AKT – Pregnancy and reproductive health

Emma Sanderson, aged 29, presents at 8 weeks’ gestation for her first antenatal appointment. She is well and reports mild nausea. This is her first pregnancy.

She is a non-smoker and drinks alcohol occasionally but has abstained since her positive pregnancy test. She is not taking any regular medications. There are no significant medical or surgical issues. No known family history of congenital anomalies.

Her BMI is 26. Blood pressure is 112/68 mmHg. Clinical examination is unremarkable.

What is the most appropriate next step in her antenatal care?

Sofia Armanios, aged 22, presents with vaginal bleeding and abdominal pain. She is 7 weeks pregnant by dates. She has not had any antenatal care yet. She is otherwise healthy and has no past medical history.

She reports increasing pain localised to the right lower abdomen. On examination, her BP is 100/64 mmHg, HR 92 bpm. She has right iliac fossa tenderness and cervical motion tenderness. A urine pregnancy test is positive. Serum β-hCG is 800 IU/L. Transvaginal ultrasound shows an empty uterus and a right adnexal mass.

What is the most appropriate next step?

Jessica Norman, aged 37, presents to discuss contraception. She recently had her second child 6 weeks ago and is currently exclusively breastfeeding. She does not plan to have more children. She has no significant medical history.

She is keen for a long-term option and asks about the best method that won’t affect breastfeeding.

What is the most appropriate contraceptive option?

Hannah Wurundjeri, aged 17, presents requesting the oral contraceptive pill. She has recently become sexually active. She has no past medical history and takes no regular medications.

She reports regular 28-day cycles and no menstrual issues. She is not in a long-term relationship but uses condoms inconsistently. She is otherwise healthy.

What is the most appropriate next step in her care?

Priya Naidu, aged 34, is 24 weeks pregnant with her first child. She presents for routine antenatal care. She is feeling well and fetal movements are normal.

Her OGTT results are as follows: Fasting 5.4 mmol/L, 1 hour 11.2 mmol/L, 2 hour 8.9 mmol/L. Her BP is 124/76 mmHg and fundal height is appropriate for gestation.

What is the most appropriate next step in her management?

Laura D’Silva, aged 32, presents with heavy menstrual bleeding that has worsened over the past year. Her cycles are regular, every 28 days, and periods last for 7–8 days with passage of clots. She has no intermenstrual or postcoital bleeding. She and her partner are planning to conceive within the next 12 months.

On examination, abdomen is soft, no masses palpable. Speculum and bimanual exam are unremarkable. Pap smear is up to date.

What is the most appropriate next step in management?

Ella Nguyen, aged 19, presents for emergency contraception after unprotected intercourse 4 days ago. She has a regular 30-day cycle and is day 16 of her current cycle. Her last menstrual period was 16 days ago. She has no medical history and takes no regular medications.

What is the most effective emergency contraception option at this stage?

Alicia Thomson, aged 45, presents with concerns about irregular heavy bleeding over the past 6 months. Periods occur every 2–6 weeks and are sometimes very heavy. She has completed her family. She has no significant medical history. Pap smear 1 year ago was normal.

On examination, her uterus is enlarged and irregular. A transvaginal ultrasound shows multiple intramural and submucosal fibroids, the largest being 4.5 cm.

What is the most appropriate next step in management?

Chloe Morrison, aged 30, G1P1, presents at 10 weeks postpartum for review. She had a normal vaginal delivery and is breastfeeding. She reports feeling very anxious, overwhelmed, and tearful most days. She says she struggles to sleep even when the baby is asleep. She is supported by her partner but feels ashamed to discuss how she feels.

She denies thoughts of self-harm. Physical recovery from birth is unremarkable.

What is the most appropriate next step in management?

Isabella Conte, aged 39, presents with primary infertility. She and her partner have been trying to conceive for 14 months. Her cycles are regular, and she reports no dysmenorrhoea or abnormal bleeding. Her partner has no known health issues. She is otherwise well, with a BMI of 24 and non-smoker. Cervical screening is up to date.

What is the most appropriate initial investigation?

Grace Makenzie, aged 26, presents with lower abdominal pain and vaginal discharge. She is sexually active with multiple partners and inconsistently uses condoms. She reports no systemic symptoms. LMP was 2 weeks ago and her cycles are regular.

On examination, she has lower abdominal tenderness, cervical motion tenderness, and purulent cervical discharge.

What is the most appropriate next step in management?

Samantha Duong, aged 40, presents for advice regarding menopausal symptoms. She has hot flushes, poor sleep, and mood lability. Her last menstrual period was 11 months ago. She has no contraindications to hormone therapy. Cervical screening is current.

What is the most appropriate management option?

Meera Singh, aged 34, presents at 18 weeks’ gestation for routine antenatal care. She is feeling well and reports normal fetal movements. Her morphology ultrasound is scheduled for next week. Her midstream urine culture from the antenatal screening shows >100,000 CFU/mL of E. coli, but she is asymptomatic.

What is the most appropriate next step in management?

