F&C OSCE Notes_University of Manchester, WL Gan

Paediatrics OSCE Notes Assess the developmental milestones of this infant / child.

i. ii. iii. iv.

Gross motor Fine motor and vision Hearing, speech and language Social, emotional, behavioural development

Gross motor – observe general movement, inspect when lying supine, assess head lag when pulled to sit, assess sitting, ventral suspension and lying prone, assess legs ( knee sag, weight bears, bounces ) Fine motor – observe hands, offer toys / beads / pencil / cubes Ask about past medical history/family history/pregnancy and antenatal history/drug history. Address parent’s concern.

Walking is considered to be delayed if it has not been achieved by 18 months. Causes of delayed walking  bottom shuffler ( normal variant )  delayed motor maturation ( often familial )  severe learning disabilities ( dysmorphic features and hypotonia )  cerebral palsy ( hypertonia )  Duchenne's muscular dystrophy  hypotonia of any cause ( Down's syndrome, Prader-Willi syndrome, Trisomy 13 )  emotional deprivation or severe chronic illness. Causes of global developmental delay  prenatal – Down’s syndrome, hypothyroidism, alcohol, congenital infection, tuberous sclerosis  perinatal – hypoxic ischemic encephalopathy, hypoglycemia, hyperbilirubinaemia  postnatal – meningitis, encephalitis, hean injury, hypoglycemia, inborn errors of metabolism Features of cerebral palsy – delayed motor milestones, abnormal tone, persistence of primitive reflexes, abnormal gait, feeding difficulties, developmental delay eg. language, social

Cranial nerves examination       i. ii.    

CN I – test for smell CN II – direct and consensual pupillary reflexes to light, accommodation reflex, visual fields, red reflex CN III, IV, VI – tract eyes following an object through horizontal and vertical planes, check for squint and nystagmus CN V – clench teeth, move jaw side to side, check for face sensation ( ophthalmic, maxillary and mandibular ) CN VII – wrinkle forehead, close eyes tightly, show teeth, puff cheeks CN VIII – hearing ( normal AC > BC ) conductive deafness – Rinne : BC > AC and Weber test : louder on the affected side sensorineural deafness – Rinne : AC > BC and Weber test : louder on the normal side CN IX – levator palate; say ahh and look for palatal elevation, uvula deviation CN X – check for hoarseness of voice or stridor CN XI – trapezius and sternocleidomastoid muscle; shrug shoulders and turn head to both sides against resistance CN XII – stick out tongue and wiggle side to side, look for atrophy or deviation

The University of Manchester | W.L. Gan | 2012

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Assess the neurological function of the child.

General inspection – wasting ( LMN ), fasciculation ( LMN ), hypertrophy, Gower’s sign, gait ( ask the child to walk to the end of the room, turn round and return ), Erb’s palsy Broad based gait ( cerebellar disorder ), waddling gait ( proximal muscle weakness ) Tone – flexing and extending the wrists and elbows while pronating and supinating the forearm  Increased tone ( hypertonia ) – UMN  Decreased tone ( hypotonia ) – LMN Power – Upper limb i. Shoulder abduction – raise your elbows like wings, don’t let me push them down ii. Elbow flexion – bring your arms like a boxer, pull me towards you * stabilize the joint and compare both sides iii. Elbow extension – push me away iv. Finger extension – straighten your fingers and stop me from bending them when I push down v. Finger flexion – grab my fingers and squeeze them as hard as possible vi. Finger abduction – spread your finger wide apart and don’t let me push them together vii. Thumb abduction – raise your thumb to the ceiling and don’t let me push it down Lower limb i. ii. iii. iv. v. vi. vii.

Hip flexion – place hands on thigh, push up against my hand Hip extension – place hands under thigh, push down against my hand Knee flexion – bend child’s knee and place hand behind heel, bring your heel to your bottom Knee extensor – bend child’s knee, kick me away Ankle dorsiflexion – hold child’s medial and lateral malleoli with one hand, place ulnar part of other hand against dorsal aspect of foot, push against my hand Ankle plantarflexion – place ulnar part of hand against the plantar aspect of foot, push down against my hand Big toe extension – place finger against the big toe, push your toe against my finger

Power Grade 0 1 2 3 4 5

Description No contraction Flicker or trace of contraction Active movement with gravity eliminated Active movement against gravity Active movement against gravity and resistance Normal power

Reflexex – biceps, supinator, triceps, knee, ankle, Babinski test is not reliable in children  Hyperreflexia – UMN  Hyporeflexia – LMN Coordination Upper limb – finger nose test, dysdiadochokinesia Lower limb – heel shin test

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Sensation – light touch, vibration, proprioception Plot the height and weight on growth chart


Examine this child with asthma.

General inspection – height ( long-term steroid use ), nebulisers or inhalers, spacer device, oxygen mask, IV lines, audible wheeze or cough, respiratory rate, oxygen saturation Hands – tremor ( beta agonist use ), flexural eczema, pulse Face – central cyanosis, use of accessory muscle, tracheal tug, nasal flaring Neck – cervical lymphadenopathy ENT – inflamed tympanic membrane, nasal discharge, allergic rhinitis, inflamed pharynx or tonsils ( URTI ), oral thrush ( steroid inhaler ) Chest Inspection – subcostal/intercostal recession, Harrison’s sulcus Palpation – chest expansion ( ↓ in pneumothorax, collapse ), tracheal deviation Percussion Auscultation – breath sounds, wheeze, crackles Abdomen – palpable liver edge ( hyperinflated chest ) Plot the height and weight on growth chart Investigations - peak flow, spirometer, skin prick for atopy, bronchial responsiveness / challenge Management of acute asthma 1. High flow oxygen 2. Salbutamol + Ipratropium bromide via volumetric spacer or nebulisers 3. Oral prednisolone or IV hydrocortisone 4. IV salbutamol ( bolus then infusion ) or aminophylline infusion 5. IV magnesium sulfate 6. If not responding ( <92% oxygen saturation ) or any life threatening features present, discuss with PICU for ventilatory support Management of chronic asthma 1. Avoid precipitants, ensure good inhaler techniques, check compliance, review treatment every 3-6 mo, rescue prednisolone in acute deterioration 2. Start preventer inhaler when symptomatic/use of salbutamol inhalers ≥ 3 times/week, waking one night/week, frequent exacerbations 3. Children < 5 yr – IH SABA – IH steroid – LRA – respiratory paediatrician 4. Children > 5 yr – IH SABA – IH steroid – IH LABA – oral theophylline or LRA – ↑ IH steroid – oral steroids

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Examine this child with cystic fibrosis. General inspection – nutritional status, sputum pot, nebulisers or inhalers, oxygen mask, medications ( Creon ), audible wheeze or cough, respiratory rate Hands – finger clubbing, peripheral cyanosis, tremor ( beta agonist use ), palmar erythema ( CF related liver disease ), pulse Face – central cyanosis, use of accessory muscle, tracheal tug, nasal flaring, nasal polyps Chest Inspection – portacath for IV access, subcostal/intercostal recession Palpation – chest expansion, tracheal deviation Percussion Auscultation – breath sounds, crackles Abdomen – Inspection - gastrostomy, scar ( surgery for meconium ileus ), insulin injection sites ( CF related DM ) Palpation – RIF mass ( distal intestinal obstruction syndrome ), hepatomegaly ( CF related liver disease ), spleen ( portal hypertension ) Plot the height and weight on growth chart Investigations a. Newborn screening ( immunoreactive trypsinogen ) b. Sweat test ( Cl- > 60mmol/L ) – gold standard c. Genotype

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Cardiovascular examination of a child. General inspection – respiratory distress, respiratory rate, sweating, ECG, oxygen mask Hands – finger clubbing ( cyanotic congenital heart disease ), peripheral cyanosis, splinter hemorrhages, Janeway lesions, Osler nodes, erythema and peeling of the palms ( Kawasaki disease ), pulse ( check for rate, rhythm, character eg. collapsing pulse, slow rising pulse, radio-radio delay – aortic dissection, radio-femoral delay – coarctation of aorta ), blood pressure Face – conjunctival pallor, conjunctivitis ( Kawasaki disease ), central cyanosis, malar flush ( mitral stenosis ), high arched palate ( Marfan syndrome – aortic dissection, aortic aneurysm, mitral valve prolapse, aortic regurgitation ), erythematous mucous membrane and red tongue ( Kawasaki disease ), dental hygiene ( IE ), dysmorphic features ( Down’ syndrome, Turner’s syndrome ) Neck – JVP often difficult to assess in children Chest Inspection – midline sternostomy scar, visible pulsation at the apex beat Palpation – apex beat, thrills, parasternal heave Auscultation – first and second heart sound, added heart sound, listen and time the murmur at mitral, tricuspid, pulmonary, aortic regions while palpating the carotid pulse Back Auscultate lung bases for crackles and radiation of murmur ( coarctation of aorta ), check for sacral edema Abdomen – check for hepatomegaly, femoral pulse Legs – check for peripheral edema Plot the height and weight on growth chart

Innocent murmur Systolic Soft in intensity grade 1 to 3 Localised, no radiation, poorly conducted Variable in position and respiration No other cardiovascular signs and symptoms

Pathological murmur Any diastolic Loud in intensity grade 4 to 6 Conducted all over precordium Thrill present Associated cardiovascular signs and symptoms

Cardiac disorder Atrial septal defect

Physical Signs Fixed and widely split second heart sound, ejection systolic murmur at upper left sternal edge Thrill at lower sternal edge, pansystolic murmur at lower left sternal edge Radio-femoral delay, ejection systolic murmur at infraclavicular area and under left scapula Clubbing, harsh ejection systolic murmur at left sternal edge Neonatal cyanosis, no murmur Continuous, machinery murmur at left upper chest, thrill at left infraclavicular region

Ventricular septal defect Coarctation of aorta Tetralogy of Fallot Transposition of great arteries Patent ductus arteriosus


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Abdominal examination of a child.

General inspection – nutritional status ( malabsorption ), neurological status ( dehydration ), vomit bowl, nasogastric tube, catheterisation, is the child drinking and eating Hands – finger clubbing (inflammatory bowel disease, chronic liver disease), leukonychia (hypoalbuminemia), koilonychia (iron deficiency anemia), capillary refill, pulse, purpura, palmar erythema (liver disease), skin turgor (dehydration) Face – conjunctival pallor and jaundice, angular stomatitis ( iron deficiency anemia ), glossitis ( B12 deficiency ), mouth ulcer ( Crohn’s disease, Coeliac disease ), cleft palate, periorbital edema ( nephrotic syndrome ), sunken orbits ( dehydration ) Abdomen Inspection – abdominal distension, swelling, scar, distended veins, rash, gastrostomy tube, stoma bag, visible peristalsis Palpation – light and deep palpation for any mass, tenderness, rebound tenderness, guarding; assess for hepatomegaly and splenomegaly, ballot the kidneys Percussion – hepatomegaly and splenomegaly, bladder distension Auscultation – bowel sounds, renal bruit, femoral bruit Examine the external genitalia and hernia orifices. Perform urine dipstick. Plot height and weight on growth chart.

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Examination of Newborn

i. ii.

General posture and movement, skin colour ( cyanosis, pallor, jaundice ), birthmarks, eyes for size and squint Cranium – head circumference ( maximum occipital-frontal circumference normal 33-37cm ), skull shape ( doliococephaly / scaphocephaly – premature infants, brachycephaly – Down’s ), fontanelle size ( anterior 4cmx4cm – closure 9 to 18 mo; posterior 1cmx1cm – closure 6 to 8 wk ), head trauma ( caput succedaneum – poorly demarcated soft tissue swelling that crosses suture lines; cephalhematoma – well demarcated soft tissue swelling that does not crosses suture lines ) iii. Ears – position, external meatus patency, pre/post auricular skin tags iv. Face – dysmorphism, nose – cloanal atresia, chin size ( Pierre-Robin sequence – micrognathia, glossoptosis, cleft palate ) v. Neck – movement, clavicular fractures, neck mass ( thyroglossal duct cyst, vascular malformation, abnormal lymphatic tissue, dermoid cyst ) vi. Chest – shape, symmetry, RR, respiratory effort ( intercostal recession, subcostal recession, sternal recession ), apex beat, listen to the heart and lungs vii. Abdomen – shape ( scaphoid abdomen suggests the presence of congenital diaphragmatic hernia ), umbilical stump, inguinal hernia, palpate for liver – normal up to 2cm below costal margin, spleen – normal up to 1cm palpable, kidney, bladder, check absent femoral pulse for coarctation of aorta viii. Genitalia – clitoris and labia ( girls ), position of urinary meatus – hypospadias ( ventral ), epispadias ( dorsal ), descended testes ( boys ) ix. Back – patency of anus ( imperforate anus ), spine – scoliosis, kyphosis, sacral naevi/dimple/hair patch/lipoma/pigmentation ( spina bifida occulta ) x. Limbs – missing/extra digits or toes, palmar creases ( 2% normal or Down syndrome ), developmental dysplasia of the hip ( Barlow and Ortolani manoeuvre ), talipes equino varus xi. Check for tone during handling and ventral suspension (baby should be able to hold head almost horizontally), hypotonia – head lag, slips through on upright position, like ‘rag doll’ on ventral suspension, total hip abduction xii. Check absent red reflex for congenital cataract and retinoblastoma xiii. Primitive reflexes ( should be disappeared by the end of 6 months ) a. Palmar grasp b. Plantar grasp c. Moro reflex d. Rooting reflex e. Asymmetrical tonic neck reflex f. Placing reflex xiv. Head circumference, length and weight measurement and plotting on growth chart Macrocephaly ( >98th centile ) – familial, hydrocephalus, achondroplasia, neurofibromatosis Microcephaly ( <2nd centile ) - fetal alcohol syndrome, Trisomy 13 and 18, CMV, craniosynostosis Delayed closure of fontanelle – hypothyroidism, malnutrition, hydrocephalus, rickets, osteogenesis imperfect, Trisomy 13, 18, and 21 Guthrie test – heel prick on Day 5 to 9 of life 1. Phenylketonuria ( ↑phenylalanine level ) 2. Congenital hypothyroidism ( ↓TSH level ) 3. Sickle cell anemia/thalassemia ( peripheral blood film ) 4. Cystic fibrosis ( immunoreactive typsin ) 5. MCAD ( inborn error of mitochondrial fatty acid metabolism )


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Child psychiatry history 1.

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3. 4. 5. a. b. c. d.

