Fertility control Flashcards

Question

3rd generation progestins

Answer 1

Desogestrel (Mercilon, Marvelon) Gestodene (Femodette, Femodene) Norgestimate (Cilest)

Answer 2

Drosperinone (Yasmin) Dienogest (Qlaira)

Answer 3

Ejaculate volume >=1.5ml (average 2-5ml) >=15 millions spermatozoa/ml >=39 million sperm/ ejaculate pH >=7.2 Motility of 40% + (progressive motility 32%+) 58%+ live sperm (vitality) 4%+ normal sperm morphology Fenton Millard (15 mil, 1.5/ml) was running down the motorway. It was the M40 progressed from M32 last year (Motility of 40%+, progressive motility 32%) Vitality peaked at 58mph (58%+ live sperm) His running style was unpredictable, had 4+ morphologies depending on the wind! (4%+ normal sperm morphology) He stopped at 7/1+1 for a P (pH > equal 7.2)

Answer 4

Lidocaine 1% 1% = 10mg/ml (recommended dose for SDI insertion 2-3ml, and removal 0.5-1ml). amide type local anaesthetics with or without adrenaline 1:200 000 (adrenaline may reduce local bleeding) MAXIMUM safe dose is 200mg (20mls of 1%)

Answer 5

Beta blockers, cimetidine, antiviral agents and noradrenaline increase the action of lidocaine QT prolonging drugs such as antipsychotics increase the risk of ventricular tachycardia (VT) Hypokalaemia (care with those on diuretics) decreases the action of lidocaine Lidocaine crosses the placenta and should not be used in early pregnancy unless the benefits outweigh the risks

Answer 6

Adverse effects usually due to actions of CNS (low dose stimulates, high dose depresses)–nervousness, dizziness, tinnitus, tremor, drowsiness, convulsions and CVS – bradycardia, reduced cardiac output, vasodilation (low BP), myocardial conduction block. Hypersensitivity reaction/allergic dermatitis. CI: complete heart block. Hypovolaemia, Caution: cardiac rhythm disturbance/congestive cardiac failure, liver or renal impairment, porphyria, myasthenia gravis, epilepsy, Avoid injection into infected/inflamed tissues → wont work as well. Crosses placenta, use if benefits outweigh risks. large doses can cause fetal bradycardia. Ok in breast feeding. Toxic from 5-10mg/L and lethal range from 6-33mg/L.. Accidental IV injection can result in excessive concentrations and acute toxicity→needs ABC/999→IV fluids to prevent Local anaesthetic systemic toxicity (LAST)

Answer 7

Decreased excitability of neurons by preventing sodium conduction/permeability and therefore blocking the initiation and propagation of action potentials At low concentrations they decrease rate of action potential increasing duration and reducing firing rate, at higher concentrations they prevent action potential firing at all Enters the open sodium channel and physically blocks it. Use-dependant → effect is greater when actional potential frequency increases as has better access to channels when they are already open. Strongly pH dependant – increased activity in higher (alkaline) pH. Clinically important as means that inflamed tissues usually more acidic and therefore may not response as well to local anaesthetic. In general block conduction in small diameter nerve fibres>large fibres which is why pain is blocked more readily than touch and why large motor axons are relatively resistant.

Answer 8

4cm long, 2mm wide 68mg Etonogestrel (EMP-IMP), Nexplanon

Answer 9

0.05% failure rate

Answer 10

Maximum concentration reached within 2 weeks average of 156 pg/ml (111−202 pg/ml) after 3 years (over 90 inhibits ovulation)

Answer 11

No extra precautions: By day 1-5 of cycle, up to day 21 after childbirth, day 5 after abortion Condoms 7 days: outside above timeframes If UPSI since LMP, PT negative; consider EC and Quickstart immediately after LNG-EC, wait 5 days after UPA-EC. PT in 21 days From CuIUD If UPSI >7d – retain Cu-IUD for 7 days OR condoms 7/7 If UPSI <7d - retain Cu-IUD for 7 days AND condoms 7/7 The only time you can’t fit an implant immediately is after UPA-EC

Answer 12

IMP <3yrs – CHC/ POP/ IMP/ DMPA/ LNG-IUS/ Cu-IUD – start immediately, no extra precautions IMP 3-4 years – PT negative, no UPSI in last 21 days start immediately, condoms 7 days (or 2 for POP) IMP 3-4 years – PT negative, UPSI in last 21 days start immediately, condoms 7 days (or 2 for POP), PT 21 days >4 years PT negative, no UPSI in last 21 days start immediately, condoms 7 days (or 2 for POP) >4 years PT negative, UPSI in last 21 days consider EC, start immediately (or after 5/7 if UPA-EC), condoms 7 days, PT 21 days DMPA consider bridging Cu-IUD If all UPSI either ≥21 days ago or <5 days ago then insert immediately. If UPSI between 5 and 21 days ago, delay insertion until pregnancy excluded by negative PT 21 days after last UPSI, consider bridging

Answer 13

Sulfonylureas Carbamazepine Rifampicin Alcohol (chronic) Phenytoin Griseofulrin Phenobarbital St johns wort

Answer 14

May reduce the effectiveness of LNG-EC and UPA-EC. The enzyme inducing NNRTIs include: Efavirenz Nevirapine Etravirine

Answer 15

IHD (cont 3, initiation 2) Hx stroke (cont 3, initiation 2) Unexplained vag bleeding (not ix) Liver cirrhosis severe decomp Liver cancer Past breast ca

Answer 16

Current breast ca

Answer 17

20% amen 30% infreq 7% freq 40% Normal 20% prolonged

Answer 18

1st line – start with ≤30 μg ethinylestradiol Advise to stop age 50 Smokers – stop CHC age ≤35 CHC can be used <50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of BMD.

Answer 19

DMPA - can be used until menopause, BUT assess risk at age 50 Review every 2 years for everyone Risk of BMD loss is not worsened by DMPA + menopause

Answer 20

Can stop contraception age 55 (even if still periods) Can continue implant/POP/IUS until age 55 52mg LNG-IUS 5 years for endometrial protection 52mg LNG-IUS for contraception: If inserted ≤age 45, can keep until menopause (or age 55) FSH not routinely measured. Can measure if on hormonal contraception and want to stop: Inaccurate if on CHC or HRT (suppressed estradiol and gonadotrophins) If wish to stop, in amenorrhoeic individuals on IMP/POP/LNG-IUS, can check FSH, if >30 IU/L then can stop in 1 year, if peri-menopausal range, check FSH in 1 year (non hormonal if aged 40-50 stop after 2 years ammen, if >50 1 year)

Answer 21

(estradiol valerate/dienogest) good COCP for HMB (also can be used in endometriosis). Remember 9 day starting window (rather than the usual 7!)

