1️⃣ Red Flags & Conditions Not to Miss

Suspected Ectopic Pregnancy

1-2%
of pregnancies are ectopic
10%
recurrence risk after one ectopic
Classic triad:

Unilateral pelvic pain, vaginal bleeding, positive pregnancy test

Examination:

Cervical excitation, adnexal tenderness, shoulder tip pain if ruptured

Action:

URGENT same-day referral to early pregnancy unit - life-threatening if ruptured

Initial management:

IV access, FBC, G&S, βHCG, avoid vaginal examination if unstable

Severe Pre-eclampsia / Eclampsia

5%
pregnancies affected by pre-eclampsia
15%
recurrence risk if previous pre-eclampsia
Symptoms:

Severe headache, visual disturbance, RUQ pain, nausea/vomiting

Signs:

BP >160/110, proteinuria, hyperreflexia, clonus

Complications:

Eclampsia, HELLP syndrome, stroke, placental abruption

Action:

URGENT hospital admission - maternal and fetal emergency

Venous Thromboembolism in Pregnancy

Risk in Pregnancy:

Pregnancy increases VTE risk 5-fold (hypercoagulable state). Leading cause of maternal death in UK. Risk highest in puerperium (first 6 weeks postpartum).

DVT Symptoms (SWOLLEN):

S - Swelling (unilateral leg), W - Warmth, O - Oedema, L - Low oxygen (if PE), L - Leg pain (calf/thigh), E - Erythema, N - Not relieved by rest

Pulmonary Embolism Red Flags:
  • • Sudden breathlessness, chest pain (pleuritic)
  • • Tachycardia, tachypnea, hypoxia
  • • Hemoptysis, syncope, collapse
  • • Raised JVP, loud P2, right ventricular heave
Immediate Action:

Do NOT wait for investigations. Start LMWH immediately (therapeutic dose) if clinical suspicion. Arrange urgent Doppler (DVT) or CTPA (PE). D-dimer unreliable in pregnancy.

Maternal Sepsis

High Mortality Risk:

Maternal sepsis is a leading cause of maternal death. Pregnancy-related infections can progress rapidly. Early recognition and treatment (Sepsis Six) is critical.

Common Sources:
  • • Chorioamnionitis (intrauterine infection)
  • • Endometritis (postpartum uterine infection)
  • • Wound infection (C-section, perineal tears)
  • • Mastitis (breast infection)
  • • Urinary tract infection/pyelonephritis
  • • Group A Streptococcus (rare but severe)
SEPSIS Recognition:

S - Slurred speech/confusion, E - Extreme shivering/muscle pain, P - Passing no urine (oliguria), S - Severe breathlessness, I - 'I feel like I might die', S - Skin mottled/cyanosed

Sepsis Six (First Hour):

1. Oxygen (high-flow if SpO2 <94%), 2. Blood cultures, 3. IV antibiotics (broad-spectrum), 4. IV fluids (500ml bolus), 5. Lactate (>2 = sepsis), 6. Urine output monitoring

Reduced Fetal Movements

Definition:

Subjective maternal perception of decreased fetal activity. Most common from 28 weeks gestation. Associated with increased risk of stillbirth, IUGR, and placental insufficiency.

Normal Patterns:

Movements felt from 16-24 weeks. Peak activity 28-32 weeks. Individual patterns vary - focus on change from normal pattern rather than absolute numbers.

Red Flags:
  • • Significant reduction in movements for >24 hours
  • • Complete absence of movements
  • • Change in pattern (active baby becoming quiet)
  • • Associated bleeding, pain, or contractions
Immediate Action:

URGENT same-day referral to maternity unit for CTG and assessment. Do NOT advise 'kick counting' or waiting. Do NOT recommend cold drinks/glucose to stimulate movement.

Hyperemesis Gravidarum

Definition:

Severe nausea and vomiting in pregnancy causing dehydration, electrolyte imbalance, and weight loss >5% pre-pregnancy weight. Affects 1-3% pregnancies.

Diagnostic Criteria:
  • • Persistent vomiting (unable to keep fluids down)
  • • Weight loss >5% of pre-pregnancy weight
  • • Dehydration and ketosis
  • • Electrolyte imbalance (hyponatremia, hypokalemia)
Red Flags for Admission:
  • • Unable to tolerate oral fluids for >24 hours
  • • Ketonuria (2+ or more)
  • • Weight loss >5%
  • • Signs of dehydration (tachycardia, hypotension)
  • • Electrolyte abnormalities
Management:

Hospital admission for IV fluids, antiemetics (cyclizine, ondansetron), thiamine supplementation. Monitor electrolytes, LFTs. Consider steroids if severe/refractory.

Postpartum Psychosis

Psychiatric Emergency:

Acute onset psychiatric condition occurring 2-4 weeks postpartum. Incidence: 0.1-0.2% (1-2 per 1000 births). High risk of infanticide and maternal suicide.

Clinical Features:
  • • Acute onset confusion, disorientation
  • • Hallucinations (auditory/visual)
  • • Delusions (often involving baby)
  • • Severe mood swings (mania/depression)
  • • Bizarre or inappropriate behavior
  • • Thoughts of harming self or baby
Risk Factors:
  • • Previous postpartum psychosis (recurrence risk 25-50%)
  • • Bipolar disorder or family history
  • • First pregnancy
  • • Sleep deprivation
Immediate Action:

URGENT psychiatric referral (same day). Consider Mental Health Act assessment. Admit to mother-baby unit if available. Never leave mother alone with baby until assessed.

2️⃣ Diagnostic Approach & Investigations

History Framework

Remember: Pregnancy status is the "vital sign" of reproductive health - always check it first!

