Rapid-recall takeaways distilled from the DRCOG question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
560 pearls · 7 specialties · Generated 6 November 2026
Fertility Regulation and Sexual Health
80 high-yield facts
Non-enzyme-inducing antibiotics do NOT reduce COC efficacy - only rifampicin and rifabutin require additional precautions as they are enzyme inducers.
Three EC methods in the UK - levonorgestrel (up to 72h), ulipristal (up to 120h), and copper IUD (up to 120h, most effective) - always discuss all options.
Nexplanon lasts 3 years with over 99.9% effectiveness - it is the most effective reversible contraceptive method available and is UKMEC 1 for most women.
Missed desogestrel POP (>12 hours late) = take it now, condoms for 48 hours, and consider EC if UPSI occurred - note the 2-day precaution period differs from the COC's 7 days.
Depo-Provera 150mg IM is given every 13 weeks - the subcutaneous Sayana Press 104mg can be self-administered at home at the same interval.
Filshie clips via laparoscopy are the commonest UK sterilisation method - lifetime failure rate is 1 in 200, and there is growing interest in bilateral salpingectomy for ovarian cancer risk reduction.
Desogestrel POP primarily inhibits ovulation (97% of cycles) - this gives it a 12-hour missed pill window compared to the 3-hour window of traditional POPs.
A partially expelled IUD/IUS must be removed and cannot be repositioned - risk of expulsion is highest in the first 3 months and is more common in nulliparous women.
Return to fertility after Depo-Provera may take up to 12 months - counsel about this before starting, especially in women planning pregnancy in the near future.
The COC reduces ovarian cancer risk by 40-50% and endometrial cancer risk by 50% with prolonged use - these benefits persist for decades after discontinuation.
LAM is 98% effective ONLY if all three criteria are met - fully breastfeeding, amenorrhoeic, and baby under 6 months; failure of any one criterion means alternative contraception is needed.
Sound the uterus before IUD/IUS insertion - 6-9cm for standard devices, minimum 5.5cm for Kyleena, and always assess uterine position to reduce perforation risk.
Trichomoniasis - frothy discharge, strawberry cervix, motile trichomonads - treat with metronidazole 400mg BD for 5-7 days PLUS partner treatment; avoid alcohol with metronidazole.
Subfertility
80 high-yield facts
Azoospermia + normal FSH + normal testes = obstructive until proven otherwise. Test for CFTR mutations - CBAVD is a common cause. Surgical sperm retrieval + ICSI is the treatment.
Core investigations = antiphospholipid antibodies + pelvic USS + parental karyotype + thyroid function + cytogenetics of POC. Antiphospholipid syndrome is the most important treatable cause.
GPs should initiate investigations promptly - semen analysis and day 21 progesterone are the key first-line tests. Do not wait for specialist referral to start basic investigations as recommended by NICE CG156.
Trigger → 36 hours → transvaginal egg collection under sedation. Single embryo transfer is standard. Blastocyst transfer (day 5) may offer higher per-transfer pregnancy rates.
Post-cancer fertility patients with reduced ovarian reserve need expedited referral - do not wait 12 months. Time is critical with declining AMH. Some centres have specific oncofertility pathways for these patients.
NICE recommends intercourse every 2-3 days throughout the cycle - no OPKs, no fertile window restriction. This reduces stress and ensures sperm are always available. Sperm survive up to 5-7 days in the female tract.
3D USS or MRI to characterise uterine anomalies - key distinction is septate vs bicornuate (different treatment). Always check renal tract. ESHRE/ESGE classification for standardised reporting.
Always repeat an abnormal semen analysis after 3 months before drawing conclusions - transient factors can cause temporarily abnormal results.
NICE recommends 3 IVF cycles for women <40 but local ICBs set their own criteria - existing children, BMI, smoking, and age are common restrictions creating a postcode lottery.
Varicoceles are the commonest surgically correctable cause of male infertility - repair may improve semen parameters, but evidence for improved pregnancy rates is limited.
Emergency Gynaecological Problems
80 high-yield facts
When the uterus is well contracted but bleeding continues, think Trauma - systematically examine the vagina, cervix, and perineum for lacerations. Good exposure is essential for accurate repair.
The patient's consent and autonomy are paramount - they choose whether to involve the police. SARCs provide integrated medical, forensic, and support services and should always be offered.
Bartholin cysts are common and usually benign - in women over 40, biopsy of the cyst wall should be performed to exclude carcinoma. Word catheter insertion can be performed as an outpatient procedure.
Septic miscarriage can progress rapidly to septic shock and multi-organ failure - early IV antibiotics and source control (surgical evacuation) are both essential components of management.
Never inform the family that the patient has sought help about forced marriage - this can trigger an escalation of violence including so-called honour killing.
The key differential for ruptured ovarian cyst is ruptured ectopic pregnancy - always confirm negative pregnancy test. Conservative management is appropriate if the patient is stable, but close observation with clear escalation criteria is essential.
Untreated cervicitis can ascend to cause PID with its associated long-term complications - prompt treatment and partner notification are essential to prevent both complications and onward transmission.
Imperforate hymen is the most common obstructive anomaly of the female genital tract - it is easily treated surgically with excellent outcomes. Delayed diagnosis can cause retrograde menstruation and endometriosis.
Placental abruption can present up to 24-48 hours after trauma - all pregnant women beyond 20 weeks with significant trauma should have a minimum of 4 hours of continuous fetal monitoring.
Ovarian cysts in pregnancy require careful monitoring but rarely need intervention - the key is to distinguish simple functional cysts (which resolve) from persistent or complex cysts that may need further assessment.
Early Pregnancy
80 high-yield facts
Methotrexate: IM injection, 50 mg/m². Criteria: stable, unruptured, no heartbeat, hCG <5000. Monitor hCG days 4, 7, then weekly. Avoid pregnancy for 3 months. ~65-95% success.
Give thiamine BEFORE dextrose - prevents Wernicke encephalopathy. Normal saline + KCl is first-line. Correct electrolytes carefully. Monitor U&Es daily. Avoid rapid sodium correction.
PAPP-A <0.4 MoM = marker of poor placentation - associated with FGR, pre-eclampsia, and stillbirth; consider enhanced growth surveillance.
Movements well established by 28 weeks. Movements do NOT reduce in late pregnancy - this myth can be dangerous. Each baby has its own pattern. Report any reduction promptly. No specific number - awareness of usual pattern.
IDA in pregnancy: oral iron first-line, recheck in 2-4 weeks. IV iron if oral fails/not tolerated/severe/late. NICE does not recommend routine iron for all. Hb thresholds vary by trimester.
CRL dating at 8-14 weeks is the gold standard - ±3-5 days accuracy. If CRL differs from LMP by >5 days, use ultrasound EDD. HC used if CRL unavailable.
Threatened miscarriage = bleeding + closed os + no products passed. ~50% continue to viable pregnancy. Confirm viability with USS. Anti-D for Rh-negative women if >12 weeks.
1 miscarriage is common (1 in 4 pregnancies). ~85% chance of successful next pregnancy. No mandatory waiting period. Investigations not needed after a single loss. Offer emotional support.
IUS reduces overall pregnancy risk but does NOT protect against ectopic - if pregnancy occurs with an IUS in situ, always suspect ectopic first.
hCG plateau (<50% rise and <50% fall over 48 hours) is a red flag for ectopic pregnancy - a normal early pregnancy should show ≥63% rise every 48 hours.
Inevitable miscarriage = heavy bleeding + open os + products visible. Remove products from os to prevent vagocervical shock. Resuscitate if haemodynamically compromised. Anti-D for Rh-negative women.
Non-urgent Gynaecological Problems
80 high-yield facts
An RMI ≥250 should prompt referral to a cancer centre - the RMI has approximately 85% sensitivity and 97% specificity for ovarian cancer when this threshold is used.
Good vulval care is the first-line management for many vulval conditions - many women improve significantly with irritant avoidance alone.
If primary dysmenorrhoea fails to respond to NSAIDs and COCP, consider secondary dysmenorrhoea (endometriosis) and refer for further investigation.
The average diagnostic delay for endometriosis in the UK is 7-8 years - GPs play a crucial role in early recognition and referral.
Use FRAX or QFracture to estimate fracture probability before requesting DEXA - this determines whether scanning is warranted based on the individual's risk profile.
The triad of vulval erosions + oral erosions + Wickham striae is characteristic of erosive lichen planus - vaginal involvement can lead to synechiae and should be assessed.
Reproductive plans are crucial - a woman who has completed her family has different treatment options (including surgical) compared with one wishing to conceive. Always ask about future fertility before recommending treatment.
The LNG-IUS should be offered to all women with HMB as first-line, regardless of whether they also want contraception - it is the most effective medical treatment and avoids systemic side effects.
Always send removed polyps for histology - although malignant change is rare, it should be excluded. If the polyp has a broad base or cannot be easily removed in clinic, referral for hysteroscopic excision is appropriate.
All removed endometrial polyps should be sent for histological examination - the risk of malignancy increases in postmenopausal women and with larger polyps.
Vaginal oestrogen can be continued long-term - symptoms often recur when treatment is stopped. It does not increase the risk of endometrial cancer or breast cancer at local doses.
The Pregnant Woman
80 high-yield facts
GROW customisation variables = maternal height, booking weight, ethnicity, parity; NOT blood pressure, glucose, or smoking; used with GAP programme to improve SGA detection and reduce stillbirth.
Previous stillbirth = consultant-led, aspirin, uterine artery Dopplers, serial growth scans, enhanced monitoring; delivery plan at 37-39 weeks; psychological support essential; previous stillbirth is the strongest single risk factor for subsequent stillbirth.
UTI in pregnancy - nitrofurantoin first-line (avoid at term); trimethoprim avoid first trimester; 7-day course; quinolones and tetracyclines contraindicated; always send MSU and do test of cure.
NICE NG133 antihypertensive target = below 135/85 mmHg - titrate dose to maintain this; review and usually wean within 2 weeks postnatally.
UK law - surrogate is legal mother at birth regardless of genetics; parental order transfers legal parenthood; surrogate's consent required at least 6 weeks after birth; commercial surrogacy is illegal.
Weight discordance >25% with absent/reversed end-diastolic flow in MCDA twins = sFGR; classify by UA Doppler (I-III); Type III is unpredictable; manage at a fetal medicine centre (RCOG GTG 51; NICE NG137).
Levothyroxine in pregnancy - increase 25-50% immediately; target TSH <2.5 first trimester; check every 4-6 weeks; most women need significant dose increases.
PRES = posterior white matter vasogenic oedema + visual disturbance + seizures in severe pre-eclampsia - REVERSIBLE with prompt BP control and delivery; MRI shows parieto-occipital oedema.
Increased white, non-offensive discharge in pregnancy = physiological leucorrhoea; no treatment needed; investigate if offensive, coloured, itchy, or painful.
Normal baseline FHR = 110-160 bpm; >160 = tachycardia (consider infection/hypoxia); <110 = bradycardia; progressive baseline rise or fall is more concerning than a single reading.
Peripartum and Neonatal
80 high-yield facts
The decision for intermittent auscultation versus CEFM should be based on clinical risk assessment - women with risk factors should have CEFM, while low-risk women may be monitored with intermittent auscultation.
elevated TSH on blood spot → confirmatory tests → immediate levothyroxine - treatment within 2-3 weeks prevents intellectual disability; lifelong replacement is usually required.