Answer 22

BMI 30-34 UKMEC 2: CHC (if BMI only RF, if more then 3) POP/IMP/LNG IUS (if BMI PLUS other RF CVD) UKMEC 3: CHC/DMPA (if BMI PLUS other RF CVD) BMI > equal 35 UKMEC 2 POP/IMP/LNG IUS (if BMI PLUS other RF CVD) UKMEC 3 CHC (if BMI ONLY RF, if more then 3) CHC/DMPA (if BMI PLUS other RF CVD) Hx of bariatric surgery = same as BMI only RF

Answer 23

DMPA can cause weight gain, esp in age<18 and BMI >30 If obese and on depo, consider injection in deltoid rather than gluteal

Answer 24

The patch may be less effective if weight >90kg

Answer 25

LNG-EC – double dose if BMI>26 or >70kg

Answer 26

Fontan’s circulation Eisenmenger’s physiology Tachycardia Pre-existing bradycardia

Answer 27

Most statins and anti-hypertensives are fine Bosentan (ERA – endothelial receptor antagonist) – decreases prog and eostro levels in contra

Answer 28

Doubles the risk (9-10 in 10,000) Baseline VTE risk = 2 in 10,000 Pregnancy & puerperium = 20 in 10,000 Lower risk progestogens = 6 in 10,000 Levonogestrel Norethisterone Norgestimate Moderate risk progestogens = 8 in 10,000 Etonogestrel Norelgestromin Higher risk progestogens = 10 in 10,000 Desogestrel Gestodene Drospirenone

Answer 29

Adrenaline 1 mg (= 10 ml 1:10 000) as a prefilled syringe Atropine 500 or 600 mcg IV/IM (two doses) for the treatment of symptomatic bradycardia Oxygen.

Answer 30

Best eye response (4) No eye opening Eye opening to pain Eye opening to sound Eyes open spontaneously Best verbal response (5) No verbal response Incomprehensible sounds Inappropriate words Confused Orientated Best motor response (6) No motor response. Abnormal extension to pain Abnormal flexion to pain Withdrawal from pain Localizing pain Obeys commands

Answer 31

Bradycardia <60 The Resuscitation Council (UK) lists shock and syncope as “adverse features” of bradycardia, for which atropine should be administered. It may be given in repeated doses to a maximum of 3 mg.9 Oxygen should also be administered. For those trained in gaining rapid intravenous (IV) access (by whatever means), give IV atropine as a single dose of 500-600 micrograms (followed by a saline flush). The heart rate will usually increase within a few minutes. If there is no improvement in the patient’s condition emergency assistance must be summoned and a further IV dose of 500-600 micrograms atropine given. Although evidence for its use in this manner is minimal, a dose of atropine (500-600 micrograms) may be given intramuscularly (IM). This recommendation is NOT part of the Resuscitation Council (UK) Bradycardia Algorithm. The atropine should be given anterolaterally in the mid-thigh with a long enough needle to ensure correct intramuscular placement. The increase in heart rate following IM atropine is significantly slower than after IV atropine and can take many minutes.

Answer 32

Atropine is an alkaloid from the plant Atropa belladonna and is a competitive antagonist to acetylcholine. It blocks muscarinic receptors in the autonomic nervous system, thus counteracting the effects of vagal stimulation. In healthy individuals this results in a modest tachycardia, since it is the parasympathetic nervous system that is blocked, rather than the sympathetic stimulated. In therapeutics it is a relatively safe and straightforward drug, which is why several doses may be administered.

Answer 33

Blocks fast voltage gated sodium channels Anti-arrhythmic Half life 2 hours Safe to use in pregnancy Hepatic metabolism Max dose is 3mg/kg (7mg/kg with adrenaline)

Answer 34

Most combinations use ethinylestradiol as oestrogen component (range from 20mcg to 35mcg) Newer pills in development using body identical 17-beta-oestradiol Zoely oestradiol valerate, metabolized -> 17-beta-oestradiol; paired w Nomegestrol acetate progestin Qlaira uses oestradiol valerate, metabolized -> 17-beta-oestradiol; paired w Dienogest progestin First line choice COCP contains 30mcg of ethinylestradiol with levonorgestrel (2nd gen) or norethisterone (1st gen) Selected due to evidence suggesting these combinations have the lowest associated VTE risk

Answer 35

In 10, 000 risk of developing within one year NOT using hormones/preg: 2 PREG: 20 CHC levonorgestrel (2)/ norethisterone (1) / norgestimate (3): 6 CHC etongestrel/ norelgestromin: 9 CHC drosperinone (4) / gestodene (3)/ desogestrel (3): 11

Answer 36

30mcg ethinylestradiol and 150mcg levonorgestrel

Answer 37

Dianette Ethinylestradiol 35 Cyproterone acetate 2000

Answer 38

Quadraphasic combined oral contraceptive Estradiol valerate 3 mg x 2, 2 mg x 22, 1 mg x 2 Dienogest 2 mg x 5, 3 mg x 17 Good for HMB

Answer 39

Estimated ~20% reduction in ovarian cancer risk for every 5 years of COCP use

Answer 40

The risk of endometrial cancer is estimated to be reduced by 50% in ever-users of the COCP Risk reduction for both persists for ‘several decades’ following cessation of use

Answer 41

Breast cancer risk is increased in current users of COCP Declines gradually following cessation of use, with no increase in risk found after 10 years from stopping Known BRCA1/2 mutation is a UKMEC 3 for CHC use; UKMEC 2 for all other hormonal methods

Answer 42

Synthetic steroidal oestrogen (long acting; 24 hours) Binds to both isoforms of oestrogen receptor (alpha> beta) with a higher affinity for oestrogen receptors than endogenous oestrogen Binding to ER alpha -> anti-gonadotropin effects Inhibits ovulation by inhibiting LH and FSH release from anterior pituitary No LH surge; no ovulation Reduces sensitivity of pituitary to GnRH Also acts to increase SHBG levels -> lower levels of circulating /active sex hormones, including testosterone -> anti-androgenic activity /reduced androgenic symptoms i.e. acne

Answer 43

VTE Unscheduled bleeding (better control with vaginal ring >> oral or patch) Libido lower may have less effect on libido

Answer 44

Qlaira and Zoely Require 9 days additional precautions if started after d1.

Answer 45

Releases an average of 33.9 ug EE and 203 ug Norelgestromin / 24 hours Efficacy may be reduced if weigh >90kg – consider alternative method No alteration in VTE SE.

Answer 46

Nuva ring (older) -> Syreni ring Both release an average of 15 μg EE and 120 μg etonogestrel at daily rates. For Nuva ring refrigeration is required; limited shelf life/ storage options for patients -> Syreni ring (unrefridgerated) Better bleeding control.