Emily Zhou, aged 28, presents for cervical screening. She had a normal Pap smear 2 years ago. She has recently become sexually active again after a long-term relationship ended. She has no symptoms and is otherwise well. She is unsure about her HPV vaccination status.

What is the most appropriate next step in her preventative care?

Natasha Karam, aged 30, presents with vulval itching and thick white discharge. She has had similar symptoms in the past. She is not sexually active and has no systemic symptoms. She is otherwise well and not on medications.

Speculum examination reveals thick curd-like discharge with mild vulvovaginal erythema.

What is the most appropriate treatment?

Rebecca Young, aged 35, presents for pre-conception counselling. She and her partner are planning to start trying for pregnancy in the next 2–3 months. She has no significant medical history, is a non-smoker and takes no regular medications.

What is the most appropriate recommendation regarding folic acid supplementation?

Angela Cardoso, aged 27, presents with severe right lower quadrant pain and vomiting. She is 35 weeks pregnant. She has no other significant symptoms. Fetal movements are present. On examination, she is febrile (38.3°C), has rebound tenderness in the right lower quadrant, and is tachycardic. Fetal heart rate is 160 bpm.

What is the most appropriate next step in her management?

Clare O’Hara, aged 38, presents with hot flushes and vaginal dryness. She has not had a menstrual period for 8 months. She has a past history of DVT 4 years ago, provoked by surgery. She is otherwise well.

What is the most appropriate treatment option for her symptoms?

Debbie Gorringe, aged 29, presents at 12 weeks’ gestation with nausea, occasional vomiting, and food aversions. She is managing to maintain hydration and oral intake. No weight loss is reported. There are no abdominal signs on examination.

What is the most appropriate initial management?

Lina Polanski, aged 42, presents with 6 weeks of amenorrhoea and new breast tenderness. A urine pregnancy test is positive. She is unsure of her dates. She has a history of miscarriage at 10 weeks 2 years ago. She is otherwise well and on no medications.

What is the most appropriate next step in her care?

Amira Khan, aged 24, presents with pelvic pain and dyspareunia. She has had these symptoms intermittently for over 12 months and they are worse around her period. She has not yet tried to conceive. She is otherwise well and has a regular menstrual cycle.

On examination, there is mild pelvic tenderness. No adnexal masses are palpable. A pelvic ultrasound is unremarkable.

What is the most appropriate next step in management?

Tracy Blackwell, aged 31, presents at 32 weeks gestation with new onset pruritus affecting her palms and soles. She has no rash. She reports disturbed sleep due to the itching. She is otherwise well and fetal movements are normal.

Her LFTs reveal mildly elevated ALT and bile acids are pending.

What is the most appropriate initial step?

Monique Elston, aged 33, is 28 weeks pregnant and presents with headaches and visual disturbances. Her BP is 158/94 mmHg and there is 2+ protein on dipstick urinalysis. She reports no abdominal pain or contractions. Fetal movements are present.

What is the most appropriate next step in her management?

Sienna Woods, aged 19, presents for medical termination of pregnancy. She is 6 weeks pregnant by dates and has confirmed intrauterine pregnancy on ultrasound. She has no medical conditions and is sure of her decision.

What is the most appropriate management option?

Fiona Abernethy, aged 36, presents for routine cervical screening. She is asymptomatic. Her last screening test was 5 years ago and was reported as normal. She is monogamous, in a same-sex relationship, and has never had HPV vaccination.

What is the most appropriate next step?

Daniela Russo, aged 29, presents 5 days postpartum with a red, painful area on her left breast and a low-grade fever. She is breastfeeding her newborn and reports adequate milk supply. The affected area is warm and tender to touch.

What is the most appropriate next step in management?

Yasmin El-Hassan, aged 43, presents with persistent intermenstrual bleeding. She has regular periods every 28 days, lasting 4–5 days. She reports no pain. There is no history of STI or contraception use. She is otherwise well.

Speculum examination shows normal external os and cervical appearance. Pap smear 2 years ago was normal. Pregnancy test is negative.

What is the most appropriate next step in management?

Louisa Tran, aged 21, presents with dysuria and vulval irritation. She is sexually active with a new partner and uses condoms inconsistently. No fever or systemic symptoms are reported. On examination, there are multiple small vesicles on an erythematous base on the vulva.

What is the most appropriate management?

Kirsty Wallace, aged 30, G2P1, presents at 36 weeks gestation with a history of gestational diabetes. She has been managed with diet and her BGLs are within target. Fundal height is appropriate. Fetal movements are normal.

What is the most appropriate next step in her care?

Heather Bailey, aged 47, presents with hot flushes, night sweats, and mood swings. She has not had a period for over 12 months. She has no personal or family history of cardiovascular disease, breast cancer, or thromboembolism.

What is the most appropriate management option?

Bianca Matthews, aged 33, presents for antenatal review at 28 weeks. She is Rhesus negative and her partner is Rhesus positive. Her first pregnancy was uncomplicated. There is no history of sensitisation. Current pregnancy has been normal to date.

What is the most appropriate management regarding Rhesus status at this visit?

