Sexual + reproductive health Flashcards
Management miscarriage
If stable + <6/40 rpt pregnanct test in 1 week, if negative- miscarriage, if positive EPAU
Early pregnancy assessment 6-12/40
Gynae 12-16+4/40
Obs after 16+4/40
Return if bleeding>2 weeks, feverish, worse abdo pain, bleeding through greater than 1 pad/hr for 2 hours
If positive preg test>3 weeks (for USS ?RPOC)
Definition pre-eclampsia
New onset BP >140/90 after 20/40 and 1 of:
Proteinuria (ACR>8)
Renal insufficiency (creatinine>90)
Liver involvement (ALT or AST>40), RUQ pain or epigastric pain
Neurological (seizure, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata)
Haematological (plt<150, DIC, haemolysis)
Uteroplacental (IUGR, abnormal umbilical artery doppler, stillbirth)
Risk factors for pre-eclampsia
High risk factors:
HTN in previous pregnancy
CKD
SLE, antiphospholipid syndrome.
T1 + T2DM
Chronic HTN
2x moderate risk factors:
1st pregnancy.
Aged>40
Pregnancy interval>10 yrs.
BMI> 35 at booking
FHx pre-eclampsia.
Multiple pregnancy
Management incr risk pre-eclampsia
Refer for consultant-led care
Aspirin 75—150 mg OD from 12 /40 until birth
Seek specialist advice if age<16, thrombophilia or uncontrolled HTN.
Folic acid + Vit D
Management pre-existing HTN in pregnancy or new HTN<20/40
Stop ACEi/thiazide
Target BP following antihypertensive treatment in pregnancy is 135/85 mmHg (start treatment is BP>140/90)
1st line Labatolol 100mg BD
2nd line Nifedipine
Aspirin 75-150mg OD from 12/40-birth
Management proteinuria in pregnancy
Check BP, admit if signs pre-eclampsia
? UTI, treat if nitirite or leuc +ve
If 2+ admit
If 1+ urine ACR + obs assess if >8
What does routine pregnancy care include?
10 antenatal appointments for nulliparous women or 7 antenatal appointments for parous women.
2 USS — a ‘dating scan’ (between 11+2 weeks and 14+1 weeks) and a ‘fetal anomaly scan’ (between 18+0 weeks and 20+6 weeks).
Immunisation flu, whooping cough
Not sleeping on back from 28/40
28/40 + 34/40 anti-D prophylaxis for rhesus-negative women.
38/40 position determined, USS if unsure
Management vomiting in pregnancy
Avoidance smells, cold simple food
Ginger tea/chews
Acupressure wrist
1st line Cyclizine/buccal prochlorperazine
2nd line ondansetron, metoclopramide
3rd line antiemetics + PO prednisolone 40-50mg OD then tapered
Consider starting pyridoxine (vitamin B6) 25 mg orally three times daily for nausea
Bloods incl TFTs LFTs U+E
Admit if weight loss>5%, clinical dehydration, ketones in urine, abnormal LFT or U+E
Differential of itch in pregnancy
Cholestasis (from 28/40, at night, soles and palms, excoriation)- itch no rash
Polymorphic eruption of pregnancy (3rd trimester, usually 1st pregnancy, twins, pruritic urticarial papules that coalesce into plaques, starts on abdominal striae, umbilical sparing, lasts 4-6 weeks)
Atopic eruption of pregnancy commonly (1st trimester, hx atopy, eczematous lesions, small papules disseminated on the trunk and limbs, and larger ‘prurigo nodules’ shins and extensor of arms)
Pemphigoid gestationis (rare2nd/3rd trimester, intense itch then erythematous urticarial papules and plaques around umbilicus, spreads then tense blisters)
Features of cholestasis
Itch from 28/40, at night, soles and palms, excoriation
Jaundice (present in about 10% of women).
Anorexia, malaise, and abdominal pain.
Dark urine, pale stools, and steatorrhoea (fatty stool).
Admit obs assessment for bloods
Management itch in pregnancy
Same day obs assess if ?cholestasis
Menthol aqueous cream
Sedating antihistamine at night
Cool baths
Aloe vera
Cotton + silk clothing
Avoid spicy foods
Steroid cream
If ?pemphigoid- obs + derm urgent ?PO steroids, risk IUGR/preterm birth
Definition and Ix for recurrent miscarriage + management
3 or more 1st trimester miscarriages then refer routine gynae
Screening for acquired thrombophilia (SLE, anti-phospholipid), TFT + TPO
Cytogenetic analysis on pregnancy tissue of the third and subsequent first-trimester miscarriage(s) and/or parental peripheral blood karyotyping
Assessment for congenital uterine anomalies.
Regular TSH measurement from 7–9 weeks of gestation is recommended in cases with TPO and/or SCH.
Heparin + aspirin if anti-phospholipid
Which medications reduce hormonal contraceptive action?