Symptoms i. Emotional symptoms ii. Conduct problems iii. Developmental delays iv. Relationship difficulties Impact i. Social impairment – family life, classroom learning, friendships, leisure activities ii. Distress for the child iii. Disruption of others Risk factors – predisposing factor, precipitating factor, perpetuating factor Strengths – protective factors Parents’ expectations and beliefs Presenting complaint + review of other symptoms ( emotions, conduct, attention and activity, somatic – sleeping, appetite, bladder, bowel, pains ) Current functioning – typical day’s activities, social relationships with friends and siblings Family history – family tree ( medical and psychiatry history ), parents’ relationship, circumstances ( housing, social services ) Personal history – birth and infancy, milestones, schools ( academic and social functioning ), physical health Establish what happened “Would you mind telling me a little bit about what’s been happening over the last few days?” “So if you don’t mind, I’d like to talk about what happened today”

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Mood "How do you feel most days?" Suicidal thoughts "Do you have any thoughts of wanting to harm or kill yourself?" "Do you have any thoughts that you would be better off dead?" Before attempt – was it planned or was it just impulsive ? suicide notes ? During attempt – what was used ? if pills, how much ? when and where did you get the pills from ? what did you think this would do ? did you think that would be enough to end your life ? After attempt – how did you get to the hospital ? how do you feel now ? do you regret it ? do you wish you would have succeeded ? how do you feel about the future ? what would stop you from acting on these thoughts ? what would help you cope with these problems ?

What to do if a patient expresses suicidal ideation     

Form a good relationship, be empathic and reassure regarding confidentiality. Assess suicidal risk Assess current mental health or physical health difficulties. Determine any support networks available to the patient. Determine risk of further harm or suicide: o History and details of any attempt or are they making plans. o What was/is the intent and are there any precipitating factors, e.g. recent bereavement. o Previous attempts at suicide or deliberate self-harm. o Use of illicit drugs or alcohol dependence. o Social circumstances. o Any concurrent mental health issues, e.g. depression.


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Management after initial assessment  If the patient is at low risk then they should be offered regular contact and counselling. You may need to consider referral to local Child and Adolescent Mental Health Services ( CAMHS ) for further follow-up.  If there are concerns about patient safety or the patient scores highly on the suicide risk score the patient should be referred for urgent mental health assessment. If you are unsure then seek advice from mental health specialists.  If a patient refuses help then a decision regarding their capacity may need to be made with psychiatric evaluation and detention under the Mental Capacity Act considered. Depression Symptoms of depression include the following:            

Persistently sad, anxious, or empty moods Loss of pleasure in usual activities (anhedonia) Feelings of helplessness, guilt, or worthlessness Crying, hopelessness, or persistent pessimism Fatigue or decreased energy Loss of memory, concentration, or decision-making capability Restlessness, irritability Sleep disturbances Change in appetite or weight Physical symptoms that defy diagnosis and do not respond to treatment (especially pain and gastrointestinal complaints) Thoughts of suicide, death, or suicide attempts Poor self-image or self-esteem

To establish the diagnosis of major depression, a patient must express one of the first 2 items above and at least 5 of the other symptoms listed. Such disturbances must be present nearly daily for at least 2 weeks.

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Oppositional Defiant Disorder – 6 month history of 4 of the following: Often loses temper Often argues with adults Often defies adult requests or rules Often deliberately annoys others Often shifts blame to others Often angry and resentful Conduct Disorder - 12 month history of at least 3 of the following: Often bullies, threatens or intimidates Often starts fights Has used weapons in fights Physically cruel to people Physically cruel to animals Stealing with force Fire setting Destruction of property Running away from home Truanting

Comorbidity o o o o o o

Generalised and/or specific learning disability Attention deficit hyperactivity disorder (ADHD) Emotional disorders (depression/anxiety) Substance misuse Poor achievement in school Poor interpersonal relationships with peers and adults

Management 

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Child o o

Treat any co-morbid disorder e.g ADHD/depression Individual work - problem-solving skills training to improve anger management and develop better coping strategies Group work - social skills training if difficulties with peer relationships

o Family o Parent management training o Family Therapy – to understand and change family dynamics that may be contributing factors to presentation and difficulties in management School o School liaison regarding any learning difficulties and strategies to manage behaviour

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Classic autism 1.Impairment of social communication: o The child:  Does not develop speech (or other effective means of communicating), or may have speech but regress.  May repeat learned phrases parrot fashion (echolalia), often inappropriately.  Has poor conversation skills such as turn-taking, volume control and listening.  Will only talk about a few favourite subjects.  Finds abstract concepts (such as time) very difficult.12 2.Impairment of social relationships: o The child:  May not like cuddles as a baby.  May not imitate people.  May not develop peer friendships easily.  Doesn't want to share interest with others.  Demonstrates little or no eye contact.  Seems happy to be alone and doesn't appear to recognise the feelings of others with an associated lack of empathy. 3.Impairment of imaginative thought: o Play may be obsessive, with a limited number of toys, in a repetitive and unusual way. The child may order or line them up and may spin the wheels of scooters or cars rather than ride them. o Only certain foods are tolerated. o A set routine is when the child is at his or her most comfortable. o Inflexibility in thought and behaviour may be shown. o Bizarre motor movements are repeated, e.g. hand flapping, spinning, rocking.

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The DSM-IV diagnostic criteria for attention deficit hyperactivity disorder 1.Either 1 or 2 (six of the nine symptoms in each section must be present for a 'combined type' diagnosis of attention deficit hyperactivity disorder (ADHD):1 o Inattention: at least six of the following symptoms persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:  Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities.  Often has difficulty sustaining attention in tasks or play activities.  Often does not seem to listen to what is being said to him or her.  Often does not follow through on instructions and fails to finish schoolwork chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).  Often has difficulty organising tasks or activities.  Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort.  Often loses things necessary for tasks or activities, e.g. school assignments, pencils, books, tools or toys.  Often easily distracted by extraneous stimuli.  Often forgetful in daily activities. o Hyperactivity/impulsivity: at least six of the following symptoms of hyperactivity or impulsivity for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:  Hyperactivity:  Often fidgets with hands or feet and squirms in seat.  Leaves seat in classroom or in other situations in which children are expected to remain seated.  Often runs about or climbs excessively in inappropriate situations (in adolescents or adults this may be limited to feelings of restlessness).  Often has difficulty playing or engaging in leisure activities quietly.  Is often on the go or often acts as if driven by a motor.  Often talks excessively.  Impulsivity:  Often blurts out answers to questions before the questions have been completed.  Often has difficulty waiting in line or awaiting his or her turn in games or group situations.  Often interrupts or intrudes on others. 2.Some hyperactive-impulsive or inattentive symptoms that caused impairment should be present before age 7 years. 3.Some impairment from symptoms must be present in two or more settings (e.g. at school or work and at home). 4.There must be clear evidence of significant impairment in social, school or work functioning. 5.The symptoms should not happen only during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder. The symptoms should not be better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

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Explanation / Counseling   

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Introduction Confidentiality Purpose of consultation o Explain a medical condition  What is Down’s syndrome ?  What causes Down’s syndrome ?  What are the implications of having a child with Down’s syndrome ?  What can we do to help your child ? o Explain a procedure/test  What is an amniocentesis ?  Why do you need an amniocentesis ?  What are the benefits and risks of having an amniocentesis ?  How would the test be carried out ?  What do you need to prepare for the test ?  When can you be informed of the result ? o Discuss management plan  What is a breech presentation ?  What are the delivery options for breech presentation ?  What are the benefits and risks associated with each option ? o Discuss test result  Why do you had the cervical screening test ?  What does the result severe dyskaryosis mean ?  What are the implications of having severe dyskaryosis smear result?  What can we do to help you ? Patient’s idea and expectation  How much do you know about Down’s syndrome ?  What do you hope to get out from this conversation today ?  Are these the issues that you would like to discuss today ? Check understanding  I have explained to you what Down’s syndrome is and the implications of having a child with Down’s syndrome. Does everything make sense to you ? Do you have anything to clarify or any question to ask so far ? Address concerns  Will my next child have Down’s syndrome ?  Can my child live an independent life in the future ? Provide resources  Patient leaflet/website  Non-governmental organisations eg Down’s Syndrome Association, Cystic Fibrosis Trust

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Down’s syndrome.      

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Down's syndrome is a life-long condition that causes delays in learning and development. Down's syndrome occurs because your baby's cells contain an extra chromosome 21. Down's syndrome is never anyone's fault; it just happens. It has never been linked with particular foods or actions or pollution, it occurs in all races and religions. Whatever else you may feel at this time, don't feel guilty. About 1 in 1,000 babies born in the UK have Down's syndrome People with Down’s syndrome tend to have a number of typical physical features. These include eyes that slant upwards, small ears, small mouth with protruding tongue, flattened nose bridge or vertical skin folds (epicanthic folds) between the upper eyelids and inner corner of the eye. Everyone with Down's syndrome will have some degree of learning difficulty. However, the level varies from person-to-person and some are more severely affected than others. Delayed speech development and delay in motor development (sitting, crawling, walking, potty training, etc) can occur. Your child will eventually learn to do all of these things but they may just take longer than a child who does not have Down's syndrome. Someone with Down's syndrome will tend to have a lower than average intelligence quotient (IQ). A number of health problems are linked to Down’s syndrome. But again, people vary, and some people with Down’s syndrome enjoy good health. Problems which are linked with Down’s syndrome include heart problems and reduced hearing and vision. Many of the problems can be treated, and frequent health checks can make sure that any problems are picked up as early as possible. Most people with Down’s syndrome live to be 50 years of age and some live to be over 70. Alzheimer’s disease (a form of senile dementia) may affect people with Down’s syndrome at an earlier age than other people. The causes of Down’s syndrome are unclear, but the single biggest risk factor for the condition seems to be the age at which a woman gives birth. The older a woman is when she has a baby, the higher the risk of her baby having Down’s syndrome. The greatest risk (1 in 30) is associated with women who are 45 years of age or over. Having said that, most Down's syndrome babies are born to younger women. This is because younger women more commonly have babies than older women. There is no cure for Down's syndrome. It will affect someone throughout their life. With help and support, those with Down’s syndrome can live an active and independent life. Antenatal screening cannot diagnose conditions such as Down’s syndrome, but it can determine the likelihood of your baby developing the syndrome. The test often includes a blood test and an ultrasound scan. Most women are screened between weeks 11 to 13. If your screening result shows that you are at a higher risk then you will be offered a diagnostic test. i.

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Chorionic villus sampling involves removing a small piece of tissue from the placenta. It can be done between weeks 11 and 13. It is estimated that approximately 2 in every 100 woman will have a miscarriage after having the CVS. ii. Amniocentesis involves using a fine needle to remove a small amount of the amniotic fluid around the unborn baby. It can be done between weeks 15 and 18. It is estimated that approximately 1 in every 100 woman will have a miscarriage after having the amniocentesis. A small number of women who have a diagnostic test will learn that their baby has Down’s syndrome. They have three options and it is entirely the parents’ decision which they choose. Options include continue with the pregnancy, make plan and prepare for the challenge that they might face brining up a child with Down’s syndrome, adoption or termination. Early intervention programmes from birth are important for a baby born with Down's syndrome. Such programmes can include speech and language therapy, physiotherapy, etc. They can help with the learning and development of a child with Down's syndrome. The earlier that such help and care is given for any problems, the better the long-term outcome is likely to be and the more likely that person is to reach their full potential. While some children with Down's syndrome may need to go to a school that caters for their special needs, many are able to go to a mainstream school. Likewise, as they get older, many people with Down's syndrome are able to cope with some kind of job. People with Down's syndrome are also able to make friends and have relationships. Having a baby with Down's syndrome can be a difficult thing for some parents to cope with. However, you should never feel that you are alone. Great support and advice for parents who have a child with Down's syndrome is available through the Down's Syndrome Association.


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Turner syndrome.

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Turner syndrome is a genetic condition that only affects females. It is caused by an abnormal sex chromosome and affects about 1 in every 2,000 baby girls. Most females are born with two X chromosomes. Turner syndrome occurs when one of the X chromosomes is completely or partially missing. At puberty, a girl with Turner syndrome will not have the normal growth spurt. Puberty usually happens in girls aged between eight and thirteen. Without treatment, someone with Turner syndrome will usually grow to around 136-147cm. Growth hormone therapy should be given to a girl with Turner syndrome as soon as it becomes obvious that she is not growing normally. It will help to prevent short height during adulthood. During puberty, a girl's ovaries usually begin to produce the sex hormones oestrogen and progesterone. However, most girls who have Turner syndrome will not produce these sex hormones, which means that they may not start their periods naturally as other girls do, may not fully develop breasts or may be infertile (unable to conceive a baby) Even though many women with Turner syndrome have undeveloped ovaries and are infertile, with hormone replacement therapy their vagina and womb may develop normally. This will mean they are able to have a normal sex life. Other characteristics include a particularly short, wide neck (webbed neck) , a broad chest and widely spaced nipples, arms that turn out slightly at the elbows, a low hairline, spoon-shaped nails, a short fourth finger or toe, low set ears, downwards slanting eyes Other associated problems include hypothyroidism, osteoporosis, scoliosis, hypertension, diabetes mellitus, glue ears, cataract, squint, urinary tract infections Most girls with Turner syndrome have good language and reading skills. However, they might face problems with social intelligence, problems with spatial awareness and numeracy and attention and hyperactivity problems Turner syndrome is sometimes suspected in pregnancy during a routine ultrasound scan. This is a procedure that uses high frequency sound waves to create an image of the developing baby. Lymphoedema, a condition that causes swelling of the body’s tissues, can affect unborn babies with Turner syndrome and may be visible on an ultrasound scan. If Turner syndrome is suspected, the diagnosis may be confirmed with a further test such as chorionic villus sampling, where a sample of cells taken from the is tested for genetic conditions or amniocentesis, where a sample of amniotic fluid is tested for genetic conditions

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Cystic fibrosis.   

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About 1 in 2500 babies in the UK are born with cystic fibrosis. Cystic fibrosis is an autosomal recessive disorder. This means that in order to develop cystic fibrosis you need to inherit two cystic fibrosis genes, one from your mother and one from your father. Around 1 in 25 people in the UK are carriers of the cystic fibrosis gene. Carriers do not have the disease as they have one normal gene which can control the salt transport in their cells. But carriers can pass the cystic fibrosis gene on to their children. When two people who carry the cystic fibrosis gene have a child, there is a: i. 1 in 4 chance that the child will have CF ii. 2 in 4 chance that the child will not have CF, but will be a carrier iii. 1 in 4 chance that the child will not have CF, and will not be a carrier Cystic fibrosis is a genetic disorder caused by a faulty gene that controls the movement of salt and water in and out of cells in the body. It affects mainly the lungs and the digestive system. In CF, thick and sticky mucus clogs up many of the body's tubes, ducts and passageways so they cannot work properly. In the lungs, this leads to frequent and severe infections. Symptoms usually begin in early childhood and include persistent cough, wheeze, repeated chest infections, malabsorption of food, and general ill health. People with cystic fibrosis should be treated with help and advice from a team of healthcare professionals at a cystic fibrosis centre. With regular visits, the patient or parent can learn how to best manage the condition. As each case is different, they can receive tailored care for their or their child's condition. There is no cure for cystic fibrosis. The aim of treatment is to ease the symptoms and make the condition easier to live with. It can also prevent or reduce the long-term damage caused by infections and other complications. Management – antibiotics, bronchodilators, pancreatic enzymes, fat-soluble vitamin supplements, mucus thinning enzyme, physiotherapy, vaccinations In virtually all men with cystic fibrosis, the tubes that carry sperm do not develop correctly, making them infertile. Women with cystic fibrosis may find that their menstrual cycle becomes absent or irregular if they are underweight. There is also an increased thickness of cervical mucus, which may reduce fertility. However, most women with cystic fibrosis can become pregnant without any difficulty. Cystic Fibrosis Trust provides information and support for people with cystic fibrosis and their carers.

