1️⃣ Red Flags & Conditions Not to Miss

Suspected Ectopic Pregnancy

Immediate
referral to early pregnancy assessment (or out-of-hours gynaecology) if positive test + pain or tenderness
No risk factors?
Still exclude ectopic – many women have none
Typical features:

Abdominal or pelvic pain, missed period, vaginal bleeding. Presentation can be atypical (e.g. dizziness, shoulder-tip pain, GI or urinary symptoms).

Examination:

Abdominal tenderness, pelvic tenderness, cervical motion tenderness; signs of shock if ruptured.

Action (NICE NG126):

Positive pregnancy test plus pain and abdominal tenderness, pelvic tenderness or cervical motion tenderness → refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology). Signs of rupture/shock → 999.

If unstable:

ABC approach and emergency transfer. Rhesus-negative women having surgical management are given anti-D in hospital (see Problems in Pregnancy).

Source: NICE NG126 Ectopic pregnancy and miscarriage (updated 2023).

Pre-eclampsia / Severe Hypertension

≥140/90
new hypertension after 20 weeks – look for proteinuria or organ dysfunction
≥160/110
severe hypertension (NICE NG133)
Symptoms:

Severe headache, visual disturbance (e.g. blurring, flashing lights), severe pain just below the ribs/epigastric pain, vomiting, sudden swelling of face, hands or feet.

Signs:

New hypertension after 20 weeks with significant proteinuria (PCR ≥30 mg/mmol or ACR ≥8 mg/mmol) or maternal organ dysfunction; hyperreflexia/clonus in severe disease.

Complications:

Eclampsia, HELLP syndrome, stroke, placental abruption, fetal growth restriction.

Action:

Suspected pre-eclampsia → same-day assessment by the maternity/obstetric team via your local pathway. Severe hypertension, severe symptoms or neurological features → emergency admission. PlGF-based testing (20+0 to 36+6 weeks) is done in secondary care.

Source: NICE NG133 Hypertension in pregnancy (updated 2023).

Venous Thromboembolism in Pregnancy & Postpartum

Why it matters:

Pregnancy is a prothrombotic state; risk is several-fold higher antenatally and higher still in the early postpartum weeks. Thrombosis and thromboembolism remain an important direct cause of maternal death in UK confidential enquiries (MBRRACE-UK).

DVT features:

Unilateral leg pain and swelling, warmth, erythema. Suspect iliac vein thrombosis with back/buttock pain and swelling of the whole limb.

Pulmonary embolism red flags:
  • • Sudden breathlessness, pleuritic chest pain
  • • Tachycardia, tachypnoea, hypoxia
  • • Haemoptysis, syncope, collapse
Immediate action:

Same-day hospital assessment (999 if PE suspected with compromise). RCOG advises that where VTE is clinically suspected, LMWH treatment is started until the diagnosis is excluded, unless strongly contraindicated. D-dimer should not be used to investigate acute VTE in pregnancy. Thrombophilia screening before treatment is not recommended.

Corrected: the previous "SWOLLEN" mnemonic mixed DVT and PE features and has been removed. LMWH dosing is weight-based and set by the hospital team – not given here.

Source: RCOG Green-top Guideline 37b (acute management of VTE in pregnancy and the puerperium). NICE does not publish a pregnancy-specific acute VTE pathway, so RCOG is used.

Maternal Sepsis

High mortality risk:

Sepsis in pregnancy or after birth can deteriorate quickly. Think sepsis in any unwell pregnant or recently pregnant woman with signs of infection.

Common sources:
  • • Chorioamnionitis (intrauterine infection)
  • • Endometritis (postpartum uterine infection)
  • • Wound infection (caesarean section, perineal tears)
  • • Mastitis / breast abscess
  • • UTI / pyelonephritis
  • • Group A Streptococcus – uncommon but can be rapidly fatal
Warning signs (UK Sepsis Trust public "SEPSIS" signs):

S – Slurred speech or confusion; E – Extreme shivering or muscle pain; P – Passing no urine (in a day); S – Severe breathlessness; I – "I feel like I might die"; S – Skin mottled or discoloured.

