Contraception

• Contraception in Postpartum → only require contraception >21 days from giving birth. As sperm can survive in the vagina for up to 7 days, and the earliest date of ovulation after giving birth is 28 days postpartum, no contraception is needed until day 21.
  • COCP can only be give after 6 weeks postpartum if breastfeeding (if not breastfeeding, don’t use in first 21 days [3 wks] due to VTE risk). POP can be started at any point.
  • Lactational Amenorrhoea → reliable method if women is exclusively breastfeeding, amenorrhoeic (no periods) and <6 months post-partum.
  • IUD/IUS → can be inserted within 48 hours of childbirth or after 4 weeks.
• Emergency Contraception → copper IUD is most effective form. If patient does not want IUD, then offer levonorgestrel (levonelle) within 72 hrs or ulipristal (ellaone) within 120 hrs.
  • IUD → avoid in patients with STI, due to risk of PID. Can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later. Can also be used as long-term contraception (5 or 10 years).
  • Ulipristal (ellaone) → caution in patients with severe asthma.
  • Levonorgestrel and Ulipristal → primarily act by inhibiting ovulation, therefore less effective once ovulation has already occured in cycle.
• COCP → increases risk of breast and cervical cancer (ones we screen for). Protective against ovarian and endometrial cancer.
  • The mechanism behind this protective effect is thought to be due to the progestogen component of the pill which opposes oestrogen's proliferative effect on the endometrium, thus reducing hyperplasia and subsequent malignant transformation. COCP increases risk of cancers we regularly screen for.
  • If you miss one pill, take the last pill ASAP but no further action is needed (ie. take next pill at regular time).
    • ≥2 pills missed → take last pill, even if it means taking two in one day. Use condoms (barrier contraception) or abstain from sex until she has taken pills for 7 days in a row.
      • Pills Missed Days 1-7 → emergency contraception if had unprotected sex in pill-free interval or week 1.
      • Pills Missed Day 8-14 → no need for emergency contraception (if first 7 days of pill taken).
      • Pills Missed Day 15-21 → finish pills in current pack and start a new pack next day (hence omit pill-free interval).
  • Have seven-day pill-free interval where bleeding occurs, unlike POP.
  • If enzyme-inducing antibiotic (rifampicin or rifbutin) is concurrently taken, additional contraception is needed due to the potential reduced efficacy of the pill.
  • Absolute contraindications (UKMEC 4) → >35yo and smoking >15 cigarettes a day, migraine with aura, history of VTE, history of stroke/IHD, breast feeding <6 weeks post-partum, uncontrolled hypertension, current breast cancer, major surgery with prolonged immobilisation, positive antiphospholipid antibodies (eg. SLE).
• POP → most common adverse effect is irregular PV bleeding. Further investigation is not needed if this bleeding is present in the first 3-months, so long as a pregnancy and sexually transmitted infections are excluded, there is an up-to-date smear and there are no symptoms suggesting another underlying disease.
• Pearl Index → number of pregancies that would be seen if 100 women were to use the contraceptive method in question for a year.
• Contraceptive Implant (Nexplanon) → can be inserted immediately following childbirth if not breastfeeding. If breastfeeding, insert after 4 weeks postpartum. Progesterone released from the implant can enter the breastmilk. Lasts for up to 3 years. Irregular/heavy bleeding is main problem. Subdermal in non-dominant arm.
• Injectable Contraceptives (Depo Provera) → given IM (subdermal) every 12 weeks (3 months). Side effect includes potential delayed return to fertility (potentially up to 12 months - only contraceptive with this issue). Associated with weight gain and osteoporosis.
• Days until Effective → instant: IUD, 2 days: POP, 7 days: COCP/Injection/Implant/IUS.
• Breast Cancer → contraindication for all hormonal contraceptives. Main option available is therefore copper IUD.

Obstetrics

• Obstetric Cholestasis → first-line medical tx is ursodeoxycholic acid.
• CTG (Cardiotocography) monitoring during labour if → suspected chorioamnionitis or sepsis, severe hypertension, oxytocin use, presence of significant meconium, fresh vaginal bleeding that develops in labour.
• Reduced Fetal Movements → first step to use handheld doppler to confirm fetal heartbeat. If >28 weeks gestation and no heartbeat detected with doppler, then offer immediate ultrasound.
  • Fetal movements start around 18-20 weeks. If nothing been felt by 24 weeks, refer to maternal fetal medicine unit.
• Placental Abruption → severe constant abdo pain + hard, tender uterus. Cocaine increases risk as it causes vasospasm in the placental blood vessels.
• Down’s Syndrome Screening → combined test at 10-14/40 (increased b-hCG, reduced PAPP-A, thickened nuchal translucency via ultrasound = high chance). Chance <1 in 150 is high risk. Offer non-invasive prenatal screening test (NIPT) to those with high risk. Or can do diagnostic tests such as CVS (11-13/40) or amniocentesis.
  • Quadruple test (b-HCG, PAPP-A, AFP, oestriol) done if booked in later, at 15-20/40. Everything down except those that are high (hCG and inhibin).
  • Increased hCG distinguishes down’s syndrome (trisomy 21) from edward syndrome (trisomy 18) and patau syndrome (trisomy 13). The results otherwise are fairly similar in all.
• Gestational Diabetes → if fasting plasma glucose <7mmol/l, a trial of diet and exercise modifications should be offered for up to 2 weeks. If there is no improvement after this, metformin should be started. If initial fasting plasma glucose was >7 mmol/l, insulin should be started.
• Chorioamnionitis → ascending bacterial infection of the amniotic fluid / membranes / placenta. Diagnosis suggested by fever, tachycardia, uterine tenderness and foul smelling discharge. Major risk factor is preterm premature rupture of membranes. Mx = prompt delivery of fetus and IV antibiotics.
  • Suspect in women with PPROM with triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia.
• N&V in Pregnancy → promethazine or cyclizine are first line drugs.