The most effective postnatal contraceptives are LARC methods (IUD/IUS/implant) - discuss these at the earliest opportunity.
two pop-offs = stop - reassess and change the plan; never persist with a failing instrument.
Emergency caesarean section carries a higher risk of endometritis than elective - prophylactic antibiotics and prompt treatment of postoperative pyrexia are essential.
Wound infection occurs in approximately 5-10% of caesarean sections - risk factors include obesity, diabetes, emergency caesarean, and prolonged labour. Women should be given clear verbal and written advice about warning signs.
Telogen effluvium is common and self-limiting - reassurance is the most important intervention. If hair loss persists beyond 12 months or is associated with other features, further investigation is warranted.
Endometritis is more common after emergency caesarean section - prophylactic antibiotics at caesarean reduce the risk. Prompt IV antibiotic treatment usually leads to rapid improvement within 48-72 hours.
The Breastfeeding Network and UKDILAS provide excellent resources for checking medication safety in lactation. The default should be to support continued breastfeeding rather than advising cessation when prescribing - most common medications are compatible.
Check BP before and annually during CHC use - BP 140-159/90-99 is UKMEC 3, and 160+/100+ is UKMEC 4 for all combined methods; stop and switch to progestogen-only or non-hormonal.
Counsel that sterilisation is permanent and irreversible with 1 in 200 failure rate - if it fails, 30% of pregnancies are ectopic, and LARC is equally effective but reversible.
First-episode genital herpes - oral aciclovir 400mg TDS for 5 days started within 5 days of onset; topical treatment alone is insufficient, and counsel about recurrence and transmission.
The copper IUD primarily works by copper ion toxicity to sperm and ova preventing fertilisation - it is NOT an abortifacient and its main action is pre-fertilisation.
The female condom is made of nitrile (latex-free), can be inserted hours before intercourse, and provides STI protection - oil-based lubricants can be used safely unlike with latex condoms.
IUD-related PID risk is only increased in the first 20 days post-insertion due to introduction of pre-existing infection - screen for STIs before insertion and the IUD does not need removal if PID responds to antibiotics.
UKMEC 3 means risks outweigh advantages but method can be used with caution - the four categories range from 1 (no restriction) to 4 (must not use).
Less than 5% of adults with acute HBV become chronic carriers (vs 90% of neonates) - HBV is 100 times more infectious than HIV sexually; vaccinate contacts and at-risk groups.
Manage troublesome implant bleeding with a 3-month COC course first - alternatives include mefenamic acid, and always exclude pregnancy, STIs, and cervical pathology.
Advise abstinence or condoms for 7 days before IUD removal to avoid pregnancy - sperm can survive 7 days, and an alternative method should be established before removal if switching.
Hepatitis B vaccination - standard schedule 0, 1, 6 months; accelerated 0, 1, 2 months plus 12-month booster; check anti-HBs after completion to confirm immunity (≥10 mIU/mL).
Some antiretrovirals interact with hormonal contraception - copper IUD, LNG-IUS, and Depo-Provera are unaffected; always check drug interactions using specialist resources.
HPV types 6 and 11 cause >90% of genital warts and are low-risk - they do NOT cause cervical cancer; HPV types 16 and 18 are the high-risk oncogenic types.
After sexual assault offer STI prophylaxis (ceftriaxone 1 g IM + doxycycline + metronidazole where indicated), emergency contraception (copper IUD preferred), hepatitis B vaccination, and consider HIV PEP based on risk assessment.
Remove the IUD early in pregnancy if threads are visible - this reduces miscarriage risk from 50% to 25%, and always exclude ectopic pregnancy with an early ultrasound.
Patient referral is the preferred method of partner notification - the patient informs contacts themselves; provider referral is available as backup; the index patient's identity is never disclosed.
Lost IUD threads - do a pregnancy test and pelvic ultrasound first to confirm intrauterine position, then X-ray only if the IUD is not seen on ultrasound.
The vaginal ring stays in for 21 days then out for 7 - it can be removed for up to 3 hours without losing efficacy, and uses the same UKMEC criteria as the COC.
Irregular bleeding is the most common implant side effect and the top reason for removal - counsel thoroughly before insertion and manage with short-course COC or NSAIDs if persistent.
POP is UKMEC 1 from day 1 postpartum during breastfeeding - COC is UKMEC 4 in the first 6 weeks of breastfeeding due to effects on milk production.
EC can be used more than once per cycle - but avoid UPA within 5 days of levonorgestrel, strongly recommend the copper IUD for ongoing protection, and always discuss regular contraception.
Post-vasectomy semen analysis at 12 weeks (after 20+ ejaculations) - clearance requires azoospermia or <100,000 non-motile sperm/mL; continue condoms until clearance is confirmed.
Amsel criteria for BV - thin grey discharge, pH >4.5, positive whiff test, and clue cells; need 3 of 4 for diagnosis - Nugent score on Gram stain is the lab gold standard.
The copper IUD is the most effective EC with <1% failure rate - it can be used up to 5 days after UPSI or up to 5 days after estimated ovulation, and provides ongoing contraception.
The LNG-IUS works primarily through local progestogen effects - endometrial thinning reduces bleeding by 90%, but most women continue to ovulate.
Bridging contraception covers the gap until LARC can be started - offer EC if needed plus POP or condoms as an interim method while awaiting IUD/IUS or implant fitting.
First-episode genital herpes in the third trimester - treat with aciclovir and plan caesarean section (30-50% neonatal transmission risk); recurrent herpes has <3% risk and is managed with suppressive aciclovir from 36 weeks.
M. genitalium - test for macrolide resistance, treat with doxycycline then guided azithromycin or moxifloxacin; always perform test of cure as treatment failure is common.
Outpatient PID = ceftriaxone 1g IM + doxycycline 14 days + metronidazole 14 days - review at 48-72 hours; admit if not improving; always do partner notification.
Refer sexual assault cases to a SARC for forensic examination - advise NOT to wash or change clothes; forensic evidence can be collected up to 7 days post-assault.
Manage copper IUD-related heavy bleeding with mefenamic acid and tranexamic acid - if these fail, consider switching to the LNG-IUS which reduces bleeding by 90%.
The symptothermal method combines temperature, cervical mucus, and calendar - it is the most effective NFP method, up to 99% with perfect use but 12-24% with typical use.
Multiple ASCVD risk factors stacking → CHC is UKMEC 3, not automatically UKMEC 4; smoking ≥15/day at age ≥35 is the threshold that pushes CHC to UKMEC 4; LARC (implant, IUS, IUD) are UKMEC 1 here and should be offered as safer alternatives.
Vasectomy has a 1 in 2000 lifetime failure rate - more effective than female sterilisation, simpler, safer, and done under local anaesthetic, but not effective until semen analysis confirms clearance.
The copper IUD is the most effective EC (<1% failure) regardless of BMI - particularly important for women with BMI >26 where oral EC efficacy is reduced.
Candidiasis - itching, thick white discharge, and normal vaginal pH (≤4.5) - this pH distinguishes it from BV and trichomoniasis; antibiotics and pregnancy are common precipitants.
The three main causes of pathological vaginal discharge are BV, candidiasis, and trichomoniasis - differentiate by colour, consistency, odour, pH, and microscopy.
PrEP is TDF/FTC (Truvada) - available daily or on-demand for MSM; requires 3-monthly HIV/STI testing and renal monitoring; reduces HIV risk by 86-99%.
Gillick competence is a clinical judgement that a child understands the treatment fully - it is decision-specific, not age-based, and any healthcare professional can assess it.
Two or more pills missed in week 1 with UPSI = condoms for 7 days PLUS emergency contraception - week 1 is the most risky time for missed pills.
Tailored COC regimens (63/7 or flexible extended) reduce withdrawal symptoms - there is no medical need for a monthly bleed on the COC.
Untreated syphilis in pregnancy causes congenital syphilis in up to 80% - benzathine penicillin is the ONLY effective treatment; erythromycin does NOT cross the placenta reliably.
Migraine with aura is UKMEC 4 for ALL combined hormonal contraception - stop immediately and switch to a progestogen-only or non-hormonal method.
One missed COC pill - take it as soon as remembered and continue normally with no additional precautions needed.
CIN grading - lower third (CIN 1), lower two-thirds (CIN 2), full thickness (CIN 3); CIN 3 has 30% progression risk to cancer over 20 years and requires excisional treatment.
Quick start the COC any day of the cycle with 7 days of additional contraception - but if starting days 1-5, no extra precautions are needed.
Doxycycline 100mg BD for 7 days is now first-line for chlamydia (not azithromycin) - use azithromycin or amoxicillin in pregnancy, and always arrange partner notification.
BV first-line treatment is metronidazole 400mg BD for 5-7 days - no partner treatment needed, but recurrence is common; intravaginal metronidazole gel is an alternative.
TPHA positive with RPR negative usually indicates past treated syphilis or very early infection - refer for specialist assessment, especially in pregnancy where vertical transmission is a risk.
Mirena provides endometrial protection for HRT for up to 5 years - it delivers progestogen locally, avoiding systemic side effects of oral progestogens.
Fraser criteria include that the young person will likely have intercourse regardless, their health would suffer without treatment, and they cannot be persuaded to involve parents - no minimum age is specified.
Gardasil-9 is offered to all Year 8 pupils (12-13 years) as a single dose - it protects against 9 HPV types and has reduced cervical cancer rates by 87% in vaccinated cohorts.
Levonorgestrel COCs have the lowest VTE risk - counsel about this when prescribing, and remember risk is highest in the first year of use.
Irregular bleeding on the POP often settles within 3-6 months - reassure and review before investigating or switching methods.
Refer gender dysphoria to a specialist GIC - GPs provide supportive primary care; do not initiate cross-sex hormones without specialist guidance; use preferred name and pronouns.
Primary syphilis is a painless chancre - treat with benzathine penicillin G 2.4 MU IM single dose; warn about the Jarisch-Herxheimer reaction within 24 hours of treatment.
RVVC (4+ episodes/year) - fluconazole induction (150mg x3 doses) then weekly maintenance for 6 months; always confirm species by culture to exclude resistant non-albicans strains.
Ground D (serious fetal handicap) has NO upper gestational limit - fetocide is recommended from 21+6 weeks; offer multidisciplinary support and sensitive counselling.
Leave the diaphragm in for at least 6 hours after intercourse, use with spermicide, and the Caya single-size diaphragm does not require fitting.
With enzyme inducers - copper IUD is first-line for EC; if declined, use levonorgestrel double dose (3mg) as UPA is NOT recommended with enzyme inducers.
Male sexual dysfunction - assess medications (beta-blockers, SSRIs), cardiovascular risk, testosterone, glucose, and thyroid; ED is a cardiovascular risk marker; address modifiable factors first.
Only Mirena is licensed for HRT endometrial protection - Levosert and Benilexa are NOT licensed for HRT despite containing the same levonorgestrel dose.
Desogestrel POP has a 12-hour window versus 3 hours for traditional POPs - this makes it the preferred POP for shift workers and women concerned about timing.
NICE recommends the LNG-IUS (Mirena) as first-line for heavy menstrual bleeding - it reduces blood loss by 90% and should be offered before oral treatments or surgery.
UPA is preferred over levonorgestrel for EC in women with BMI >26 - the copper IUD is the best option at any BMI, and levonorgestrel efficacy is significantly reduced at higher body weight.
Start cART immediately in HIV-positive pregnant women - aim for undetectable viral load by 36 weeks to reduce vertical transmission to <0.5%; vaginal delivery if VL undetectable.