Antiepileptics – barbiturates, carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, topiramate
Antibiotics – rifabutin, rifampicin
Antiretrovirals
St John’s wort
Duration of LARCs
Mirena- 6yrs contraception, 10 yrs contraception if age>45, 5 yrs HRT
Copper coil- most are 10 yrs
Implant- 3 yrs
Depo-porvera + sayana press- 13 weeks
Cons of depo/sayana-press
Weight gain
Can’t be reversed
Delayed return to fertility
Bone density loss
Spotting-> 70% amennorhoeic
Mood swings/acne
Emergency contraception options
Cu-IUD- within 5 days of earliest estimated ovulation (day 19 of a 28 day cycle) or
up to 5 days after 1st UPSI within current cycle.
Ulipristal acetate- selective progesterone receptor modulator single-dose 30 mg tablet. Not in IBD/VTE/severe asthma, within 5 days UPSI
Oral levonorgestrel- single-dose 1.5 mg tablet, within 4 days UPSI
Vasectomy stats
Local anaesthetic in primary care
1 in 300 chance of failure, <1 in 2000 if post‑procedure tests are clear.
Not reversible on NHS
Infections 1.3%, haematomas 1.4%
Post‑vasectomy pain up to 15%
Vasectomy contraindications
No definite contraindications
Relative: varicocele/hydrocele/hernia affecting anatomy
Bleeding disorders
Ensure wouldn’t want further children even if lost family/new partner
Post vasectomy advice
Rest for 72 hours.
Abstain from sexual activity for 7 days.
Wear tight‑fitting underpants for the first week
semen analysis at 16 weeks post-procedure
How to test for chlamydia and gonorrhoea
Yellow NAATs swab
Self swab or HVS
First pass urine sample in males
Anorectal if symptoms/MSM
If epidymo-orchitis severe urology, otherwise sexual health
If PID severe admit gynae, otherwise sexual health
Treatment chlamydia
Doxycycline 100mg BD PO for 7 days
Azithromycin 1g OD PO on day 1 then 500mg OD PO on day 2 and day 3 (+ test of curse as resistance)
Attend sexual health for contact screening: Inform all sexual contacts last 6m (if asymptomatic) or 4 weeks prior to symptoms
Ensure had STI screen incl BBVs
No sex 7 days
Treatment gonorrhoea
Ceftriaxone 1 g STAT IM
STI assessment: Contact tracing
PID- admit gynae
conjunctivitis- admit ophthalmology
Differential in epididymo-orchitis
sexually active men- STI, Chlamydia + gonorrhoea most common, Mycoplasma genitalium sometimes.
In non‑sexually active males- UTI, E coli most common
Torsion should be excluded, surgery required within 6 hours, to ensure testicular salvage.
Hydrocele
Epididymal cyst
Testicular tumour
Strangulated inguinal-scrotal hernia
Trauma
Mumps– headache, fever and parotid swelling is followed 7 to 10 days later by unilateral testicular swelling or epididymo-orchitis in up to 40% of post-pubertal males.
Amiodarone withdrawal
Management of epididymo-orchitis
If sepsis/abscess- admit urology
Urine MSU + urine NAATs
If likely STI (esp if urethral discharge)- sexual health
If likely UTI- levofloxacin 500mg OD 10-14 days
Review in 3 days + 2 weeks
If fails to respond, urology assessment or USS or ?STI instead
Transmission of herpes
Most likely:
during sexual contact.
when the skin is broken.
when there are lesions present, e.g. vesicles or ulcers
Can spread skin to skin asymptomatically via shedding
Symptoms of genital herpes
Blisters or ulcers in the anogenital region, including buttocks, sacral area, and upper thigh. Lesions may be atypical.
Groin, leg, or buttock pain.
Vaginal or urethral discharge with cervical or urethral lesions.
Fever, malaise, myalgia, headache.
Inguinal lymphadenopathy.
Cervicitis, urethritis.
Primary infection usually worst
Differential diagnoses to herpes
Syphilis
Apthous ulcer
EBV
Behçet disease
Secondary scratching of psoriasis, eczema
Lichen sclerosus- superficial erosions
LGV- esp in MSM
Mpox
Management genital herpes
Refer sexual health if pregnant or if 1st presentation
STI screen + viral swab
Treat within 5 days if new lesions Aciclovir 400mg TDS PO (if still developing new lesions, or persistent pain, can prolong course to a further 5 days)
Further episodes immediate short course aciclovir 800mg TDS 2 days, or suppressive therapy (400mg BD) if more than 6 episodes per year
Risks of genital herpes in pregnancy
Maternal transmission risk is highest with primary genital herpes infection during labour or within 6 weeks of delivery.
Neonatal HSV is a rare, but serious and potentially fatal, infection occurring within the first 4- 6 weeks of life.
C-section may be indicated.