Natalie Burton, aged 29, presents at 6 weeks postpartum. She is formula feeding her baby and reports no vaginal bleeding for the last 2 weeks. She would like to restart contraception and prefers a long-acting reversible method.

What is the most appropriate next step?

Jade Chen, aged 20, presents with lower abdominal pain and a missed period. A urine pregnancy test is positive. She is unsure of the date of her last menstrual period. She has some mild spotting and no significant medical history.

What is the most appropriate next step?

Hannah Middleton, aged 25, presents with 3 months of secondary amenorrhoea. She is sexually active and has regular cycles previously. She has gained 6 kg recently and reports acne and increased hair growth on her chin.

What is the most likely diagnosis?

Rachel Ncube, aged 41, presents with heavy and irregular menstrual bleeding. Her cycles vary from 21 to 40 days, with occasional spotting between periods. She has completed her family and does not want future pregnancies. Cervical screening is up to date.

What is the most appropriate long-term management?

Emily Roberts, aged 37, presents at 14 weeks gestation for routine antenatal care. Her blood group is A negative. She had a first trimester threatened miscarriage at 9 weeks but did not require intervention. This is her first pregnancy and she is otherwise well.

What is the most appropriate next step regarding Rhesus management?

Olivia Sutton, aged 32, presents with concerns about fertility. She has been trying to conceive for 8 months. She has regular 30-day cycles and no significant symptoms. Her partner has no known health issues. She has no history of STI or pelvic surgery.

What is the most appropriate next step?

Linda Chau, aged 40, presents at 10 weeks gestation. She has been experiencing persistent nausea and vomiting, unable to keep food or fluids down. She has lost 4 kg since becoming pregnant. Examination shows mild dehydration and ketones in urine.

What is the most appropriate management?

Georgia Wallace, aged 34, presents with dyspareunia and a history of pelvic inflammatory disease 5 years ago. She is trying to conceive but has been unsuccessful for 18 months. Her cycles are regular. Her cervical screening is up to date.

What is the most appropriate investigation?

Teresa Edwards, aged 26, presents with sudden onset of severe left lower abdominal pain. She is 7 weeks pregnant by dates. She has had mild spotting over the last 2 days. Her blood pressure is 98/64 mmHg and pulse is 104 bpm. Abdomen is tender and guarding is present in the left iliac fossa. Transvaginal ultrasound shows free fluid in the pouch of Douglas and no intrauterine pregnancy.

What is the most likely diagnosis?

Shelley Anderson, aged 30, presents at 24 weeks gestation complaining of lower back pain, pelvic pressure, and a sensation of heaviness. She denies contractions or fluid loss. Examination reveals soft, non-tender uterus and closed cervix on speculum exam. Urinalysis is normal.

What is the most appropriate next step?

Isla Thorne, aged 18, presents with postcoital bleeding. She is sexually active with multiple partners and inconsistently uses condoms. She is otherwise asymptomatic. Cervical screening has never been performed.

On examination, the cervix appears erythematous with contact bleeding. There is no discharge or adnexal tenderness.

What is the most appropriate next step?

Rita de la Cruz, aged 42, presents with concerns about menopause. She has irregular, infrequent periods, night sweats, mood changes, and poor sleep. She wants to confirm if she is in menopause. Her last period was 3 months ago.

What is the most appropriate management?

Fatima Al-Zahrani, aged 36, presents at 38 weeks gestation reporting decreased fetal movements for the past 12 hours. She has been otherwise well and has had an uncomplicated pregnancy. There is no pain or bleeding.

What is the most appropriate next step?

Claire Zhang, aged 26, presents with vaginal discharge and mild vulval irritation. She is sexually active and uses the oral contraceptive pill. She has no fever or abdominal pain. On examination, thin white discharge with a fishy odour is noted. pH is elevated and whiff test is positive.

What is the most likely diagnosis?

Stephanie Clarke, aged 39, presents at 12 weeks gestation requesting information about screening for chromosomal abnormalities. She has a strong preference for non-invasive options and is anxious about risks associated with diagnostic procedures.

What is the most appropriate test to offer her?

Angela Varga, aged 29, presents 3 days postpartum with severe perineal pain, fever (38.5°C), and purulent lochia. She had a spontaneous vaginal delivery with a second-degree tear. Examination reveals perineal erythema and swelling, with tenderness on palpation.

What is the most appropriate next step?

Kelly Nguyen, aged 17, presents with primary amenorrhoea. She has normal breast development and pubic hair. On examination, she has a blind-ending vaginal pouch and no palpable uterus.

What is the most likely diagnosis?

Nadia Karimi, aged 34, presents with new-onset pelvic heaviness and urinary urgency. On examination, a bulge is visible at the vaginal introitus when bearing down. She is 1 year postpartum after vaginal delivery and does not plan more children.

What is the most appropriate initial management?

Melissa Green, aged 31, presents at 20 weeks gestation with a history of hypothyroidism. She is taking thyroxine 100 mcg daily. Her thyroid function test shows TSH 4.2 mIU/L (normal range in pregnancy: 0.1–2.5), and FT4 is within normal limits.

What is the most appropriate next step in her management?