Core Symptoms

  • • Menstrual history: LMP, cycle regularity, flow
  • • Bleeding: Amount, timing, associated pain
  • • Pain: Location, character, radiation
  • • Discharge: Color, odor, associated symptoms
  • • Systemic: Nausea, breast tenderness, fatigue
  • • Urinary: Frequency, dysuria, incontinence

Key Differentiators

  • • Onset: Sudden (hours) vs gradual (days/weeks)
  • • Pregnancy status: Always check if reproductive age
  • • Sexual history: Contraception, STI risk
  • • Obstetric history: Gravidity, parity, complications
  • • Family history: Genetic conditions, cancers
  • • Medications: Hormones, teratogens

Maternal Health Examination

Antenatal Examination

  • • Blood pressure: Baseline and monitoring for pre-eclampsia
  • • Urinalysis: Protein, glucose, nitrites, leucocytes
  • • Abdominal palpation: Fundal height, lie, presentation
  • • Fetal heart: Doppler from 12 weeks, normal 110-160 bpm
  • • Edema: Physiological vs pathological
  • • Weight: Appropriate gain, BMI monitoring

Postnatal Examination

  • • General wellbeing: Recovery, pain, fatigue
  • • Perineal/wound: Healing, infection signs
  • • Lochia: Amount, color, odor
  • • Uterine involution: Size, tenderness
  • • Breast examination: If breastfeeding issues
  • • Mental state: Mood, bonding, EPDS screening

Investigations in Maternal Health

Routine Antenatal Tests

  • • FBC: Anemia screening (Hb <110 g/L)
  • • Blood group & antibodies: Rhesus status, atypical antibodies
  • • Infection screen: HIV, hepatitis B, syphilis, rubella immunity
  • • Urine culture: Asymptomatic bacteriuria
  • • Down's screening: Combined test 11-14 weeks
  • • Glucose tolerance: 24-28 weeks if risk factors

Problem-Specific Tests

  • • βHCG: Pregnancy confirmation, ectopic assessment
  • • Progesterone: Day 21 for ovulation confirmation
  • • Thyroid function: TSH, T4 if symptoms/history
  • • Liver function: If itching (obstetric cholestasis)
  • • Coagulation: If bleeding disorder suspected
  • • Kleihauer test: Feto-maternal hemorrhage

When to Refer

Same-Day Referral

  • • Suspected ectopic pregnancy
  • • Severe pre-eclampsia (BP >160/110 + symptoms)
  • • Antepartum hemorrhage
  • • Reduced fetal movements
  • • Suspected sepsis in pregnancy/postpartum
  • • Hyperemesis with dehydration/ketosis
  • • Postpartum psychosis
  • • Secondary postpartum hemorrhage

Routine Referral

  • • High-risk pregnancy (diabetes, hypertension)
  • • Previous pregnancy complications
  • • Subfertility after 12 months trying
  • • Recurrent miscarriage (≥3 consecutive)
  • • Abnormal screening results
  • • Mental health concerns
  • • Social complications (domestic violence)
  • • Multiple pregnancy

3️⃣ Contraception in UK General Practice

Big Picture Overview

Contraception prevents pregnancy by stopping ovulation, fertilisation or implantation. In the UK, contraception is provided free of charge on the NHS to reduce unplanned pregnancy and remove cost barriers.

NICE CKS: offer all suitable methods (including LARC), use shared decision‑making, and apply UKMEC 2025 to assess safety.

Effectiveness Snapshot (Typical Use)

Method Type Examples Typical Failure/Year Key Point
LARC - intrauterine Cu-IUD (T-Safe, TT380), LNG-IUS (Mirena®, Levosert®, Benilexa®, Kyleena®, Jaydess®) <1% Most effective, user-independent
LARC - implant Nexplanon® <1% 3 years, quick return of fertility
Injection Depo-Provera®, Sayana Press® ~4% 12-13 weeks, bone health considerations
CHC (COC/patch/ring) Rigevidon®, Microgynon 30®, Millinette®, Evra® patch, NuvaRing® ~9% User-dependent, non-contraceptive benefits
POP Cerazette®, Cerelle®, Aizea®, Slinda®, Noriday®, Norgeston® ~9% Preferred when oestrogen inappropriate
Barrier / FAM Condoms, diaphragms, fertility awareness 13-23% STI protection and add-on method
💡 Mnemonic: LARC First – Leave All Risk to Coils/implant

History Before Prescribing - "5 Ps + MEDS + RISK"

Use this for any contraception consult (including quick-start).

5 Ps

1. Pregnancy: Intention (avoid/delay/achieve), LMP, cycle pattern, recent UPSI, pregnancy test if indicated
2. Periods & gynae: Regularity, flow, pain, IMB/PCB, past PID/ectopic, fibroids/endometriosis, smear history
3. Past medical: VTE/PE, stroke/TIA, IHD, cardiomyopathy, hypertension, migraine (with/without aura), diabetes, liver disease, cancer (esp. breast), epilepsy, bariatric surgery
4. Past contraception: Methods tried, failures, side-effects, what they liked/disliked
5. Personal/partner sexual history: Partners, new partner, condom use, STI history, safeguarding/consent, DV/SV

MEDS

MEDS & lifestyle: Enzyme inducers (some antiepileptics, rifampicin, some HIV drugs, St John's wort), psychotropics, anticoagulants, teratogens; allergies, smoking/vaping, alcohol, drugs, BMI

RISK

RISK factors & red flags: VTE/arterial risk: age, smoking, BMI, immobility/surgery, strong FHx, thrombophilia, breast symptoms, abnormal bleeding, pelvic pain
Relationship, safety, readiness: Coercion, capacity/Fraser competence, what they want from contraception (effectiveness, bleeding, "hormone-free", convenience)
💡 Hook phrase: "5 Ps + MEDS + RISK before you script"

UKMEC 2025 - Using the Categories

UKMEC 2025 is the current UK medical eligibility criteria for contraception.