16


Phenylketonuria.

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Phenylketonuria (PKU) is a rare genetic condition that is present from birth. In most people the phenylalanine that is found in food is broken down by an enzyme known as phenylalanine hydroxylase (PAH). In people with PKU, the PAH enzyme does not work properly due to the genetic mutation. As a result, the phenylalanine levels in the blood and other tissues rise. Phenylalanine is thought to have a toxic effect on the brain, resulting in brain damage and learning difficulties. The main source of phenylalanine for humans is food that is high in protein such us meat, fish, eggs, cheese and milk All newborn babies who are born in the UK, and those who are born in other developed countries, are routinely screened for high phenylalanine levels using the heel prick test which is carried out during the first week of a baby’s life. If a high phenylalanine level is found on screening and confirmed by further testing, the baby will immediately be started on a low protein diet and a special supplements which contain all the essential nutrients that are absent from the low protein diet.. Regular testing ensures that the phenylalanine level remains low. Keeping phenylalanine levels within the target range will prevent any damage to the brain and ensure that the child grows up with normal levels of intelligence. Usually, the longer treatment is delayed, the more severe the learning disability becomes. Other symptoms of untreated PKU include behavioural difficulties, such as frequent temper tantrums and episodes of self-harm, very fair skin and hair, eczema and fits. People with PKU also have to avoid food products that contain aspartame. Aspartame is an artificial sweetener that can be found in sugar substitutes, such as artificial sweeteners that are often used in tea and coffee, diet versions of fizzy drinks, chewing gum. All food products that contain aspartame or a related product should state on the packet ‘contains a source of phenylalanine’. All the genes in your body come in pairs. You receive one half of the pair from your mother and the other half from your father. The mutation that causes PKU is an autosomal recessive mutation. This means that you need to receive two copies of the mutated gene in order to develop the condition - one from your mother and one from your father. You will not develop PKU if you only receive one copy of the mutated gene from one of your parents, but you will carry the mutated gene. If you are a carrier of the mutated gene and you conceive a baby with a partner who is also a carrier there is a: i. 1 in 4 chance that the baby will receive a pair of normal genes ii. 1 in 2 chance that the baby will receive one normal gene and one mutated gene and become a carrier of the mutated PAH1 gene but will not develop any symptoms. iii. 1 in 4 chance that the baby will receive a pair of mutated genes and develop PKU

17


Marfan’s Syndrome    

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Marfan's syndrome can affect connective tissue in different parts of your body including your heart, blood vessels, eyes and skeleton. It can affect different people in different ways and to different degrees. Some people with Marfan's syndrome are only mildly affected while others are more severely affected. Marfan's syndrome is thought to affect about 1 in 3,300 people. It affects both males and females equally. You can inherit Marfan's syndrome from just one of your parents. It is known as an autosomal dominant disorder - only one of your parents needs to have the gene mutation to pass it on to you. If you have Marfan's syndrome, for each child that you have, there is a 50:50 chance that they will also have Marfan's syndrome. Marfan's syndrome can make the wall of your aorta, the main artery in your body, weak. Your aorta runs from your heart, through the centre of your chest, and then through the centre of your abdomen. It then divides into branches that supply blood to your legs. Because the walls of the aorta are weak, it can widen or 'bulge out'. This is known as an aneurysm. About 7-8 out of 10 people with Marfan's syndrome have widening of the aorta. In severe cases, the widened aorta can tear or rupture. This can cause severe internal bleeding and possible death. If you have Marfan's syndrome you will generally be taller and thinner than other members of your family without Marfan's syndrome. You may have hypermobile joints. This means that your joints are very loose and flexible. More than 6 out of 10 people with Marfan's syndrome have scoliosis. This is where you have lateral (sideways) curvature of your backbone. It can lead to back pain and deformity. About half of people with Marfan's syndrome have lens dislocation. This means that your lens within your eye moves, or falls, into an abnormal position. There is no cure for Marfan's syndrome. However, various treatments are available to help with the problems that Marfan's syndrome causes. Because Marfan's syndrome may affect different parts of your body, you may have follow-up with a number of different specialists. For example, a cardiologist (heart specialist), an ophthalmologist (eye specialist), an orthopaedic surgeon (bone and joint specialist), a geneticist (a specialist in genetic problems), etc. The fact that Marfan's syndrome can affect your heart is the major risk associated with Marfan's syndrome. If heart problems are left untreated, they can lead to death in some cases. For this reason, it is important that Marfan's syndrome is recognised early so that you can have continuous monitoring, especially of any heart problems, and treatment can be carried out to avoid complications such as aortic rupture or tearing. Rarely, eye problems related to Marfan's syndrome can lead to loss of vision.

18


Duchenne Muscular Dystrophy    

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Duchenne's muscular dystrophy (DMD) is a genetic condition which affects the muscles, causing muscle weakness. It is a serious condition which starts in early childhood. About 1 in 3,500 boys in the UK are born with DMD. Muscles contain a protein (chemical) called dystrophin, which is necessary for muscles to function properly. People with DMD have a shortage of dystrophin in their muscles. The lack of dystrophin leads to muscle fibre damage and a gradual weakening of the muscles. The shortage of dystrophin is caused by a faulty gene. DMD is inherited in a pattern called 'X-linked inheritance'. The DMD gene is 'carried' by women, but does not usually cause problems in girls or women. This is because of there being two X chromosomes in women: one X chromosome has the 'faulty' DMD gene, and the other X chromosome has a normal gene, which compensates for the faulty one. In contrast, boys with the DMD gene do not have a second X chromosome and so they cannot compensate for the faulty gene. Therefore, boys with the DMD gene always have symptoms of the disease. The DMD gene can be passed on from parent to child. For a woman who carries the DMD gene, there is a 1 in 2 chance that her sons will have DMD, and a 1 in 2 chance that her daughters will carry the gene. The symptoms usually start around age 1-3 years. Parents may notice their child having difficulty with walking, running, jumping and climbing stairs. The boy may be late in starting to walk. Some boys with DMD also have a learning difficulty. Usually this is not severe. DMD is a very serious condition and it does shorten life. Because the muscle weakness increases gradually over the years, complications eventually develop. The breathing or heart problems usually become more serious for older teenagers or people in their twenties. In the past, most people with DMD did not live beyond their early twenties. Improvements in treatment have meant that life expectancy has increased. At present, average life expectancy for people with DMD is 27 years. Treatment with medication called 'corticosteroids' (or 'steroids') can help to maintain the child's muscle strength. At some time after the age of 8 years, the child's leg muscles become significantly weaker. Walking gradually gets more difficult, and a wheelchair is needed. After the child starts needing a wheelchair, this is also the time that complications tend to begin, so it is important to monitor the boy's health and to treat any complications early. Your child will need regular check-ups. This may involve different specialists, for example, heart and lung checks, orthopaedic care for bones and joints, physiotherapists, and dieticians. Girls and women who carry the DMD gene are usually well and have no symptoms of DMD themselves. A woman who has the DMD gene can pass it on to her children. A small number of women carrying the DMD gene may develop some muscle weakness themselves. The muscle weakness is usually mild. Some women carrying the DMD gene may develop heart muscle disease (cardiomyopathy) or an abnormal heart rhythm.

19


Nocturnal enuresis.   

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Bedwetting is common in children under the age of five and it will often resolve itself in time. Although bedwetting doesn't pose a threat to a child’s physical health, it can have a considerable psychological impact on their self-esteem and confidence, particularly in older children. Reassuring your child that everything is okay is very important if they regularly wet the bed. Your child should know that it's not their fault, they're not alone and it will get better. You should also never tell off or punish a child who wets the bed. Not only can this cause distress, it's also likely to make the problem worse. Due to the smaller size of their bladder, children are more likely to need to pass urine during the night; particularly if their urine production is higher than it should be. in some children the nerves attached to the bladder may not yet be fully developed, so they don't generate a strong enough signal to send to the brain. Bedwetting can also run in families. In about half of cases, one of the child’s parents (usually the father) had a history of bedwetting as a child. Bedwetting is slightly more common in boys than in girls. In some cases, bedwetting can be a sign that your child is upset or worried. Starting a new school, being bullied or the arrival of a new baby in the family can all be very stressful for a young child. Management plan i. ii. iii.

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restricting the amount of liquid your child drinks in the evening - avoid drinks with caffeine in them, such as cola, because caffeine encourages the production of urine bedwetting alarm - over time, the alarm should help train a child to wake up once their bladder is full or helping them hold on to their urine during the night medications eg. desmopressin

Bedwetting usually only becomes a concern in children who are five years of age or over and who are wetting the bed at least twice a week. In rare cases, bedwetting may be the symptom of an underlying health condition, such as type 1 diabetes, constipation, urinary tract infections and damage to the nerve which controls the bladder.

Bedwetting history          

Has bedwetting started suddenly after a previous history of dryness or has this been a persistent problem since early childhood? If there has been no history of bedwetting, could there be any medical, physical or emotional triggers that might explain the symptoms? How many nights a week does bedwetting happen? How many times a night does bedwetting happen? Is there a large amount of urine? Does your child wake up after wetting the bed? Is your child having any daytime symptoms, such as a frequent or urgent need to urinate, loss of bladder control (urinary incontinence), or are they straining to pass urine? Is your child having any additional symptoms that are unrelated to urination, such as constipation, feeling thirsty all the time or a high temperature (fever) of 38°C or above? How much fluid does your child drink during the day and have you ever tried restricting their fluid intake? How often does your child go to the toilet during the course of a day?

20


Food allergy   

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A food allergy is when the immune system generates an adverse reaction to specific proteins found in food. In children, the foods that most commonly cause an allergic reaction are eggs, milk, soya, wheat and peanuts. In some cases, what may appear to be a food allergy may actually be a food intolerance. Unlike a true food allergy, a food intolerance doesn't involve the immune system. With a true food allergy, even tiny amounts of the food can cause a severe reaction. In most cases, someone who has a food intolerance can eat small amounts of the food with only mild symptoms, such as indigestion or heartburn. The symptoms of a food allergy usually develop within a few minutes to an hour after exposure to the food. Common symptoms include a tingling or burning sensation in your lips and mouth, swelling of your lips or face, an itchy, blotchy skin rash, wheezing, nausea, abdominal pains, vomiting, diarrhoea, and streaming eyes or nose. The onset of the symptoms of an anaphylactic reaction is sudden and the symptoms can rapidly worsen. Symptoms include an itchy sensation in your throat, rapid swelling of your throat, mouth, lips and face, an itchy, red skin rash that quickly spreads across your body, streaming eyes and nose, sneezing, nausea, vomiting, rapid heart beat, increasing breathing difficulties, a sudden intense feeling of apprehension and fear, a sharp and sudden drop in your blood pressure, which can make you feel light-headed and confused, and unconsciousness. Anaphylaxis is a medical emergency and, without prompt treatment, it can lead to coma and possibly death. Most children will ‘outgrow’ food allergies to milk, eggs, soya and wheat by the time that they start school. Peanut allergies are usually more persistent. An estimated 80% of children with peanut allergies remain allergic to peanuts for the rest of their life. Treatment involves identifying the specific food that triggers the allergic reaction and then avoiding it. As part of your elimination diet, it is very important that you read the list of ingredients on the label of any pre-packed food or drink products you buy. Take care when you are not preparing your food. When eating out, ask staff which foods contain nuts and the risk of contamination of other foods. Do not eat anything you are unsure about. If your child has an allergy to nuts then make sure that they do not share food with other children at parties and other group events. It is vitally important that if an allergic reaction starts you get treatment as quickly as possible. The sooner your reaction is treated, the better. Mild reactions can be treated with an antihistamine medicine. More serious reactions are treated with adrenaline which, if given quickly, can reverse the symptoms of the reaction. Adrenaline is given by an injection so that it can work straightaway. If you have a severe reaction to nuts you will be given an adrenaline injection (like a pen) that you can carry with you all the time. Brand names include EpiPen® and Anapen®. These adrenaline injections come in different doses for adults and children. They work by injecting adrenaline into your thigh muscle when you press a button or jab it against your skin. If you have a severe allergy you must carry your adrenaline injection with you at all times. Some people keep adrenaline in the places where they spend most of their time - for example, at home, at school or at work. Many people carry two injections 'just in case'. Check the expiry date on the adrenaline regularly. If it passes the expiry date, get a new one. Also, make sure that you know how to use it properly. Your family and friends should know how to use it too, in case you are not able to. Notify your child's school about their allergy. Depending how severe your child’s allergy could be, it may be useful to provide the staff at their school with an emergency action plan in case of accidental exposure. Arrange with the school nurse, or another appropriate staff member, to hold a supply of adrenalin and to administer it if necessary. Food allergy bracelets are also available, which explain how other people can help your child in an emergency.

21


Febrile seizure.  

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Febrile seizures are a relatively common childhood condition, referring to a child having a seizure (fit) when they have a high temperature of 38ºC or above. This is usually the result of an infection. The cells in the brain, known as neurons, communicate with each other using electrical impulses. A seizure occurs when the electrical impulses become disrupted. This can cause the brain and the body to behave abnormally. Most children have what is known as a tonic clonic seizure. During a tonic clonic seizure, the child's body becomes stiff, they lose consciousness and their arms and legs twitch. Some children may wet themselves. Although febrile seizures may be very frightening, most are harmless and do not pose a threat to a child’s health. Febrile seizures are quite common. An estimated 1 in 20 children will have at least one febrile seizure at some point. Most febrile seizures occur between the ages of six months and five years. The cause of febrile seizures is unknown, although the condition appears to run in some families. Around 1 in 4 children who are affected by febrile seizures will have a family history of the condition. There is no evidence to suggest that febrile seizures cause any lasting damage, such as brain damage or learning difficulties. Many parents worry that if their child has one or more febrile seizures, they will develop epilepsy when they get older. Epilepsy is a condition where a person has repeated seizures (fits) without fever. However, a very small number of children who have febrile seizures go on to have epilepsy. It is estimated that children with a history of simple febrile seizures have a 1 in 50 chance of developing epilepsy in later life. Paracetamol and ibuprofen have been shown to be effective in reducing a high temperature. Removing any unnecessary clothes and bedding will also help to lower your child’s temperature. If your child is having a febrile seizure, place them in the recovery position. Lay them on their side, on a soft surface, with their face turned to one side. This will stop them swallowing any vomit. It will keep their airway open and help to prevent injury. If the seizure lasts for longer than five minutes, dial 999 to ask for an ambulance to take your child to the nearest hospital. While there is probably nothing seriously wrong with your child, it is best to be sure. Avoid putting anything in your child’s mouth while they are having a seizure. There is a slight chance that they might bite their tongue, but any damage is not usually serious and will heal within a few days. Trying to stop someone biting their tongue by placing your hand or an object in their mouth could be dangerous for you and for them. There is no evidence that vaccinations increase the risk of recurring febrile seizures. About one third of children will have a febrile seizure again during a subsequent infection. This often occurs within a year of the first episode. It is not recommended that your child is given a prescription of regular medicines to prevent further febrile seizures. This is because the adverse side effects associated with many medicines outweigh any risks that are associated with the seizures themselves. Regular medicine is not likely to prevent recurrence of further febrile seizures.