HPV 16 and 18 cause 70% of cervical cancers via E6/E7 oncoprotein-mediated inactivation of p53 and Rb - most HPV infections clear, but persistent high-risk infection over 10-20 years can progress to cancer.
IVF success declines with age - under 35 is ~30-35%, at 40-42 is ~10-15%, over 43 is <5% with own eggs. Donor eggs maintain high success rates regardless of recipient age.
Prolactin >1000 mU/L with amenorrhoea and galactorrhoea = MRI pituitary to exclude prolactinoma. Cabergoline is the first-line treatment, which can restore fertility.
Recurrent miscarriage = 3 or more losses (RCOG), affecting ~1% of couples. Consider investigation after 2 losses if >35 or patient request. ~50% remain unexplained with good prognosis.
Advise weight loss before fertility treatment in women with BMI >30 - even modest weight reduction can significantly improve ovulatory function and conception rates.
Excessive exercise + energy deficit → hypothalamic suppression → anovulation. RED-S in female athletes. Moderate exercise is beneficial. Advise reducing training and increasing calories.
NICE CG156 states 12 months as the standard threshold, but earlier investigation is warranted for women over 36 or those with known risk factors. Advise couples not to delay seeking help if concerned.
Severe OAT = IVF with ICSI. NEVER give testosterone to a man wanting fertility - it suppresses spermatogenesis. ICSI needs only 1 motile sperm per oocyte.
APS + recurrent miscarriage = aspirin 75 mg pre-conception + LMWH from positive pregnancy test. Aspirin alone is insufficient - the combination is key. Continue aspirin until 36 weeks.
Unexplained recurrent miscarriage has a good prognosis (60-75% success). Supportive care is the cornerstone. Trisomy in POC is reassuring. Avoid unproven empirical treatments.
Hydrosalpinx reduces IVF success - consider salpingectomy before IVF. Bilateral tubal disease = IVF is the most effective treatment option.
Smoking cessation is the single most impactful lifestyle intervention for both partners - refer to NHS Stop Smoking services. Also advise reducing caffeine below 200 mg/day and limiting alcohol consumption.
Exogenous testosterone = contraceptive for men. It suppresses FSH/LH → stops spermatogenesis. Usually reversible over 6-12 months after cessation. Increasingly common cause of male infertility.
Weight restoration is first-line for hypothalamic amenorrhoea - clomifene does not work. Ensure BMI ≥19 before considering any assisted reproduction.
Menstruation ≠ normal fertility after chemotherapy. Check AMH, AFC, and FSH to assess residual ovarian reserve. Alkylating agents are the most gonadotoxic. Waiting time varies by cancer type.
Spermatogenesis takes ~74 days - repeat abnormal semen analysis after 3 months to assess sperm produced after any transient insult.
Premenstrual symptoms suggest progesterone exposure and likely ovulation, but always confirm with mid-luteal progesterone measurement.
Alkylating agents = highest gonadotoxic risk. ABVD = relatively low risk. Age amplifies risk. Counsel all patients about fertility impact regardless of regimen risk category.
NICE CG156 = comprehensive fertility guideline (investigation to treatment). HFEA = UK fertility regulator (licensing, inspection, register, storage, consent). Both are essential knowledge for DRCOG.
Always ask about childhood testicular history - undescended testes, orchidopexy, testicular torsion, and mumps orchitis are key male fertility risk factors.
WHO Group I = low FSH/LH (hypothalamic-pituitary failure); Group II = normal FSH/LH (PCOS); Group III = high FSH (ovarian failure). Treatment approach differs for each group.
Female fertility falls after 35 and markedly after 40; refer women aged 36+ earlier rather than waiting 12 months (NICE CG156). Monthly fecundity at 39 is around 10-15%. Do not delay - time is the key modifiable factor, and paternal age over 40 also reduces fertility.
Laparoscopy and dye is the gold standard for tubal assessment - it provides direct visualisation, detects adhesions and endometriosis, and allows simultaneous treatment.
Primary = never conceived; secondary = previously conceived but unable to again. An ectopic pregnancy counts as a previous conception for classification purposes.
IUI success = ~10-15% per cycle. Cumulative over 6 cycles = ~20-30%. Stimulated is better than unstimulated. Consider IVF after 3-6 failed IUI cycles.
IVF sequence = suppress → stimulate → collect → fertilise → culture → transfer. Regulated by HFEA in the UK. Single embryo transfer is standard practice.
NICE recommends 3 full IVF cycles for women <40 and 1 cycle for women 40-42. Actual NHS funding varies by region - the 'postcode lottery' persists. Multiple indications beyond tubal disease exist for IVF.
Folic acid 5 mg indications: diabetes, BMI >30, previous NTD, AEDs, coeliac, sickle cell/thalassaemia. Start pre-conception, continue to 12 weeks. Requires prescription (400 mcg is OTC).
Endometriosis affects fertility through multiple mechanisms - medical suppression does not improve fertility. Surgical treatment of mild disease may help, and IVF is effective for moderate-severe disease.
APS in recurrent miscarriage = aspirin pre-conception + LMWH from positive pregnancy test. Dramatically reduces miscarriage risk. Continue LMWH until at least 34-36 weeks. Postnatal thromboprophylaxis for 6-12 weeks.
A sibling of someone with cystic fibrosis has a 2 in 3 carrier risk. Test the at-risk individual first, then the partner if positive, and offer genetic counselling (including PGT-M, prenatal diagnosis, or acceptance of risk) if both are carriers.
Clomifene = SERM, blocks hypothalamic oestrogen receptors → increased FSH → ovulation. First-line for PCOS anovulation. Maximum 6 ovulatory cycles. Risk of twins ~8-10%.
5-10% weight loss can restore ovulation in PCOS - this is first-line before drugs. Even modest reduction improves fertility treatment success and pregnancy outcomes.
Visual disturbances on clomifene = STOP immediately and do not re-challenge. Multiple follicles (≥3) increase multiple pregnancy risk - consider cycle cancellation.
WHO 2021 lower reference limits: volume ≥1.4 mL, concentration ≥16M/mL, total motility ≥42%, progressive motility ≥30%, morphology ≥4%. Normal results do not need repeating.
SSRIs can be used in pregnancy with shared decision-making. Sertraline is preferred. Do not abruptly stop - risk of relapse. NICE CG192 guides pre-conception mental health management.
Sperm banking = simple ejaculated sample, non-invasive. Store for up to 55 years (HFEA). Quality may already be affected by cancer. Bank before any treatment if possible. Even one sample is valuable.
ICSI = inject one sperm directly into the oocyte. Main indication = severe male factor. Also used with surgically retrieved sperm and after failed conventional IVF fertilisation.
Letrozole = aromatase inhibitor, now recommended as first-line for PCOS ovulation induction by international guidelines. Better live birth rates than clomifene. Used off-label in the UK.
In UK surrogacy - the birth mother is the legal mother. Commercial surrogacy is illegal. Arrangements are not enforceable. A parental order transfers legal parenthood after birth.
Discuss fertility impact with ALL reproductive-age cancer patients. Refer for preservation before gonadotoxic treatment. Egg freezing takes ~2 weeks. HFEA storage limit now 55 years.
Age 36+ = earlier referral after 6 months (not 12). Initiate GP investigations promptly. Other indications for early referral include known causes of infertility.
Always ask about previous STIs - chlamydia is often silent but can cause significant tubal damage affecting fertility.
Metformin is an adjunct, not first-line monotherapy, for PCOS ovulation induction. It improves insulin resistance and can augment the effect of clomifene/letrozole.
Ovarian transposition (oophoropexy) moves ovaries out of the radiation field. Pelvic radiotherapy is highly gonadotoxic at low doses. Uterine damage also affects future pregnancy capacity.
PRISM trial - vaginal progesterone 400 mg BD improves live birth in recurrent miscarriage (≥3 losses). Start from positive test, continue to 16 weeks. Greatest benefit with early bleeding plus recurrent miscarriage history.
Universal antenatal HIV screening - opt-out with >95% uptake. With cART, MTCT <0.5%. Pre-conception diagnosis allows optimal management. BHIVA guidelines are the reference standard.
Limit caffeine to 200 mg/day when trying to conceive and in pregnancy. 1 cup instant coffee ≈ 100 mg, 1 cup tea ≈ 75 mg. Don't forget hidden sources (chocolate, energy drinks).
Women trying to conceive = avoid alcohol or limit to 1-2 units once/twice weekly. No safe level in pregnancy. Men should stay within 14 units/week. Advise precautionary approach.
Valproate = 10% malformation risk + 30-40% neurodevelopmental risk. Switch to lamotrigine or levetiracetam before conception. Folic acid 5 mg. Never stop AEDs abruptly.
Unexplained infertility has a reasonable natural conception prognosis - advise expectant management for up to 2 years in younger women. IVF after 2 years or sooner if woman is >36.
NICE explicitly advises against BBT charting for fertility timing - it causes stress, is retrospective, and is inaccurate. Regular intercourse every 2-3 days is the recommended approach.
Offer counselling and support group information at all stages. HFEA requires clinics to provide counselling. Both partners affected. Fertility Network UK for peer support. Never say 'just relax.'
All pregnant women = vitamin D 10 mcg (400 IU) daily. Higher risk: darker skin, covered clothing, limited outdoors, BMI >30. Available free via Healthy Start scheme.
OTC = surgical removal and freezing of ovarian cortex. No stimulation needed. Only option for pre-pubertal girls. Risk of reimplanting malignant cells in blood cancers.
Screen for thyroid disease in women with infertility, particularly with menstrual irregularity - treat hypothyroidism to achieve TSH <2.5 mU/L pre-conception. Levothyroxine dose typically needs increasing by 25-50% once pregnancy is confirmed.
AFC, AMH, and FSH together assess ovarian reserve - low AFC (<5-7), low AMH, and high FSH collectively suggest diminished reserve.
Type 2 diabetes pre-conception: HbA1c <48, continue metformin, stop gliclazide (may need insulin), folic acid 5 mg, weight loss, retinal and renal screening.
Klinefelter (47,XXY) = small testes, elevated FSH, low testosterone, azoospermia. Micro-TESE retrieves sperm in ~30-50%. Testosterone replacement suppresses any residual spermatogenesis.
Uterine septum = most common congenital anomaly, associated with miscarriage. Hysteroscopic resection may improve outcomes. Distinguish septate from bicornuate uterus - surgery differs.
IUI = washed, concentrated sperm placed directly in the uterine cavity via the cervix at ovulation. Outpatient, no anaesthesia. ~10-15% success per cycle.
HFEA requires clinics to offer 3 types of counselling: implications, support, and therapeutic. Offered but not mandatory (except donor/surrogacy where strongly recommended). Must be independent of clinical team.
AMH measures quantity (reserve), not quality - a low AMH does not preclude natural conception. It is most useful for predicting IVF stimulation response.
Time is of the essence for women over 35 - refer after 6 months of trying. Counsel that both natural and assisted conception success rates decline with maternal age.
POI = amenorrhoea + FSH >25 IU/L on two occasions 4-6 weeks apart + age <40. HRT until 51 and consider egg donation for fertility.
Diabetic women need: HbA1c <48, switch ACE inhibitors and statins, folic acid 5 mg. Pre-conception care dramatically reduces congenital malformation risk.
Smoking reduces female fertility through multiple mechanisms. Both partners should stop. Refer to NHS Stop Smoking services. Effects on ovarian reserve may be partially irreversible.