Categories

UKMEC 2025 Definition Phrase for Trainees
1 No restriction "Method can be used."
2 Benefits generally outweigh risks "Method can generally be used with caution."
3 Risks usually outweigh benefits "Method not usually recommended; seek advice."
4 Unacceptable health risk "Do not use this method."
💡 Mnemonic: 1–2 okay, 3 avoid, 4 no way

UKMEC Scores for 15 Common Presentations

Condition CHC (COC/Patch/Ring) POP DMPA Injection Implant Cu-IUD LNG-IUS
Migraine with aura 4 1 2 1 1 1
Current VTE/PE 4 2 3 2 1 2
History of VTE/PE 3 2 2 2 1 2
Smoking age ≥35 3 1 1 1 1 1
BMI ≥35 3 1 1 1 1 1
Hypertension (controlled) 3 1 2 1 1 1
Diabetes with complications 3 2 3 2 1 2
Current breast cancer 4 4 4 4 1 4
Breastfeeding <6 weeks 4 1 1 1 1 1
Breastfeeding 6w-6m 3 1 1 1 1 1
Liver cirrhosis 4 3 3 3 1 3
Gallbladder disease 3 1 1 1 1 1
Epilepsy on enzyme inducers 3 3 1 3 1 1
Inflammatory bowel disease 2 1 1 1 2 2
SLE with antiphospholipid 4 2 3 2 1 2
Note for trainees: Categories above are indicative only. Always check the official UKMEC 2025 full and summary tables for the exact category for each method in each individual case.

Choosing a Method - COC vs POP vs LARC

Combined Hormonal Contraception (CHC)

First-line COC options (if UKMEC 1–2 for CHC):

Oestrogen/progestogen Brand examples Use notes
EE 30 µg / levonorgestrel 150 µg Rigevidon®, Levest®, Maexeni®, Microgynon 30® Common first-line, relatively lower VTE risk among COCs
EE 20 µg / levonorgestrel 100 µg Millinette 20/75® Consider if oestrogen side-effects on 30 µg
Estradiol 1.5 mg / nomegestrol 2.5 mg Zoely® 24/4 regimen; still CHC for UKMEC

Good for: cycle control, dysmenorrhoea, acne, PMS/PMDD, endometriosis (symptom control)

Avoid/be cautious: UKMEC 3–4 (migraine with aura, major VTE/arterial disease, high-risk smokers, complex hypertension, some cancer histories)

Progestogen-only Pills (POPs)

Type Brand examples Window Notes
Desogestrel POP Cerazette®, Cerelle®, Aizea®, Feanolla® 12-hour First-line POP; ovulation-inhibiting
DRSP POP Slinda® 24-hour 24/4; may help mood/acne in some
Traditional POP Noriday®, Norgeston® 3-hour More BTB; mucus-based

Good for: breastfeeding, migraine with aura, VTE risk, perimenopause, smokers ≥35, high BMI

Mirena and Other LNG-IUS

When to Use a 52 mg LNG-IUS (Mirena®, Benilexa®, Levosert®)

  • • Long-term contraception – 52 mg devices supported by FSRH for up to 8 years for contraception (check latest CEU statement)
  • • Heavy menstrual bleeding and dysmenorrhoea
  • • Endometrial protection with oestrogen HRT for 5 years

Key Comparison

Feature 52 mg LNG-IUS Lower-dose LNG-IUS (Kyleena®, Jaydess®)
Duration Up to 8 years (contraception) 3-5 years (device-specific)
Bleeding Often amenorrhoea/hypomenorrhoea Similar direction, smaller device
Extra indication HMB, HRT endometrial protection Contraception only
💡 Mnemonic: MIRENA – Menorrhagia, IUS, Reduces bleeding, Endometrial protection, Non-daily, Anaemia improves

Emergency Contraception (EC)

Method Brand examples Window Notes
Cu-IUD T-Safe, TT380 Up to 5 days after UPSI/ovulation Most effective; then ongoing contraception
Ulipristal acetate 30 mg ellaOne® Up to 120 h Delay CHC/POP 5 days; avoid with enzyme inducers
Levonorgestrel 1.5 mg Levonelle One Step®, Upostelle®, Emerres® Up to 72 h (sometimes 120 h) Less effective later and with high BMI
💡 Mnemonic: CU-UP-LEVO – CUpper coil, Ulipristal, LEVOnorgestrel (most → least effective)

Common Problems: Coils and Bleeding

Abdominal Pain After IUD/IUS - "PAINS"

  • • Period late / pregnancy symptoms → pregnancy/ectopic
  • • Abdominal pain severe/increasing → perforation or PID
  • • Infection signs → fever, discharge, dyspareunia
  • • Not feeling well → systemic illness/sepsis
  • • String changes → expulsion/malposition

Initial GP work-up: pregnancy test, STI tests, speculum (threads), bimanual if indicated, ultrasound/urgent gynae if concern

Bleeding Issues and Post-Pill-Change

Unscheduled bleeding is very common in first 3 months on a new hormonal method.