Answer 47

Postpartum 0-3 weeks if also has another risk factor for VTE (UKMEC 3 if not other risk factors) OR post-partum 0-6 weeks if breastfeeding Age >=35 years AND smoker >=15/day (Note if stops smoking for >1 year risk falls back to UKMEC 2 ) CVD risk falls significantly within 1-2 years of cessation; all cause mortality takes 20 years to fall Hypertension systolic >=160, diastolic >=100 Vascular disease History of ischaemic heart disease/ stroke Atrial fibrillation (think concurrent clot risk factors) Migraine with aura (Unless last episode >=5 years ago in which case UKMEC 3) Current / past VTE Major surgery (or any surgery to lower limb) with anticipated prolonged lower limb immobilisation (Switch method 4 weeks prior and can switch back at + 2 weeks from recovered mobility ) Known thrombophilia Lupus with + APLS antibodies (Lupus with negative APLS UKMEC 2) Complicated valvular / congenital heart disease Cardiomyopathy with impaired cardiac function Current breast cancer Severe/decompensated liver cirrhosis Hepatocellular adenoma or carcinoma

Answer 48

Benign, well vascularised and often solitary liver tumours, associated small risk of malignant transformation Typically occur in young women who are taking exogenous oestrogen containing medicines (CHC primarily) More rare in recent years as oestrogen content of modern CHC is low Up to 50% asymptomatic with normal LFTs in most cases If oestrogen is withdrawn they usually spontaneously resolve CHC should be withdrawn and use with a known hepatocellular adenoma is a UKMEC 4 Occasionally require surgical intervention if persistent or very large Large range in size; 2- 15cm (larger tumours may be at risk of rupture à heamoperitoneum)

Answer 49

Oestrogen -> increased thyroid binding globulin Can increase thyroxine requirements for those with hypothyroidism on treatment/ replacement Thyroid function should be checked within + 6 weeks from commencing CHC in those with hypothyroidism

Answer 50

Women trekking to high altitudes (above 4500 m or 14 500 feet) for periods of more than 1 week may be advised to consider switching to a safer alternative contraceptive method.

Answer 51

A: Advanced HIV (CD4 <200) Asymptomatic chlamydia Anatomical abnormalities distorting uterine cavity V: Very Long QT syndrome known, pelVic tuberculosis (continuation) O: Organ transplant with complications, Oncological Background of Breast Cancer (LNG-IUS Exclusive) I: In between 48 hours and 4 weeks post partum, Ischemic heart disease new diagnosis (LNG-IUS only) D: Decreasing hCG levels with Gestational trophoblastic neoplasia Decompensated cirrhosis or liver tumors (benign or malignant) (LNG-IUS only) S: Surgery to cervix

Answer 52

Neoplasia - Endometrial and cervical (initiation), - Current breast cancer (LNG-IUS only) Elevated serum hCG persistently Gestational trophoblastic neoplasia Vaginal - Unexplained vaginal bleeding (initiation)/ Known pelVic tuberculosis (initiation) Exudate - Current pelvic inflammatory disease (PID), purulent cervicitis, gonorrhoea or symptomatic chlamydia (initiation) Recent sepsis with abortion/ birth

Answer 53

levonorgestrel (30mcg) OR norethisterone (350mcg) 3h window only

Answer 54

75mcg – now largely replaced traditional POPs Mechanism = inhibition of ovulation primarily

Answer 55

IHD (cont 3, initiation 2) Hx stroke (cont 3, initiation 2) Liver cirrhosis severe decomp Hepatocellular adenoma/ carcinoma Past breast ca

Answer 56

Current breast ca

Answer 57

UKMEC 2 for CHC/POP UKMEC 3 for DMPA/Imp UKMEC 4 for IUS/IUD for I (but 2 for C)

Answer 58

24 active pills followed by 4 day pill free interval (and withdrawal bleed) 24 hour window for pills Anti-mineralocorticoid effects - Potassium sparing diuretic effect; reduced reabsorption of sodium and water -> May be beneficial for bloating and mastalgia symptoms -> Theoretical BP reducing effect (no evidence yet to back this up) Additional UKMEC precautions for DRSP POP due to action as aldosterone antagonist (1) Severe renal insufficiency/acute renal failure (2) Hyperkalaemia or hypoaldosteronism (Addison’s)/use of potassium sparing medications

Answer 59

Etonogestrel Total amount contained in implant = 68 mg Reaches ovulation inhibitory levels within first day (90pg/ml) 7 days to become effective (fully inhibit) unless fitted within day 1-5 of cycle/ up to 21 days post-natal Maximum serum concentration within 2 weeks Then declines rapidly Mean serum concentration at 1 year = 200pg/ml Mean serum concentration after 3 years = 156pg/ml Time from insertion /Release rate 5-6 WEEKS: 60-70 mcg/ day End of year 1: 35 mcg/day End of year 2: 30 mcg/day End of year 3: 25 mcg/day

Answer 60

Amide type local anaesthetic agent 1% = 10mg/ml Recommended dose for SDI insertion is 2-3ml 1% (20-30mg) and removal 0.5-1ml (5-10mg) Maximum safe dose 200mg (20mls of 1%)

Answer 61

5% cream Mixed content – lidocaine and prilocaine Apply 1-2 hours prior to procedure Safe to use in pregnancy Note prilocaine generally not used in obstetrics due to risk of methaemoglobinaemia however topical use of EMLA is widely accepted as safe within obstetric practice Should only be used on intact skin

Answer 62

IM = Depo Provera 150mg in 1ml Given by healthcare professional only, into gluteal muscle U/O/Q buttock SPC says should be given every 12 weeks - FSRH recommend can be given up to every 14 weeks SC = Sayana Press 104mg in 0.65ml Can be given into abdomen or upper thigh by HCP or by patient (if trained) SPC says should be given every 13 weeks - FSRH recommend can be given up to every 14 weeks Reduces circulating oestrogen (most suppressive of all progestogen contraceptives) -> reduced BMD Can be given early (from 10 weeks interval) if desired i.e. to achieve amenorrhea in irregular or HMB Absorption rates: DEPO PROV Immediately after injection of 150 mg/ml Depo Provera, plasma levels = 1.7 nmol/L ---> Two weeks after 150mg/ml Depo Provera levels = 6.8 nmol/l SAYANA Lower peak plasma concentrations following Sayana > Depo Peak ~1 week from administration Average peak plasma concentration 1.5ng/ml (0.5 – 3.0ng/ml) Concentrations fall to the initial levels for both options by the end of 3 months

Answer 63

Administration here likely to result in effective SC administration FSRH recommend alternative IM administration site into DELTOID OR use of intentional subcutaneous injectable (Sayana press) into thigh or lower abdomen

Answer 64

The ventrogluteal site provides access to the gluteus medius and minimus muscles whilst avoiding nerves and blood vessels. 1. The patient can be positioned prone, semi-prone or supine for this procedure, so choose whichever is most comfortable for the patient. 2. Place the palm of your hand over the greater trochanter of the patient’s hip, with your thumb pointing anteriorly. 3. Extend your index finger to touch the anterior superior iliac crest and point your middle finger towards the iliac crest to form a V-shape. 4. Insert the needle between your index and middle fingers (i.e. within the V-shape).