GP action:

Assess using NICE NG51 risk stratification (which includes pregnant and recently pregnant women). High-risk features → emergency transfer by 999 with a pre-alert. In hospital, high-risk patients should receive antibiotics within 1 hour (NICE NG51).

Corrected: the previous "Sepsis Six" bundle details (e.g. "lactate >2 = sepsis", fixed fluid bolus) were hospital protocol content not taken from NICE and have been removed.

Source: NICE NG51 Suspected sepsis (updated 2024); RCOG Green-top Guideline 64a/64b (maternal sepsis).

Reduced Fetal Movements

Definition:

The woman's perception that her baby's movements have reduced or changed from her usual pattern. Associated with stillbirth and fetal growth restriction.

Normal patterns:

Movements are usually first felt between 16 and 24 weeks. There is no set number of "normal" movements – focus on any change from the baby's usual pattern.

Red flags:
  • • Any reduction or change in the usual pattern
  • • No movements
  • • Reduced movements with bleeding, pain or contractions
Immediate action:

Advise the woman to contact her maternity unit immediately, at any time of day or night – not to wait until the next day. GPs should arrange same-day maternity unit assessment (CTG from 28 weeks). Do not advise home Dopplers, kick-counting charts, or cold drinks/sugary snacks to "wake the baby".

Corrected: the previous red flag "reduction for >24 hours" could delay assessment and has been removed.

Source: RCOG Green-top Guideline 57 (Reduced fetal movements); NHS England Saving Babies' Lives Care Bundle.

Hyperemesis Gravidarum (HG)

Definition:

The severe end of nausea and vomiting of pregnancy (NVP): protracted vomiting with more than 5% weight loss, dehydration and electrolyte imbalance. Affects about 0.3–3.6% of pregnancies. NVP should start before 16 weeks – consider other causes if it starts later.

Assessing severity:
  • • Use a validated score – PUQE (and HELP to track response)
  • • Weight, hydration status, ability to keep down fluids and oral antiemetics
  • • U&E and other bloods as needed; exclude other causes (e.g. UTI)
  • • Ask about mental health – HG can cause major psychological distress
Refer for ambulatory/inpatient care if:
  • • Unable to keep down fluids or oral antiemetics despite treatment
  • • Continued vomiting with >5% weight loss despite oral antiemetics
  • • Clinical dehydration or electrolyte disturbance
  • • Comorbidity (e.g. diabetes, or UTI with inability to tolerate oral antibiotics)
Changed (RCOG 2024): ketonuria is not an indicator of dehydration and should not be used to assess severity. Older admission criteria (including those that list "ketonuria 2+") should be read with this in mind.
Management:

First-line antiemetics: H1 antihistamines (e.g. cyclizine, promethazine), phenothiazines (e.g. prochlorperazine, chlorpromazine) or doxylamine/pyridoxine (Xonvea®). Ondansetron is safe and effective as second-line – counsel about a very small absolute increase in orofacial clefting with first-trimester use. Combine drugs if one fails. Thiamine (oral 100 mg three times daily, or IV as Pabrinex®) for anyone admitted with vomiting or severely reduced intake. Doses for antiemetics: see BNF and RCOG GTG 69 Appendix III.

Source: RCOG Green-top Guideline 69 (2024). NICE CKS "Nausea/vomiting in pregnancy" also covers this topic – check it alongside for primary-care prescribing detail.

Postpartum Psychosis

Psychiatric emergency:

Usually begins suddenly in the first 2 weeks after birth. Carries a serious risk to mother and baby.

Clinical features:
  • • Rapidly changing mood (mania, depression or mixed)
  • • Confusion, perplexity, disorientation
  • • Hallucinations and delusions (often involving the baby)
  • • Marked behavioural change, severe insomnia
  • • Thoughts of harming self or baby
Highest-risk women (be alert in the first 2 weeks):
  • • Any past or present severe mental illness (e.g. bipolar disorder, previous postpartum psychosis)
  • • Severe perinatal mental illness in a first-degree relative
Immediate action (NICE CG192):

Sudden onset of symptoms suggesting postpartum psychosis → refer to secondary mental health services (preferably specialist perinatal) for assessment within 4 hours. Ensure the safety of mother and baby while waiting; consider Mental Health Act assessment where needed; mother-and-baby unit admission if available.

