Reproductive Health Workbook 2 Flashcards

1
Q

Describe the physiology of breastfeeding

A

controlled by the let-down reflex

In response to suckling, oxytocin is released from the pituitary gland which stimulates myoepithelial cells that surround alveoli to contract, squeezing milk out of the breast

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2
Q

What are the components of breast milk?

A

Water (90%)
Lactose (7%)
Fat (2%)
Protein (1%)
Vitamins and Minerals

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3
Q

What support is available for women to achieve successful breastfeeding?

A

1-to-1 support for breastfeeding
Midwives, health visitors and trained local volunteers (peer supporters)

Breastfeeding drop-ins, cafes and centres

Helplines and websites e.g. National Breastfeeding Helpline and La Leche League

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4
Q

Give some common drugs that are contraindicated in breastfeeding

A

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas

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5
Q

What features would you look for on examination of suspected mastitis?

A

Erythema of the breast
Swelling of the breast
the presence of fluctuation suggests abscess formation

Other differentials to look out for:
Galactocele: smooth round painless swelling
Breast cancer (inflammatory cancer): diffuse painful redness with skin oedema (peau d’orange)
Fat necrosis of breast: presents as a firm lump with bruised skin

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6
Q

Lactational mastitis happens due to milk stasis due to reduced breastfeeding. Give some key risk factors

A

Changes in feeding regime
Introduction of bottle feeding
Poor attachment of the infant to the breast
Maternal stress and fatigue

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7
Q

How does chlamydia present in women? Ix? Mx?

A

cervicitis (discharge, bleeding), dysuria

Ix: NAATs are now the investigation of choice, the vulvovaginal swab is first-line, test two weeks after exposure

gram negative rod

Mx: doxycycline (7 day course) is first-line
Check if pregnant : azithromycin 1g stat
alert partners, treat then test

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8
Q

How does gonorrhea present in women? Ix? Mx?

A

cervicitis e.g. leading to vaginal discharge

Ix: NAAT

gram negative diplococcus

Mx: single dose of IM ceftriaxone 1g
if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose)

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9
Q

Risks of untreated PID?

A

perihepatitis (Fitz-Hugh Curtis Syndrome)
infertility
chronic pelvic pain
ectopic pregnancy

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10
Q

Presentation of chlamydia in men?

A

Urethral discharge (usually clear)
Dysuria
Proctitis
Epididmyo-orchitis is a complication of chlamydial infection, and patients may present with scrotal pain.

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11
Q

Presentation of gonorrhea in men?

A

Mucopurulent urethral discharge
Dysuria

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12
Q

What is a BBV risk assessment?

A

Blood Borne Virus (BBV) Risk Assessment

used to identify those at risk of BBVs, including Hepatitis B, Hepatitis C and HIV

number of partners, use of contraception, partners with known BBV, IV drug use

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13
Q

What is Chemsex? What drugs are often involved?

A

intentional sex under the influence of psychoactive drugs, mostly among MSM

mephedrone, γ-hydroxybutyrate (GHB), γ-butyrolactone (GBL), and crystallised methamphetamine

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14
Q

How does epidiymo-orchitis present?
Main differential?
Mx?

A

unilateral testicular pain and swelling
urethral discharge may be present

testicular torsion

if an STI is the most likely cause advise urgent referral to a local specialist sexual health clinic

if enteric organisms are the most likely cause send an MSU as above
treat empirically with an oral quinolone for 2 weeks (e.g. ciprofloxacin)

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15
Q

What should you ascertain if symptoms of epididymitis have not improved with tx / returned after tx?

A

Check compliance with treatment

check sexual abstinence and ensure that partner notification is complete if not already undertaken

consider alternative diagnoses

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16
Q

What may USS show in epididymitis?

A

an enlarged hypoechoic or hyperechoic (presumably secondary to hemorrhage) epididymis

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17
Q

What is the risk of transmission of untreated HIV?

A

25-30%

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18
Q

Factors which reduce vertical transmission of HIV (from 25-30% to 2%)?

A

antepartum:
maternal antiretroviral therapy

intrapartum:
mode of delivery (caesarean section)
IV infusions of zidovudine if patient presents in labour

post-partum:
neonatal antiretroviral therapy
infant feeding (bottle feeding)

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19
Q

Can women with HIV have a vaginal delivery?