NICE says evidence for complementary therapies in fertility is not established. They may provide psychological benefit but should not replace evidence-based treatment. Herbal remedies may interact with fertility drugs.
PCOS = anovulatory infertility. Weight loss is first-line in overweight patients. The LH:FSH ratio is often elevated, and hyperandrogenism is characteristic.
NICE advises regular intercourse every 2-3 days rather than OPK-guided timing - this is less stressful and equally effective for most couples.
Iodine is critical for fetal brain development. UK has no iodine fortification programme. Vegans and women avoiding dairy/fish are at risk. Avoid kelp (excessive iodine). 150 mcg daily in supplements is appropriate.
Perforations during resectoscopic procedures (using diathermy) carry a higher risk of bowel thermal injury than perforations from blunt instruments - always perform laparoscopy to assess after resectoscopic perforation.
PCB requires clinical assessment including speculum examination - the key is to exclude cervical cancer and STIs. If symptoms persist or screening is overdue, refer to colposcopy.
Endometritis can progress to peritonitis, sepsis, and pelvic abscess if inadequately treated. A low threshold for imaging (ultrasound) should exist if the patient fails to respond to antibiotics, to exclude retained products or pelvic collection.
Sepsis is the leading cause of direct maternal death in the UK (MBRRACE) - early recognition and prompt treatment save lives. The Sepsis Six must be started within 1 hour of recognition.
Post-operative AKI with hydronephrosis should always raise suspicion for ureteric injury - urgent imaging and decompression are essential to prevent irreversible renal damage.
Vaginal evisceration is rare but can be life-threatening if bowel becomes ischaemic or perforated. Patients should be counselled to avoid sexual intercourse for at least 6-8 weeks after hysterectomy to allow adequate vault healing.
Endometrial hyperplasia WITHOUT atypia has a low cancer risk (<5%) and can be managed with progestogens. Hyperplasia WITH atypia has a much higher cancer risk and typically requires hysterectomy.
Ruptured endometriomas can cause severe chemical peritonitis that may be mistaken for surgical emergencies - a history of endometriosis and characteristic ultrasound findings guide the diagnosis.
The mandatory reporting duty applies to girls under 18 - for adult women, FGM should be documented, support offered, and safeguarding considered for any daughters or female relatives under 18 who may be at risk.
The blood loss visible externally may underestimate the true loss (concealed abruption) - always assess the clinical picture holistically. DIC complicates approximately 10% of severe abruptions.
In any woman of reproductive age with acute abdominal pain, always consider gynaecological causes even when the pregnancy test is negative - ovarian torsion, ruptured cyst, and PID can all present with acute abdominal pain and a negative pregnancy test.
TOA can be life-threatening if it ruptures - close monitoring, escalation of antibiotics, and timely intervention are essential. Fertility counselling should be provided as TOA is associated with significant tubal damage.
Forensic evidence can be stored anonymously at the SARC while the patient decides whether to report to police - this preserves the patient's options without pressuring them into immediate decisions.
Information can be shared at MARAC without the victim's consent if there is a serious risk to life - this is supported by the Crime and Disorder Act 1998 and data protection legislation. Pregnancy, strangulation, and threats to kill are all significant risk factors for domestic homicide.
Surgical site infection occurs in approximately 5-10% of gynaecological procedures - risk factors include obesity, diabetes, prolonged surgery, and emergency procedures. Prophylactic antibiotics at induction reduce but do not eliminate the risk.
Any woman of reproductive age with haemoperitoneum and a positive pregnancy test should be treated as having a ruptured ectopic pregnancy until proven otherwise - this is a time-critical surgical emergency.
Deinfibulation is a legal and recommended procedure - it is reinfibulation (re-stitching after delivery) that is a criminal offence under the FGM Act 2003. Always document the type of FGM and the deinfibulation procedure clearly.
Always screen for STIs in women with IMB - chlamydia is a common and treatable cause that is easily overlooked if swabs are not taken.
PTSD following sexual assault is common and treatable - early recognition and referral to specialist trauma-focused therapy significantly improves outcomes. A compassionate, trauma-informed approach in all healthcare interactions is essential.
All women undergoing major gynaecological surgery should have a VTE risk assessment and receive appropriate thromboprophylaxis (LMWH and TED stockings). Cancer surgery carries the highest VTE risk - extended prophylaxis for 28 days may be recommended.
The 4 mm threshold has a high negative predictive value but is not infallible - women with recurrent PMB should be re-investigated regardless of initial endometrial thickness. Atrophic vaginitis is the most common cause of PMB.
Intermittent pelvic pain in a young woman with a known ovarian dermoid should raise suspicion for intermittent torsion - do not dismiss waxing and waning pain as it may represent the ovary torting and spontaneously detorting.
Large pelvic masses (fibroids, ovarian cysts) can cause urinary retention through mechanical compression - urethral catheterisation provides immediate relief, and definitive management of the underlying mass is planned subsequently (BAUS acute urinary retention pathway; NICE CKS LUTS in women).
Always perform an ultrasound to confirm intrauterine pregnancy and exclude ectopic before IUD removal in pregnancy. Counsel the woman about the small miscarriage risk from the removal procedure.
Post-operative urinary retention is particularly common after vaginal prolapse surgery - monitor voiding carefully in the post-operative period with bladder scans, and have a low threshold for catheterisation.
Monitor for magnesium toxicity - check patellar reflexes, respiratory rate, and urine output. Calcium gluconate is the antidote for magnesium toxicity.
Heavy bleeding in miscarriage can be life-threatening - prompt resuscitation and surgical evacuation are essential. Always check the cervical os for products causing cervical shock.
Pain disproportionate to findings + crepitus + rapid progression + systemic sepsis = necrotising fasciitis until proven otherwise. This is a surgical emergency - do not delay debridement.
A gynaecologist and general surgeon should ideally both be available when diagnostic laparoscopy is performed for unclear RIF pain in young women - this allows management of both gynaecological and appendiceal pathology.
A positive pregnancy test in an IUD user should always prompt urgent ultrasound to locate the pregnancy - never assume it is intrauterine.
Vaginal cuff dehiscence occurs most commonly within the first 3 months after hysterectomy. Patients should be advised to avoid sexual intercourse for at least 6-8 weeks post-operatively and to present urgently if they develop vaginal discharge, bleeding, or the sensation of something protruding.
This syndrome is the reason many gynaecologists prefer not to perform tubal sterilisation and endometrial ablation concurrently - the combination creates the conditions for PATSS.
Always confirm a negative pregnancy test to exclude ruptured ectopic pregnancy, which is the most important differential. Conservative management is appropriate if the patient is stable, but clear escalation criteria and safety-netting must be in place.
Always commence antibiotics before surgical evacuation in infected retained products to reduce the risk of septicaemia. The postpartum uterus is at higher risk of perforation - experienced operators and ultrasound guidance improve safety.
Torsion of a pedunculated fibroid should be considered in any woman with known fibroids presenting with acute pain - ultrasound with Doppler assessment of fibroid vascularity can support the diagnosis, but surgical exploration should not be delayed if clinical suspicion is high.
The purpose of the medical examination is to identify injuries needing treatment, collect forensic evidence if appropriate, and document findings - it should never be a source of further harm to the child.
Ruptured ectopic pregnancy is a surgical emergency - any woman of reproductive age with acute abdominal pain and haemodynamic instability must have a pregnancy test and be treated as a potential ruptured ectopic until proven otherwise.
The most common reason for missing threads is retraction into the cervical canal - thread retrieval can often be performed with a thread retriever or cytobrush. Always perform a pregnancy test first.
FGM is a criminal offence in the UK and a form of child abuse. Healthcare professionals have a mandatory duty to report FGM in girls under 18 to the police under Section 5B of the FGM Act 2003.
Conversion to laparotomy should always be included in the consent discussion for laparoscopic surgery - it is a safety measure, not a complication. The decision to convert should be made early rather than persisting with a laparoscopic approach when safety is compromised.
High-risk DASH assessments should trigger a MARAC referral - this multi-agency approach has been shown to reduce repeat victimisation. Healthcare professionals can share information without consent if there is a serious risk to life.
Concealed haemorrhage after caesarean section can present insidiously - maintain vigilance for unexplained tachycardia and falling haemoglobin in the postoperative period.
Free fluid in the pouch of Douglas in the context of ectopic pregnancy suggests haemoperitoneum - even if currently stable, the patient is at risk of acute deterioration and requires surgical intervention.
Caesarean section is the single most important risk factor for postpartum endometritis - prophylactic antibiotics at the time of surgery reduce but do not eliminate the risk.
Epidural analgesia is the most common risk factor for postpartum urinary retention - ensure voiding is documented within 6 hours of delivery or catheter removal.
Never use the accompanying person as an interpreter when trafficking is suspected. Use professional interpretation services and create a safe environment for the patient to disclose.
Cornual ectopic pregnancy is associated with higher mortality than tubal ectopic due to delayed presentation and massive haemorrhage at rupture - early diagnosis with high-resolution ultrasound and appropriate specialist management are essential.
Examine the perineum promptly in any woman with increasing or unexpected pain after vaginal delivery - postpartum haematomas can expand rapidly and cause significant morbidity, and large, tense, expanding or painful haematomas need theatre evacuation rather than observation.
Domestic abuse affects approximately 1 in 4 women and often escalates during pregnancy - healthcare professionals have a duty to enquire, document, and support. The patient's safety is paramount.
Perineal wound breakdown causes significant distress - compassionate care, effective analgesia, and timely referral to physiotherapy are all important components of management.
NEVER perform a vaginal examination in suspected placenta praevia - this is a critical safety point. The placental position should be confirmed by ultrasound before any vaginal examination.
Red degeneration is a clinical diagnosis - MRI can be used if uncertainty exists but is not always needed. Reassure the patient that the condition is self-limiting.
Cuff cellulitis occurs in approximately 5-10% of hysterectomies - prophylactic antibiotics at the time of surgery reduce the risk. Most cases respond well to antibiotics, but failure to improve should prompt imaging to exclude a collection.
Ovarian torsion is a surgical emergency at any gestation - laparoscopy can be performed safely in pregnancy with appropriate modifications (open entry technique, left lateral tilt, careful insufflation pressure).
The balance between ensuring complete evacuation and avoiding excessive endometrial damage is key to preventing Asherman syndrome. Ultrasound guidance and gentle technique are the cornerstones of prevention.
A change in the character of previously diagnosed Mittelschmerz should prompt reassessment - do not assume that all mid-cycle pain in a woman with a prior diagnosis is always the same condition. Pelvic ultrasound is safe, non-invasive, and informative.
Appendicitis is the most common surgical emergency - in women of reproductive age, always perform a pregnancy test and consider gynaecological differentials. If diagnostic uncertainty persists, CT abdomen/pelvis or diagnostic laparoscopy can be both diagnostic and therapeutic.
Women on anticoagulants who develop heavy vaginal bleeding need both emergency gynaecological management and specialist anticoagulation advice - multidisciplinary care is essential.
Delayed bowel injury (presenting days after laparoscopy) is often due to unrecognised thermal injury - a high index of suspicion and early CT imaging can aid diagnosis. Delayed recognition of bowel injury significantly increases morbidity and mortality.
VVF causes devastating social and psychological consequences - empathetic care, timely surgical repair, and multidisciplinary support are essential.
The hand must remain in the vagina elevating the presenting part until delivery is achieved - this may be for many minutes during transfer to theatre. Bladder filling can provide additional elevation of the presenting part.