Source: NICE CG192 Antenatal and postnatal mental health.

Severe Chickenpox in Pregnancy

Why it matters:

Adults, including pregnant women, have more complications than children – pneumonia, hepatitis and encephalitis. Pneumonia may be more severe later in pregnancy.

Features of potentially life-threatening chickenpox (refer immediately to a hospital with ICU access):
  • • Respiratory symptoms (cough, breathlessness, chest pain)
  • • Neurological symptoms – photophobia, seizures, drowsiness
  • • Haemorrhagic rash or bleeding
  • • Dense rash, with or without mucosal lesions
Consider hospital assessment even without complications if she:

Smokes, has chronic lung disease, is immunosuppressed (including systemic steroids in the last 3 months) or is in the second half of pregnancy.

Key points:

IV aciclovir for all pregnant women with severe chickenpox. See the woman away from other pregnant women (and neonates). VZIG has no role once the rash has appeared.

Source: RCOG Green-top Guideline 13 (2024 update). Full pathway in the Chickenpox in Pregnancy section.

2️⃣ Diagnostic Approach & Investigations

History Framework

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

Core Symptoms

  • • Menstrual history: LMP, cycle regularity, flow
  • • Bleeding: amount, timing, associated pain
  • • Pain: location, character, radiation
  • • Discharge: colour, odour, associated symptoms
  • • Systemic: nausea, breast tenderness, fatigue
  • • Urinary: frequency, dysuria, incontinence

Key Differentiators

  • • Onset: sudden (hours) vs gradual (days/weeks)
  • • Pregnancy status: always check if of reproductive age
  • • Sexual history: contraception, STI risk
  • • Obstetric history: gravidity, parity, complications
  • • Infection contacts: chickenpox/shingles or other rash illness; previous chickenpox or varicella vaccination
  • • Family history: genetic conditions, cancers
  • • Medications: hormones, teratogens

Maternal Health Examination

Antenatal Examination

  • • Blood pressure and urine for protein at every antenatal appointment
  • • Symphysis–fundal height: measured from 24 weeks and plotted
  • • Abdominal palpation: lie and presentation later in pregnancy
  • • Fetal heart: may be offered for reassurance if requested – it is not a substitute for maternity unit assessment when movements are reduced
  • • Oedema: physiological vs sudden new swelling (pre-eclampsia)
  • • Height, weight, BMI: at booking

Postnatal Examination

  • • General wellbeing: recovery, pain, fatigue
  • • Perineum/wound: healing, infection signs
  • • Lochia: amount, colour, odour
  • • Uterine involution: size, tenderness
  • • Breast examination: if feeding problems
  • • Mental state: mood, bonding – Whooley questions + GAD-2 (NICE CG192)
Corrected: removed "fetal heart Doppler from 12 weeks" as a routine examination step, and replaced EPDS as the first-line postnatal screen with the NICE CG192 approach.

Source: NICE NG201 Antenatal care (2021); NICE CG192.

Investigations in Maternal Health

Routine Antenatal Tests (England)

  • • FBC: anaemia screening at booking and 28 weeks
  • • Blood group & antibodies: booking and 28 weeks
  • • Infectious diseases screening: HIV, hepatitis B, syphilis
  • • Sickle cell & thalassaemia screening: ideally by 10 weeks
  • • Urine culture: asymptomatic bacteriuria
  • • Combined screening test: 11+2 to 14+1 weeks
  • • 75 g OGTT: 24–28 weeks if risk factors for gestational diabetes (NICE NG3)
Corrected: routine antenatal rubella susceptibility screening stopped in England in 2016 – check MMR vaccination history instead and offer MMR after birth if needed.

Problem-Specific Tests

  • • hCG: pregnancy confirmation; serial serum hCG is interpreted in secondary care
  • • Mid-luteal progesterone: day 21 of a 28-day cycle to confirm ovulation
  • • Thyroid function: if symptoms or known thyroid disease
  • • LFTs + bile acids: if itching (intrahepatic cholestasis of pregnancy)
  • • VZV IgG: urgently after chickenpox/shingles contact if no reliable history of immunity – the booking blood sample can be used
  • • Coagulation: if bleeding disorder suspected
  • • Feto-maternal haemorrhage testing: after sensitising events later in pregnancy, per local anti-D policy (NICE NG126: do not use a Kleihauer test in early pregnancy loss)

Sources: NICE NG201; NHS Infectious Diseases in Pregnancy and Fetal Anomaly Screening Programmes; NICE NG3; NICE NG126; RCOG GTG 13.