"BLEED" Approach
  • • Beginning – how long since start/change (≤3 months often watch-and-wait)
  • • Lapses – missed pills, late starts, vomiting/diarrhoea, interacting drugs
  • • Exclude pregnancy and STIs; check smear
  • • Examine – speculum if IMB/PCB, pain, red flags
  • • Decide – reassure vs change method vs investigate
Scenario Time Frame Usual Response
Spotting on new COC <3 months Reassure; check adherence; consider extended regimen
Persistent BTB on low-dose COC >3 months Consider higher EE or different progestogen (if UKMEC allows)
Irregular bleeding on POP/implant 3-6 months Reassure; consider NSAIDs or short COC overlay; change method if unacceptable

4️⃣ Preconception Care

Preconception Consultation Framework

Comprehensive assessment, risk stratification, establish care pathway, provide information and support. Ideally completed 3 months before conception.

Essential Components

  • • Medical history: chronic conditions (diabetes, hypertension, epilepsy, thyroid disease)
  • • Medication review: teratogenic drugs, safe alternatives
  • • Family history: genetic conditions, congenital abnormalities
  • • Lifestyle: smoking, alcohol, BMI, exercise, diet
  • • Immunization status: rubella, varicella, hepatitis B
  • • Cervical screening up to date
  • • Mental health assessment
  • • Occupational/environmental exposures
Key Message: Preconception care is about optimizing health before pregnancy to improve outcomes for both mother and baby.

Folic Acid Supplementation

Folic Acid Dosing: Start at least 1 month before conception and continue until 12 weeks gestation.
Risk Category Dose Indications
Standard Risk 400 mcg daily All women planning pregnancy
High Risk 5 mg daily BMI ≥30, diabetes, previous NTD, anti-epileptic drugs, sickle cell disease, thalassaemia, multiple pregnancy

Additional Considerations

  • • Continue until 12 weeks gestation (neural tube closure complete)
  • • Available over-the-counter (400mcg) or on prescription (5mg)
  • • Food sources: green leafy vegetables, fortified cereals, citrus fruits
  • • No upper limit for dietary folate, but supplement limit is 1mg/day unless high-risk

Medication Review & Optimization

Teratogenic Medications - STOP Before Conception: ACE inhibitors, ARBs, statins, warfarin, sodium valproate, isotretinoin, methotrexate, lithium (discuss with specialist).

Common Medication Switches

Condition Avoid Safe Alternative Notes
Hypertension ACE-I, ARBs Labetalol, nifedipine, methyldopa Switch before conception
Anticoagulation Warfarin LMWH (enoxaparin) Switch when planning pregnancy
Epilepsy Valproate Lamotrigine, levetiracetam Specialist advice essential
Diabetes Most oral agents Insulin (metformin OK) Optimize control pre-conception
Thyroid - Levothyroxine TSH <2.5 mIU/L target

Lifestyle Optimization

Factor Recommendation Rationale
Smoking Stop completely Reduces miscarriage, IUGR, preterm birth, SIDS
Alcohol Avoid completely No safe level - risk of fetal alcohol syndrome
BMI Aim 18.5-24.9 BMI ≥30: ↑ gestational diabetes, pre-eclampsia, stillbirth
Exercise 150 min/week moderate Improves outcomes, reduces GDM risk
Caffeine <200mg/day High intake linked to miscarriage, low birth weight
Vitamin D 10 mcg daily All women, especially high-risk groups

Additional Lifestyle Advice

  • • Diet: Balanced diet with plenty of fruits and vegetables
  • • Food safety: Avoid unpasteurized products, raw/undercooked meat, high-mercury fish
  • • Occupational hazards: Review workplace exposures (chemicals, radiation, infections)
  • • Stress management: Techniques to reduce stress and improve mental wellbeing
  • • Sleep hygiene: Adequate sleep (7-9 hours) for optimal health

5️⃣ Antenatal Care

Booking Appointment (<10 weeks)

First comprehensive antenatal appointment, ideally before 10 weeks gestation. Establishes baseline, identifies risk factors, and initiates care pathway.

History Taking

  • • Current pregnancy: LMP, EDD calculation, symptoms
  • • Obstetric history: Previous pregnancies, deliveries, complications
  • • Medical history: Chronic conditions, medications, allergies
  • • Family history: Genetic conditions, pregnancy complications
  • • Social history: Smoking, alcohol, drugs, domestic violence
  • • Mental health: Previous depression, current mood

Examinations & Tests

  • • General: Height, weight, BMI, blood pressure
  • • Abdominal: Palpation if >12 weeks
  • • Blood tests: FBC, blood group, infection screen
  • • Urine: Dipstick and culture
  • • Cervical screening: If due
  • • Dating scan: Arrange 10-14 weeks
Key Actions: Prescribe folic acid (if not already taking), discuss lifestyle advice, arrange dating scan, and provide pregnancy information booklet.

Routine Antenatal Schedule

Standard schedule for uncomplicated pregnancies. More frequent visits may be needed for high-risk pregnancies.

Gestation Visit Type Key Activities Tests/Scans
8-12 weeks Booking Full history, examination, risk assessment Booking bloods, urine culture
10-14 weeks Dating scan Confirm dates, viability, multiple pregnancy Dating USS, combined screening
16 weeks Midwife Review results, discuss screening Review blood results
18-20 weeks Anomaly scan Structural abnormalities, placental position Anomaly USS
25 weeks Midwife (primips) BP, urine, fundal height, fetal heart -
28 weeks Midwife BP, urine, fundal height, Anti-D if Rh- FBC, antibodies, GTT if indicated
31 weeks Midwife (primips) BP, urine, fundal height, presentation -
34 weeks Midwife BP, urine, fundal height, Anti-D if Rh- -
36 weeks Midwife BP, urine, fundal height, presentation FBC if previous anemia
38 weeks Midwife BP, urine, fundal height, birth planning -
40 weeks Midwife BP, urine, fundal height, discuss induction -
41 weeks Midwife Membrane sweep, induction planning CTG, AFI assessment

Antenatal Screening

Understanding Down's Syndrome

Down's syndrome is a genetic condition caused by an extra copy of chromosome 21. People with Down's syndrome have learning difficulties and may have associated health conditions, but many live fulfilling, independent lives. The chance of having a baby with Down's syndrome increases with maternal age, but babies with Down's syndrome are born to women of all ages.