Ultrasound interpretation in the postpartum period can be challenging - a normal postpartum endometrium can appear thickened and echogenic. Clinical correlation with symptoms, inflammatory markers, and clinical assessment is essential.
Haematometra in a postmenopausal woman should always prompt investigation to exclude underlying endometrial pathology - cervical stenosis can mask endometrial cancer by preventing bleeding.
Women with FGM should be identified at antenatal booking and referred early to specialist services - this allows adequate time for deinfibulation, psychological preparation, and birth planning.
The 4 Ts (Tone, Trauma, Tissue, Thrombin) provide a systematic approach to PPH - if Tone is excluded (well-contracted uterus), proceed to assess Trauma. Good exposure is essential for identifying genital tract injuries.
The threshold for admitting PID should be low when the patient is systemically unwell - delayed treatment increases the risk of tubo-ovarian abscess, sepsis, and long-term fertility-damaging sequelae.
Never rely on cervical cytology alone when a suspicious cervical lesion is visible - refer urgently for colposcopic assessment and biopsy. The presence of a visible lesion bypasses the screening pathway.
OHSS is a potentially fatal iatrogenic condition - the main causes of death are thromboembolism, renal failure, and ARDS. VTE prophylaxis with LMWH is essential throughout the illness and should continue until symptoms resolve and the woman is fully mobile.
In emergencies, consent may need to be abbreviated but must still include the key elements - document the discussion carefully. If the patient lacks capacity, treat in their best interests under the Mental Capacity Act 2005.
All laparoscopic entries carry risk - an alternative to the Veress technique is open (Hasson) entry, which involves a mini-incision to enter the peritoneum under direct vision and may be safer in patients with previous surgery.
Always send products for histology - molar pregnancy may be incidental. Register all confirmed moles with a GTD centre. UK has 3 specialist centres. hCG monitoring is mandatory.
Ground E: substantial risk of serious handicap - no gestational limit. Two doctors' signatures required. Most fetal abnormality terminations use Ground E. Methods vary by gestation.
Miscarriage Association: helpline, online forums, peer support, information leaflets. Tommy's, Ectopic Pregnancy Trust, SANDS also available. Proactively offer these resources to all women experiencing pregnancy loss.
FOQ identifies risk → laboratory testing → if carrier, partner testing → if both carriers, genetic counselling and prenatal diagnosis. Aim for results by 10-12 weeks.
UK has 3 GTD centres providing national surveillance. All confirmed moles are registered. hCG monitoring detects GTN early. Near-100% cure rates. Initiated by histopathology lab notification.
Polyhydramnios: AFI >25 cm or DVP >8 cm. Diabetes is commonest identifiable cause. Investigate: detailed anomaly scan, glucose, antibodies, TORCH. Complications: preterm labour, cord prolapse, malpresentation.
Empty uterus + adnexal mass separate from ovary + free fluid = ectopic pregnancy. 'Bagel sign' = tubal ring. hCG above discriminatory level with no IUP is highly suspicious.
CRL is the gold standard for first trimester dating - accurate to ±3-5 days between 8 and 13+6 weeks; use head circumference if CRL exceeds 84 mm.
Incomplete miscarriage = some products passed, retained tissue on USS (endometrial thickness >15 mm). Three management options: expectant, medical (misoprostol), or surgical (MVA/ERPC). Patient choice is central.
Screen-positive (≥1:150) = offer diagnostic testing (CVS/amniocentesis) ± NIPT as interim; NIPT is NOT diagnostic - positive results need invasive confirmation.
Septic miscarriage = emergency. Sepsis 6 bundle. IV antibiotics within 1 hour. Urgent surgical evacuation of infected retained products. Monitor for deterioration - ITU if needed. Sepsis kills - act fast.
Increased NT + normal karyotype - cardiac defects are the strongest association; risk increases with NT thickness; always offer fetal echocardiography.
Ectopic pregnancy on USS = adnexal mass SEPARATE from the ovary - the 'bagel sign' is a hyperechoic ring around a hypoechoic centre.
Awareness of baby's pattern, NOT formal counting charts. AFFIRM trial showed no stillbirth reduction with structured counting. Report changes in usual pattern promptly. Saving Babies' Lives Care Bundle Element 2.
CF carrier frequency ~1 in 25 in Northern Europeans. Not routine antenatal screening. Offer testing with family history or echogenic bowel on USS. Sister of affected child = 2/3 carrier risk. Autosomal recessive - 25% risk if both carriers.
Misoprostol 800 mcg vaginally is the key agent. Mifepristone pre-treatment improves efficacy. Success ~80-85%. Expect heavy bleeding and cramping. Follow-up pregnancy test at 3 weeks. May need surgical management if incomplete.
Bereavement care at ALL gestations. Sensitive communication, time, written info, follow-up, support services, memorialisation. Never minimise the loss. National Bereavement Care Pathway guides practice.
Cardiac activity in ectopic = absolute contraindication to methotrexate - these patients need surgical management.
Laparoscopic salpingectomy = first-line surgical treatment for ectopic with healthy contralateral tube; consider salpingotomy only if contralateral tube is damaged/absent.
UK uses risk-factor approach, NOT universal screening. IAP for risk factors: previous GBS baby, GBS bacteriuria, preterm labour, PROM >18 hrs, intrapartum fever. GBS3 trial will inform future policy.
SCH = blood between chorion and uterine wall. Most resolve spontaneously with good outcome. Larger haematomas have modestly increased miscarriage risk. Expectant management. No bedrest, no anticoagulants. Fetal heartbeat is reassuring.
Missed miscarriage = fetal pole with no heartbeat. CRL ≥7 mm with no heartbeat = likely non-viable but repeat scan after ≥7 days per NICE NG126. Discuss management options sensitively.
Complete miscarriage = empty uterus on USS + resolving symptoms + history of tissue passage. Pregnancy test may remain positive for up to 3 weeks. No treatment needed. Distinguish from ectopic (empty uterus but no tissue passed).
Suction evacuation is the gold standard for molar pregnancy. Oxytocin cover during evacuation. Avoid medical management. Anti-D for Rh-negative. Register with GTD centre.
Choriocarcinoma can follow ANY pregnancy - not just molar. Highly malignant but highly curable with chemotherapy. hCG is the tumour marker. Pulmonary metastases are common. Cure rates >95% with appropriate treatment.
HG is a recognised pregnancy-related condition - sick leave is protected under the Equality Act. Validate the severity. GP can issue fit notes. Psychological support is important. Pregnancy Sickness Support charity for peer support.
Retained products + infection = IV antibiotics THEN surgical evacuation. Don't delay surgery once antibiotics started. Oral antibiotics insufficient for pelvic sepsis. Monitor for deterioration.
cffDNA comes from the placenta, not directly from the fetus. ~10-15% of total cfDNA. NGS detects chromosomal over-representation. Fetal fraction must be >4%. Low fetal fraction → test failure.
Rh-negative women → anti-D antibodies if exposed to Rh-positive fetal cells → HDFN in future pregnancies. Prevented by anti-D prophylaxis. Check at booking and 28 weeks.
RAADP at 28 weeks (± 34 weeks). 72-hour window for sensitising events. Postnatal: cord blood group + Kleihauer test. Cell-free fetal DNA now available for targeted prophylaxis.
~10 visits for nulliparous, ~7 for multiparous (NICE CG62). Key milestones: booking, 16, 25, 28, 31, 34, 36, 38, 40, 41 weeks. BP, urine, SFH at each visit from 24 weeks.
Mean sac diameter of ≥25 mm with no embryo visible indicates missed miscarriage - if <25 mm, classify as pregnancy of uncertain viability and rescan.
Chronic ectopic = prolonged symptoms + low/declining hCG + complex adnexal mass - it does not present with acute haemodynamic compromise like ruptured ectopic.
After salpingectomy - conceive after one normal period; 60% natural conception rate with one tube; offer early scan at 6 weeks in future pregnancies.
Increased NT + normal karyotype still requires detailed anomaly scan and fetal echocardiography - cardiac defects are the most common structural association.
CVS = from 11 weeks, 1-2% additional miscarriage risk, results via QF-PCR in 3 days - earlier than amniocentesis (15 weeks) but slightly higher risk.
Non-directive counselling after abnormal prenatal diagnosis - present balanced information, respect autonomy, allow time, offer specialist support; never recommend for or against termination.
TVUS is preferred in early pregnancy because of its superior resolution - it detects intrauterine pregnancies approximately one week earlier than transabdominal scanning.
EPAUs provide comprehensive early pregnancy assessment - USS, hCG, clinical evaluation, and management. Accept GP and self-referrals. NICE NG126 recommends EPAU access for all women with early pregnancy symptoms.
hCG above 1,500 IU/L with an empty uterus on TVUS is ectopic until proven otherwise - serial hCG at 48 hours helps determine management.
Avoid pregnancy during GTD monitoring - hCG surveillance would be impossible. Use reliable contraception. Avoid IUD/IUS until hCG normal. COCP is safe. Conceive after monitoring complete.
COVID-19 vaccine recommended in pregnancy (any trimester). mRNA vaccines (Pfizer/Moderna) preferred. Extensive safety data. Pregnant women at increased risk of severe COVID-19. Passive protection for newborn.
Normal hCG doubling = every 48-72 hours (≥63% rise in 48 hours). Peaks at 8-12 weeks. Suboptimal rise = suspect ectopic. Very high = consider molar pregnancy. Rate of rise slows at higher levels.
Minimum 7-day interval for repeat PUV scan - scanning too early risks misdiagnosis and unnecessary intervention.
Low-lying placenta at 20 weeks: >90% resolve. Rescan at 32-36 weeks. If persistent praevia → caesarean section at 36-37 weeks. Counsell about bleeding risk. TVS is more accurate than transabdominal for assessing position.
Pertussis vaccine from 16 weeks (ideally 16-32 weeks). Given in EACH pregnancy. ~90% effective in protecting newborns. Inactivated vaccine - safe in pregnancy. Bridges gap until infant vaccination at 8 weeks.
Asherman syndrome = intrauterine adhesions after uterine surgery. Presents with amenorrhoea/hypomenorrhoea + normal hormones + infertility. Diagnose and treat by hysteroscopy. Prevention: avoid excessive curettage, use suction not sharp instruments.
Plateauing hCG over 3+ weeks post-molar evacuation = GTN - refer to specialist trophoblastic centre; cure rates exceed 98% with appropriate chemotherapy.
Partial mole = triploid, some fetal tissue, cystic placental changes, lower hCG than complete mole. GTN risk 0.5-5%. hCG monitoring mandatory. Often diagnosed on histology after presumed miscarriage.
VTE risk assessment at booking, admission, and postnatally. Previous VTE = antenatal LMWH. VTE is a leading cause of maternal death. LMWH is safe in pregnancy (does not cross placenta). Warfarin is teratogenic.
hCG above discriminatory level + empty uterus = presume ectopic until proven otherwise. Discriminatory level ~1500-2000 IU/L for TVS. Adnexal mass may not be visible. Serial hCG + repeat USS + safety-netting.
Anti-D for Rh-negative women: after 12 weeks (any management), or with surgical/medical management at any gestation. 250 IU IM within 72 hours. Not needed for expectant management before 12 weeks.
CVS = placental biopsy from 11 weeks. Advantage: earlier diagnosis than amniocentesis. Risk similar (~0.5-1% miscarriage). Small risk of confined placental mosaicism.
Salpingectomy = standard for tubal ectopic with healthy contralateral tube. Laparoscopic if stable. Salpingotomy considered if only one tube. Anti-D for Rh-negative women. Histology on specimen.