When to Refer

Same-Day / Emergency

  • • Suspected ectopic pregnancy (immediate)
  • • Suspected pre-eclampsia (same day); severe hypertension ≥160/110 or severe symptoms (emergency)
  • • Antepartum haemorrhage
  • • Reduced or altered fetal movements
  • • Suspected sepsis in pregnancy or after birth
  • • Hyperemesis – unable to keep down fluids or oral antiemetics
  • • Suspected postpartum psychosis (assessment within 4 hours)
  • • Secondary postpartum haemorrhage
  • • Chickenpox in pregnancy – seek immediate specialist (obstetric) advice; severe features → hospital

Routine / Planned

  • • High-risk pregnancy (e.g. pre-existing diabetes, chronic hypertension)
  • • Previous pregnancy complications
  • • Fertility problems: under 36 after 12 months of trying; 36 or over – at presentation (NICE NG257)
  • • Recurrent miscarriage: 3 or more first-trimester losses (need not be consecutive) or 1 or more second-trimester loss (RCOG GTG 17, 2023)
  • • Abnormal screening results
  • • Perinatal mental health concerns; any history of severe mental illness
  • • Safeguarding concerns (e.g. domestic abuse)
  • • Multiple pregnancy

Sources: NICE NG126, NG133, CG192, NG257; NICE CKS Chickenpox (scenario: pregnant woman); RCOG GTG 13 and 17.

3️⃣ Contraception in UK General Practice

Big Picture Overview

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

NICE CKS & CoSRH: offer all suitable methods (including LARC), use shared decision-making, and check safety with UKMEC 2025.

Effectiveness Snapshot (% pregnant in first year of typical use)

Method TypeExamplesTypical useKey Point
LARC – intrauterineCu-IUD (T-Safe®, TT380®); LNG-IUD (Mirena®, Levosert®, Benilexa®, Kyleena®, Jaydess®)Cu-IUD 0.8%; LNG-IUD 0.2%Most effective, user-independent
LARC – implantNexplanon®0.05%Licensed for 3 years; quick return of fertility
InjectionDepo-Provera®, Sayana Press®6%Every 13 weeks; bone health; UKMEC 2025 raised DMPA categories for several VTE-related conditions
CHC (COC/patch/ring)Rigevidon®, Microgynon 30®, Millinette®, Evra® patch, NuvaRing®9%User-dependent, non-contraceptive benefits
POPCerazette®, Cerelle®, Aizea®, Slynd®, Noriday®, Norgeston®9%Preferred when oestrogen inappropriate
BarrierMale condom18%STI protection; add-on method
💡 Mnemonic: LARC First – Leave All Risk to Coils/implant

Sources: CoSRH (FSRH) Combined Hormonal Contraception guideline effectiveness table; UKMEC 2025 (CoSRH, December 2025). Fertility-awareness method effectiveness varies widely by method and user – see CoSRH guidance.

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

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

5 Ps

1. Pregnancy: intention (avoid/delay/achieve), LMP, cycle pattern, recent UPSI, pregnancy test if indicated
2. Periods & gynae: regularity, flow, pain, IMB/PCB, past PID/ectopic, fibroids/endometriosis, cervical screening history
3. Past medical: VTE/PE, stroke/TIA, IHD, cardiomyopathy, hypertension, migraine (with/without aura), diabetes, liver disease, cancer (esp. breast), epilepsy, bariatric surgery
4. Past contraception: methods tried, failures, side-effects, likes/dislikes
5. Personal/partner sexual history: partners, new partner, condom use, STI history, safeguarding/consent, domestic or sexual violence

MEDS

Medicines & lifestyle: enzyme inducers (some antiepileptics, rifampicin, some HIV drugs, St John's wort), psychotropics, anticoagulants, teratogens; allergies, smoking/vaping, alcohol, drugs, BMI. UKMEC 2025 no longer scores drug interactions – check CoSRH drug-interaction guidance / Stockley's.