Answer 65

1. Position the patient sitting on a chair with their arm relaxed. 2. Expose the patient’s upper arm and shoulder. 3. Palpate the lower edge of the acromial process and administer the intramuscular injection approximately 2.5cm below this.

Answer 66

The vastus lateralis muscle is relatively easy to locate and access making it an ideal site for intramuscular injections. To locate the site, divide the front thigh into thirds vertically and horizontally to make six squares and inject into the outer middle square.

Answer 67

The most effective copper coils contain 380mm2 of copper 5 years = Nova T (380 unbanded), 10 years = T Safe (380 banded), prevention of fertilization via direct toxic effect on both sperm and ovum Extended contraceptive use recommended by FSRH if device with >300mm2 copper inserted when >=40 years --> May be retained and used until age 55 years

Answer 68

Earliest possible day of implantation of 6 days post-fertilisation (later on days 8-10 in majority) 5 day rule ensures that any existing implanted pregnancies are not disrupted (would be abortive not contraceptive here)

Answer 69

Mirena 32x32mm frame with 4.4mm insertion tube diameter BROWN threads Licensed for 8 years for contraception, or can be kept until age 55 if fitted on/ after 45th birthday Licensed for 4 years for endometrial protection / FSRH recommend any 52mg device be used for 5 years for endometrial protection ****1st year releases ~ 20mcg/ 24 hours LNG --> reduces to 7mcg/ 24 hours LNG by end of 8 year licence**** Circulating plasma LNG concentrations: 276 pg/ml in year 1 196 pg/ml in year 2 177 pg/ml in year 4

Answer 70

One handed insertion with 52mg total LNG content Blue threads 32 x 32mm frame with 4.8mm insertion tube diameter (insertion tube slightly wider than Mirena) Licensed for treatment HMB; recommended but not licensed for 5 years of endometrial protection 6 year contraceptive licence and recommended duration of use SPC specifies a minimum cavity length for insertion of 5.5cm Initial LNG release 20 mcg/24 hours in 1st year --> 8.6 mcg/24 hours by end of 6 year licence Similar circulating levels to Mirena as above NB Levosert also available; exactly the same product as Benilexa but with 2 handed inserting device

Answer 71

One handed ‘EvoInserter’ with 19.5mg total LNG content Blue threads with silver ring for improved ultrasound visibility 28 x 30mm frame with 3.8mm insertion tube diameter (same as Jaydess) Licensed and recommended for 5 years for contraception Not recommended for use for HMB treatment or endometrial protection LNG release: Initial – 17.5 mcg/24 hours Average release over 1st year – 12.6 mcg/24 hours By end of 1st year – 9.8 mcg/24 hours At end of 5 year licence – 7.4 mcg/24 hours Average release over 5 year licence – 9.0 mcg/24 hours Circulating plasma LNG concentrations: 162 pg/ml in 1st week 91 pg/ml at 3 years 83 pg/ml by end of 5 year licence

Answer 72

Lowest hormone device with only 13.5mg total LNG content Brown threads Same size as Kyleena – 28x 30mm frame with 3.8mm insertion tube diameter and silver USS band Only 3 year licence / recommended duration of use as contraception Not recommended for HMB treatment or endometrial protection LNG release: Initially 14 mcg/24 hours Average release over 1st year = 8 mcg/ 24 hours By end of 1st year = 6 mcg/24 hours By end of 3 year licence = 5 mcg/24 hours Average release over 3 year licence = 6 mcg/24 hours Circulating plasma LNG concerntrations: 162 pg/ml in 1st week 59 pg/ml by end of 3 year licence

Answer 73

Mirena Jaydess

Answer 74

Background perforation risk from fitting 1-2/1000 If breast/chest feeding significant increase in risk to ~6/1000 Expulsion risk in general population is accepted as 5% or 1:20 patients Factors that increase risk of expulsion following fitting: Adolescence History of previous expulsion Heavy menstrual bleeding Uterine abnormality i.e. fibroids Menstrual cup use Insertion immediately post-partum (vaginal delivery >> LSCS) Insertion immediately following late first trimester or second trimester termination

Answer 75

Can occur due to vagal stimulation via the cervix (Most common in nulliparous patients) Atropine 500 mcg IV should be given for patients with persistent/ unstable bradycardia If IV access not possible then it can be given IM (outside of resus council algorithm) Should be given into anterolateral mid-thigh with long enough needle to ensure IM administration Takes longer to work than IV administration Atropine is a non-selective muscarinic receptor antagonist - Inhibition of parasympathetic activation of cardiac M2 receptors (which usually act to decrease SA node conduction velocity and therefore heart rate) - Increased SA node firing as a result and therefore increase in heart rate

Answer 76

1 tablet = 30mg ulipristal acetate Selective progesterone receptor modulator Licensed up to 120 hours (5 days) post-UPSI Delays ovulation by at least 5 days (time for any sperm in the reproductive tract from UPSI to die) Able to act until LH peak; later possibility of efficacy compared to Levonelle Delays ovulation by >5 days Ineffective beyond the LH peak/ post ovulation Most will ovulate and therefore have pregnancy risk later in the same cycle May not be as effective above weight of 85kg or BMI 30 - Double dose not recommended NOT suitable for severe asthmatics requiring oral glucocorticoids Has anti-glucocorticoid activity Can use in breastfeeding Not suitable to use if progestogen containing compounds used in last 1 week (7 days) Delay any quick starting of hormonal contraceptives until 5 days post-UPA use

Answer 77

1 tablet = 1.5mg levonorgestrel Progestogen Licensed up to 72 hours post-UPSI (3 days) // FSRH recommend use up to 96 hours post-UPSI (4 days) Delays ovulation by at least 5 days (time for any sperm in the reproductive tract from UPSI to die) Able to act until the beginning of the LH surge and not beyond this point Ineffective post LH surge and post ovulation Most will ovulate and therefore have pregnancy risk later in the same cycle If weight >70kg or BMI >26; double dose required If taking enzyme inhibitors; double dose required Safe to breast feed and no medical contraindications