IVF increases heterotopic risk to ~1 in 100. An IUP does NOT exclude ectopic. Treat ectopic surgically; preserve IUP. Methotrexate is contraindicated. Always check adnexae in IVF pregnancies.
Anembryonic pregnancy: gestational sac without embryo. NICE criteria: MSD ≥25 mm with no pole (single scan) OR empty sac on two scans ≥7 days apart. Management same as missed miscarriage. Chromosomal abnormality usually causative.
After 24 weeks, termination is legal under Grounds A (life risk), B (grave permanent injury), and E (serious handicap) - only Ground C has the 24-week limit.
Corpus luteum = WITHIN the ovary + 'ring of fire' on Doppler; ectopic = SEPARATE from the ovary - this distinction is critical to avoid misdiagnosis.
Combined test = NT + free beta-hCG + PAPP-A at 11-13+6 weeks. Screens for T21, T18, T13. ~85-90% detection for T21. It is a screening test, not diagnostic. Higher-chance → NIPT or amnio/CVS.
Quadruple test: 14-20 weeks, 4 blood markers (AFP, uE3, hCG, inhibin A). Detection ~81% for T21. Second-trimester alternative to combined test. Higher-chance cut-off ≥1 in 150.
NIPT for T21 = >99% sensitivity, >99.9% specificity - BUT it is screening, not diagnostic; positive results always need invasive confirmation.
Risk assessment at booking determines care pathway. Multiple risk factors → consultant-led MDT care. Diabetes + obesity + previous PET = high-risk. Aspirin 150 mg from 12 weeks for PET prevention.
cffDNA can determine fetal RhD status from maternal blood from ~11-12 weeks. If fetus is RhD-negative → no anti-D needed. Implemented in NHS. Sensitivity >99%. Reduces unnecessary anti-D by ~one-third.
Karyotype detects balanced rearrangements (which microarray cannot); microarray detects submicroscopic CNVs (which karyotype cannot) - choose based on clinical indication.
Ask about mental health at booking (NICE CG192). Previous severe postnatal depression = high recurrence risk (25-50%). Refer to perinatal mental health services. Management plan for pregnancy and postnatal period.
High-risk NIPT → genetic counselling → invasive diagnostic testing (amnio/CVS) to confirm. NIPT is screening, not diagnostic. No irreversible decisions without confirmation. Non-directive counselling about options.
Routine enquiry for ALL women at booking (in private). Respond with empathy, assess safety, support services, document, safeguard. Pregnancy increases risk. Never tell her to leave immediately. National DV Helpline: 0808 2000 247.
Comprehensive pregnancy employment protections: paid antenatal time, no discrimination, mandatory risk assessment, maternity leave/pay. GP provides MAT B1 and fit notes. Equality Act protects against pregnancy-related dismissal.
PUQE score: nausea hours + vomiting episodes + retching episodes. Mild ≤6, moderate 7-12, severe ≥13. Use alongside clinical assessment. Guides treatment intensity and monitors response.
The POP-Q system eliminates subjective terminology - it provides precise measurements that can track prolapse progression or improvement with treatment.
Managing expectations is crucial - patients should understand that adhesiolysis may not resolve pain and adhesions are likely to reform.
The key diagnostic feature is the cyclical nature - symptoms MUST resolve in the follicular phase. A prospective symptom diary for 2 months is essential to confirm the diagnosis before commencing treatment.
Digital splinting (supporting the posterior vaginal wall to defecate) is a classic symptom of rectocele - asking about this specifically can help make the diagnosis.
Breast development without pubic hair is a key clinical sign - consider androgen insensitivity syndrome (46,XY) and arrange karyotyping.
Treating the urgency component first is pragmatic - it avoids unnecessary surgery for the stress component, which may improve once urgency is controlled.
Endometrial cancer is the most common gynaecological cancer in the UK - obesity is the single most important modifiable risk factor, with risk increasing proportionally with BMI.
Prolapse is graded using the POP-Q system - management depends on the degree of prolapse, symptoms, and the woman's preferences.
Route of administration matters - transdermal oestrogen with micronised progesterone is the lowest-risk HRT combination. This is an important DRCOG teaching point.
A 3-day bladder diary is the single most useful initial investigation for urinary incontinence - it helps distinguish stress from urgency incontinence and identifies modifiable factors (excessive fluid intake, caffeine).
The decision to start HRT should be individualised - discuss the benefits (symptom relief, bone protection) and risks (breast cancer, VTE) in the context of the individual woman's risk profile.
The menopause is a retrospective diagnosis - it is confirmed 12 months after the last menstrual period. Perimenopause refers to the symptomatic transition period before the final period, which can last several years.
Non-hormonal options are less effective than HRT but can provide meaningful symptom relief - CBT is particularly useful as an adjunct to medication. Complementary therapies (e.g., black cohosh) have limited evidence but some women find them helpful.
The mantra 'all postmenopausal bleeding is endometrial cancer until proven otherwise' - even a single episode warrants investigation via the PMB pathway.
The NHS GP has a duty to inform patients about the risks of unregulated preparations and offer evidence-based regulated alternatives - this is a common and important medicolegal issue.
Up to 20% of normal women have polycystic ovarian morphology on ultrasound without PCOS - the diagnosis requires additional features. Always exclude other causes of hyperandrogenism.
Hyperplasia without atypia is managed medically (LNG-IUS), but atypical hyperplasia usually warrants hysterectomy - this is a key management distinction for the DRCOG.
Borderline ovarian tumours have an excellent prognosis (>95% 10-year survival for Stage I) but require long-term follow-up - fertility-sparing surgery is appropriate but patients must be counselled about the small recurrence risk.
Lymph node status is the most important prognostic factor in vulval cancer - the sentinel lymph node technique has reduced the morbidity of groin dissection for early-stage disease.
Always ensure reliable contraception when prescribing anti-androgens - the teratogenic risk is significant. Monitor liver function with cyproterone acetate and potassium levels with spironolactone.
HRT in young women with POI is physiological replacement, not additional risk - it should be strongly encouraged until age 51.
Pelvic congestion is an under-recognised cause of chronic pelvic pain - consider it in multiparous women with postural pain and visible varicosities.
TENS is a low-risk, patient-controlled option that empowers women to manage their own pain - it is particularly appealing to those who prefer to minimise medication use.
Staging does not always correlate with pain severity - women with Stage I disease can have severe pain, while some with Stage IV may have minimal symptoms. Treatment should be guided by symptoms and individual patient factors.
Every molar pregnancy in the UK must be registered with a specialist GTD centre for serial hCG surveillance - this centralised system achieves near-100% cure rates for GTN.
Herbal supplements are not harmless - black cohosh hepatotoxicity is a real risk. Always ask patients about supplement use and document it, as many do not volunteer this information.
The quality of primary debulking surgery is the single most important prognostic factor - complete cytoreduction (no residual disease) significantly improves survival compared with suboptimal debulking.
A mildly raised CA-125 in a premenopausal woman is most often benign - endometriosis is one of the commonest causes - so always interpret it alongside menopausal status and ultrasound, not in isolation.
Mixed incontinence (stress and urge) is common - treatment should target the predominant component first.
Hormonal treatment for endometriosis suppresses ovulation and does not improve fertility - it should be discontinued when a woman is trying to conceive.
Endometrial ablation requires reliable contraception post-procedure - the LNG-IUS can be used after ablation or tubal sterilisation can be offered at the same time.
Chronic pain management focuses on improving function and quality of life - setting expectations that the goal is not pain elimination but improved coping and function is essential for patient satisfaction.
Excision of endometriomas can reduce ovarian reserve - discuss this with the patient, particularly if bilateral surgery is needed. AMH measurement before surgery can help counsel about fertility implications.
Depth of myometrial invasion is a key prognostic factor - Stage IB (>50% invasion) has a higher risk of lymph node metastasis than Stage IA, which influences the need for lymphadenectomy.
Persistent IMB is a red flag for endometrial pathology - always investigate with ultrasound and consider referral if symptoms persist despite normal initial investigations.
Adenomyosis management follows the same stepwise approach as HMB - LNG-IUS first, then additional medical options, then surgical options for refractory cases.
Regular pessary follow-up (every 6 months) is essential to prevent complications - patients should be educated about symptoms that require earlier review (bleeding, discharge, pain, difficulty with voiding/defecation).
Radical trachelectomy offers a fertility-sparing option for selected early-stage tumours - success depends on tumour size, histology, and absence of lymphovascular space invasion.
Colposuspension has experienced a resurgence following the mesh controversy - it is a well-established, mesh-free procedure with good long-term outcomes for SUI.
Imiquimod is most effective for HPV-related usual-type VIN - differentiated VIN (associated with lichen sclerosus) should be excised. Long-term follow-up is essential regardless of treatment modality.
Provoked vestibulodynia is the most common cause of superficial dyspareunia in young women - the cotton-swab test is the key diagnostic tool.
Luteal-phase-only dosing of SSRIs is unique to PMS - it works because serotonin effects on PMS are rapid and do not require the 2-4 weeks typical for depression treatment.
Submucosal fibroids disproportionately cause HMB and subfertility - even small submucosal fibroids can cause significant symptoms, while large subserosal fibroids may be asymptomatic.
Women who have had a hysterectomy for cervical cancer or high-grade CIN should continue vault smears - VAIN can develop in the vaginal vault years after surgery.
Pain related to bladder filling is the distinguishing feature of IC/BPS - this differentiates it from overactive bladder where urgency without pain predominates.
Anticholinergics should be used with caution in elderly women due to cognitive side effects - mirabegron may be preferred in older patients or those with contraindications to anticholinergics.
Consider nerve entrapment in any patient with persistent neuropathic pain after lower abdominal surgery - diagnostic nerve block can confirm the diagnosis and provide therapeutic relief.
Aortic dissection is the most serious cardiovascular risk in Turner syndrome - regular aortic root imaging is essential, particularly during pregnancy (which carries very high cardiovascular risk).
Investigation should be guided by the clinical picture - not all women with HMB need imaging. A full blood count should be performed for all, and ultrasound reserved for those with additional features suggesting structural pathology.
Cyclical dyschezia (painful defecation during menstruation) is a key symptom of deep infiltrating endometriosis involving the bowel - this should prompt referral for specialist assessment.
Documenting the depth and location of myometrial incisions is crucial for advising on future delivery mode - this information should be communicated clearly to the patient and her future obstetrician.
GnRH analogues are a bridge treatment - they are effective but not long-term monotherapy. Add-back HRT (e.g., tibolone or continuous combined HRT) mitigates menopausal symptoms and bone loss without reducing efficacy.
GnRH analogues are a bridge to surgery - fibroids regrow rapidly after cessation. They should not be used for more than 6 months without add-back therapy due to the risk of osteoporosis.
Endometriosis should be suspected in any woman of reproductive age with cyclical pelvic pain, particularly if associated with dyspareunia and subfertility - the diagnostic delay can be reduced by recognising the symptom pattern early.
Oestrogen-only HRT after hysterectomy has the most favourable risk profile - it does not increase breast cancer risk for at least 7 years of use (WHI study data).
Annual review of HRT should include assessment of ongoing need, symptom control, and any changes in risk factors - the woman's informed preferences should guide the decision.
Vaginal moisturisers and lubricants are available over the counter and can significantly improve quality of life - recommend them proactively to postmenopausal women.
The presence of atypia is the critical factor - atypical hyperplasia has a high risk of progression to or coexistence with endometrial cancer and is usually managed with hysterectomy.
