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MRCOG PART 2 SBAs and EMQs

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ESSAY 341 answer

ESSAY 341 answer Posted by Dr Dyslexia V.

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a)      History in regards to past contraception usage would be important . The type of contraception or compliance and contraception failure in spite proper  adherence to it. Her menstrual history is important as the last menstrual period and presence of any recent coitus could lead to a ongoing pregnancy currently. Her cycle length, presence of dysmenorrheal or menorrhagia history could dictate usage of hormonal contraception. Sexual history in regards of the number of sexual partner and usage of condom could infer the risk of sexually transmitted disease(STD). History of any previous pelvic inflammatory disease or treatment is important as well and relevant for intrauterine contraceptive device(IUCD) usage. Underlying medical history diabetes, hypertension with any end organ damage, migraine or venous thrombo embolism(VTE) is important as it is a contraindication for combine oral contraceptive(COC) pill. History of any current drugs usage such as anti epileptic drugs such as phenytoin or antibiotic such as ampicillin which are enzyme inducers which could cause hormonal contraception failure. Social history such as smoking increases the risk of VTE in usage of COC. History of previous cervical disease or previous cervical smear results is important for usage of IUCD. Examination of her should include blood pressure for presence of hypertension. Abdominal examination for presence of any pelvic mass is also as presence of a fibroid which could cause distorted uterine cavity which is a contraindication for IUDC insertion. A pelvic examination to assess the cervix of any suspicious lesion should also be done to assess the difficulty for insertion of IUCD.

b)      Hormonal contraception include COC pills, progestogens such as POP progesterone only pills, injectables such as depot medrooxyprogesterone acetate(DMPA), etonegesterol implant such as implanol. Her known risk factors is currently being morbidly obese with a BMI of 40 makes her UKMEC category 3 for COCP as there is increase in VTE, increase in myocardial infarction and stroke with its usage. POP could be used in her as there is no contraindication to its usage in obesity. It is easily used and it is used continuously without any breaks and easily available with a failure rate of 0.3 per 100 women if properly used. The drawback includes its small window of daily usage time of 3 hours compared to cerazette which has a twelve hours window period makes it difficult to adhere. It has the disadvantage of causing irregular bleed in 40% of the women and amenorrhea in about 20% of women after 1 year of usage. It has other disadvantage which include mood irritability, breast tenderness, bloatedness and depression. This also increased risk of ectopic pregnancy if pregnancy occurs during usage of POP. DMPA are other method which is reliable as it requires less level of commitment as it is a 3 monthly injection. It is however associated with weight gain as these patients are already obese. It is also associated a decrease in bone mineral density and a delay in return of fertility up to a year when discontinued. It is associated with amenorrhea in about 70% of patient after 1 year of usage. The progesterone only implant such as etonegesterol is beneficial as its usage which lasts about 3 years for contraception. It has a rapid return to fertility upon discontinuation. It also reduces an overall risk of ectopic pregnancy compared to the POPs. It has no association with increase in weight or loss of bone mineral density however it is associated with irregular bleeding in which 20% will become amenorrheic and 50% will have irregular bleeding.

c)       There is no contraindication to reuse of IUCD either copper bearing IUCD or LNG intrauterine system in this patient. This device will be ideal for a patient who wishes not to take regular medication and is keen for long acting reversible contraception. The intrauterine device CU380 is licensed  for 8 years used while LNG IUS is licensed for 5 years for contraception. Both has the advantage of rapid return of fertility after discontinuation of use as this patient is young. The risk of perforation is up to in 1000 insertion and it would be higher in this patient as she is obese and it would be technically difficult. The risk of PID is increased in the first 20 days of insertion especially in a lady who has 3 unwanted pregnancies with medical termination. The LNG IUS will be useful to control any idiopathic menorrhagia which could be present in obese patient.

Answer Posted by PAUL A.

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