22


Asthma 

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Asthma affects the airways, the small tubes that carry air in and out of the lungs (known as the bronchi). If your child has asthma, the airways of their lungs are more sensitive than normal. When your child comes into contact with something that irritates their lungs, known as a trigger, their airways become narrow, the lining becomes inflamed, the muscles around them tighten, and there is an increase in the production of sticky mucus or phlegm. This makes it difficult to breathe and causes wheezing, coughing, shortness of breath and can make the chest feel tight. The most common trigger of an asthma attack is having an upper respiratory tract infection, such as a cold or flu. Other common triggers include exercise, especially in cold weather, an allergy to and contact with house dust mites, animal fur, grass and tree pollen or exposure to air pollution, especially tobacco smoke. Some known factors increase the likelihood of developing wheezing and asthma, including i. a family history of asthma or other related allergic conditions such as eczema, hay fever or a food allergy ii. developing another atopic condition such as eczema, hay fever or a food allergy iii. having acute bronchiolitis (lung infection, common in babies, that is caused by a virus) iv. being exposed to tobacco smoke, particularly if the child's mother smokes during pregnancy v. being born prematurely Reliever inhalers are taken as soon as asthma symptoms develop. The inhaler, also known as a reliever, contains a medicine called a short-acting beta2-agonist. This will relieve the symptoms of asthma. Relievers work fast by relaxing the muscles surrounding the narrowed airways. This allows the airways to open wider, making it easier to breathe. If your child's symptoms are mild and do not occur often, they will just be given a reliever inhaler. It is usually blue. The main side effects include a mild shaking of the hands, headache and muscle cramps. Preventer inhalers work over time to reduce the amount of inflammation and ‘twitchiness’ in the airways and prevent asthma attacks occurring. Your child will normally be recommended to take their preventer inhaler every day to prevent symptoms. Your child will need to use their preventer inhaler daily for some time before they gain the full benefit. They should still use their reliever inhaler to relieve symptoms. The preventer inhaler contains a medicine called an inhaled corticosteroid. Examples of preventer medicines include beclometasone, budesonide and fluticasone. Preventers are usually brown, red or orange. Preventer treatment is normally recommended if your child: i. has asthma symptoms more than twice a week ii. wakes at least once a week due to asthma symptoms iii. has to use a reliever inhaler more than twice a week

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Inhaled corticosteroids (preventers) occasionally cause fungal infections (oral thrush) in the mouth and throat. Your child should rinse their mouth thoroughly after inhaling a dose Some people, and most young children, find using inhalers difficult. A spacer can help. Spacers are large plastic containers that have a mouthpiece at one end and a hole for the inhaler at the other. The medicine is ‘puffed’ into the spacer by the inhaler and it is then breathed in through the spacer mouthpiece. Children under the age of three have the spacer attached to a facemask rather than a mouthpiece, to make it easier for them to breathe in the medicine. Spacers are also good for reducing the risk of thrush in the mouth or throat, which is an occasional side effect of inhaled steroid medicines. Steroid inhalers should always be taken with a spacer. As your child grows up, they should be encouraged to manage their asthma. They can do this gradually with support from the people involved in their care, their doctor and asthma nurse. It is important for them to learn about asthma medicines and how to recognise the symptoms of an asthma attack. Knowing how to look after themselves can increase your child’s quality of life and allow them to be more active and independent. Some children with asthma are encouraged to get a yearly flu jab each autumn to protect against flu (influenza). They are also recommended to get an anti-pneumococcal vaccination. This is a one-off injection that protects against a serious chest infection called pneumococcal pneumonia. Poorly controlled asthma can have an adverse impact on your child's quality of life. The condition can lead to fatigue, underperformance or absence from school and psychological problems, including stress, anxiety and depression.


23

Autism 1.

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Autism is a lifelong developmental disability that affects how a person communicates with, and relates to, other people. It is a spectrum condition, which means that, while all people with autism share certain difficulties, their condition will affect them in different ways. Some people with autism are able to live relatively independent lives but others may have accompanying learning disabilities and need a lifetime of specialist support. People with autism have said that the world, to them, is a mass of people, places and events which they struggle to make sense of, and which can cause them considerable anxiety. Symptoms typically start sometime in the first three years of life. Some children with Asperger's syndrome may not seem to have any symptoms until later on; even after they have started school. People with autism may also experience over- or under-sensitivity to sounds, touch, tastes, smells, light or colours. Around one in 100 children has an ASD. Boys are four times more likely than girls to have an ASD. ASD can cause a wide range of symptoms, which are grouped into three broad categories: i. Problems and difficulties with social interaction  lack of understanding and awareness of other people's emotions and feelings  they might not make eye contact  they might isolate themselves and play on their own  they might find it hard to tell or show you how they feel  they might find it hard to form friendships ii. Impaired language and communication skills  delayed language development  inability to start conversations or take part in them properly  they might not understand what you need to know – give too much or too little information.  they might take things literally e.g. pull your socks up. iii. Difficulties with imagination and flexible thinking  they develop set routines of behaviour, which can upset the child if the routines are broken  they might engage in repetitive movements eg. hand flapping, spinning, rocking.  they might be obsessive about special things or interest  they might find it hard to predict what will happen next, or what could happen next  they might be overwhelmed by too much choices  they might find it hard to cope in new or unfamiliar situations The cause is not known. In recent years, there was some speculation that the measles, mumps and rubella (MMR) vaccine may somehow cause autism. However, there is no evidence to support this. ASD can run in some families. The risk of a brother or sister of a person with an ASD being affected is around one in ten. There are some conditions in which ASD is more common. These include Down's syndrome, Tourette's syndrome and tuberous sclerosis. Most children with ASD are under the care of a specialist in child psychiatry. This usually will have involved being referred to the Child and Adolescent Mental Health Services (CAMHS). i. Speech and language therapy is a type of skills training designed to improve your child's language skills, which can improve their ability to interact with others socially. ii. Behavioural therapy which aims to reward and reinforce positive behaviour while discourage and redirect inappropriate behaviour iii. Medication eg SSRI can be used to treat repetitive thoughts and behaviour / aggressive behaviour, such as tantrums or self-harming. There is no cure for ASD. The specialist education and support aim to maximise the potential of each child as they grow into adults. It is thought that the earlier the specialist input is started, the better the outcome.


24

MMR vaccination.

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The MMR vaccine contains weakened versions of live measles, mumps and rubella viruses. The vaccine works by triggering the immune system to produce antibodies against measles, mumps and rubella. If you come into contact with one of the diseases, your immune system will recognise it and immediately produce the antibodies needed to fight it. MMR is the combined vaccine that protects against Measles, Mumps and Rubella. The first MMR vaccine is given to children as part of the routine vaccination schedule, usually within a month of their first birthday. They'll then have a booster dose before starting school, which is usually between three and five years of age. The vaccine is given as a single injection into the muscle of the thigh or upper arm. There may be some redness and swelling where the injection is given, but this should soon disappear. Measles, mumps and rubella are diseases that have serious complications: o Measles causes ear infection, pneumonia, convulsion and brain damage. o Mumps used to be the main cause of viral meningitis in children. It also causes deafness, miscarriage, inflammation of the pancreas and pain and swelling in the testicles. o Rubella can lead to painful joints, blood disorders and swelling of the brain. It damages unborn babies and may cause miscarriage if women catch the disease while pregnant. Babies born with congenital rubella syndrome may have some degree of deafness, blindness and damage to their heart or brain.

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Immunisations are generally safe and effective. It might not be advisable if o the immune system is not working properly then some vaccines are not given. For example, in children with HIV infection, children undergoing chemotherapy or who are receiving high doses of steroids. o a child has previously had a severe reaction to the same vaccine.

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My child is allergic to eggs. Can she have the MMR vaccination? Yes, the MMR vaccine can be safely given to children who have a severe allergy to egg. This is because MMR vaccine is grown on chick cells, not the egg white or yolk.

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Does MMR vaccine causes autism ? Investigations by Sunday Times journalist Brian Deer revealed that the lead author of the article, Andrew Wakefield, had multiple undeclared conflicts of interest, had manipulated evidence, and had broken other ethical codes. The Lancet paper was partially retracted in 2004 and fully retracted in 2010, and Wakefield was found guilty by the General Medical Council of serious professional misconduct in May 2010 and was struck off the Medical Register, meaning he could no longer practice as a doctor. The research was declared fraudulent in 2011 by the BMJ. The scientific consensus is that no evidence links the vaccine to the development of autism, and that the vaccine's benefits greatly outweigh its risks. Therefore, your child should have his MMR jab to protect him against measles, mumps and rubella.

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Why single vaccines are not recommended ? If single vaccines were used there would be a time gap between the three vaccines that could potentially put the child at risk of developing these diseases. Measles, mumps and rubella vaccines are not available separately on the NHS. The NHS does not recommend single measles, mumps or rubella vaccines because there is no evidence to support the use of single vaccines or to suggest that they are 'safer' than MMR.


25

Testicular torsion.     

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Within the scrotum, the testicles are secured at either end by a structure called the spermatic cord. Sometimes, this cord gets twisted around a testicle, cutting off the blood supply to the testicle. Symptoms of testicular torsion include sudden and severe pain in the testicle, testicular tenderness and swelling, nausea, vomiting or abdominal pain. Testicular torsion occurs most often in young males less than 25 years of age, can result from an injury to the testicles or from strenuous activity. It also can occur for no apparent reason. The testicular salvage rate is 90 percent if detorsion occurs less than six hours from the onset of symptoms, but it falls to 50 percent after 12 hours and to less than 10 percent after 24 hours. Testicular torsion requires immediate medical attention. Treatment usually involves correction of the problem through an operation. Testicular function may be saved if the condition is diagnosed and corrected immediately. If the blood supply to the testicle is cut off for a long period of time, the testicle can become permanently damaged and may need to be removed. Whether the affected testis is removed or conserved, the contralateral one should undergo orchidopexy, as the risk of recurrence on the other side is otherwise high. The testicle will be stitched to the inside of the scrotum to prevent the spermatic cord twisting again. Fertility should be maintained even after the loss of one testicle. There will be no apparent changes noted physically besides the loss of the testicle. Following surgery for testicular torsion, patient may need to avoid strenuous activity for about a week.

26


Squint.   

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   

A squint is a condition where your eyes look in different directions. One eye turns inwards, outwards, upwards or downwards while the other eye looks forwards. The medical name for a squint is strabismus. The misalignment of the eyes can be caused by a problem with the eye muscles or by an uncorrected vision problem, such as short-sightedness or long-sightedness. Squints are common and affect about 1 in 20 children. They usually develop before a child is five years of age, but they can appear later. Up to around three months of age, many babies occasionally squint as their vision develops. This is normal and nothing to worry about. If your child still has a squint after this age, you should visit your GP. It is very important that a squint is picked up and treated as early as possible to avoid vision problems developing. If a squint is identified when a child is young, there is a good chance that it will be successfully treated. If your child has a squint, their eyes are no longer working together and they may see two images (double vision) instead of one. To avoid double vision, your child’s brain ignores the signals from the eye with the squint and only recognises images from the normal eye. As the squinting eye is not being used, it eventually becomes ‘lazy’. In older children, a squint may cause double vision but not result in a lazy eye. This is because their vision has fully developed and their brain is unable to ignore signals from the eye with the squint. If the vision in the eye that squints is poor, your child may have to wear a patch over their other eye to encourage the vision to develop. Risk factors for developing squint - family history of squints or lazy eye ( amblyopia ), having a condition that affects the nervous system, such as cerebral palsy, being born prematurely or with a low birth weight. Several types of treatment are available for squints, including glasses, an eye patch, botulinum toxin injections, eye exercises and corrective surgery.

Classification of squints o By the direction of the squinting eye: inwards ( esotropia ), outwards ( exotropia ), upwards (hypertropia), downwards (hypotropia) o Whether the squint is present all the time ( constant ), or comes and goes ( intermittent ). o Whether the affected eye turns when the eyes are open and being used (manifest squint) or whether the eye turns only when it is covered or shut (latent squint), but looks fine when the eyes are open. o Whether the severity (angle) of the squint is the same in all directions or not:  Non-paralytic (concomitant) squint - both eye movements are full but only one eye is directed towards the target. There is a constant angle of deviation which is unrelated to the direction of gaze. This tends to be the squint of childhood.  Paralytic (incomitant) squint - there is under-action of at least one of the extraocular muscles and the degree of squint is dependent on the direction of gaze (being largest when the globe is rotated towards the field of action of the relevant muscles or their associated nerve). Examination o A young baby should be examined for the presence of epicanthic folds (crescenteric folds of skin on each side of the nose) which could give rise to pseudoesotropia: the impression that the eyes are turned inwards when in fact they are not. The corneal reflection test (Hirschberg's test) can help to rule this out. o Corneal refleection test - hold a pen torch about an arm's length (~33 cm) away from the patient and shine it in front of their eyes. If the patient is able to understand instructions, ask them to look at the light (babies will tend to look towards it anyway, even if briefly). Observe where the reflection of the pen torch lies with respect to the cornea. It should be central bilaterally. If it lies at the inner margin of the pupil, there is an outward deviation (exotropia) of the eye. If it lies at the outer margin, an esotropia is present. o Cover/uncover test - an object to focus on is held in front of the patient who is instructed to focus on it. One eye is completely occluded for several seconds and the uncovered eye is observed for movement as it focuses on the object. This eye is then covered and the other eye is observed for movement. Movement of the eye outwards confirms that there is an esotropia (i.e. the eye was turned inwards initially) and vice versa for exotropia. The test is repeated for objects at 6 metres and far distance, which may also reveal a vertical squint.


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Obstetrics and Gynaecological OSCE Notes

Menstrual history 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Menorrhagia / amenorrhoea / metrorrhagia / postmenopausal bleeding / postcoital bleeding Age of menarche / last menstrual period / age of menopause Cycle – duration / days of bleeding / regularity / number of pads used Dysmenorrhoea / dyspareunia Urinary symptoms / haematuria Bowel symptoms / rectal bleeding Use of contraception / hormone replacement therapy Last cervical smear date and result Weight loss Alcohol / smoking Family history of breast, ovarian, endometrial cancer

Sexual history 1. 2. 3. 4. 5. 6. 7. 8.