RISK

Risk factors & red flags: VTE/arterial risk – age, smoking, BMI, immobility/surgery, first-degree family history of VTE, thrombophilia, breast symptoms, abnormal bleeding, pelvic pain. UKMEC 2025 adds multiple VTE risk factors as a condition.
Relationship, safety, readiness: coercion, capacity/Fraser competence, what they want (effectiveness, bleeding, "hormone-free", convenience)
💡 Hook phrase: "5 Ps + MEDS + RISK before you script"

UKMEC 2025 – Using the Categories

UKMEC 2025 (College of Sexual & Reproductive Healthcare, December 2025) is the current UK medical eligibility criteria for contraceptive use. It relates to safety, not effectiveness.

Categories

UKMECDefinitionPhrase for Trainees
1No restriction for use of the method"Method can be used."
2Advantages generally outweigh the theoretical or proven risks"Can generally be used – think about it."
3Risks usually outweigh advantages; needs expert clinical judgement and/or specialist referral"Not usually recommended; seek advice."
4Unacceptable health risk"Do not use this method."
💡 Mnemonic: 1–2 okay, 3 avoid, 4 no way. New in 2025: several UKMEC 2s that relate to the same risk may add up; several UKMEC 3s may together be an unacceptable risk.

UKMEC 2025 Categories for Common Presentations

ConditionCHCPOPDMPAImplantCu-IUDLNG-IUD
Migraine with aura (any age)422212
History (≥5 years ago) of migraine with aura322212
History of VTE or current VTE (on anticoagulants)423212
Family history of VTE (first-degree relative)312111
Multiple risk factors for VTE (new)413111
Smoking, age ≥35, <15 cigarettes/day311111
Smoking, age ≥35, ≥15 cigarettes/day411111
BMI ≥35 kg/m²312111
Controlled hypertension312111
Diabetes with nephropathy/retinopathy/neuropathy322212
Breast cancer – currently being treated444414
Breastfeeding, 0 to <6 weeks postpartum4121Timing-based: 0–48 h = 1; 48 h to <4 weeks = 3; ≥4 weeks = 1
Breastfeeding, ≥6 weeks to <6 months (primarily breastfeeding)211111
Severe (decompensated) cirrhosis433313
Current symptomatic gallbladder disease322212
Inflammatory bowel disease222111
SLE with positive antiphospholipid antibodies423212
What changed from the previous version of this page: history of VTE is now CHC 4 (was shown as 3); POP/implant/LNG-IUD for migraine with aura are 2 (were shown as 1); CHC when primarily breastfeeding 6 weeks–6 months is 2 (was 3); DMPA is now 2 for BMI ≥35 and for complicated diabetes, and 3 for VTE history and multiple VTE risk factors. "Epilepsy on enzyme inducers" has been removed as a row – epilepsy itself is UKMEC 1 for all methods, and UKMEC 2025 does not score drug interactions (check CoSRH drug-interaction guidance). "Depression" has been replaced by an overarching statement on anxiety and mood disorders.
Note for trainees: some conditions have different categories for initiation and continuation, and cancer, stroke and IHD rows are more detailed than shown. Always check the full UKMEC 2025 tables for the individual patient.

Source: CoSRH UKMEC 2025 Summary Tables and "Summary of key changes" (December 2025).

Choosing a Method – COC vs POP vs LARC

Combined Hormonal Contraception (CHC)

Common COC options (if UKMEC 1–2 for CHC):

Oestrogen/progestogenBrand examplesUse notes
EE 30 µg / levonorgestrel 150 µgRigevidon®, Levest®, Maexeni®, Microgynon 30®Common first choice; levonorgestrel COCs have among the lower VTE risks of COCs
EE 20 µg / gestodene 75 µgMillinette 20/75®, Femodette®, Sunya®Lower-oestrogen option if oestrogenic side-effects; gestodene COCs carry a higher VTE risk than levonorgestrel COCs (see SmPC)
Estradiol 1.5 mg / nomegestrol acetate 2.5 mgZoely®24/4 regimen; still CHC for UKMEC

Good for: cycle control, dysmenorrhoea, acne, PMS, endometriosis symptom control

Avoid/be cautious: UKMEC 3–4 (e.g. migraine with aura, VTE history, multiple VTE risk factors, smokers ≥35, hypertension, some cancer histories)

Corrected: Millinette 20/75® contains ethinylestradiol 20 µg with gestodene 75 µg (SmPC, emc) – the previous page listed it as a levonorgestrel 100 µg pill. The row has been re-labelled.

