1 pint
100
Which pill good for PCOS
Yasmin COCP or any pill with Drospirenone
101
Who are ferility apps not appropriate for
Those who have irregular cycles, or who are at irregular cycle times eg puberty, post partum, perimenopause or post contraception
102
3 criteria for LAM
How effective?
<6mo post partum
Feeding every 4h day, 6h night
Amenorrhoeic
98% effective
103
Modifiable factors affecting male fertility
Smoking
Alcohol
Drugs
Increased weight
Anabolic steroids
104
Unmodifiable factors affecting male fertility
Hormone imbalance
Undescended testes
Testicular overheating
Injury
Varicoceole
Tumour
105
What conference is there to help vitims of DV? What do they do? Give examples of meaures
MARAC - multi agency risk assessment conference
- Info shared on highest risk domestic violence abuse causes (between representatives of local police, health, child protection etc).
- After sharing, a co-ordinated action plan is made to safeguard the adult victim.
- ANY PROFESSIONAL can refer a victim of DV to the MARAC
e.g. red flag on address for 999 calls, CCTV, safety locks fitted
106
What is the law related to DV?
Clare's law - the domestic violence disclosure scheme. Enables someone to request info from the police about a partners previous h/o DV or violent acts.
107
Who to refer or signpost victims of DV to?
1. Safeguarding at UHS - there is an OOH dury team as well as in hours.
2. Victim support - charity that provides emotional and practical help. Can be contacted regardless of whether police are involved.
3. CGL has self referral pathway for victims of DV
4. Refer to service lead - provide a safety plan, and details of available resources if the person does not wish to engage at this time.
108
Framework for questions around DV
The four HARK questions were developed as a framework for helping identify people who have suffered domestic abuse, and found to be a sensitive tool.[12]This stands for:
Humiliation: "In the last year, have you been humiliated or emotionally abused in other ways by your partner?" "Does your partner make you feel bad about yourself?" "Do you feel you can do nothing right?"
Afraid: "In the last year have you been afraid of your partner or ex-partner?" "What does your partner do that scares you?"
Rape: "In the last year have you been raped by your partner or forced to have any kind of sexual activity?" "Do you ever feel you have to have sex when you don't want to?" "Are you ever forced to do anything you are not comfortable with?"
Kick: "In the last year have you been physically hurt by your partner?" "Does your partner threaten to hurt you?"
109
Framework for questions around DV
The four HARK questions were developed as a framework for helping identify people who have suffered domestic abuse, and found to be a sensitive tool.[12]This stands for:
Humiliation: "In the last year, have you been humiliated or emotionally abused in other ways by your partner?" "Does your partner make you feel bad about yourself?" "Do you feel you can do nothing right?"
Afraid: "In the last year have you been afraid of your partner or ex-partner?" "What does your partner do that scares you?"
Rape: "In the last year have you been raped by your partner or forced to have any kind of sexual activity?" "Do you ever feel you have to have sex when you don't want to?" "Are you ever forced to do anything you are not comfortable with?"
Kick: "In the last year have you been physically hurt by your partner?" "Does your partner threaten to hurt you?"
110
Teach me how to use Sayana Press
1. Choose correct injection site - belly (not navel) or front of the thigh.
2. Wash your hands.
3. Open the pouch, take out the device. Check expiry
4. Holding the port, mix hard for 30 seconds, make sure is completely mixed.
5. Point needle up, hold cap with one hand and port with other, close the gap.
6. Take cap of needle, hold by port, with other hand pinch 4cm of skin.
7. Press the needle straight into the skin, port touching skin, squeeze reservoir slowly for 5-7s.
8. Pull out. Dispose in sharps bin.
8. Set reminder for 3 months from today for next one. Can give 2w early or 4w late.
111
How to insert the vaginal ring
1. Clean hands
2. Squeeze the ring between thumb and finger, push up into vagina until feels comfortable. Does not need to cover cervix.
2. If uncomfy push a bit further in
3. To remove, hook a finger and gently pull out.
112
How do I put a diaphragm in?
1. NB. Must cover cervix
2. Clean hands. Locate cervix first. Feels like end of your nose.
3. Put small amount of spermicide on the upper sruface of the diaphragm and on the rim
4. Put index finger on top of diaphragm, squeeze it between thumb and other fingers.
5. Slide into vagina up and back.
6. If cervix not covered, remove by hooking under rip and pulling down. Retry.
7. If your cap or diaphragm and spermicide are in place but 3 or more hours have passed and you haven't had sex then you will need to re-apply the spermicide.
8. Leave in for at least 6 hours after last sex. If have sex again within this time more spermicide should be used - dont remove cap/diaphrag, just insert spermicide high into vagina.
9. Don't use silicone or oil based lube. Check for tears or holes.
May help to squat, lie down or stand with one foot up on a chair
113
How do I put a vaginal cap in?
1. N.B must cover cervix.
2. Clean hands. Locate cervix- feels like end of your nose
3. Fill 1/3 of cap with spermicide. Dont put it around the rim as may stop it staying in place.
4. Squeeze sides of cap together between thumb and first 2 fingers. Cap must nearly cover cervix.
5. If your cap or diaphragm and spermicide are in place but 3 or more hours have passed and you haven't had sex then you will need to re-apply the spermicide.
6. Leave in for at least 6 hours after last sex. If have sex again within this time more spermicide should be used - dont remove cap/diaphrag, just insert spermicide high into vagina.
7. Don't use silicone or oil based lube. Check for tears or holes.