Symptoms suggestive of STI eg. urethral discharge, vaginal discharge, dysuria, painful ulcers, blisters, itchiness, smell History of STI Sexual contact in the last 6 months ( casual or regular partner, vaginal/oral/anal ) Previous HIV test Sex abroad Intravenous drug use Last menstrual period / last cervical smear Use of contraception

Obstetrics history 1. 2. 3. 4.

5.

Current pregnancy – outcome, gestational week, last menstrual period, expected date of delivery, planned / unplanned pregnancy Symptoms of pregnancy – morning sickness, breast tenderness, urinary frequency, heartburn, backache Complications of pregnancy – anemia, gestational diabetes, pre eclampsia Antenatal care and screening tests – booking, folic acid supplementation, blood pressure, urine for protein, anti D prophylaxis, blood tests for rubella, HIV, syphilis, hepatitis B, dating and anomaly ultrasound scan, screening test for Down’s syndrome Previous pregnancy – outcome, gender, mode of delivery, birth weight, labour progress, postnatal complications, breastfeeding

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Antenatal Examination Exposure – from xiphisternum to pubic symphysis General inspection – pulse, conjunctival pallor ( anemia ), jaundice, chloasma, peripheral edema Inspection – abdomen distension consistent with 37 week of pregnancy, umbilicus, Pfannenstiel scar (low transverse scar from previous caesarean delivery), laparoscopic scar, linea nigra, stria gravidarum, visible fetal movements (after 24 weeks) Palpation Symphysis-fundal height – use the ulnar border of your left hand, move downwards from the xiphisternum until the fundus is felt. Once the upper limit is established, place a measuring tape, blind side up, measuring the distance from the fundus to the pubic symphysis. Turn the tape around to reveal the SFH in centimetres. Fetal movements, lie ( longitudinal, transverse, oblique ), presentation ( cephalic, breech, shoulder ) Engagement – when the widest diameter of the presenting part enters the maternal pelvis to a level below the plane of the pelvic inlet. It is described in fifth of head palpable. If the fetal head is palpable by only two or less finger breadths, it is already engaged. Auscultation – Pinard’s stethoscope on anterior fetal shoulder from 24 weeks, Doppler from 12 weeks ( normal fetal heart rate 110 to 160 beats per minute ) for fetal heart sound, palpate for maternal pulse to differentiate between maternal heart rate and fetal heart rate Offer to measure blood pressure and test urine for proteinuria and glucosuria. Summary This is Mrs Foster who is currently 37 weeks pregnant. Her abdomen is consistent with a single uterine pregnancy and her SFH is 36cm. The fetus is in longitudinal lie and is cephalic in presentation. The head is 5/5 palpable and not engaged. On Doppler auscultation, the fetal heart rate is normal at 140 beats per minute.

Mechanisms of Labour 1.

2. 3. 4.

5. 6. 7. 8.

Engagement ( head enters pelvis in occipito-transverse position ) * transverse diameter of the pelvic inlet is greater than anterior-posterior diameter. Engagement normally occurs before the onset of labour in nulliparous but may not occur until labour is well established in multiparous Descent and flexion ( passive movement due to resistance of levator muscles which brings the chin close to the chest – from occipitofrontal to suboccipitobregmatic diameter ) Internal rotation ( head rotates into occipito-anterior position ) * anterior-posterior diameter of pelvic outlet is greater than transverse diameter Descent and extension. Crowning is when the largest diameter of the fetal head is emerging from the vaginal opening and the head would not recede back even as the uterine contractions crease. Further extension, using the symphysis pubis as a fulcrum, leads to appearance of the bregma, followed by the face and the chin. Restitution ( head rotates back to be in line with its normal relationship to the fetal shoulders ) External rotation ( when the shoulders reach the pelvic floor, they rotate into the AP diameter of pelvis, fetal head rotates so that the face looks laterally at the maternal thigh ) Delivery of shoulders ( anterior shoulder is delivered by lateral body flexion in posterior direction and posterior shoulder is delivered by lateral body flexion in anterior direction ) The rest of the body follows.


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Breast Examination Inspection – look at both breasts for size, symmetry, colour, scar, dimpling or tethering of skin, ulceration; nipple for discharge, skin changes, inversion; axillae for mass or colour change. Inspect under the breast as well. Inspect for dimpling when you ask the patient to lean forward while sitting, press her hands against hips and arms crossed above head. Palpation – patient lying supine and hand on the side to be examined placed behind the head. Start from asymptomatic side and ask for any pain. Palpate four quadrants of the breast including the axillary tail of Spencer and areolar region. Comment on any breast lump for site, size, shape, consistency, mobility, temperature, tenderness, overlying skin changes Ask the patient to gently squeeze and express nipple discharge Palpate for lymphadenopathy in the axillary ( lateral, pectoral, central, subscapular, apical ), supraclavicular and cervical areas. Check for metastasis in liver, lung, brain and bone.

Diagnosis of early stage breast cancer by triple assessment 1. 2. 3.

Clinical examination Imaging ( ultrasound or mammography ) Fine needle aspiration cytology / core biopsy

Nottingham Prognostic Index – tumour size, histological grade, node status

30


Pre-conception counseling for women with diabetes. 1. 2.

3.

4. 5. 6. 7. 8. 9.    

Give advice about the avoidance of unplanned pregnancies. Give advice about good glycaemic control before conception and during pregnancy to reduce the risks of stillbirth, miscarriage, congenital malformation and neonatal death. o The aim is to maintain HbA1c below 6.1% if that can be safely achieved. Any reduction towards 6.1% is likely to reduce the risk of congenital malformations. o Women with HbA1c above 10% should be strongly advised to avoid pregnancy. o As well as self-monitoring of blood glucose, HbA1c testing should be offered monthly. Discuss how diabetes affects pregnancy and how pregnancy affects diabetes, including: o The role of diet, weight and exercise: women with diabetes who are planning to become pregnant and who have a body mass index >27 kg/m2, should be offered advice on how to lose weight o Risks of hypoglycaemia and its unawareness during pregnancy. o Effects of nausea and vomiting on glycaemic control. o Increased risk of having a large for gestational age baby and the possible complications of this (birth trauma, induction of labour, Caesarean section). o Diabetic retinopathy and the importance of assessment for this before pregnancy. Retinal assessment should be offered at the first pre-conception appointment (if it has not taken place within the last 6 months). It should then be offered every year if no retinopathy is found. o Diabetic nephropathy and the importance of assessment for this before and during pregnancy. This should include a measure of microalbuminuria and serum creatinine/eGFR. If serum creatinine is ≥120 μmol/L, or the eGFR is <45 ml/minute/1.73 m2, a referral should be made to a nephrologist before contraception is discontinued. o Why it is important to achieve good glycaemic control for the mother during labour and birth and the importance of early feeding of the baby to reduce the risk of neonatal hypoglycaemia. o The possibility of admission to the neonatal unit for the baby during the neonatal period, due to transient morbidity. o The risk of the baby developing obesity and/or diabetes in later life. Discuss that the risks associated with pregnancy increase with the duration of the diabetes. Women should be advised that they will need frequent contact with health professionals during their pregnancy. Women with diabetes who are planning to become pregnant should take 5 mg folic acid daily until 12 weeks of gestation to reduce the risk of neural tube defects. Ketone testing strips should be offered to women, who should be advised to test for ketonuria or ketonaemia if they become hypoglycaemic or unwell. Smoking cessation advice and support should be given as appropriate. Advice on reducing or cutting down alcohol should be given as appropriate. Medication for diabetes and diabetic complications before and during pregnancy Metformin should be used as an adjunct or alternative to insulin in the pre-conception period and during pregnancy, when the likely benefits from improved glycaemic control outweigh the potential for harm. All other hypoglycaemic agents should be discontinued before pregnancy, and insulin substituted. Angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists should be stopped before conception or as soon as pregnancy is confirmed. They should be substituted for alternative antihypertensives that are known to be safe in pregnancy. Statins should be stopped before pregnancy or as soon as pregnancy is confirmed.

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Combined contraceptive pills.  

The combined pill contains hormones oestrogen and progestogen. These are similar to the natural hormones women produce in their ovaries. You take the pill every day for 21 days, then stop for seven days. During that week, you have a period-type bleed. After seven days, you start taking the pill again.

How does the combined pill work?   

Stops the ovaries releasing an egg each month (ovulation) Thickens the mucus in the cervix, making it difficult for sperm to reach an egg Makes the lining of the womb thinner so it is less likely to accept a fertilised egg

How effective is it? 

If used correctly, the combined pill can be more than 99% effective. This means that fewer than one woman in 100 who takes the pill will get pregnant in one year.

Added benefits    

makes your bleeds regular, lighter and less painful reduces the risk of cancer of the ovary, womb and colon reduces acne in some women reduce the risk of fibroids, ovarian cysts and (non-cancerous) breast disease

Side effects      

Headaches, nausea, breast tenderness and mood changes Breakthrough bleeding (unexpected bleeding on pill-taking days) and spotting Raised blood pressure A very small number of women may develop a blood clot, which can block a vein (venous thrombosis) or an artery (arterial thrombosis, heart attack or stroke) A small increase in risk of being diagnosed with breast cancer A small increase in the risk of cervical cancer if the pill is used continuously for more than five years

How do you take it ?  

The pill can be started up to and including the fifth day of a period. If taken at this time it is effective straight away. If started at any other time, additional contraception has to be used for seven days. The pill is taken every day for 21 days until the pack is finished. You then have a break of seven days when you have a 'withdrawal bleed', which is usually shorter and lighter than a normal period. Everyday pills have 21 active pills and seven placebo tablets. These are taken without a break and must be taken in the order listed on the pack.

Who can use the pill ? The pill may be unsuitable if you:     

Think you might already be pregnant Smoke and are over 35, or are over 35 and stopped smoking less than a year ago Are very overweight Take certain medicines - always check Have had a previous thrombosis


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    

Have a heart abnormality, circulatory disease or high blood pressure Have very severe migraines or migraines with aura Have breast cancer now or within the last five years Have active liver or gall bladder disease Have diabetes with complications, or have had diabetes for more than 20 years

What else should I know?  

You could get pregnant if you don’t take the pill at the same time every day, you miss one, you vomit or have severe diarrhoea, or you take some other types of medication. The pill does not protect you against sexually transmitted infections

What if I forget to take the pill? If you’re on the combined contraceptive pill and you miss a pill, what you need to do depends on:  

how many pills you’ve missed (you’ve missed a pill when it’s more than 24 hours since you should have taken it) when you missed your pill (where you are in the pack)

Missing two or more pills can make your pill less effective at preventing pregnancy. What if I’ve missed one pill? If you’ve missed one pill anywhere in the pack or started a new pack one day late, you’re still protected against pregnancy. You should:   

take the last pill you missed now, even if this means taking two pills in one day carry on taking the rest of the pack as normal take your seven-day pill-free break as normal or, if you’re on an Every Day pill, take your inactive pills

You don’t need to use extra contraception. What if I’ve missed two or more pills? If you’ve missed two or more pills anywhere in the pack or started a new pack two or more days late (48 hours or more), your protection against pregnancy may be affected. You should:    

take the last pill you missed now, even if this means taking two pills in one day leave any earlier missed pills carry on taking the rest of the pack as normal use extra contraception, such as condoms, for the next seven days

When you start your next pack after missing two or more pills:  

if there are seven or more pills left in the pack after the last missed pill: finish the pack, take your seven-day pill-free break as normal or take your inactive pills before you start your next pack if there are fewer than seven pills left in the pack after the missed pill: finish the pack and start a new pack the next day – this means missing out the pill-free break or not taking your inactive pills

If you’ve had unprotected sex in the previous seven days and you’ve missed two or more pills in the first week of a pack, you may also need emergency contraception.


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Progesterone-only Pills 

The progestogen-only pill (POP) contains a hormone called progestogen. This is similar to the natural hormone progesterone that women produce in their ovaries.

How does it work?   

It thickens the mucus in the cervix to stop sperm meeting an egg. It makes the lining of the womb thinner, so it's less likely to accept a fertilised egg. Sometimes it stops the ovaries from releasing an egg (ovulation) - this is the main action of the POP called Cerazette.

How reliable is the progestogen-only pill? 

Its effectiveness depends on how carefully it's used. The POP is 99 per cent effective when taken according to instructions. This means that using this method, one woman in 100 will get pregnant in a year.

How do you use it?  

The POP can be started up to and including the fifth day of a period. If taken at this time it's effective straight away. If started at any other time, additional contraception has to be used for two days. It needs to be taken at the same time each day and is taken every day until the pack is finished. A new pack is started immediately without any break, which means you'll be taking pills during your period.

Added benefits   

You can use it while breastfeeding. You can use it if you cannot use oestrogens. You can use it if you smoke and are 35 and over.

Side effects   

Light, more frequent or irregular periods - or they may stop. Breast tenderness, acne Possible increase in the risk of being diagnosed with breast cancer

The POP does not protect you against sexually transmitted infections. If you forget to take the progestogen-only pill     

You've 'missed a pill' if you take it more than three hours later than your chosen time. This is 12 hours later for Cerazette. It's important to take it at the same time every day, but if you forget: You won't be protected against pregnancy, so take the pill as soon as you remember and use additional contraception for two days. Take your next pill at the usual time - this may mean taking two pills in one day. If you're sick within two hours of taking the pill, it will not have been absorbed properly, so take another pill as soon as you feel well enough. If you continue to be sick or have severe diarrhoea for more than 24 hours, seek advice.

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Intrauterine System An intrauterine system (IUS) is a small, T-shaped contraceptive device that fits inside the womb and releases the female hormone progestogen into the body. The IUS that's available in the UK is called Mirena. It works for up to five years after being fitted. If you're 45 or older when you have the IUS fitted, it can be left until you reach menopause or you no longer need contraception. How does it work ? i. ii. iii.

It thickens the mucus in the cervix to stop sperm meeting an egg. It makes the lining of the womb thinner, so it's less likely to accept a fertilised egg. Sometimes it stops the ovaries from releasing an egg (ovulation)

How effective is IUS ? 

The IUS is more than 99% effective in preventing pregnancy. This means that less than one in every 100 women who use the IUS will get pregnant over five years.

Added benefits 

The IUS is safe and effective as a long-lasting method of contraception. Once it’s in place you won’t have to remember to take or use contraception to prevent pregnancy. It can also make your periods lighter, shorter or even stop them completely after the first year. This may help women with heavy periods or painful periods.