Laparoscopic surgery is preferred where possible - the overall prognosis for endometrial cancer is relatively good (80% 5-year survival for Stage I) because the majority present early due to the symptom of postmenopausal bleeding.
The key message is to avoid pregnancy until follow-up is complete - once discharged from surveillance, future pregnancy is safe with no increased recurrence risk beyond normal.
Always consider IBS in women with chronic pelvic pain - a holistic approach addressing both gynaecological and gastrointestinal symptoms improves outcomes.
Generalised vulvodynia is often part of a wider chronic pain syndrome - addressing the broader pain picture (including co-existing conditions) improves outcomes.
Erosive lichen planus is a chronic relapsing condition requiring long-term specialist management - vaginal involvement must be assessed and treated to prevent synechiae and stenosis.
Sacral neuromodulation is a last-resort treatment before considering major surgery (augmentation cystoplasty) - the test phase allows patient selection before permanent implantation.
Non-classic CAH is more common than previously thought - a morning 17-hydroxyprogesterone level should be checked in all women with hyperandrogenism to avoid missing this treatable condition.
Supervised pelvic floor muscle training is the cornerstone of conservative prolapse management under NICE NG123, and many women with mild-to-moderate prolapse improve significantly without surgery.
Breast development with absent body hair in a phenotypic female is the classic presentation - the karyotype (46,XY) confirms the diagnosis. Sensitive disclosure and psychological support are paramount.
Sentinel lymph node biopsy has significantly reduced the morbidity of groin surgery (lymphoedema, wound breakdown) - it is the standard of care for selected early-stage vulval cancers at specialist centres.
HPV vaccination is one of the most effective cancer-prevention interventions, but vaccinated women still need cervical screening because around 30% of cervical cancers are caused by HPV types not contained in the vaccine.
Learning disabilities = reasonable adjustments + presume capacity + person-centred; capacity is decision-specific; accessible information; support worker involvement with consent; safeguarding awareness.
Sulphonylureas (gliclazide) - stop in pregnancy; cross placenta → fetal hyperinsulinaemia → neonatal hypoglycaemia; replace with insulin; metformin can continue.
Pathological CTG = urgent senior review + conservative measures + consider FBS or deliver; pre-terminal = no variability, no reactivity = immediate delivery without FBS.
Post-dates management - membrane sweep at 40 and 41 weeks; offer IOL from 41+0; if declined, twice-weekly CTG + AFI from 42 weeks; respect maternal autonomy with documentation.
RCOG VTE scoring - four or more factors means LMWH from the first trimester, three factors means LMWH from 28 weeks; reassess at booking, on any admission, and after delivery.
Methyldopa = third-line in pregnancy; MUST stop within 2 days of delivery due to postnatal depression risk; switch to enalapril or continue labetalol/nifedipine postpartum.
Shoulder dystocia prediction is unreliable - discuss caesarean when EFW >4.5 kg (non-diabetic) or >4.0 kg (diabetic); most dystocia is unpredicted.
ICP recurrence rate = 45-90% in subsequent pregnancies - monitor bile acids from early third trimester; avoid oestrogen-containing contraception if possible.
Carboprost = 250µg deep IM, max 8 doses; contraindicated in ASTHMA (bronchospasm); NOT IV; third-line after oxytocin and ergometrine for PPH.
Vaginal breech criteria - frank breech, normal EFW, adequate pelvis, experienced team, multiparity; footling breech and EFW >3.8 kg are contraindications; Term Breech Trial favours caesarean overall.
Breech at 36 weeks - offer ECV first; if unsuccessful, discuss planned caesarean vs vaginal breech delivery; ECV success ~50%; anti-D for Rh-negative women after ECV.
Pruritus + palms/soles + nocturnal + no rash = suspect ICP - check SERUM BILE ACIDS and LFTs urgently; bile acids ≥10 micromol/L is diagnostic.
Pre-eclampsia prevention = aspirin 150 mg from 12 weeks to 36 weeks; one HIGH-risk factor OR two+ MODERATE-risk factors qualify; previous pre-eclampsia is a high-risk factor.
Pregnancy increases COVID-19 severity - independent risk factor for ICU; VTE prophylaxis essential; vaccination recommended at any gestation; breastfeeding encouraged.
Zika in pregnancy = microcephaly and brain abnormalities; avoid travel to endemic areas; DEET is safe; sexual transmission possible - condoms if partner travelled to endemic area.
Duty of candour = open, honest, timely communication when harm occurs; apology is not admission of liability; legally mandated; applies to all notifiable incidents; builds trust and reduces complaints.
Genital warts in pregnancy - cryotherapy and excision are safe; podophyllotoxin and imiquimod are contraindicated; warts often enlarge but regress postpartum; caesarean only for large obstructing warts.
Normal CTG = baseline 110-160, variability ≥5 bpm, accelerations present, no decelerations; use DR C BRAVADO for systematic interpretation.
Opioid dependence in pregnancy - methadone maintenance first-line; avoid detoxification due to relapse risk; buprenorphine (alone, not Suboxone) is an alternative.
NSAIDs contraindicated after 28 weeks - risk of premature ductus closure and oligohydramnios; paracetamol is the safe alternative; even topical NSAIDs should be used cautiously.
NICE GDM diagnostic thresholds are fasting ≥5.6 mmol/L OR 2-hour ≥7.8 mmol/L - only one abnormal value is needed for diagnosis.
Hydroxycarbamide is TERATOGENIC - must be stopped in pregnancy; sickle cell pregnancy needs 5mg folic acid, aspirin, VTE assessment, and multidisciplinary care.
ICP delivery timing - bile acids <40: deliver 38-39 weeks; ≥40: deliver by 37 weeks; ≥100: consider 35-36 weeks; weekly bile acid monitoring guides timing.
Under-16 pregnancy + significant age gap = safeguarding assessment essential; not automatic social services removal; Gillick competence for consent; NICE CG110 guides care of vulnerable groups.
MgSO4 toxicity signs in order = absent reflexes → respiratory depression → cardiac arrest; STOP infusion + give calcium gluconate 1g IV; monitor reflexes, resp rate, urine output HOURLY.
HBsAg+ mother with high VL/HBeAg+ = vaccine + HBIG within 12 hours of birth; complete vaccination schedule; test infant at 12 months; breastfeeding is safe.
Chickenpox in pregnancy after 20 weeks - oral aciclovir if within 24 hours of rash; safe in pregnancy; IV aciclovir for severe complications; VZIG is for exposure prophylaxis only.
Hypothyroidism in pregnancy - start levothyroxine immediately; aim TSH <2.5 mU/L in first trimester; monitor every 4-6 weeks and titrate dose.
First trimester hyperthyroidism = PTU; switch to carbimazole after 16 weeks; radioactive iodine is absolutely contraindicated in pregnancy.
Triplets = high-risk, specialist fetal medicine care; counsel about MFPR option; deliver by 35+0 weeks (trichorionic); 2-weekly scans if any monochorionic pair.
HIV + undetectable VL at 36 weeks = vaginal delivery appropriate; VL >400 = caesarean; neonatal PEP for all; breastfeeding not recommended in UK.
DVT in pregnancy - compression ultrasound first-line; D-dimer is unreliable; start LMWH empirically while awaiting imaging if clinical suspicion is high.
Never step down asthma treatment in pregnancy - uncontrolled asthma is more dangerous than the medications; ICS, SABA, and LABAs are all safe.
Maternal varicella -5 to +2 days of delivery = neonatal VZIG; mortality up to 30% without intervention; monitor for neonatal infection; IV aciclovir if neonate develops varicella.
ICP treatment - UDCA 10-15mg/kg/day first-line for symptom relief; PITCHES trial showed limited perinatal benefit; monitor bile acids weekly to guide delivery timing.
Xonvea = doxylamine + pyridoxine; licensed specifically for NVP; extensive safety data; antihistamine + B6 combination; drowsiness is the main side effect.
Valproate = 10% major malformations + 30-40% neurodevelopmental disorders; MHRA PPP mandatory; switch before conception if possible; dose-dependent risk but no safe threshold.
Vasa praevia = fetal vessels over the os; rupture causes fetal exsanguination; antenatal diagnosis dramatically improves survival; deliver by caesarean at 34-36 weeks.
GDM with good control - deliver between 39+0 and 40+6; earlier if complications arise such as macrosomia or poor control.
Pregnancy + lack of capacity = Mental Capacity Act (not MHA); best interests framework; court for significant decisions; MHA cannot authorise obstetric treatment; least restrictive option; detailed documentation essential.
When switching from ACE inhibitors in pregnancy - labetalol is first-line; avoid beta-blockers only if asthma is present, then use nifedipine.
ECV absolute contraindications = ruptured membranes, abnormal CTG, APH, placenta praevia, multiple pregnancy; previous caesarean is a relative contraindication.
Screening-detected short cervix in nulliparous singleton - vaginal progesterone first-line (NICE NG25); Arabin pessary is an adjunct with evolving evidence; cerclage is reserved for prior preterm birth or dilated cervix with exposed membranes.
Microcytic anaemia + low ferritin in pregnancy = iron deficiency - check ferritin to distinguish from thalassaemia trait where ferritin is normal.
VBAC success ~72-75%; higher if previous vaginal delivery; uterine rupture risk ~0.5%; continuous CTG in labour; counsel risks and benefits.
Post-GDM pathway - fasting glucose at 6-13 weeks postnatal, then annual HbA1c lifelong surveillance.
Safe pregnancy antihypertensives = labetalol, nifedipine, methyldopa - NEVER use ACE inhibitors or ARBs in pregnancy.
ITP treatment ladder in pregnancy - first-line prednisolone, second-line IVIg; target >50 for delivery, >80 for epidural.
VTE treatment in pregnancy = treatment-dose LMWH throughout; warfarin and DOACs are contraindicated; continue for remainder of pregnancy plus at least 6 weeks postnatal.
PTU in first trimester (avoids carbimazole teratogenicity) → switch to carbimazole after 16 weeks (avoids PTU hepatotoxicity) - the classic pregnancy switch.
CKD preconception - stop ACE inhibitors/ARBs immediately and switch to labetalol; aspirin 150mg from 12 weeks; multidisciplinary monitoring throughout pregnancy.
BMI ≥30 in pregnancy - OGTT screening, VTE risk assessment, consider aspirin, folic acid 5mg, consultant-led care, anaesthetic review, serial growth assessment.
Preterm labour = regular contractions + cervical change; use transvaginal cervical length and fFN to guide management; <15mm = high risk of delivery.
Previous preterm birth - offer vaginal progesterone 16-34 weeks + serial cervical length monitoring; consider cerclage if cervix shortens to <25mm.
sFGR vs TTTS - sFGR has growth discordance with normal fluid; TTTS has fluid discordance; sFGR Type III (intermittent AEDF) is unpredictable and needs specialist monitoring.
Toxoplasmosis prevention - avoid cat litter, garden with gloves, cook meat thoroughly, wash produce; do NOT need to rehome cats; UK does not routinely screen.
Varicella pneumonia in pregnancy = emergency - IV aciclovir 10mg/kg 8-hourly; mortality 10-20% without treatment; start oral aciclovir for all pregnant women with chickenpox.
Non-immune + measles exposure = HNIG within 6 days; MMR contraindicated in pregnancy (live vaccine); measles in pregnancy can be fatal; vaccinate postnatally.
Growth scan triggers - SFH below 10th centile or centile crossing; high-risk women get serial scans from 28 weeks; low-risk women use SFH screening with customised charts.