Progestogen-only Pills (POPs)

TypeBrand examplesMissed-pill windowNotes
Desogestrel POPCerazette®, Cerelle®, Aizea®, Feanolla®12 hoursOvulation-inhibiting; widely used first choice
Drospirenone POPSlynd®24 hours24/4 regimen; avoid in severe renal insufficiency (UKMEC 2025 footnote)
Traditional POPNoriday®, Norgeston®3 hoursMore unscheduled bleeding

Useful when oestrogen is unsuitable: breastfeeding (UKMEC 1), migraine with aura (UKMEC 2), history of VTE (UKMEC 2), smokers ≥35 (UKMEC 1), BMI ≥35 (UKMEC 1).

Sources: UKMEC 2025; CoSRH (FSRH) Progestogen-only Pills guideline (2022, amended 2023); Millinette 20/75 SmPC (emc). Check the BNF for current products before prescribing.

Levonorgestrel Intrauterine Devices (LNG-IUD)

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

  • • Long-term contraception – 52 mg LNG-IUD is licensed for 8 years for contraception (UKMEC 2025)
  • • Heavy menstrual bleeding – NICE NG88 recommends the LNG-IUD as first-line treatment for HMB with no identified pathology
  • • Endometrial protection with oestrogen HRT – check the current CoSRH/British Menopause Society statement on duration of use for this indication

Key Comparison

Feature52 mg LNG-IUD19.5 mg (Kyleena®)13.5 mg (Jaydess®)
Licensed duration (contraception)8 years5 years3 years
BleedingOften amenorrhoea/light bleedingLighter bleeding common; amenorrhoea less likely than 52 mg
Extra indicationsHMB; endometrial protectionContraception only
💡 Mnemonic: MIRENA – Menorrhagia, IUD, Reduces bleeding, Endometrial protection, Non-daily, Anaemia improves
Updated: terminology changed from "IUS" to "LNG-IUD" in line with CoSRH/UKMEC 2025. The previous "up to 8 years (check CEU statement)" is now a licensed duration. A specific endometrial-protection duration has not been stated here because it could not be verified against a current primary source during this update.

Sources: UKMEC 2025 (device durations); NICE NG88 Heavy menstrual bleeding.

Emergency Contraception (EC)

MethodBrand examplesWindowNotes
Cu-IUDT-Safe®, TT380®Up to 5 days after first UPSI, or up to 5 days after earliest likely ovulationMost effective; only method effective after ovulation; not affected by BMI or drugs; gives ongoing contraception. Offer first-line where appropriate.
Ulipristal acetate 30 mgellaOne®Up to 120 hMore effective than levonorgestrel; avoid progestogen for 5 days afterwards (then quick-start); reduced by enzyme inducers
Levonorgestrel 1.5 mgLevonelle®, Upostelle®, Emerres®Licensed up to 72 hDouble dose (3 mg) recommended with enzyme inducers, and should be considered if BMI >26 kg/m² or weight >70 kg
💡 Mnemonic: CU-UP-LEVO – CUpper coil, Ulipristal, LEVOnorgestrel (most → least effective)

Source: CoSRH (FSRH) Emergency Contraception guideline (2017, amended); CoSRH CEU statement on LNG-EC dose and weight/BMI.