Who might be not suitable ?         

if you think you may already be pregnant if you have breast cancer (or have had it) in the last five years cervical cancer liver disease unexplained vaginal bleeding between periods or after sex arterial disease or history of serious heart disease or stroke thrombosis (blood clots) in any vein or artery an untreated sexually transmitted infection (STI) or pelvic infection problems with your uterus or cervix

Insertion of the IUS  Your GP or clinician will perform an internal examination to check the position of the womb before fitting the IUS. You may also be tested for infection and offered antibiotics. It takes about 15 to 20 minutes to insert an IUS. The vagina is held open, like it is during a cervical smear test, and the IUS is inserted through the cervix and into the womb.  If it is fitted in the first seven days of your menstrual cycle, the IUS protects against pregnancy immediately. If it is fitted at another time, another type of contraception has to be used for the first seven days.  Your IUS can be removed at any time by a trained doctor or nurse. The most common reasons that women stop using an IUD are vaginal bleeding and pain. As soon as an IUS is taken out, your normal fertility should return. Side effects  Altered patterns of menstrual bleeding are common - irregular bleeding and spotting (common in the first six months of treatment) and amenorrhoea in particular.  An IUD doesn't protect against sexually transmitted infections, so you may have to use condoms as well. If you get an STI while you have an IUD fitted, it could lead to a pelvic infection if left untreated.  Occasionally the IUD is rejected by the womb (expulsion) or can move (displacement). In very rare cases, an IUD can go through (perforate) the womb or neck of the womb (cervix) when it's put in. There's a small increased risk of ectopic pregnancy if a woman becomes pregnant while using an IUD.  Routinely 3-6 weeks after fitting or after the first period to check threads and to exclude infection or perforation.


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Contraceptive Injection There are two versions of the contraceptive injection: Depo-Provera, which lasts for 12 weeks, and Noristerat, which lasts for eight weeks. The most popular is Depo-Provera. How does the contraceptive injection work? The injection contains progestogen. Progestogen thickens the mucus in the cervix, which stops sperm reaching an egg. It also thins the lining of the womb so that an egg can't implant itself there. In some women, the injection stops ovulation (the release of an egg). How effective is the injection? If used correctly it's more than 99% effective. This means that fewer than one woman in 100 who uses the injection will become pregnant in a year. Added benefits?     

The injection lasts for eight weeks or 12 weeks (depending on the type), so you don't have to think about contraception every day or every time you have sex. It can be useful for women who might forget to take the contraceptive pill every day. It can be useful for women who can't use contraception that contains oestrogen. It's not affected by medication. The contraceptive injection may provide some protection against cancer of the womb and pelvic inflammatory disease.

What else should I know?      

Side effects can include weight gain, headaches, mood swings, breast tenderness and irregular bleeding. The injection can't be removed from your body, so if you have side effects they'll last as long as the injection (eight or 12 weeks) and for some time afterwards. Your periods may become more irregular or longer, or stop altogether (amenorrhoea). Having no periods is a common effect of the contraceptive injection. It's not harmful, but you may want to take it into consideration. Treatment is available if your bleeding is heavy or longer than normal – talk to your doctor or nurse about this. It can take up to one year for your fertility to return to normal after the injection wears off, so it may not be suitable if you want to have a baby in the near future. Using Depo-Provera affects your natural oestrogen levels, which can cause thinning of the bones. This isn't a problem for most women because the bone replaces itself when you stop the injection, and it doesn't appear to cause any long-term problems. Thinning of the bones may be a problem for women who already have risk factors for osteoporosis (such as low oestrogen, or a family history of osteoporosis). It may also be a concern for women under 19 because the body is still making bone at this age. Women under 19 may use DepoProvera, but only after careful evaluation by a doctor.

By using condoms as well as the injection, you'll help to protect yourself against sexually transmitted infections (STIs).

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Contraceptive Implant The contraceptive implant is a small flexible tube that's inserted under the skin of your upper arm. It releases the hormone progestogen to prevent pregnancy. The implant is about 40mm long and contains progestogen. Who can insert the implant? The implant is inserted under the skin in the inner side of your upper arm by a trained professional. It lasts for three years. An injection of local anaesthetic is used to numb the skin. A small cut is made and the implant placed under the skin. The wound is dressed and will soon heal just like any other small cut. You can have the implant removed at any time, and your natural fertility will return very quickly. This means that once the implant is removed, you could get pregnant as easily as if you'd never had the implant. How does the implant work? The implant stops the release of an egg from the ovary by slowly releasing progestogen into your body. It thickens the cervical mucus and thins the womb lining. This makes it harder for sperm to move through your cervix, and less likely for your womb to accept a fertilised egg. How effective is it? If implanted correctly, it's more than 99% effective. Fewer than one woman in 1,000 will get pregnant in one year. Added benefits?     

It's very useful for women who know they don't want to get pregnant for a while. Once the implant is in place, you don't have to think about contraception for three years. It can be useful for women who can't use contraception that contains oestrogen. It's very useful for women who find it difficult to take a pill at the same time every day. It is not affected by antibiotics. If you have side effects, the implant can be taken out.

What else should I know about the implant?   

When it's first put in, you may feel some bruising, tenderness or swelling around the implant. In the first year after the implant is fitted, your periods may become irregular, lighter, heavier or longer. This usually settles down after the first year. A common side effect of the implant is that your periods stop (amenorrhoea). It's not harmful, but you may want to consider this before deciding to have an implant.

By using condoms as well as the implant, you'll help to protect yourself against sexually transmitted infections (STIs).

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Hormone Replacement Therapy.   



Hormone replacement therapy (HRT) is a treatment used to replace the female hormones (oestrogen and progesterone) that a woman’s body is no longer producing because of the menopause. The average age for women to have the menopause is 52. Oestrogen plays an important role in the release of eggs from the ovaries. It also helps in the regulation of women’s periods and many other body functions. The reduction of oestrogen causes most of the menopausal symptoms, including hot flushes, vaginal dryness, mood changes, stress incontinence (leaking urine when you cough or sneeze), night sweats, thinning of the bone (osteoporosis). A falling level of progesterone increases your risk of developing cancer of the womb lining (endometrial cancer).

Benefits  Reduces vasomotor symptoms eg, hot flushes, sleep or mood disturbances  Reduces urogenital symptoms eg, stress incontinence, vaginal dryness  Reduces risk of osteoporosis  Reduces risks of cancer of the colon and rectum Risks  Breast cancer, endometrial cancer, ovarian cancer, stroke, coronary heart disease, venous thromboembolism Types of HRT i.

Cyclical HRT is recommended for women who are experiencing menopausal symptoms but still have their periods. There are two types of cyclical HRT:



Monthly HRT - where you take oestrogen every day and also take progestogen at the end of your menstrual cycle for 14 days ( for women with regular periods ) Three-monthly HRT - where you take oestrogen every day and also take progestogen for 14 days every 13 weeks ( for women with irregular periods )



ii.

Continuous combined HRT is usually recommended for women who are post-menopausal. Continuous HRT involves taking oestrogen and progestogen every day.

Contraindications       

Pregnancy and breast-feeding Undiagnosed abnormal vaginal bleeding Venous thromboembolic disease Active or recent angina or myocardial infarction Suspected, current or past breast cancer Endometrial cancer or other oestrogen-dependent cancer Active liver disease with abnormal liver function tests



Most women should be able to stop taking HRT once their menopausal symptoms have finished. This is normally between two to five years. It is usually recommended that you decrease your dose of HRT gradually over time, rather than stopping suddenly.

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Prescribing HRT 



Women with an intact uterus o Vasomotor symptoms  Perimenopausal: systemic cyclical combined HRT (a 3-monthly regimen can be used for women with infrequent periods or who cannot tolerate progestogens).  Postmenopausal: systemic continuous combined HRT or tibolone. o Urogenital symptoms  Perimenopausal: low-dose vaginal oestrogen or systemic cyclical combined HRT.  Postmenopausal: low-dose vaginal oestrogen or systemic continuous combined HRT. Women who have had a hysterectomy o Vasomotor symptoms: systemic oestrogen-only HRT. o Urogenital symptoms: low-dose vaginal oestrogen or systemic oestrogen-only HRT.

Side-effects of HRT   

Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches. Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression, pelvic pain. Bleeding: monthly sequential preparations should produce regular, predictable and acceptable bleeds starting towards the end, or soon after, the progestogen phase. Breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens.

 

HRT does not suppress ovulation. In those with an intact uterus, contraception should be used: o o

For one year after the last menstrual period in woman >50. For two years after the last menstrual period in woman <50.

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Discuss the delivery options for breech presentation.

Breech means that your baby is lying bottom first or feet first in the womb (uterus) instead of in the usual head first position. In early pregnancy, breech is very common. As pregnancy continues, a baby usually turns naturally into the head first position. Between 37 and 42 weeks (term), most babies are lying head first ready to be born. Three in every 100 (3%) babies are breech at the end of pregnancy. Why are some babies breech? Sometimes it is just a matter of chance that a baby does not turn and remains in the breech position. At other times certain factors make it difficult for a baby to turn during pregnancy. These might include the amount of fluid in the womb (either too much or too little), the position of the placenta or if there is more than one baby in the womb. What can be done? If you are 36 weeks pregnant and the baby is in a breech position, you'll usually be offered the option of an external cephalic version (ECV). This is when pressure is put on your tummy to try to turn the baby into a head-down (cephalic) position. ECV is successful for about half of all women (50%). Is ECV safe for me and my baby? ECV is generally safe and does not cause labour to begin. The baby’s heart will be monitored before and after the ECV. Like any medical procedure, complications can sometimes occur. About one in 200 (0.5%) babies need to be delivered by emergency caesarean section immediately after an ECV because of bleeding from the placenta and/or changes in the baby’s heartbeat. An ECV should be carried out in a place where the baby can be delivered by emergency caesarean section if necessary. ECV should not be carried out if: 

you need a caesarean section for other reasons



you have had vaginal bleeding during the previous seven days



the baby’s heart rate tracing (also known as a CTG) is abnormal



your womb is not the normal pear-shape (some women have a womb which resembles a heart-shape, known as a bicornuate uterus)



your waters have broken before you go into labour (see RCOG Patient Information When your waters break early (preterm prelabour rupture of membranes))



you are expecting twins or more (except before delivering the last baby).

What are my choices for birth? Depending on your situation, your choices may include a caesarean delivery – this is a surgical operation where a cut is made in your abdomen and your baby is delivered through that cut or vaginal breech birth.

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Where a vaginal breech birth is being considered, 

the obstetrician is trained and experienced in delivering a breech baby vaginally



there are facilities at your hospital for an emergency caesarean delivery



there are no particular features about your pregnancy that make vaginal breech birth more risky.

Your obstetrician may strongly advise you against a vaginal birth if: 

your baby is a footling breech



your baby is large (over 3800 grams)



your baby is small (less than 2000 grams)



your baby is in a certain position: for example, if the neck is very tilted back (hyper-extended)



you have had a caesarean delivery in a previous pregnancy



you have a narrow pelvis (as there is less room for the baby to pass safely through the birth canal)



you have a low-lying placenta



you have pre-eclampsia

What can I expect in labour with a breech baby? You can have the same choice of pain relief choices as with a baby who is head first. If you have a vaginal breech birth, you are advised that your baby’s heart rate should be monitored continuously. In some circumstances, you may need an emergency caesarean delivery during labour. Forceps may be used to assist the baby to be born. This is because the baby’s head is the last part to emerge and may need to be helped through the birth canal. A paediatrician will attend the birth to check the baby.

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Vaginal birth after caesarean What are my choices for birth after a caesarean delivery? More than one in five women (20%) in the UK currently give birth by caesarean delivery (a surgical operation where a cut is made in your abdomen and your baby is delivered through that cut). Many women have more than one caesarean delivery. If you have had one or more caesarean deliveries, you may be thinking about how to give birth next time. Whether you choose to have a vaginal birth or a caesarean delivery in a future pregnancy, either choice is safe with different risks and benefits. Overall, both are safe choices with only very small risks. In considering your choices, your obstetrician will ask you about your medical history and about your previous pregnancies. They will want to know about: 

the reason you had the caesarean delivery and what happened – was it an emergency?



the type of cut that was made in your uterus (womb)



how you felt about your previous birth. Do you have any concerns?



whether your current pregnancy has been straightforward or have there been any problems or complications?

What is an elective repeat caesarean delivery? An elective caesarean means a planned caesarean. The date is usually planned in advance at your hospital antenatal visit. The caesarean delivery usually happens in the seven days before your due date, unless there is a reason why you or your baby need an earlier delivery. What are the advantages of a successful VBAC? The advantages of a successful VBAC include: 

a vaginal birth (which might include an assisted birth)



a greater chance of an uncomplicated normal birth in future pregnancies



a shorter recovery and a shorter stay in hospital



less abdominal pain after birth



not having surgery.

When is VBAC likely to be successful? Overall, about three out of four women (75%) with a straightforward pregnancy who go into labour give birth vaginally following one caesarean delivery. If you have had a vaginal birth, either before or after your caesarean delivery, about nine out of ten women (90%) have a vaginal birth. Most women with two previous caesarean deliveries will have their next baby by caesarean delivery. However, should you go into labour your chance of a successful vaginal birth is slightly less than this (between 70% and 75%).

42

What are my chances of a successful VBAC? A number of factors (risk factors) make the chance of a successful vaginal birth less likely. These are when you:




have never had a vaginal birth



need to be induced



did not make progress in labour and needed a caesarean delivery (usually owing to the position of the baby)



are overweight – a body mass index (BMI) over 30 at booking.

What are the disadvantages of VBAC? The disadvantages of VBAC include: 

Emergency caesarean delivery There is a chance you will need to have an emergency caesarean delivery during your labour. This happens in 25 out of 100 women (25%). This is only slightly higher than if you were labouring for the first time, when the chance of an emergency caesarean delivery is 20 in 100 women (20%). The usual reasons for an emergency caesarean delivery are labour slowing or if there is a concern for the wellbeing of the baby.



Blood transfusion and infection in the uterus Women choosing VBAC have a one in 100 (1%) higher chance of needing a blood transfusion or having an infection in the uterus compared with women who choose a planned caesarean delivery.



Scar weakening or scar rupture There is a chance that the scar on your uterus will weaken and open. If the scar opens completely (scar rupture) this may have serious consequences for you and your baby. This occurs only in two to eight women in 1000 (about 0.5%). Being induced increases the chance of this happening. If there are signs of these complications, your baby will be delivered by emergency caesarean delivery.



Risks to your baby The risk of your baby dying or being brain damaged if you undergo VBAC is very small (two in 1000 women or 0.2%). This is no higher than if you were labouring for the first time, but it is higher than if you have an elective repeat caesarean delivery (one in 1000 or 0.1%). However, this has to be balanced against the risks to you if you have a caesarean delivery (see below).

These disadvantages are more likely in women who attempt VBAC and are unsuccessful. When is VBAC not advisable? There are very few occasions when VBAC is not advisable and repeat caesarean delivery is a safer choice. These are when: 

you have had three or more previous caesarean deliveries



the uterus has ruptured during a previous labour



you have a high uterine incision (classical caesarean)



you have other pregnancy complications that require a caesarean delivery.

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What are the advantages of elective repeat caesarean delivery? The advantages of elective repeat caesarean delivery include: 

virtually no risk of uterine scar rupture



it avoids the risks of labour and particularly the risk of possible brain damage or stillbirth from lack of oxygen during labour (one in 1000 or 0.1%)



knowledge of the date of delivery.