Important: Use respectful language. Avoid terms like "defect," "abnormal gene," or "suffering from." Instead, use "has Down's syndrome" or "person with Down's syndrome."

Approximate Risk at Term by Maternal Age

Age 40
~1 in 100
Age 45
~1 in 50
Age 50
~1 in 10-15

Screening Tests (Non-invasive)

Test Timing Components Detection Rate False Positive Rate False Negative Rate
Combined Test 11-14 weeks NT + βhCG + PAPP-A + maternal age 85% 5% 15%
Quadruple Test 15-20 weeks AFP + βhCG + uE3 + inhibin A + maternal age 75% 5% 25%
NIPT (cfDNA) From 10 weeks Cell-free fetal DNA analysis >99% <0.5% <1%

Diagnostic (Definitive) Tests

Test Timing Method Accuracy Miscarriage Risk
CVS (Chorionic Villus Sampling) 10-13 weeks Transabdominal or transcervical needle biopsy of placental tissue >99% ~1 in 200-400
Amniocentesis 15-20 weeks Transabdominal needle aspiration of amniotic fluid >99% ~1 in 200-400
Key Points: Screening tests give a risk assessment, not a diagnosis. Diagnostic tests are definitive but carry a small miscarriage risk. All screening is optional and requires informed consent.

Common Antenatal Problems

Minor Symptoms

  • • Nausea/vomiting: Ginger, small frequent meals, antiemetics if severe
  • • Heartburn: Antacids, avoid spicy foods, sleep propped up
  • • Constipation: Increase fiber, fluids, exercise; lactulose if needed
  • • Hemorrhoids: Topical treatments, avoid straining
  • • Backache: Physiotherapy, support belts, paracetamol
  • • Leg cramps: Stretching, massage, magnesium supplements

Concerning Symptoms

  • • Vaginal bleeding: Always investigate - may indicate miscarriage, placental problems
  • • Severe headache: Rule out pre-eclampsia, especially if visual symptoms
  • • Abdominal pain: Consider ectopic, miscarriage, abruption, labor
  • • Reduced fetal movements: Urgent assessment required
  • • Persistent vomiting: May indicate hyperemesis gravidarum
  • • Urinary symptoms: UTI common in pregnancy, can lead to pyelonephritis

When to Refer Urgently

Same-day referral: Heavy bleeding, severe abdominal pain, signs of pre-eclampsia (BP >160/110 + proteinuria + symptoms), reduced fetal movements, suspected rupture of membranes <37 weeks.

6️⃣ Problems in Pregnancy

Miscarriage

Statistics by Age

1 in 4
pregnancies end in miscarriage
10%
risk at age 25
20%
risk at age 35
30%
risk at age 40
50%
risk at age 45

Types of Miscarriage

Type Bleeding Pain Cervix Management
Threatened Light Mild cramping Closed Expectant, pelvic rest
Inevitable Heavy Cramping Open Expectant or surgical
Incomplete Heavy, ongoing Severe cramping Open Surgical evacuation
Complete Settling Resolving Closed Follow-up βHCG
Missed None/minimal None Closed Expectant, medical, or surgical

GP Management

  • • Assessment: Bleeding amount, pain severity, vital signs
  • • Investigations: βHCG, FBC, blood group
  • • Referral: Same-day if heavy bleeding, severe pain, or hemodynamic compromise
  • • Support: Emotional support, information leaflets, follow-up
  • • Anti-D: Give if Rh-negative and bleeding >12 weeks

Pre-eclampsia

5%
pregnancies affected by pre-eclampsia
15%
recurrence risk if previous pre-eclampsia

Definition & Diagnosis

New-onset hypertension (≥140/90 mmHg) after 20 weeks gestation with proteinuria (≥300mg/24h or protein:creatinine ratio ≥30mg/mmol) or other maternal organ dysfunction.

Risk Factors
  • • First pregnancy, new partner, >10 years since last pregnancy
  • • Age >40 years, BMI >35, family history
  • • Previous pre-eclampsia, chronic hypertension, diabetes
  • • Multiple pregnancy, molar pregnancy
  • • Autoimmune conditions (SLE, antiphospholipid syndrome)

Clinical Features

Mild Pre-eclampsia
  • • BP 140-159/90-109 mmHg
  • • Proteinuria present
  • • Usually asymptomatic
  • • Normal reflexes
Severe Pre-eclampsia
  • • BP ≥160/110 mmHg
  • • Severe headache, visual disturbance
  • • RUQ/epigastric pain
  • • Hyperreflexia, clonus
  • • Oliguria, pulmonary edema

GP Management

  • • Monitoring: Regular BP checks, urine dipstick, symptom review
  • • Urgent referral if: BP ≥160/110, symptoms, proteinuria ≥2+
  • • Prevention: Low-dose aspirin 75mg from 12 weeks if high risk
  • • Education: Warning signs, when to seek help

Placenta Praevia

Definition & Classification

Placenta implanted in lower uterine segment, covering or close to internal cervical os. Incidence: 0.5% of pregnancies.