Answer 78

Caya – fits ‘all’ (80%) Not recommended within 6 weeks of delivery Must be inserted with spermicide between 0-2 hours prior to sex Must remain in place for minimum of 6 hours after sex If subsequent episodes of sex within the 6 hour leave in window, diaphragm should not be removed but additional spermicide should be inserted into the vagina using an applicator Diaphragm should be removed and washed at least once/ 24 hours Main risk of use is association with toxic shock syndrome (TSS), higher around time of menstruation NB: Spermicide preparation nonoxinol-9 = associated with increased risks of HIV transmission Mechanism: vaginal mucosal irritation Individuals at higher risk of HIV infection --> advise not to use methods requiring spermicide

Answer 79

Fertile window - 8 days per cycle (1d ovum and 7d sperm life expectancy) UPSI in the follicular phase is associated with pregnancy risk (d1-9 low risk) UPSI in the post-ovulatory phase of the cycle has a very low risk of pregnancy The use of a single indicator is NOT recommended: Typical use failure rate of 24%/ year (higher than condoms at 18% with typical use) Women stopping hormonal contraception --> FAM should not reply on predictors of fertility until menstruation has re-established AND they have had a minimum of 3 cycles When approaching menopause, natural family planning = unreliable

Answer 80

The survival of sperm is dependent on the presence of alkaline cervical secretions Secretions like raw egg white – thin/wet/stretchy – are suggestive of fertility Alkaline in nature Allow maximum sperm penetrance into reproductive tract Pregnancy more likely on days when cervical secretions present Abstinence /use of barrier method recommended from the first day that any secretions are noted, continuing until 3 consecutive ‘dry days’ after secretions noted to revert to being thicker/ absent

Answer 81

Defined as the temperature measured BEFORE rising from bed, when resting for at least 3 hours Progesterone --> increased in BBT Post ovulatory ‘infertile phase’ confirmed once BBT on 3 consecutive days is >= 0.2 degrees higher than in the previous 6 days Following ovulation progesterone --> increase in BBT which is maintained until menstruation UPSI >6 days before and >2 days after the rise in BBT associated with negligible pregnancy risk When used alone, UPSI is not recommended in the pre-ovulatory phase and abstinence is recommended for ~ 16 days per cycle If UPSI only occurs in the identified post-ovulatory phase (PERFECT USE) failure rate of BBT monitoring alone is 6.6%/ year If UPSI does occur in the pre-ovulatory phase as well, this rises to 19% failure rate/ year

Answer 82

Use of the calendar method ALONE recommends women to track their cycle length for a minimum of 12 cycles before relying on the data to make predictions First fertile day = Shortest cycle length – 20 days (i.e. 26 days – 20 = day 6) Last fertile day = Longest cycle length – 10 = (i.e. 30 days – 10 = day 20) Requires a long period of abstinence if using correctly A simplified version = standard days method, often allows for less abstinence days Suitable only if cycles between 26-32 days length consistently Advises abstinence between days 8-19 inclusive

Answer 83

Urinary LH as reliable measure to detect ovulation 100% correlation with USS evidence of ovulation Testing utilises urine strips with antibodies to estrone-3-glucuronide and LH This method alone recommends avoidance of sexual activity when hormone is detected Limited in scope of evidence base, appears to have high failure rate compared to other FA methods Testing is designed and licensed to assist with conception, not contraception, and likely under-estimates the fertile window (especially preceding LH detection/ ovulation) When correlated with cervical secretions, secretions were noted ~2 days before test detected LH +

Answer 84

The cervix is low, firm and has a closed os at infertile times in the cycle Around the ovulatory window the cervix becomes higher, softer and the os dilates When using this method alone the fertile window is from the first sign of cervical change --> +3 days of the cervix resuming it’s lower/firm/os closed position No studies demonstrating efficacy of this method in isolation, so would not be advised to use alone

Answer 85

Exclusively breast/chest feeding (small amounts of occasional water/ vitamins permitted only) Every 4 hours throughout day Every 6 hours throughout night No more than 6 months post-partum Continued amenorrhoea 98% efficacious for contraception if these criteria are fulfilled

Answer 86

Suckling disrupts hypothalamic GnRH pulsatility Mechanoreceptors in breast alveoli -> prolactin and oxytocin release from pituitary Prolactin -> stimulates milk production, also interrupts GnRH pulses Oxytocin -> activates milk release (via myoepithelial contractions) Disrupted GnRH -> reduced LH release from anterior pituitary -> Anovulation maintenance FSH is still released so there is follicular development, but no ovulation As suckling frequency reduces -> GnRH pulsatility resumes -> LH surge -> ovulation The effect of expression of breast milk on efficacy of LAM is unknown, but theoretically may reduce efficacy

Answer 87

Failure rate of approximately 1 in 2000 (0.05%) after clearance has been given  10 x more effective than female sterilisation (which has failure rate of 1 in 200 / 0.5%)  Warming anaesthetic to body temperature (37) before injection à significant reduction in pain when compared to injecting local anaesthetic at room temperature  Minimally invasive approach = using needle with no incision/ <10mm incision w no sutures required   Less perioperative bleeding  Reduced pain, both during and after vasectomy  Less post-vasectomy infections Fewer haematomas  Cauterisation followed by division of the vas deferens à lowest likelihood of early recanalisation (failure) when compared to other occlusion techniques i.e. ligation or clips (high failure rate)  After vasectomy men should be informed of the need to use additional contraception until PVSA has been undertaken and clearance/special clearance given Evidence suggests that 12 weeks post-vasectomy is the optimal timing to schedule the first PVSA 80% of men should have achieved azoospermia by this interval

Answer 88

Postal semen samples can be used for PVSA but are not be suitable for sperm motility testing (needed for special clearance measures) In a small proportion of men non-motile sperm will persist following vasectomy -> “special clearance”

Answer 89

In a small proportion of men non-motile sperm will persist following vasectomy -> “special clearance” Special clearance can be given to stop additional contraception if < 100 000 non-motile sperm/ml are observed in a fresh (NOT postal) semen sample post-vasectomy

Answer 90

If motile sperm are still observed in a fresh sample 7 months post-procedure = failed procedure

Answer 91

If a vas deferens on one side cannot be palpated or located, unilateral vasectomy can be carried out, and the man advised to comply with additional contraception until sterility is confirmed as per usual PVSA These men should be informed of the probability of ipsilateral renal agenesis and may be referred for renal ultrasound 

Answer 92

Refer to urology specialist if bilateral absence of vas deferens or other anomaly of vas suspected 

Answer 93

Women using CHC, the POP, IUC or non-hormonal contraception should be advised to continue their contraceptive method for at least 7 days after laparoscopic sterilisation  If sterilisation scheduled for HFI the hormone-free interval should be omitted ***The progestogen-only implant can be removed at the time of the procedure (or any time following) ****

Answer 94

Recanalisation  Fistula  Incomplete occlusion  Slippage of the occlusive device  Occlusive device placed on wrong anatomical structure  