A

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended

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20
Q

What neonatal therapy can be offered to babies of mothers with HIV?

A

zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml.

Otherwise triple ART should be used

Therapy should be continued for 4-6 weeks.

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21
Q

Can women with HIV breastfeed?

A

they should be advised against it

if the mother is well-controlled with a low viral load the risk of transmission is low, but it is still not non-existent

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22
Q

How can the risk be reduced for a partner of someone with HIV?

A

compliance with ART - undetectable viral load
using barrier contraception
not sharing sex toys
partner can receive pre/post exposure prophylaxis

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23
Q

When admitted in labour, who should a patient with HIV make aware of her diagnosis?

A

staff directly involved in her care
midwife, obstetrician, any neonatal doctors

24
Q

what does U=U mean? How can you explain this to a patient?

A

‘Undetectable = Untransmittable’ (U=U) is a campaign explaining how the sexual transmission of HIV can be stopped.

“When a person is living with HIV and is on effective treatment, it lowers the level of HIV (the viral load) in the blood. When the levels are extremely low (below 200 copies/ml of blood ) it is referred to as an undetectable viral load.At this stage, HIV cannot be passed on sexually.”

25
Q

Risk factors for developing STIs?

A

unprotected sexual contact with multiple partners
MSM
history of STIs
sexual assault
use of alcohol and recreational drugs
prostitution

26
Q

Causes of urethritis? How may you differentiate with a clinic-based investigation?

A

chlamydia, gonorrhoea, mycoplasma, NSU, UTI

urethral swab and microscopy - will show gonorrhoea but not chlamydia

27
Q

How should you investigate a man with suspected chlamydia?
What else could you test for?

A

NAAT using urine sample
can also do urethral/ rectal swabs

In general, when a patient attends a GUM clinic for STI screening, as a minimum, they are tested for:

Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)

28
Q

Advice and follow up for a patient with diagnosed chlamydia?

A

Advice:
Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Provide advice about ways to prevent future infection

Follow up:
Refer all patients to GUM for contact tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Consider safeguarding issues and sexual abuse in children and young people

29
Q

Mx of chlamydia? Challenges of providing tx?

A

doxycycline 100mg twice a day for 7 days

resistance to antibiotics, poor patient compliance, failure to abstain from sex, failure to notify partners

30
Q

Tx for non-specific urethritis?

A

doxycycline 100mg twice a day for 7 days

31
Q

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. How does it present?

A

primary features:
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy

secondary features:
systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers

32
Q

How can syphilis be investigated?

A

patient with typical ulcer in clinic:
urethral swab from base of ulcer taken for dark ground microscopy

can send off treponemal PCR (for early syphilis)

send off blood test for syphilis serology - non-treponemal and treponemal tests can be carried out - antibodies will be seen 3 months after infection acquired

33
Q

How is syphilis managed?

A

single deep intramuscular dose of benzathine benzylpenicillin

34
Q

What is the Jarisch-Herxheimer reaction?

A

sometimes seen following treatment of syphilis
fever, rash, tachycardia after the first dose of antibiotic
anti pyrexials and supportive mx

35
Q

Advice for a patient leaving sexual health clinic with treated syphilis?

A

abstain from sex until end of treatment course
partner notification
advice on how to prevent future infections
warning about potential Jarisch-Herxheimer reaction
come back at 6 and 12 weeks after tx to be retested

36
Q

What causes genital ulcers?

A

Painful
Common= Genital herpes
Rare = Chancroid

Painless
Common = syphilis
Rare = Lymphogranuloma venereum (caused by chlamydia)

Non infective:
trauma, malignancy, skin conditions, autoimmune (e.g. Bechets)

37
Q

How effective is the pill compared to condoms?

A

COCP:
Perfect use: more than 99% effective
Typical use: around 91% effective

Male condoms:
Perfect use: 98% effective
Typical use: around 82% effective

38
Q

COCP mode of action?

A

inhibits ovulation

39
Q

POP mode of action ( excluding desogestrel)?

A

thickens cervical mucus

40
Q

The desogestrel-only pill, injectable contraceptive (medroxyprogesterone acetate) and the implant (etonogestrel) all have the same mechanism of action. What is it?