Grade Description Distance from Os Delivery Mode
Minor (Grade I-II) Low-lying placenta >2cm from os Vaginal delivery possible
Major (Grade III) Marginal praevia Reaches but doesn't cover os Usually cesarean
Major (Grade IV) Complete praevia Completely covers os Cesarean mandatory

Risk Factors

  • • Previous cesarean section or uterine surgery
  • • Multiparity, advanced maternal age
  • • Previous placenta praevia
  • • Multiple pregnancy, smoking
  • • Previous termination of pregnancy

Clinical Presentation

  • • Classic triad: Painless, bright red vaginal bleeding in third trimester
  • • Bleeding may be recurrent and increasingly severe
  • • Malpresentation (breech, transverse lie) common
  • • Uterus soft and non-tender
  • • Fetal heart usually normal unless severe hemorrhage

GP Management

NEVER perform vaginal examination if placenta praevia suspected - may precipitate massive hemorrhage.
  • • Immediate: ABC assessment, IV access, FBC, G&S, urgent obstetric referral
  • • Monitoring: Maternal vital signs, fetal heart rate
  • • Advice: Pelvic rest, avoid intercourse, report any bleeding
  • • Follow-up: Serial scans to monitor placental position

Placental Abruption

Definition & Incidence

Premature separation of normally implanted placenta from uterine wall after 20 weeks gestation. Incidence: 0.5-1% of pregnancies. Major cause of maternal and fetal morbidity/mortality.

Risk Factors

  • • Previous abruption (recurrence risk 10-15%)
  • • Hypertension (chronic or pregnancy-induced)
  • • Trauma (domestic violence, RTA)
  • • Smoking, cocaine use
  • • Polyhydramnios, multiple pregnancy
  • • Thrombophilia, advanced maternal age

Clinical Features

Revealed Abruption
  • • Vaginal bleeding (dark, clotted)
  • • Abdominal pain (constant, severe)
  • • Uterine tenderness
  • • Normal or slightly enlarged uterus
Concealed Abruption
  • • No visible bleeding
  • • Severe abdominal pain
  • • Woody, hard uterus
  • • Maternal shock out of proportion
  • • Fetal distress/death

GP Management

OBSTETRIC EMERGENCY: Call 999 for immediate transfer. Do not delay for investigations.
  • • Immediate: ABC, high-flow oxygen, IV access (2 large bore)
  • • Monitoring: Vital signs, fetal heart rate if viable gestation
  • • Investigations: FBC, coagulation, G&S, crossmatch
  • • Transfer: Blue light to obstetric unit with resuscitation facilities

Ectopic Pregnancy

1-2%
of pregnancies are ectopic
10%
recurrence risk after one ectopic

Risk Factors

  • • Previous ectopic pregnancy (strongest risk factor)
  • • Previous pelvic inflammatory disease
  • • Previous tubal surgery or sterilization
  • • IUD in situ (if pregnancy occurs)
  • • Assisted conception (IVF)
  • • Smoking, advanced maternal age

Clinical Presentation

Early/Unruptured
  • • Missed period, positive pregnancy test
  • • Unilateral pelvic pain (cramping)
  • • Vaginal bleeding (scanty, dark)
  • • Cervical excitation tenderness
  • • Adnexal mass may be palpable
Ruptured
  • • Sudden severe abdominal pain
  • • Shoulder tip pain (diaphragmatic irritation)
  • • Collapse, shock, pallor
  • • Tachycardia, hypotension
  • • Abdominal distension, guarding

GP Management

High Index of Suspicion: Any woman of reproductive age with abdominal pain + positive pregnancy test = ectopic until proven otherwise.
  • • Assessment: Vital signs, abdominal examination, pregnancy test
  • • Investigations: βHCG, FBC, blood group and save
  • • Referral: Same-day to early pregnancy unit or A&E if unstable
  • • Avoid: Vaginal examination if hemodynamically unstable
  • • Emergency: Call 999 if signs of rupture/shock

7️⃣ Postnatal Care

Postnatal Care Framework

Comprehensive care for mother and baby from birth to 6-8 weeks postpartum. Focus on physical recovery, mental health, infant feeding, and family adjustment.

Timeline of Care

Timing Provider Focus Key Assessments
Day 1-2 Midwife Initial recovery Vital signs, bleeding, feeding, baby checks
Day 3-5 Midwife Feeding establishment Breastfeeding, jaundice, weight loss
Day 5-7 Midwife Newborn screening Heel prick test, hearing screen
Day 10-14 Midwife/HV Ongoing support Feeding, mood, family adjustment
6-8 weeks GP Comprehensive review Physical recovery, mental health, contraception

Red Flags - When to Seek Urgent Help

Immediate referral: Heavy bleeding (>500ml or soaking pad hourly), signs of infection (fever, offensive discharge), severe headache, chest pain/breathlessness, calf pain/swelling, thoughts of self-harm.

6-8 Week Postnatal Check

Comprehensive assessment of maternal physical and mental health, contraceptive needs, and infant development. Opportunity to address concerns and plan ongoing care.