Recurrent lesions at term are a relative indication for c-section
If infection in 3rd trimester, must see GUM and inform Obs
If recurrent lesions, could consider suppression via GUM
Complications of untreated gonorrhoea
PID->Tubal infertility, Ectopic pregnancy
Adverse pregnancy outcomes:
Chorioamnionitis, PROM, Neonatal conjunctivitis
Epididymo‑orchitis, Prostatitis (rarely)
In men and women:
Septic or reactive arthritis
Tenosynovitis
Fever
Systemic upset and a diffuse pustular erythematous rash
Higher risk for HIV
In the past year if they given drugs/money for sex
Hx STI
MSM or sex with MSM
MSM– if currently taking PrEP
If any of their sexual partners are HIV‑positive and, if so, is the partner on treatment for their HIV
If, in the last 2 years, they have needed to have PEP for HIV
Chem-sex
Who is eligible for PrEP?
men having condomless anal sex with other men or trans and non‑binary people.
heterosexual people at higher risk of acquiring HIV- having sex with someone who is HIV‑positive and not on treatment.
Decisions to start and stop PrEP are made by GUM
Not required if partner is HIV positive on treatment with undetectable viral load
Who is eligible for PEP
High risk activity, within 72 hrs
If risk is>1 in 1000
Usually not indicated if saliva/oral sex only/blood splash onto intact skin, discarded needle, unknown status of partner
In hours- urgent GUM, OOH ED for starter pack
Total 28 day course
What immunisations should be considered in high risk populations for STI/BBVs?
HPV- MSM, transgender, or a sex worker (via GUM age<45)
Hepatitis A – if MSM, overseas partner, sex industry worker, HIV‑positive, or diagnosed with hepatitis B or C.
Hepatitis B – if MSM, sex worker, transgender, partner of a hepatitis B‑positive person, chronic carrier, or HIV‑positive.
Treatment of genital warts
If not visible or minimal, consider no treatment, also contraindiciated in pregnancy
Treatment is cosmetic rather than curative
Imiquimod- leave on overnight then was off
Podophyllotoxin- avoid sex
Smoking cessation
STI screen
Routine GUM if:
if perianal warts with anorectal symptoms.
for non‑sinister cervical warts.
for consideration of cryotherapy, surgical, or topical treatment.
if lesions persist after 6m treatment
PID treatment
Admit if acute abdomen, fever, vomiting,
Pregnant woman with PID
Mass suggestive of a tubo-ovarian abscess
Not tolerating or responding to oral therapy
Otherwise: Ceftriaxone 1g IM STAT
+
Metronidazole 400mg BD PO for 14 days
+
Doxycycline 100mg BD PO for 14 days
Abstain from sex 14 days, contraception?
Symptoms of syphilis
Genital or mouth lesions – whether single or multiple, painful or painless, current or in the past
Fever, sore throat, general malaise
Joint, muscle pain
Hair loss
Sore, red eye
Changes in vision or hearing – especially new onset tinnitus
Condylomata lata (similar to genital warts in appearance but moist).
lymphadenopathy.
a rash – non-itchy, rough red or brown papules or plaques in secondary syphilis. The rash usually involves the trunk, and frequently the palms and soles
Types of vaginal discharge
Physiological discharge is often a thick liquid, plain white or off‑white, with no odour or signs of inflammation.
Thick white curd-like may be seen with vulvovaginal candidiasis. There may be white vaginal or cervical plaques.
Fishy‑smelling white or grey adherent may be seen with bacterial vaginosis.
Classic profuse yellow frothy discharge occurs in 10 to 30% of women with trichomoniasis.
Management recurrent vaginal candidiasis
exclude diabetes, iron deficiency, HIV/immunosuppression
If a link between recurrence + sexual intercourse is reported, to use a water‑based lubricant.
avoid perfumed soaps or wipes, douching., tight non-breathable underwear or panty liners
Fluconazole 150mg PO every 72 hours for 3 doses induction
then
Fluconazole 150mg PO once a week for 6 months maintenance.
Or
Clotrimazole pessary 500 mg every week for 6 months, dose to be administered following topical imidazole for 10–14 days.
Candida speciation- if Candida glabrata->sexual health
Treatment BV
Metronidazole 400 mg BD PO for 7 days if symptomatic or TOP
Alternatively metronidazole/clindamycin gel
Resolves spontaneously in up to 33% of non-pregnant women, and 50% of pregnant women.
Advise against:
use of vaginal douching, shower gel, and antiseptic agents or shampoo in the bath, or
any genital washing with shower gels or feminine products.
Treatment trichomoniasis
Metronidazole 400mg BD PO for 5-7 days
Who should take 5mg folic acid?
Pre-conception and until 12 weeks of pregnancy if:
Either partner has an neural tube defect (NTD)
Previous pregnancy affected by an NTD, or FHx
Anti–epileptic medication.
Diabetes mellitus, sickle cell anaemia, or thalassaemia.
Obesity (BMI>30)
Definitions of primary vs secondary amenorrhoea
primary amenorrhoea – absence of menarche by age 15 years, or age 13 years if absent secondary sexual characteristics.
secondary amenorrhoea – no menstruation for 3-6 months in a woman with previously normal and regular menses, or 6-12 months in a woman with previous oligomenorrhoea
4 main causes secondary amenorrhoea
PCOS
Premature ovarian insufficiency
Hyperprolactinaemia
Hypothalamic amenorrhoea