A

Primary: Inhibits ovulation
Also: thickens cervical mucus

41
Q

IUD mode of action?

A

Decreases sperm motility and survival

42
Q

IUS (levonorgestrel) mode of action?

A

Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus

43
Q

How long does it take for the different types of contraceptive to become effective ? (if not first day of period)

A

instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

44
Q

Outline the 3 main types of emergency contraception

A

Levonorgestrel (Levonelle) - up to 3 days (72 hrs) after UPSI, dose doubled if obese, does not interfere with hormonal contraceptives

Ulipristal acetate (ellaOne)- up to 5 days (120hrs) after UPSI , be careful w severe asthma, wait 5 days before restarting hormonal contraceptives

IUD - up to 5 days after UPSI / ovulation, most effective

45
Q

Why is EC different than getting an abortion?

A

the ‘morning after pill’ is a progestogen-only hormone pill and works by delaying the release of an egg from an ovary, therefore preventing pregnancy

an abortion terminates an existing pregnancy

46
Q

Risks of coil insertion?

A

IUDs make periods heavier, longer and more painful

IUS is associated with initial irregular bleeding, later women typically have intermittent light menses and some women become amenorrhoeic

Both:
uterine perforation
ectopic pregnancies
PID
expulsion: most likely to occur in the first 3 months

47
Q

Missed pill rules for COCP?

A

1 pill missed : take ASAP and don’t worry

2 pills missed: week 1 = emergency contraception, week 3 = omit the break and no need for emergency contraception

48
Q

The decision of whether to start a women on the COCP is guided by the UK Medical Eligibility Criteria (UKMEC).

UKMEC 1: 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: unacceptable health risk

Give some examples of UKMEC 4 conditions

A

> 35 years old and smoking > 15 cigarettes/day
migraine with aura
history of thromboembolic disease, stroke or IHD
uncontrolled hypertension
breast feeding < 6 weeks post-partum
current breast cancer
positive antiphospholipid antibodies (e.g. in SLE)

49
Q

Which contraceptive is most likely to cause weight gain?

A

depo-provera (injectable)

50
Q

How does COCP affect cancer risk?

A

increased risk of breast and cervical cancer - (BC)
protective against ovarian and endometrial cancer

51
Q

What are the options for postpartum contraception?

A

only required after 21 days

POP- can be started at any time, can still breastfeed
COCP- should not be used for 21 days due to VTE risk
Coils - can be inserted within 48 hours of childbirth or after 4 weeks
Lactational amenorrhea method - effective for 6 months if exclusively breastfeeding and no periods

52
Q

when can women using non-hormonal forms of contraception be advised to stop using contraception due to the menopause?

A

after 1 year of amenorrhoea if aged over 50 years,
after 2 years of amenorrhoea if aged under 50 years

53
Q

What information would you need before providing emergency contraception?

A

when was the unprotected sex?
at what point in their cycle are they? (e.g. when was their LMP)
what is their weight? (high BMI may need higher dose)
do they have any other medical conditions e.g. severe asthma (avoid ulipristal)
are they currently on hormonal contraceptives or any other medications?
have they ever taken emergency contraception before and if so when was it?

54
Q

What assessment would you consider before initiating a COCP ?

A

Assess using UKMEC criteria for risk factors and eligibility e.g. PMH, fam hx, smoking status
Take blood pressure
Record BMI

55
Q

Risks of COCP?

A

Nausea and abdominal pain
Headache
Breast pain and/or tenderness
Menstrual irregularities
Hypertension
VTE
Breast and cervical cancer

56
Q

How would you explain the key differences between Nexaplanon and Mirena to a patient?

A

Nexaplanon = subdermal implant into the arm, Progestin-only, lasts 3 years

Mirena = IUS (inserted into uterus) Progestin-only , lasts 5-7 years

57
Q

What advice should you give to a patient who has just taken ellaOne?

A

If you vomit (be sick, throw up) within 3 hours of taking the tablet, take another tablet as soon as possible

If you have unprotected sex after taking the tablet, it will not stop you from becoming pregnant

After you take the tablet and until your next period comes, you should use condoms every time you have sex.