Maternal Assessment

  • • General wellbeing: Energy levels, sleep, appetite
  • • Physical recovery: Perineal healing, cesarean wound, lochia
  • • Breastfeeding: Establishment, problems, support needs
  • • Bladder/bowel: Continence, constipation
  • • Sexual health: Resumption of intercourse, dyspareunia
  • • Mental health: Mood, bonding, EPDS screening

Examinations & Tests

  • • Vital signs: Blood pressure, weight
  • • Abdominal: Uterine involution, cesarean scar
  • • Perineal: Healing, episiotomy/tear repair
  • • Cervical smear: If due (can delay 3 months post-delivery)
  • • Blood tests: FBC if anemic, TFTs if indicated
  • • Rubella immunity: If not immune, offer MMR

Infant Assessment

  • • Growth: Weight gain, feeding patterns
  • • Development: Social smile, head control, visual tracking
  • • Immunizations: 8-week vaccines due
  • • Screening results: Newborn bloodspot, hearing
  • • Safety: Safe sleeping, car seat use

Perinatal Mental Health

10-15%
postnatal depression rate
0.1-0.2%
postpartum psychosis incidence

Postnatal Depression

Risk Factors
  • • Previous depression/anxiety
  • • Poor social support
  • • Relationship problems
  • • Unplanned pregnancy
  • • Birth complications
  • • Breastfeeding difficulties
Symptoms
  • • Persistent low mood, anxiety
  • • Loss of interest, pleasure
  • • Fatigue, sleep disturbance
  • • Guilt, worthlessness
  • • Difficulty bonding with baby
  • • Thoughts of self-harm

Edinburgh Postnatal Depression Scale (EPDS)

10-item questionnaire screening tool. Score ≥13 suggests possible depression. Question 10 (self-harm thoughts) requires immediate assessment regardless of total score.

Screening Schedule: Offer EPDS at booking, 28 weeks, 6-8 weeks postnatal, and 3-4 months postnatal.

Management

Severity EPDS Score Management
Mild 10-12 Self-help, peer support, follow-up in 2 weeks
Moderate 13-17 Counseling, CBT, consider antidepressants
Severe ≥18 Urgent psychiatric referral, antidepressants
Self-harm risk Q10 positive Same-day psychiatric assessment

Postnatal Contraception

Fertility can return as early as 21 days postpartum. Contraception should be discussed before discharge and reviewed at 6-8 weeks.

Timing of Contraception

Method Breastfeeding Not Breastfeeding Notes
Condoms Immediately Immediately No hormonal effects
POP Immediately Day 21 Safe in breastfeeding
CHC 6 weeks (if not exclusive BF) Day 21 May reduce milk supply
Implant Immediately Day 21 3-year duration
IUD/IUS 48h or 4+ weeks 48h or 4+ weeks Avoid 48h-4 weeks (↑ perforation)
Sterilization Immediately or later Immediately or later Consider reversibility

Lactational Amenorrhea Method (LAM)

Natural contraception through breastfeeding. 98% effective if ALL criteria met:

  • • Exclusive breastfeeding (no supplements, minimal pacifier use)
  • • Amenorrheic (no periods since lochia stopped)
  • • Baby <6 months old
  • • Feeding frequency: ≤6 hours day, ≤4 hours night

Special Considerations

  • • Emergency contraception: Can be used while breastfeeding
  • • Copper IUD: Most effective emergency contraception, then ongoing use
  • • Return of fertility: Unpredictable, especially with mixed feeding
  • • Pregnancy spacing: Recommend 18-24 months between pregnancies
  • • Future fertility: Discuss family planning intentions

8️⃣ Fertility & Subfertility

Definition & Initial Assessment

1 in 7
couples affected by subfertility
84%
conceive within 1 year

Definition

Subfertility: Failure to conceive after 12 months of regular unprotected sexual intercourse (or 6 months if woman >35 years).

Primary: Never conceived before

Secondary: Previously conceived (regardless of outcome)

Initial History

Female Partner
  • • Age, duration of trying to conceive
  • • Menstrual history: cycle length, regularity
  • • Previous pregnancies, contraception history
  • • Medical history: PCOS, endometriosis, PID
  • • Surgical history: pelvic surgery
  • • Medications, allergies
  • • Lifestyle: BMI, smoking, alcohol, exercise
Male Partner
  • • Age, previous children
  • • Medical history: mumps, diabetes, cancer treatment
  • • Surgical history: hernia repair, vasectomy
  • • Medications: especially chemotherapy, steroids
  • • Occupational exposures: heat, chemicals
  • • Lifestyle: smoking, alcohol, drugs
  • • Sexual function: erectile dysfunction, frequency

General Advice

  • • Timing: Regular intercourse every 2-3 days throughout cycle
  • • Folic acid: 400mcg daily for women trying to conceive
  • • Lifestyle: Healthy BMI (19-25), stop smoking, limit alcohol
  • • Age factor: Female fertility declines significantly after 35
  • • Stress: Acknowledge impact but avoid blame

Fertility Investigations

Systematic approach to identify treatable causes. Investigate both partners simultaneously to avoid delays.

Female Investigations

Investigation Timing Purpose Normal Values
Day 21 Progesterone Day 21 of 28-day cycle (or 7 days before expected period) Confirm ovulation >30 nmol/L suggests ovulation
Day 2-5 Hormones Early follicular phase Assess ovarian reserve, exclude PCOS FSH <10 IU/L, LH:FSH ratio <2:1
AMH Any time Ovarian reserve Age-dependent (>15 pmol/L good)
Prolactin Any time Exclude hyperprolactinemia <500 mIU/L
TSH Any time Thyroid function 0.5-4.0 mIU/L
Rubella immunity Any time Vaccination if needed IgG positive

Male Investigations

Important Pre-Test Requirement:

A man must not masturbate or ejaculate for 2-7 days before the test.

If the sperm test is abnormal, YOU MUST REPEAT the test 3 months later. Not any earlier because it takes sperm about 75 days to regenerate.

Mild/moderate abnormality → repeat at 3 months (gold standard). Severe abnormality → repeat at 1 month.

Say to the patient: Sperm take about three months to develop. So if a test looks unusual, we repeat it after about 12 weeks to see if it’s a true pattern rather than just a temporary dip from illness or lifestyle.