However, since caesarean delivery is planned for seven days before the due date, there is a chance that you will go into labour before the date of your caesarean delivery. One in ten women (10%) go into labour before this date. What are the disadvantages of elective repeat caesarean delivery? The disadvantages of elective repeat caesarean delivery include: 

A longer and possibly more difficult operation A repeat caesarean delivery usually takes longer than the first operation because of scar tissue. Scar tissue may also make the operation more difficult and can result in damage to the bowel or bladder. There are rare reports of accidental cutting of the baby at caesarean delivery.



Chance of a blood clot (thrombosis) A blood clot that occurs in the lung is called a pulmonary embolus. A pulmonary embolus can be life threatening (death occurs in less than one in 1000 caesarean deliveries). See RCOG Patient Information Venous thrombosis in pregnancy and after birth: information for you.



There is a longer recovery period You may need extra help at home and will be unable to drive for about six weeks after delivery (check with your insurance company).



Breathing problems for your baby Breathing problems are quite common after caesarean delivery and usually do not last long. Occasionally, the baby will need to go to the special care baby unit. Between three to four in 100 babies (3–4%) born by planned caesarean delivery have breathing problems compared with two to three in 100 (2–3%) following VBAC. Waiting until seven days before the due date minimises this problem.



A need for elective caesarean delivery in future pregnancies More scar tissue occurs with each caesarean delivery. This increases the possibility of the placenta growing into the scar making it difficult to remove at caesarean (placenta accreta or percreta). This can result in bleeding and may require a hysterectomy. All serious risks increase with every caesarean delivery you have.


44

Discuss home birth with the patient. If you have a straightforward pregnancy and both you and the baby are well, you might choose to give birth at home. In England, around one in every 50 babies is born at home. If you give birth at home, you'll be supported by a midwife who will be with you while you're in labour. If you need any help or your labour is not progressing as well as it should, your midwife will make arrangements for you to be transferred to hospital. The advantages of giving birth at home include:     

being in familiar surroundings where you may feel more relaxed and able to cope you don't have to interrupt your labour to go into hospital you will not need to leave your other children, if you have any you will not have to be separated from your partner after the birth you are more likely to be looked after by a midwife who you have got to know during your pregnancy

There are some things you should think about if you are considering a home birth:   

you may need to transfer to a hospital if there are complications epidurals are not available at home your doctor or midwife may recommend that you give birth in hospital; for example if you are expecting twins or if your baby is breech - your midwife or doctor will explain

Social conditions If a woman requests a home delivery the community midwife will perform an assessment, including visiting the place of the intended confinement.    

There should be adequate standards of heating, lighting and hygiene. There should be adequate social support. This may be a husband (or partner), mother or even mother-in-law. There should be someone to help look after existing children and provide such support that she can be relieved of usual household duties in her time of need. Should it become necessary to transfer her to hospital this should not be unusually difficult.

Obstetric risks      

The risk of adverse outcome is higher for a first baby than for a second, with a lower risk still for a third but, for fourth and subsequent babies, the risk is greater than for the first and rises progressively. The first baby is best born in a hospital environment because the adequacy of the maternal pelvis is untested and the experience of childbirth is new. Maternal age is a significant risk factor and, a general rule may be that the appropriate age for home delivery is over 20 but under 35 years. Such complications as breech presentation, unstable lie, multiple pregnancy and pre-eclampsia all necessitate hospital delivery. A history of antepartum haemorrhage may suggest that the placenta is inadequate and so there is risk of fetal distress in labour. Labour should be spontaneous and at term - that may be defined as between 37 and 42 weeks' gestation.

Medical risks – significant disease may add to the risk of labour for both mother and child and so should indicate hospital confinement. 

The most common significant medical condition is gestational diabetes. This will require intensive monitoring of both mother and child in labour. Cardiac disease in pregnancy usually represents a risk and essential hypertension puts the placenta at risk.


45

HPV vaccination.   

      

Human papillomavirus (HPV) is a virus that can affect the skin and mucosa. The mucosa are the moist membranes that line different parts of the body, including the mouth, throat and genital area. Infection with some high-risk types of HPV can cause abnormal tissue growth as well as other cell changes that can lead to cervical cancer (cancer of the neck of the womb). Clinical trials of Cervarix (the HPV vaccine used in the UK vaccination programme) have shown that it protects against two types of HPV (HPV-16 and HPV-18) which are responsible for about 70% of cervical cancer cases. The vaccine has been shown to work better for people who are given the vaccine when they are younger, before they are sexually active, compared to when it is given to adults. However, the vaccine does not protect against all types of HPV and it is therefore not guaranteed to prevent cervical cancer. This is why regular cervical screening continues to play an important role in detecting potentially cancerous cell changes in the cervix (neck of the womb). The vaccination is given in secondary schools to girls aged 12 to 13. The HPV vaccine will be given as an injection into the muscle of the upper arm or thigh (upper leg). The vaccination consists of three doses and all three injections are needed to ensure full protection against the virus. The second injection will be given one to two months after the first injection and the third injection will be given about six months after the first. All three doses should be given within a 12-month period. Very common side effects of the HPV vaccine include pain at the injection site, redness or swelling at the injection site, headaches, muscle pain, tiredness You should not have the vaccine if you are have had an allergic reaction to a previous HPV vaccine. It is safe in people who have egg, yeast or nut allergies. You should not have it if you have a high temperature or are generally ill. However, it is still possible to be immunised with the HPV vaccine if you have a common cold. Taking the contraceptive pill does not interfere with the vaccine.

46


Bacterial vaginosis. 

  



   

Bacterial vaginosis (BV) occurs when there is a change in the natural bacterial balance in your vagina. Your vagina should contain lactobacilli. The lactobacilli produce lactic acid. This makes the vagina slightly acidic, which prevents other bacteria from growing there. However, if you have BV, you have less lactobacilli, which means that your vagina is not as acidic as it should be. This allows other types of bacteria to grow. BV is not a sexually transmitted infection because it is not passed to other people through intimate sexual contact. You might notice a change in your usual vaginal discharge. Your discharge may become thin and watery, change to a white or grey colour or develop a strong, unpleasant, fishy smell particularly after sexual intercourse. BV does not usually cause itching or irritation. BV often causes no symptoms, or the symptoms are mild. Also, there is a good chance that BV will gradually clear without treatment, as the balance of bacteria in the vagina may correct itself. So, if you have no symptoms or only mild symptoms, not treating is an option. However, if you are pregnant and you are found to have BV but have no symptoms, you may still be advised to take antibiotic treatment. Metronidazole is the most common and preferred antibiotic treatment for BV. It is available in tablets to be swallowed twice a day, for seven days. Do not drink any alcohol while taking metronidazole, and for at least 48 hours after stopping treatment. The interaction with alcohol can cause vomiting and other problems such as flushing and an increased pulse rate. If you have untreated BV, you may have an increased risk of developing HIV infection if you have sex with someone who is infected with HIV. Women with untreated BV may be at an increased risk of developing pelvic inflammatory disease (PID), a condition that involves infection and inflammation of the womb and fallopian tubes. If you have untreated BV during pregnancy, you have an increased risk of developing some complications of pregnancy. For example, early labour, miscarriage, having a low birth weight baby or developing an infection of the uterus (womb) after childbirth. You may be able to lower your risk of developing BV if you a. stop using scented soaps and perfumed bubble bath b. stop using vaginal deodorant c. stop douching ( washing or cleaning out your vagina ) d. stop putting antiseptic liquids in the bath e. stop using strong detergents to wash your underwear. These can upset the natural bacterial balance in your vagina, making it more likely that you will develop BV.

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Vaginal thrush.  

Vaginal thrush is caused by the overgrowth of a yeast-like fungus that lives naturally in the vagina. Up to half of women have Candida living naturally in their vagina without it causing any symptoms. It's thought that there has to be a change in the natural balance of the vagina, which leads to an explosion in the growth of Candida that causes the symptoms of thrush. The natural balance may be altered or upset by certain situations eg, when you are pregnant, if you have diabetes or if you take antibiotics. People with a poor immune system are also more likely to get thrush eg, people on chemotherapy for certain cancers, people taking high-dose steroids, etc.

Typical symptoms include:    

itching and soreness around the entrance to the vagina pain during sex a stinging sensation when you urinate vaginal discharge, although this isn't always present; the discharge is usually odourless; it can be thin and watery, or thick and white, like cottage cheese

Anti-thrush treatments come as:   

     

an anti-thrush pessary (clotrimazole, econazole, miconazole) to deal with Candida in the vagina. A pessary is a specially-shaped lump of anti-thrush medication that you insert into the vagina using an applicator an anti-thrush cream to deal with Candida on the skin around the entrance to the vagina. anti-thrush tablets and pills (fluconazole, which is taken as a single dose, or itraconazole which is taken as two doses over the course of one day). Do not take these treatments if you are pregnant or breast-feeding. Pessaries and creams are the recommended treatment if you're pregnant or breastfeeding. Oral treatments are simpler and more convenient than pessaries and creams, but they can have side effects (nausea, vomiting, headache, diarrhoea, wind, constipation, bloating, upset stomach). Thrush occurs more commonly in pregnant women, and can be more difficult to clear. It can take several days of topical treatment to clear thrush if you are pregnant. If you have thrush when your baby is born, the baby may catch it during the delivery. This is nothing to worry about, and can easily be treated. Vaginal thrush isn't a sexually transmitted infection but it can occasionally be passed on during sex. So, if you have thrush it's best to avoid having sex until you've completed a course of treatment and the infection has cleared up. Male sexual partners do not need treatment unless they have symptoms of thrush on their penis. Symptoms in men include redness, itch, and soreness of the foreskin and the glans of the penis.

To reduce your risk of vaginal thrush:    

wash your vaginal area with water and avoid perfumed soaps, shower gels, vaginal deodorants, or douches avoid latex condoms, spermicidal creams or lubricants if they irritate your genital area avoid tight-fitting underwear or tights wear cotton underwear and loose-fitting trousers and skirts

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Trichomonas vaginalis 

Trichomoniasis is a common sexually transmitted infection (STI) caused by a tiny parasite called Trichomonas vaginalis. Trichomoniasis is believed to be very common, but many infected men and women will not have any symptoms. Women are more likely to have symptoms of trichomoniasis than men.

Trichomoniasis affects the vagina and urethra (tube through which urine passes), causing any of the following symptoms:     

Soreness, inflammation (swelling) and itching around the vagina. Sometimes your inner thighs also become itchy. A change in vaginal discharge. Your discharge may appear thicker, thinner, frothy or yellow or green in colour. You may also produce more discharge than normal and it may have an unpleasant, fishy smell. Pain or discomfort when passing urine. Discomfort during sexual intercourse. Pain in your lower abdomen (tummy).

Trichomoniasis affects the urethra (tube through which urine passes) and occasionally the prostate gland (a gland at the neck of the bladder that helps produce semen), causing any of the following symptoms:   

pain after urination and ejaculation thin white discharge from the penis discomfort during sexual intercourse



Trichomoniasis is usually treated quickly and easily. Most people will be prescribed an antibiotic known as metronidazole, which, if taken correctly, is very effective. You will usually have to take metronidazole twice a day, for five to seven days. Metronidazole can cause nausea, vomiting and a slight metallic taste in your mouth. It is best to take it after food. If you start vomiting, contact your GP, as the treatment will not be effective. Do not drink alcohol while taking metronidazole or for at least 48 hours after finishing the course of antibiotics. Drinking alcohol while taking this medicine can cause more severe side effects. Don't have sexual intercourse while you are being treated for trichomoniasis, otherwise you may become reinfected. If you were prescribed a single one-day dose of antibiotics, you need to avoid sexual intercourse for seven days after you have taken the medication. It is also important that your partner is tested for the infection, as they too must be treated. If your sexual partner is not treated, then this increases the risk of reinfection. Like any sexually transmitted infection (STI), the best way to prevent trichomoniasis is to practise safe sex. This means always using a condom.

     

If you get trichomoniasis while you are pregnant, you may be at risk of passing the infection on to your baby. Trichomoniasis may cause your baby to be born prematurely, or be a low birth weight. Pregnant women can safely take metronidazole. However, pregnant women who experience side effects when taking metronidazole or who do not wish to take the medicine may be prescribed clotrimazole. A clotrimazole pessary is a type of antifungal medicine that is inserted into the vagina. It is very safe for pregnant women to use and will help relieve symptoms of trichomoniasis. However, it is far less effective than antibiotics and is unlikely to cure the infection.

49


Chlamydial infection As chlamydia is a sexually transmitted infection (STI), it is passed on from one person to another during intimate sexual contact. You can catch chlamydia through unprotected vaginal, anal or oral sex. In women, genital chlamydia does not always cause symptoms. Signs and symptoms can appear 1-3 weeks after coming into contact with chlamydia, many months later or not until the infection has spread to other parts of your body. Some women may notice:      

cystitis (pain when passing urine) a change in their vaginal discharge lower abdominal pain pain and/or bleeding during sexual intercourse bleeding after sex bleeding between periods or heavier periods

If left untreated, the chlamydial infection can spread to the womb and cause Pelvic Inflammatory Disease (PID). PID is a major cause of infertility, ectopic pregnancy and miscarriage. Symptoms of genital chlamydia are more common in men than in women. Signs and symptoms can appear 1-3 weeks after coming in contact with chlamydia, many months later or not until the infection has spread to other parts of your body. Some men may notice:   

a white, cloudy or watery discharge from the tip of the penis pain when passing urine pain in the testicles

Some men have mild symptoms that disappear after two or three days. However, after the discomfort disappears, you may still have the chlamydia infection. This means that you can pass it on to a sexual partner. You are at risk of complications such as inflamed and swollen testicles, reactive arthritis and infertility. The two most commonly prescribed antibiotics to treat chlamydia are  

azithromycin (single dose) doxycycline (usually two capsules a day for a week)

It is important that you finish all the capsules prescribed to you. If you do not, the treatment may not be effective at getting rid of the infection. The side effects of antibiotics are usually mild. The most common side effects include stomach pain, diarrhoea and feeling sick. Occasionally, doxycycline can cause a skin rash if you are exposed to too much sunlight (photosensitivity). Chlamydia is easily passed on through intimate sexual contact. If you are diagnosed with the infection, anyone you have recently had sex with in the last six months may also have it. It is important that your current partner and any other recent sexual partners are tested and treated. Your local genitourinary medicine (GUM) or sexual health clinic may be able to help by notifying any of your previous partners on your behalf. A contact slip can be sent to them explaining that they may have been exposed to a sexually transmitted infection (STI). It will suggest that they go for a check-up. The slip sometimes notes what the infection is but will not have your name on it, so your confidentiality is protected. If you or your current partner is diagnosed with chlamydia, do not have sex until you have both finished your course of treatment. Chlamydia can be successfully prevented by using condoms every time you have vaginal or anal sex.