Pregnancy insulin - rapid-acting: aspart or lispro; basal: isophane (NPH) or detemir; insulin requirements increase 50-100% from mid-pregnancy; adjust doses every 1-2 weeks.
Ergometrine contraindicated in hypertension/pre-eclampsia - causes vasoconstriction and BP rise; use oxytocin alone in hypertensive women; Syntometrine = oxytocin + ergometrine for normotensive women.
Candidiasis in pregnancy = topical clotrimazole (pessary + cream); oral fluconazole NOT recommended; candidiasis is common due to hormonal changes; may need longer or repeated courses.
Isotretinoin = most potent common teratogen (~25-30% malformation rate); strict pregnancy prevention programme; contraception 1 month before, during, and 1 month after; monthly pregnancy tests.
Stable pre-eclampsia = planned delivery at 37+0-37+6 weeks; earlier if condition deteriorates; corticosteroids before 34 weeks; magnesium sulphate for neuroprotection <34 weeks.
Elective caesarean for breech = plan at 39+0 weeks to optimise fetal maturity and reduce respiratory morbidity; advise urgent attendance if labour starts before planned date.
stop oxytocin first - it is the most reversible cause; left lateral positioning and terbutaline are the next steps before considering emergency delivery.
high spinal = hypotension + bradycardia + respiratory compromise + arm weakness - vasopressors, fluids, and airway management are the immediate priorities.
Physiological management carries a slightly higher risk of PPH compared with active management - women should be counselled about this, and the midwife must be prepared to convert to active management if complications arise.
MCADD = cannot burn fat during fasting - avoid prolonged fasting + emergency glucose regimen during illness; no fat restriction needed.
Consistency and completeness in vaginal examination findings are essential for accurate partogram completion and identification of abnormal labour progress.
The decision to prescribe antidepressants in breastfeeding should involve a careful risk-benefit discussion - untreated depression also carries risks for both mother and baby.
vesicles + sepsis-like illness in a neonate = consider HSV - start IV aciclovir immediately; do not wait for results.
Persistent perineal pain beyond 2 weeks should prompt wound assessment - wound infection and wound breakdown are treatable complications. Pelvic floor exercises should begin early and continue long-term.
manual rotation is a useful first-line technique for persistent OP position - less invasive than rotational instruments, with good success rates in experienced hands.
The three main indications for instrumental delivery are fetal compromise, inadequate progress, and maternal medical conditions - but prerequisites must always be confirmed before proceeding.
Puerperal psychosis is a medical emergency - same-day psychiatric assessment is required. Never leave the mother alone with the baby until psychiatric assessment has been completed.
An EPDS score ≥13 suggests probable depression requiring further assessment - always ask about thoughts of self-harm and harm to the baby. Sertraline is the preferred SSRI in breastfeeding as it has low transfer into breast milk.
Epidural is the gold standard for labour analgesia - women should be informed of the benefits (effective pain relief) and risks (hypotension, prolonged second stage, increased instrumental delivery rate, rare complications) to make an informed choice.
Significant meconium requires escalation of care - CEFM, senior obstetric awareness, and neonatal team present at delivery. The previous practice of routine suctioning of the meconium-stained neonate at birth is no longer recommended; instead, standard NLS protocols are followed.
elevated IRT + two CFTR mutations = likely CF - confirmatory sweat test + specialist CF centre referral; early treatment improves long-term outcomes significantly.
The type of uterine incision has major implications for future pregnancies - a classical incision mandates elective caesarean delivery in subsequent pregnancies due to the high risk of uterine rupture in labour.
Postnatal care should be individualised - women with additional risk factors (e.g., caesarean section, mental health concerns, feeding difficulties) may need more frequent contacts. All visits should include assessment for postnatal depression using the Edinburgh Postnatal Depression Scale.
PPH is defined as ≥500 mL blood loss - the 4 Ts (Tone, Trauma, Tissue, Thrombin) provide a systematic framework for identifying the cause and guiding management.
In women with a previous caesarean section, avoid prostaglandins where possible and consider balloon catheter ripening followed by careful oxytocin augmentation with continuous CTG monitoring.
The decision to proceed to hysterectomy should not be delayed once it is clear that conservative measures have failed - delay increases morbidity and mortality.
sequential instruments = higher neonatal risk - the decision requires senior involvement, theatre setting, and clear justification that delivery is achievable with the second instrument.
cephalhaematoma = subperiosteal + limited by sutures + resolves spontaneously - do not aspirate; monitor for jaundice and anaemia.
Oxytocin is a high-risk medication in labour - it requires continuous fetal monitoring, careful dose titration, and the ability to reduce or stop the infusion immediately if hyperstimulation occurs.
cup feeding avoids nipple confusion, supports breastfeeding transition, and is WHO-recommended - suitable from 30-32 weeks with trained supervision.
placenta accreta spectrum is now the leading indication - antenatal MDT planning and consent are essential for optimising outcomes.
benzylpenicillin + gentamicin = gold standard for early-onset neonatal sepsis - give within 1 hour, review at 36-48 hours based on cultures.
Ventouse = more neonatal scalp trauma, less maternal perineal trauma. Forceps = less neonatal scalp trauma, more maternal perineal trauma - the choice requires balancing these risks.
counter-pressure above the symphysis during cord traction is essential to prevent uterine inversion - never pull the cord without guarding the uterus.
gradual weight loss + balanced diet + exercise + continued breastfeeding - no crash diets or pharmacotherapy while breastfeeding; aim for pre-pregnancy weight by 6-12 months.
Weight loss assessment must consider the trajectory - a baby still losing at 2 weeks needs different management from one who lost 8% at day 3 but is now gaining.
Approximately 1-2 per 1000 babies have permanent hearing loss - early detection through newborn screening enables intervention before 6 months, which is critical for speech and language development.
internal iliac ligation = approximately 48% reduction in pelvic blood flow + fertility preserved - requires an experienced surgeon and detailed knowledge of retroperitoneal anatomy (RCOG GTG 52).
LATCH = Latch + Audible swallowing + Type of nipple + Comfort + Hold - a structured tool identifying breastfeeding difficulties early for targeted support.
neonatal palliative care = comfort + pain management + family time + memory-making + bereavement support - a compassionate, individualised approach respecting parental wishes.
most common medications are safe in breastfeeding - check UKDILAS/LactMed; do not unnecessarily advise stopping breastfeeding as this is usually more harmful than minimal drug transfer.
pelvic floor exercises from early postpartum + walking; high-impact sport from 12 weeks after pelvic floor assessment - individualised advice based on mode of delivery and recovery.
Bakri balloon = 250-500 mL saline inflation + 12-24 hours in situ - a bridging measure between medical and surgical management of PPH.
The Birthplace study (2011) demonstrated that for low-risk multiparous women, home birth is as safe as hospital birth - however, a robust transfer plan must be in place in case of complications.
category 1 = immediate threat to life = within 30 minutes - but aim for faster; every minute counts in true emergencies like cord prolapse and sustained bradycardia.
Always check maternal blood-borne virus status before applying an FSE - this should be documented in the handheld notes and checked on the electronic system.
GPs and health visitors can support women returning to work by providing information about their rights and encouraging workplaces to support breastfeeding - this contributes to longer breastfeeding duration and improved maternal and child health.
NICE EONS risk assessment = PROM + fever + prematurity + GBS - one risk factor may warrant observation; two or more or clinical signs warrant investigation and antibiotics.
wound infection post-CS = swab + antibiotics + drain if collection - prophylactic antibiotics at CS reduce infection rates by 60-70%.
prolonged jaundice + pale stools + dark urine + conjugated hyperbilirubinaemia = biliary atresia until proven otherwise - Kasai before 60 days is critical.
MAS = meconium + respiratory distress + patchy CXR infiltrates + hyperinflation - manage supportively with ventilation, surfactant, and iNO if PPHN develops.
preterm <32 weeks = plastic bag + radiant warmer + hat + warm room - do not dry these babies; the plastic bag prevents evaporative heat loss.
Failed IOL is a common and distressing situation - compassionate counselling about options (including caesarean section) is essential. Document the discussion clearly and involve the woman in shared decision-making.
Kielland forceps = rotational instrument for malposition - experienced operator only, theatre setting, and higher risk than non-rotational instruments.
AFE is a diagnosis of exclusion - there is no confirmatory diagnostic test. Treatment is entirely supportive, and maternal mortality remains high despite advances in critical care.
flank pain + rising creatinine post-CS/hysterectomy = suspect ureteric injury - CT urogram and urgent urology referral are essential.
Cord prolapse requires immediate delivery - the decision-to-delivery interval should be as short as possible. The key principle is to prevent cord compression by elevating the presenting part while preparing for emergency caesarean.
Sheehan syndrome is rare in developed countries due to improved obstetric care, but should be suspected in any woman with symptoms of hypopituitarism following severe PPH - failure to lactate is often the earliest sign.
Assessment of tongue tie should be performed by a trained practitioner - the degree of restriction and its functional impact on feeding determine whether frenotomy is indicated.
compound presentation often resolves spontaneously - watchful waiting with continuous monitoring is the initial approach, reserving caesarean section for persistent obstruction.
The reduced complication rate of elective caesarean supports the importance of timely decision-making - avoiding delayed conversion from labour to emergency caesarean when clear indications exist.
Accurate classification of perineal tears is essential - all third- and fourth-degree tears should be repaired by an experienced operator, ideally in theatre with adequate anaesthesia (RCOG GTG No. 29).
Accurate understanding of labour stage definitions is fundamental to clinical communication - always document which stage of labour a woman is in when providing clinical handover.
VBAC should be planned in a unit with continuous CTG monitoring and immediate access to caesarean section - the decision should involve shared decision-making with comprehensive documentation.
IR = prophylactic balloon catheters for planned accreta + UAE for ongoing PPH in stable patients - MDT planning is essential.
LAST = perioral tingling → seizures → cardiovascular collapse - Intralipid 20% is the specific treatment alongside standard resuscitation.
Jaundice <24 hours = always pathological. Think haemolysis first - ABO incompatibility, Rhesus disease, G6PD deficiency, and spherocytosis.
Pulse oximetry screening does not replace clinical examination - a normal pulse oximetry does not exclude all congenital heart disease. All findings should be communicated to the parents and documented in the child health record.
Skin-to-skin contact should only be interrupted if there is a clinical concern about the baby - routine observations and weighing can wait. Staff should be trained in safe positioning to prevent positional asphyxia during skin-to-skin.
The red reflex examination is a critical screening test - ensure the room is darkened, use the ophthalmoscope correctly, and compare both eyes. Any abnormality warrants urgent specialist referral.
early bonding difficulties = common and usually transient - skin-to-skin, supported feeding, reassurance, and follow-up; consider perinatal mental health referral if persistent.
Wound infection after caesarean section should prompt consideration of endometritis, which may coexist. If the patient is systemically unwell, hospital admission for IV antibiotics may be required.
Postnatal thyroiditis can be misdiagnosed as postnatal depression or Graves disease - check TPO antibodies and consider the clinical context. The hypothyroid phase may require levothyroxine, and approximately 20-30% develop permanent hypothyroidism.
The Apgar score should not delay resuscitation - if the baby is not breathing, commence NLS algorithm immediately. The score is a retrospective assessment tool, not a guide for initiating treatment.
Women's health physiotherapists have specialist expertise in postnatal musculoskeletal conditions - early referral prevents chronic pain and improves functional recovery.