Parameter Normal Range (WHO 2010) Clinical Significance
Volume ≥1.5 mL Ejaculatory duct obstruction if low
Concentration ≥15 million/mL Oligozoospermia if <15 million/mL
Total count ≥39 million Overall sperm production
Motility ≥40% motile Asthenozoospermia if <40%
Morphology ≥4% normal forms Teratozoospermia if <4%

Further Investigations

  • • Tubal patency: HSG or laparoscopy + dye test
  • • Pelvic ultrasound: Assess ovaries, uterus, exclude fibroids
  • • Genetic testing: If recurrent miscarriage or family history
  • • Sperm DNA fragmentation: If unexplained male factor
  • • Post-coital test: Rarely used now

Common Causes of Subfertility

45%
female factors
33%
male factors
20%
unexplained
10%
combined factors

Female Causes

Category Condition Prevalence Key Features
Ovulatory PCOS 20-25% Irregular cycles, hirsutism, obesity
Hypothalamic dysfunction 10% Low BMI, stress, excessive exercise
Premature ovarian failure 1% Age <40, high FSH, low AMH
Tubal PID/Chlamydia 12-15% History of STI, pelvic surgery
Endometriosis 5-10% Dysmenorrhea, deep dyspareunia
Uterine Fibroids 2-5% Heavy periods, pelvic pressure

Male Causes

Category Condition Prevalence Key Features
Sperm production Idiopathic oligospermia 60-70% No identifiable cause
Varicocele 15% Scrotal swelling, may be painful
Obstruction Vas deferens absence 1-2% Associated with CF gene mutations
Hormonal Hypogonadism 2-5% Low testosterone, small testes
Genetic Klinefelter syndrome <1% XXY karyotype, azoospermia

Unexplained Subfertility

Diagnosis of exclusion when all standard investigations are normal. May represent subtle abnormalities not detected by routine tests.

  • • Management: Expectant management initially, then ovulation induction
  • • Prognosis: 60% conceive naturally within 3 years
  • • Age factor: Prognosis worse with increasing female age

Referral Criteria & IVF

When to Refer

Scenario Timing Rationale
Woman aged <35 After 12 months trying Standard definition of subfertility
Woman aged ≥35 After 6 months trying Age-related fertility decline
Known fertility problems Before trying to conceive Optimize treatment before conception
Abnormal investigations As soon as identified Specialist assessment needed
Recurrent miscarriage After 3 consecutive losses Investigation for underlying causes

NHS IVF Criteria (England)

Criteria vary by CCG. General requirements include:

  • • Age: Woman typically 23-39 years (varies by area)
  • • Relationship: Stable relationship >2-3 years
  • • Previous children: Neither partner has living children (some areas)
  • • Lifestyle: Non-smoking, healthy BMI (19-30)
  • • Duration: Trying to conceive >2-3 years
  • • Medical: No reversible causes identified

IVF Success Rates

Age Group Live Birth Rate per Cycle Cumulative Rate (3 cycles)
Under 35 32% ~65%
35-37 25% ~55%
38-39 19% ~45%
40-42 11% ~30%
Over 42 5% ~15%

Alternative Options

  • • Donor gametes: Sperm, egg, or embryo donation
  • • Surrogacy: When woman cannot carry pregnancy
  • • Adoption: Alternative route to parenthood
  • • Counseling: Support for decision-making and coping

Ovarian Hyperstimulation Syndrome (OHSS)

Definition & Pathophysiology

Iatrogenic complication of ovulation induction, characterized by massive ovarian enlargement and increased capillary permeability leading to fluid shifts. Incidence: 1-5% of IVF cycles (severe form <1%).

Mechanism: Excessive response to gonadotropins → multiple follicle development → high estradiol and VEGF → increased vascular permeability → third-space fluid accumulation.

Risk Factors

Patient Factors
  • • Young age (<35 years)
  • • Low BMI
  • • PCOS
  • • High AMH levels
  • • Previous OHSS
  • • Pregnancy (especially multiple)
Treatment Factors
  • • High gonadotropin doses
  • • hCG trigger (vs GnRH agonist)
  • • Fresh embryo transfer
  • • Multiple follicles (>20)
  • • High estradiol levels

Classification & Clinical Features

Severity Ovarian Size Symptoms Complications
Mild 5-12 cm Abdominal bloating, mild pain None
Moderate >12 cm Nausea, vomiting, ascites Ultrasound evidence of ascites
Severe >12 cm Dyspnea, oliguria, tachycardia Hemoconcentration, hyponatremia, liver dysfunction
Critical >12 cm Severe dyspnea, anuria Thromboembolism, renal failure, ARDS

GP Management

Red Flags: Severe abdominal pain, breathlessness, reduced urine output, rapid weight gain (>1kg/day), calf pain/swelling. Urgent referral to fertility unit or A&E.
Mild OHSS
  • • Symptomatic treatment
  • • Adequate fluid intake
  • • Paracetamol for pain
  • • Daily weight monitoring
  • • Avoid strenuous activity
Moderate/Severe OHSS
  • • Urgent referral to fertility unit
  • • FBC, U&E, LFTs, coagulation
  • • Pelvic ultrasound
  • • Consider hospital admission
  • • Thromboprophylaxis

Prevention Strategies

  • • Risk assessment: AMH, antral follicle count, previous response
  • • Protocol modification: Lower starting doses, GnRH antagonist protocols
  • • Trigger alternatives: GnRH agonist instead of hCG
  • • Freeze-all strategy: Avoid fresh transfer in high-risk cycles
  • • Coasting: Withhold gonadotropins if high estradiol