Answer 95

The lifetime risk of failure, using a mix of occlusion methods, is estimated to be 1 in 200 (0.5%)  Filshie clip failure rate of 2–3 per 1000 at 10 years

Answer 96

Young age <30 at time of procedure   Nulliparous or low parity (2 or fewer children)  Being in unhappy relationship/ spousal conflict at the time of procedure   Not being in a relationship at the time of procedure  Remarriage/ change of partner – desire to have children with new partner  Death of a child  Psychological problems  Psychosexual issues  Coercion by spouse or healthcare professional   Timing of procedure in relation to pregnancy – increased incidence of regret when sterilisation performed at the time of caesarean section 

Answer 97

IUS UKMEC 2 for <20 (Younger women using IUC may have an increased risk of expulsion compared with older women) DMPA <18 and >45 UKMEC 2 (women should be informed that use of DMPA is associated with a small reduction in bone mineral density (BMD) but this usually recovers after discontinuation. Evidence for any longterm effects of DMPA on BMD in women aged <18 years is lacking. LT use review every 2 years) CHC Age >=40 UKMEC 2 (Guidance from the FSRH supports use of CHC up to age 50 years if there are no medical contraindications to use.) unless smoking ... <35 and smoking: UKMEC 2 Age >35 and <15 cig/day: UKMEC 3 Age >35 and ≥15 cig/day: UKMEC 4 Age >35 and Stopped <1yr: UKMEC 3 Age >35 and Stopped ≥1yr: UKMEC 2

Answer 98

Women using depot experience initial loss of BMD due to hypoestrogenic effects There is no evidence that this BMD loss is repeated or worsened by onset of menopause (just experienced earlier) however that is the theoretical risk/ concern with this method

Answer 99

Excess mortality associated with smoking is only apparent from age 35 The mortality rate from all causes (including cancers) decreases to that of a non-smoker within 20 years of smoking cessation. The cardiovascular disease (CVD) risk associated with smoking decreases within 1 to 5 years of smoking cessation.

Answer 100

3 x higher COCP containing levonorgestrel or norethisterone (lowest VTE risk associated) should be prioritised and used first line in women >40 years (where baseline risk slightly higher therefore of even greater importance) Additionally using formulations <=30ug EE content (lowest associated risk VTE, CVD and stroke) Rigevidon, Microgynon, Ovranette and Levest (30mcg ethinylestradiol and 150mcg levonorgestrel

Answer 101

CHC can protect/maintain BMD in perimenopausal women safely and provide some perimenopausal symptom relief, up to age 50, compared to non-users (similar to HRT) It can be used as an alternative to HRT, not in addition to HRT ALL progesterone only based contraceptive methods can be used alongside HRT safely

Answer 102

A Cu-IUD containing ≥300 mm2 copper inserted at >= 40 years can remain in situ until age 55 OR 2 years after the LMP if age <50 years 1 year after the LMP if age >=50 years Any 52mg LNG-IUD inserted at >= 45 years can remain in situ until age 55 for contraception

Answer 103

If women on PROGESTERONE ONLY hormonal contraception want to stop before the age of 55, consider checking FSH If FSH >= 30 then continue hormonal contraception for 1 year, then stop safely If FSH <30 then continue hormonal contraception for 1 year and recheck FSH level Oestrogen containing agents (CHC methods or HRT) -> gonadotropin suppression therefore not suitable to check FSH levels for this group of women

Answer 104

Possible(reversible) effect of sulfasalazine sperm quality, quantity and male factor fertility Standard 400mcg folic acid is usually advised Higher 5mg dosing may be recommended is concurrent use of sulfasalazine (can effect folate absorption) or previous small bowel resection Medications: (1) If either partner using MTX – delay conception for 3 months following completion (2) Mycophenolate mofetil – delay conception for 6 weeks from completion (female) / 3 months (male) (3) TNF-a inhibitors (infliximab, adalimumab) – delay conception for 6 months following completion Contraception efficacy (A) Efficacy of oral contraception unlikey to be reduced by large bowel disease Unless diarrhoea >24 hours; missed pill rules to be followed (B) Efficacy of oral contraception may be reduced by small bowel disease and associated malabsorption

Answer 105

Lack of good data to inform on risk of breast cancer recurrence with use of hormonal contraceptives Hormonal contraception should be avoided after breast cancer, regardless of hormone receptor status Use of LNG-IUD may be considered on case by case basis, with involvement of breast specialist Some evidence that LNG-IUD reduces risk of endometrial hyperplasia / polyps in Tamoxifen users Safest methods of effective contraception: Cu-IUD Sterilisation (female or male) – however this is permanent Cu-IUD is first line for EC, however both LNG and UPA oral EC can be offered in this population

Answer 106

Cu-IUD, LNG-IUD and depot offer effective contraception with use of all ART agents. CHC, POP, SDI and oral EC susceptible to enzyme inducing reactions -> reduced efficacy. Consider BMD risk – depot use not generally advised alongside concurrent TDF tenofovir for this reason. TAF Tenofovir could be used alongside depot. For IUC, fitting/ initiation is not generally advised if CD4 count <200 (UKMEC 3); however can be considered in exception and prophylactic antibiotic cover may be provided. EG. Emergency Cu-IUD fittings, especially if on enzyme inducing medications where PO EC less effective. IUC remains UKMEC 2 for continuation of method at CD4 <200. There are NO expected interactions between NRTIs or integrase inhibitors (-gravir ending agents) and contraceptives. Boosted integrase inhibitor (with cobicistat) may specifically reduce EE dose and should not be used with 20mcg EE preparations of CHC. Some NNRTIs are known enzyme inducers – efavirenz, etravirine and nevirapine. Protease inhibitors (-navir ending agents) may interact with hormonal contraceptives --> increased progesterone exposure, however this is not expected to effect contraceptive efficacy, but may increase risk/rates of side effects such as irregular bleeding

Answer 107

Irregular bleeding on implant, LNG-IUS or injectable

Answer 108

Pre-term birth Low birthweight and SGA babies Stillbirths and neonatal deaths WHO recommends 24 months Earliest expected ovulation post-child birth (including losses >24 weeks gestation) is day 28 (why 21 as give 7d sperm life span)

Answer 109

CHC is safest to be restarted after 6 weeks post-partum as a general rule NON BREAST FEEDING (A) PLUS VTE RF UKMEC 4 for first 3 weeks for non-breastfeeding mothers WITH other VTE risk factors (Peri-natal VTE risks TBA: immobility, transfusion at delivery, BMI >=30, PPH, LSCS, PET & smokers) UKMEC 3 from 3-6 weeks for non-breastfeeding mothers WITH other VTE risk factors. (B) PLUS NO VTE RF UKMEC 3 for first 3 weeks for non-breastfeeding mothers WITHOUT other VTE risk factors. UKMEC 2 from 3-6 weeks (safe) for non-breastfeeding mothers WITHOUT other risk factors UKMEC 1 at >= 6 weeks if not-breastfeeding BREAST FEEDING UKMEC 4 for first 6 weeks if breastfeeding UKMEC 2 at >=6 weeks if breastfeeding Falls to UKMEC 1 from >=6 months