50

Gonorrhoea Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria called Neisseria gonorrhoeae. Gonorrhoea is easily passed between people through unprotected vaginal, oral or anal sex. Anyone who is sexually active can contract gonorrhoea, especially people who change partners frequently or do not use a barrier method of contraception, such as a condom, when having sexual intercourse. About one in 10 infected men and half of infected women will not experience any obvious symptoms after contracting gonorrhoea, which means it can go untreated for some time. In women, symptoms of gonorrhoea can include:    

an unusual discharge from the vagina, which may be thick, and green or yellow in colour pain when passing urine pain or tenderness in the lower abdominal area (this is less common) bleeding between periods or heavier periods (this is less common)

Nine out of 10 men who contract gonorrhoea experience symptoms after they are infected, which can include:    

an unusual discharge from the tip of the penis, which may be white, yellow or green pain or a burning sensation when urinating inflammation (swelling) of the foreskin pain or tenderness in the testicles or prostate gland (this is rare)

It is important to receive treatment for gonorrhoea as quickly as possible. It is unlikely the infection will go away without treatment and, if you delay treatment, you risk the infection causing complications and more serious health problems. You may also pass the infection onto someone else. Gonorrhoea is treated with a single dose of antibiotics, either ceftriaxone, cefixime or spectinomycin The antibiotics are either given orally (as a pill) or as an injection. Treatment is at least 95% effective and you should only have to go back for a follow-up test if the signs and symptoms do not go away You should avoid sexual intercourse and intimate contact with other partners until you (and your partner) have both finished the course of treatment. This is to prevent reinfection or passing the infection onto anyone else. It is important that your current partner and any other recent sexual partners are tested and treated. Complications   

In women, gonorrhoea can spread to the reproductive organs and cause pelvic inflammatory disease (PID). PID can lead to long-term pelvic pain, ectopic pregnancy and infertility. In men, gonorrhoea can cause painful infection in the testicles and prostate gland, which can lead to reduced fertility. If you are pregnant, gonorrhoea can be passed from you to your baby during birth. This can lead to your newborn baby having an infection of the eyes (conjunctivitis), which can lead to blindness if not treated.

Gonorrhoea can be successfully prevented by using condoms every time you have vaginal or anal sex.

51


Cervical cancer screening / cervical smear test

A cervical screening test (smear test) is a method of preventing cervical cancer by detecting abnormal cells in the cervix (neck of the womb). In the UK, cervical cancer is the second most common cancer in women under 35 (after breast cancer). About 2,800 women a year are diagnosed with cervical cancer. All women aged between 25 and 64 are invited for cervical screening. Making an appointment - You will receive a letter from your local primary care trust or GP asking you to make an appointment for a cervical screening test. You can have the test at your GP surgery or a family planning clinic. It is best to have the screening test in the middle of the menstrual cycle, so book your appointment to coincide with this. The screening - The cervical screening test usually takes around five minutes. You will be asked to undress from the waist down and lie on a couch. The doctor or nurse will gently put an instrument, called a speculum, into your vagina. This holds the walls of the vagina open so that the cervix can be seen. A small brush-like instrument is then used to gently wipe some cells off the surface of the cervix. It may be a bit uncomfortable or embarrassing, but for most women it is not painful. If you find the test painful, tell the doctor or nurse because they may be able to reduce your discomfort. Try to relax as much as possible as being tense makes the test harder to carry out. Taking slow, deep breaths will help. In the laboratory - The cell sample is now taken using liquid-based cytology (LBC). The head of the brush on which your cells have been collected is broken off into a small pot of preservative liquid, or rinsed directly into the preservative liquid. The sample is then sent to a laboratory, where it is treated to remove any other material that may have been picked up, such as mucus or blood. A sample of the remaining cells is put on a slide and laboratory staff look at the cells under a microscope to see if there are any abnormal cells. The Cancer Screening Programme aims to notify people within 14 days with the results of their test. Smear result Normal Inadequate

Action Inform patient the result is normal and routine recall after 3 or 5 years Repeat within 3 months. Refer for colposcopy after three consecutive inadequate samples.

Borderline

Borderline nuclear change in endocervical cells - refer for colposcopy Borderline nuclear change in squamous cells - repeat within 6 months. Refer for colposcopy if there are 3 consecutive borderline smears.

Mild dyskaryosis (CIN I) Moderate dyskaryosis (CIN II ) Severe dyskaryosis (CIN III)

Repeat within 6 months. Refer for colposcopy if changes persist. Refer for colposcopy

Refer for colposcopy

You may require treatment if the results of your colposcopy indicate that you have abnormal cells in your cervix.     

Large loop excision of the transformation zone (LLETZ) Cone biopsy Cryotherapy Laser treatment Cold coagulation

52


Sterilisation.  



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Sterilisation is a permanent method of contraception, suitable for women or men who are sure they never want children or don't want more children. Sterilisation works by stopping the egg and the sperm meeting. This is done by blocking the fallopian tubes (which carry the egg from the ovary to the womb) in women or the vas deferens (the tube that carries sperm from the testicles to the penis) in men. Vasectomy is very effective – about one in 2,000 male sterilisations fails. Men will need to use contraception after vasectomy until a semen test shows there are no sperm. This test is usually done around eight weeks after vasectomy. Female sterilisation is a minor operation that permanently prevents a woman from being able to get pregnant. It is usually carried out under general anaesthetic, and involves blocking or sealing the fallopian tubes. The advantage of sterilisation is you don't have to think of contraception again. About 1 in 200 women will become pregnant after sterilisation. This is because the tubes can, rarely, come back together again after being cut or blocked. You need to use contraception until the operation is done and for four weeks afterwards. As with any surgery, there's a small risk of complications: these include internal bleeding, infection or damage to other organs. If the operation fails, this may increase the risk of ectopic pregnancy (when a fertilised egg implants outside the womb, usually in a fallopian tube). Female sterilisation does not protect against sexually transmitted infections, so always use a condom to protect yourself and your partner against STIs. Although sterilisation is not 100% reliable, and also a reversal can be attempted (although not on the NHS), it should be considered permanent and irreversible for anyone undergoing it. You should not consider sterilisation if you're unsure, under any stress (for example after birth, miscarriage or abortion) or have any family or relationship crisis. Research shows that more women and men regret sterilisation if they were sterilised when they were under 30, had no children or were not in a relationship. Have you considered the alternatives? Female sterilisation is not 100% effective. Other reversible methods of contraception are more effective such as the intrauterine system (IUS), contraceptive implants and injections.

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Stress incontinence.

Stress incontinence is when the pelvic floor muscles are too weak to prevent urination, causing urine to leak when your bladder is under pressure, for example when you cough or laugh. The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. Stress incontinence is common in women who have had children. It is also more common with increasing age as the muscles become weaker, particularly after the menopause. Stress incontinence is also more common in women who are obese. Conservative treatments  

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Lifestyle changes – reducing caffeine intake, losing weight if you are overweight or obese Pelvic floor muscle training – o doing a minimum of eight muscle contractions at least three times a day o doing these exercises for at least three months o continuing with these exercise after three months if they are helping Bladder training – involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course will usually last for at least six weeks.

Duloxetine is a possible medication for stress incontinence. NICE does not recommend duloxetine as an initial treatment for women with mainly stress incontinence. Various surgical operations are used to treat stress incontinence. They tend only to be used when the pelvic floor muscle exercises have not helped. The operations aim to 'tighten' or support the muscles and structures below the bladder.

Uterine prolapse

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The uterus (womb) is usually held in place by muscles, tissue and ligaments. Prolapse happens when the tissues that support the uterus become so weak that the uterus cannot stay in place and it slips down from its normal position. This can cause a sensation of something coming down or out of the vagina, an uncomfortable feeling of fullness, difficulty having sex and leaking a small amount of urine when you cough, sneeze or exercise (stress incontinence). Up to half of all women who have had children are affected by some degree of prolapse. It is more common as women get older, particularly in those who have gone through the menopause. Mild cases of prolapse may not need treatment. Lifestyle changes such as weight loss and pelvic floor exercises may be recommended instead. More severe cases of prolapse may be treated effectively using a device that is inserted into the vagina called a vaginal pessary. This helps to hold the uterus in place. There are also several different surgical techniques that can be used. For example, a mesh can be inserted to support the uterus in vaginal repair operation. Other surgeries include sacrohysteropexy, sacrocolpopexy, sacrospinous fixation and hysterectomy. Uterine prolapse can return after surgery in about 16 in 100 women. Prevention of uterine prolapse o Regular pelvic floor exercises, especially if you are planning to get pregnant, are pregnant, or have given birth. o If you are overweight, try to lose weight. o Eat a high-fibre diet (plenty of fruit and vegetables and wholegrain bread and cereal) and drink plenty of water to avoid constipation. o If you smoke, try to stop smoking. o Avoid occupations that involve heavy lifting.


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Breastfeeding Breastfeeding is the healthiest way to feed your baby. Exclusive breastfeeding is recommended for around the first six months of your baby's life. After that, giving your baby breast milk alongside other food will help them continue to grow and develop. Breastfeeding is good for babies. Breastfed babies have:     

less chance of diarrhoea and vomiting and having to go to hospital as a result fewer chest and ear infections and having to go to hospital as a result less chance of being constipated less likelihood of becoming obese and therefore developing type 2 diabetes and other illnesses later in life less chance of developing eczema

Breastfeeding does not only benefit your baby. It benefits your health too. Breastfeeding is good for mums as it:     

lowers your risk of getting breast and ovarian cancer easier to lose weight after giving birth saves money – infant formula, the sterilising equipment and feeding equipment can be costly can help to build a strong bond between you and your baby delays the return of your periods

Breastfeeding is a skill that needs to be learnt, and it can take time and practice to get the hang of it.    

Are you comfortable? It’s worth getting comfortable before a feed. Remember when you feed to relax your shoulders and arms. Are your baby’s head and body in a straight line? If not, your baby might not be able to swallow easily. Are you holding your baby close to you, facing your breast? Support their neck, shoulders and back. They should be able to tilt their head back and swallow easily, and shouldn’t have to reach out to feed. Is your baby’s nose opposite your nipple? Your baby needs to get a big mouthful of breast from beneath the nipple. Placing your baby with their nose level with your nipple will allow them to reach up and attach to the breast well.

How do you know that your baby is getting enough milk?     

Your baby will appear content and satisfied after most feeds. They should be healthy and gaining weight after the first two weeks. Your breasts and nipples should not be sore. After the first few days, your baby should have at least six wet nappies a day. After the first few days they should also pass at least two yellow stools every day.

An over-supply of milk can build up in your breasts for a variety of reasons. If your baby is not well attached it may be hard for them to take your milk effectively, and some parts of your breast may not be drained during a feed. This is the area of your breast that may feel sore or painful. It’s important to deal with a sore breast or a blocked duct as soon as possible so that it doesn’t lead to mastitis (inflammation of the breast). If you have mastitis you're likely to have at least two of the following symptoms:     

breast or breasts that feels hot and tender a red patch of skin that's painful to touch general feeling of illness, as if you have flu feeling achy, tired and tearful you may have an increased temperature

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This can happen very suddenly and can get worse very quickly. It's important to carry on breastfeeding as this helps to speed up your recovery. If you think you might have a blocked duct or mastitis, try the following:       

Check and improve the attachment of your baby at the breast – ask your midwife, health visitor or volunteer breastfeeding supporter. Feed your baby more often. Let your baby feed on the tender breast first. If your breasts still feel full after a feed or your baby can’t feed, hand express some milk to relieve the fullness. Warmth on your breast before a feed can help the milk to flow and make you feel more comfortable. Try warm flannels or a bath or shower. While your baby is feeding, gently stroke the lumpy or tender area towards your nipple with your fingertips. This should help the milk to flow. If you can, take a painkiller such as paracetamol or ibuprofen.

Mastitis may also be a sign of infection. If there's no improvement within 12 to 24 hours, or you start to feel worse, contact your GP or healthcare professional. If necessary, they can prescribe antibiotics that can be taken while breastfeeding. Stopping breastfeeding will make your symptoms worse, so ask for help and support early.

"I have to go back to work soon - so is it worthwhile just for a short period of time?" YES, even if you only breastfeed for a short period of time there are benefits. In particular, the advantage of preventing infection has a knock-on effect, and you will have given the baby valuable antibodies. But, if possible, try to continue breastfeeding for six months.

"It's too embarrassing and inconvenient whilst out." Have you noticed that more shops and public places now provide mother and baby rooms to cater for breastfeeding mothers? Breastfeeding has become a much more accepted part of society.

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Rhesus Disease    

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Rhesus disease also known as haemolytic disease of the foetus and newborn – is a condition where antibodies in a pregnant woman’s blood destroy her baby's blood cells. Rhesus disease only happens when the mother has rhesus-negative blood (RhD negative) and the baby in her womb has rhesus-positive blood (RhD positive). The mother must have also been previously sensitised to RhD-positive blood. Sensitisation happens when a woman with RhD-negative blood is exposed to RhD-positive blood. This could happen during a pregnancy with an RhD-positive baby, or if the woman has a blood transfusion with RhDpositive blood. The woman’s body responds to the RhD-positive blood by generating antibodies (infection-fighting protein molecules) that recognise the "alien" blood cells and destroy them. This is known as "sensitisation" the first time it happens. If sensitisation has already occurred, the next time the woman is exposed to RhD-positive blood her body will start to produce antibodies immediately, and in larger amounts. If she is pregnant with an RhD-positive baby, the antibodies can cross the placenta and cause rhesus disease in the unborn baby. After the baby has been born, the mother's antibodies can remain in the baby for a few months and can continue to attack its red blood cells. All women are offered blood tests as part of their antenatal screening to determine whether their blood is RhD negative or positive. If the mother is RhD negative then she will be offered injections of anti-D immunoglobulin at certain points in her pregnancy when she may be exposed to the baby’s red blood cells. The anti-D immunoglobulin neutralises any foetal RhD-positive antigens that have entered the mother’s blood. If the antigens have been neutralised, the mother’s blood will not start to produce antibodies. There are currently two ways that you can receive routine antenatal anti-D prophylaxis (RAADP): i.

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a one-dose treatment: where you will receive an injection of immunoglobulin in your shoulder at some point during weeks 28 to 30 of your pregnancy ii. a two-dose treatment: where you will receive two injections into your shoulder; one during the 28th week and the other during the 34th week of your pregnancy Treatment for rhesus disease after delivery includes phototherapy, blood transfusions and a solution of antibodies given through a vein to prevent red blood cells being destroyed (intravenous immunoglobulin). If rhesus disease is left untreated, it can cause severe anemia, fetal heart failure, swelling and stillbirth (when a baby dies in the womb before it is born). Rhesus disease makes the body produce excessive amounts of bilirubin. Without prompt treatment, a build-up of bilirubin in the brain can lead to a neurological condition called kernicterus. This can lead to complications such as deafness, blindness, brain damage, learning difficulties or even death.

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F&amp;C OSCE Notes_University of Manchester, WL Gan

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F&C OSCE Notes_University of Manchester, WL Gan