Answer 110

IUC can be fitted immediately following delivery of placenta -> 48 hours post-delivery (UKMEC 1) It should not generally be fitted within 48 hours – 4 weeks post-natal (UMEC 3) It returns to UKMEC 1 from 4 weeks post-natal

Answer 111

For women having medical abortions, the implant can be fitted at the time of mifepristone Depot can also be used in this way, though evidence of slightly higher rates of continuing pregnancy when given WITH mifepristone that women would need to be counselled about

Answer 112

Carbamazepine Rifampicin, rifabutin, ritonavir* (both inhibiting and inducing activity!) Alcohol (chronic) Phenytoin Grisofulvin Phenobarbitone Sulfonylueas, St John’s Wort Plus: TOPIRAMATE ALL protease inhibitors Some of NNRTI class – Efavirenz, Etravirine, Nevirapine If using an enzyme inducing medication for <4 weeks: Can continue usual contraception as long as use condoms as well If using an enzyme inducing medication for >4 weeks à switch to a more suitable form of contraception Methods not impacted by enzyme inducers = Depo injection, intrauterine contraception, barrier contraception Enzyme inducers also reduce efficacy of oral emergency contraception Cu-IUD should be offered first line If not acceptable/ contraindicated then double dose LNG (effectiveness unknown)

Answer 113

P450 enzyme inhibitors do not reduce contraceptive efficacy but may increase side effects risks/ reduce method tolerability or acceptability Sulfonamides Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol (binging/ acute) Ciprofloxacin Erythromycin (clarithromycin) Sodium valproate Chloremphenicol Omeprazole Metronidazole Also grapefruit NB: ritonavir (protease inhibitor) unique example with both inducing and inhibiting properties

Answer 114

teratogen = topiramate, elfavirenz Teratogen only: SDI/IUD/IUS Teratogen + enzyme inducer: IUS/IUD/DMPA AND condoms Do not recommend CHC/POP/SDI (methods impacted by enzyme induction)

Answer 115

CHC can lower levels of lamotrigine and therefore seizure threshold Higher doses of lamotrigine may be required CHC best avoided if on lamotrigine If needs to be used it should be used continuously on an extended regime with input/ monitoring of lamotrigine levels by the patient’s lamotrigine prescriber/provider

Answer 116

Lamotrigine may reduce progestogen levels (FSRH guidance) Desogestrel may increase lamotrigine levels (FSRH guidance)

Answer 117

Evidence of interaction with progesterone injectable contraceptive on bone health Both agents have risk of loss of BMD à combined effect Alternative contraceptive method should be used Important for trans-men who have historically popularly used DMPA for contraception and increasingly using PrEP

Answer 118

Maternal or paternal history of MTD Previous pregnancy with NTD Pre-existing diabetes, sickle cell anaemia, or thalassaemia. BMI >=30 Epilepsy Note: Women with sickle cell disease, thalassaemia, or thalassaemia TRAIT should take folic acid 5 mg daily throughout pregnancy. Others just the 12 weeks.

Answer 119

Most HIV+ women should take standard 400mcg folic acid dose Higher dose of 5mg recommended if: (1) Dolutegravir concurrent use (this particular integrase inhibitor increases risk of NTDs – HAART) (2) Co-trimoxazole concurrent use

Answer 120

Isotretanoin is a retinoid agent/ potent vitamin A derivative and highly teratogenic CNS defects Craniofacial defects Ocular defects Effect can go up to 2 years?

Answer 121

Hb <110 in first trimester Hb <105 second/third trimester Hb <100 in post-partum period Iron deficient if ferritin <30 (even if compensated/ non-anaemic) If anaemia identified at 28/40 bloods, treat with oral iron and recheck levels at + 2 weeks

Answer 122

If HbA1c >=86 (10%) delaying pregnancy should be advised until diabetic control more optimised

Answer 123

VASCULAR VACCINATIONS Vaccinations should be up to date Annual influenza vaccine Pneumococcal vaccine (if not received in last 5 years) ANTIBX Women with sickle cell are hyposplenic and at increased risk of infections, especially with encapsulated organisms such as H influenzae, N meningitidis and S pneumoniae Daily antibiotics prophylaxis is recommended during pregnancy with penicillin V (phenoxymethylpenicillin) STOP MEDS (1) ARBs and ACEi should be stopped / converted (teratogenic – reno-protective use for CKD with SCD) Renal function and proteinuria should be monitored monthly throughout pregnancy (2) HYDROXYCARBAMIDE Hydroxycarbamide should be discontinued pre-conceptually (teratogenic in animal studies) Currently the only licensed treatment for SCD in the UK – reduces painful crises and ACS **Exception: women unable to receive transfusion due to multiple red cell alloantibodies or previous severe transfusion reaction** COUNSELLING Women should be counselled pre-conceptually about their options – partner testing +/- PIGP (type of IVF that involves testing embryos before implantation) U LMWH All women with SCD should receive prophylactic LMWH for 6 weeks post-partum Consider prophylactic LMWH from 28 weeks gestation à 6 weeks post-partum If any additional VTE risk factors, LMWH prophylaxis is recommended from conception ASPIRIIN higher risk of pre-eclampsia; consider 75-150mg/day aspirin from 12 weeks REPEAT GROWTH SCANS MONTHLY associated with IUGR; women should be offered monthly growth scans from 24 weeks

Answer 124

POC assoc with reduced crisis - all 1 Cu-IUD a two only because assoc with increased blood loss CHC 2 i think for increased VTE

Answer 125

Fertility may be reduced in thalassaemia patients where long term chelation has been inadequate -> depositions in the anterior pituitary Significant increase risk of IUGR and maternal cardiomyopathy due to iron overload Women with thalassaemia should have specialist cardiac assessment at 28 weeks gestation Women with thalassaemia should have monthly growth scans from 24 weeks gestation Iron chelators are not recommended in pregnancy due to lack of safety data Should ideally be stopped 3 months prior to conception and throughout pregnancy Time without chelation can à new endocrinopathies due to iron deposition (i.e. DM) Aggressive chelation pre-conceptually -> reduced iron burden and risk of end organ damage If women have had a splenectomy they should receive prophylactic penicillin V (phenoxymethylpenicillin) throughout pregnancy, as well as annual influenza vaccine and pneumococcal vaccine (if not received within last 5 years) Women with thalassaemia are associated with increased peri-natal VTE risk (1) If previous splenectomy OR plts >600: 75-150mg aspirin from 12 weeks (2) If previous splenectomy AND plts >600: LMWH proph AND 75-150mg aspirin from 12/40 (3) LMWH prophylaxis is recommended for 6 weeks post-partum

Answer 126

Measure prolactin levels in women planning a pregnancy taking prolactin raising anti-psychotic medications Haloperidol, amisulpride, risperidone

Answer 127

Often associated with use of NSAID or DMARD agents which can have adverse pregnancy outcomes NSAID mechanism: cyclooxygenase inhibitors (COX) à reduced prostaglandin levels (anti-inflammatory effect) NSAID use can be acceptable for short periods at lowest dose possible within the first trimester. NSAID use is not recommended after 20 weeks gestation, and is contraindicated in the third trimester (from 28 weeks). Effective contraception whilst using DMARDs.

Answer 128

NSAID use can be acceptable for short periods at lowest dose possible within the first trimester. NSAID use is not recommended after 20 weeks gestation, and is contraindicated in the third trimester (from 28 weeks) as associated with: (1) Premature closed of fetal ductus arteriosus (2) Renal dysfunction in the fetus and oligohydramnios (3) Increased risk of uterine atony and PPH If use of NSAIDs beyond 20 weeks cannot be avoided, consider additional monitoring of fetus (cardiac and amniotic fluid assessments)

Answer 129

Methotrexate – folate antagonist via inhibitor of dihydrofolate reductase Associated with reduced fertility during treatment (effects sperm and ova) Associated with severe embryopathy Conception not recommended within 3/12 of use (in either parent) --> Inhibition of thymidine synthesis and inhibition of DNA synthesis --> Increases sensitivity of T cells to apoptosis (reduced number of T cells) --> Reduced immune response Limited evidence about MTX and breastfeeding – bnf states should not be used whilst breastfeeding NHS website states breastfeeding may be possible depending on dose of MTX, but is not advised within 24 hours of taking a dose of the medication

Answer 130

Must wait minimum of 6 months after treatment with radioactive iodine before conception

Answer 131

Levothyroxine dose usually needs to be increased during pregnancy

Answer 132

Carbamazepine and lamotrigine = safe agents during pregnancy Little evidence around safety of levetiracetam and phenytoin use Sodium valproate well established teratogen with long term implications for fetal neurodevelopment Wherever possible AED treatment should be adjusted prior to conception, and valproate withdrawn 2/3 of women with epilepsy will not have seizure deterioration in pregnancy Women with epilepsy can deliver as normal – epilepsy does not necessitate an elective LSCS AEDs are associated with IUGR and serial growth scans are recommended from 28 weeks gestation It is generally considered safe to breastfeed on anti-epileptic drug treatment, including sodium valproate

Answer 133

Warfarin exposure in the first trimester (weeks 6 – 12 especially) associated with warfarin embryopathy Rates of ~5%/ 1 in 20 in exposed fetuses - Hypoplasia of nasal bridge - Congenital heart defect - Ventriculomegaly - Agenesis of corpus callosum - Stippled epiphyses ****Despite association with fetal abnormality, warfarin is the safest anticoagulant for women with metallic heart valves in pregnancy **** Fetal loss (fetal mortality rate) occurs in 1 in 3 pregnancies for women with a metallic heart valve Warfarin safe in breast feeding

Answer 134

Autosomal recessive condition caused by mutation in CFTR gene Good pre-pregnancy lung function (>=60% predicted) = tolerate pregnancy well/ have good outcomes Women with poor pre-pregnancy lung function (<60% predicted) have higher risk of preterm delivery and complications Pregnancy in cystic fibrosis does NOT shorten maternal survival

Answer 135

TORCH infections (toxoplasmosis, other organisms, rubella, cytomegalovirus, and herpes simplex) can lead to congenital abnormalities.

Answer 136

Protazoa parasite Mat infection: cat feces, undercooked pork/lamb Pregnant woman usually asymptomatic -> transplacental transmission to fetus in first 6 months of pregnancy can cause congenital toxoplasmosis Treatment with Spiramycin Neonatal sequelae worse if infection during first 10 weeks of pregnancy Triad in neonate: (1) Chorioretinitis (2) Hydrocephalus (3) Intracranial calcifications

Answer 137

Treponema pallidum HIV Parvovirus B19 Varicella zoster virus (chicken pox) Listeria monocytogenes

Answer 138

Respiratory transmission Can cause symmetrical arthritis and aplastic anaemia (absence of reticulocytes) in pregnant women Transplacental transmission -> fetal aplastic anaemia (1) Increased compensatory cardiac workload -> increased pressure within fetal vasculature (2) Vessels can become ‘leaky’ -> HYDROPS FETALIS (3) High risk of spontaneous abortion if occurring <20 weeks No association with permanent defects/ malformations if pregnancy surpasses the infection

Answer 139

Ingestion of contaminated food, particularly unpasteurised dairy and deli meats Maternal gastroenteritis may occur, and in severe cases can cause sepsis Primary risk is with amnionitis (amniotic fluid infection) and transplacental transfer to fetus -> miscarriage, pre-term birth, stillbirth or neonatal sepsis/meningitis following delivery

Answer 140

Respiratory transmission or contact with skin lesions Risk is in maternal infection (no history of previous vaccination or infection conferring immunity) Transplacental transmission to fetus in 1st or 2nd trimester (<28/40) -> congenital varicella syndrome Low birth weight Limb atrophy Microcephaly Cataracts Cortical atrophy and intellectual disability If maternal infection occurs in last 4 weeks of pregnancy -> risk of neonatal varicella infection If possible delay delivery until +7 days from onset maternal rash to allow for some antibody transfer to the fetus Management of maternal exposure: (1) VZV is infectious until the lesions have fully crusted; this usually takes ~5 days (2) If non-immune maternal exposure then varicella IgG (VZIG) should be given ASAP (3) Evidence of efficacy when given up to 10 days following exposure /first appearance of rash if continuous exposure i.e. household contact (4) VZIG is not effective once maternal chickenpox rash has developed, and should not be used (5) Consideration of oral aciclovir if presenting within 24 hours of onset of rash A second dose indicated if further exposure occurs and >=3 weeks since last VZIG dose given

Answer 141

Most common congenital infection (usually asymp) Neonates typically affected when primary infection in pregnancy Clinical features Deafness Visual impairment (Chorioretinitis) Seizures and neurodevelopment delay Hepatosplenomegaly with jaundice Petecial Rash Periventricular calcifications

Answer 142

Genital HSV infection occurring in early pregnancy is associated: Increased risk of spontaneous abortion, IUGR, preterm labour and congenital herpes (rare 2 per 100,000 live births) Clinical features Neonatal Herpes can lead to severe neurological impairment and death