Common Problems: Coils and Bleeding

Abdominal Pain After IUD Insertion – "PAINS"

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

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

Bleeding Problems on Hormonal Contraception

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

"BLEED" Approach
  • • Beginning – how long since start/change (≤3 months: often watch and wait)
  • • Lapses – missed pills, late starts, vomiting/diarrhoea, interacting drugs
  • • Exclude pregnancy and STIs; check cervical screening is up to date
  • • Examine – speculum if IMB/PCB, pain or red flags
  • • Decide – reassure vs change method vs investigate
ScenarioTime FrameUsual Response
Spotting on new COC<3 monthsReassure; check adherence
Persistent unscheduled bleeding on COC>3 monthsExclude causes; consider a different progestogen or higher oestrogen dose if UKMEC allows
Irregular bleeding on POP/implantAny timeExclude causes; offer treatment options or method change per CoSRH problematic bleeding guidance

Source: CoSRH (FSRH) Problematic bleeding with hormonal contraception guidance. Treatment regimens (e.g. short courses of NSAID or COC for implant bleeding) – check that guideline for current drug choices and durations.

4️⃣ Preconception Care

Preconception Consultation Framework

Comprehensive assessment, risk stratification, a care plan, and information and support – ideally a few months before trying to conceive.

Essential Components

  • • Medical history: chronic conditions (diabetes, hypertension, epilepsy, thyroid disease, severe mental illness)
  • • Medication review: teratogenic drugs, safer alternatives
  • • Family history: genetic conditions, congenital abnormalities
  • • Lifestyle: smoking, alcohol, BMI, exercise, diet
  • • Immunity: MMR (2 documented doses); chickenpox – if no history of chickenpox/shingles or vaccination, consider VZV IgG testing and vaccination if seronegative (avoid pregnancy for 4 weeks after completing the 2-dose course)
  • • Cervical screening up to date
  • • Mental health assessment
  • • Occupational/environmental exposures
Key Message: Preconception care is about optimising health before pregnancy to improve outcomes for mother and baby.

Source (varicella): RCOG GTG 13 (2024). Note: RCOG notes postpartum/pre-pregnancy varicella vaccination is not currently a routine NHS indication – discuss local provision.

Folic Acid Supplementation

Timing: start when planning pregnancy (or as soon as pregnancy is suspected) and continue until 12 weeks.
GroupDoseWho
Everyone planning, or who may become, pregnant400 micrograms dailyAll – available over the counter (and in Healthy Start vitamins)
Increased risk of neural tube defect or other congenital malformation5 mg daily (prescription)She or her partner has, or there is a family history of, an NTD or other congenital malformation; previous pregnancy affected by an NTD or other congenital malformation; diabetes; a haematological condition needing folic acid (e.g. sickle cell disease, thalassaemia); medicines that affect folate absorption/metabolism (e.g. antiepileptics, HIV medicines)
Changed (NICE NG247, 2025): reassure anyone with a BMI of 25 kg/m² or more, or at increased risk of pre-eclampsia, that they do not need more than 400 micrograms unless they have one of the risk factors above. BMI ≥30 and multiple pregnancy have been removed from the 5 mg list. After bariatric surgery: advise contact with the bariatric unit for individualised micronutrient advice.

Additional Considerations

  • • Folic acid until 12 weeks – the period of neural tube closure
  • • Food sources: green leafy vegetables, fortified cereals

Source: NICE NG247 Maternal and child nutrition (2025), folic acid recommendations.

Medication Review & Optimisation

Review before conception (specialist input where needed): ACE inhibitors, ARBs, statins, warfarin/other oral anticoagulants, sodium valproate (and other antiepileptics), isotretinoin, methotrexate, lithium. Valproate and isotretinoin are subject to MHRA pregnancy prevention programmes.

Common Medication Switches

ConditionConcernApproachNotes & source
HypertensionACE inhibitors, ARBsDiscuss alternatives when planning pregnancy; if pregnant, stop ACEi/ARB within 2 working days of notification and switchLabetalol first-line; nifedipine if labetalol unsuitable; methyldopa if neither suitable (NICE NG133)
AnticoagulationWarfarin / other oral anticoagulants (fetal risk)Switch to LMWH as soon as pregnancy is confirmed – ideally within 2 weeks of the missed period and before 6 weeksCounsel preconception; specialist plan (RCOG GTG 37a)
EpilepsyValproate (and topiramate)Specialist review before conception – do not stop antiepileptics abruptlyMHRA valproate & antiepileptic safety advice
DiabetesGlycaemic control; most non-insulin agentsMetformin can be used; other glucose-lowering agents usually switched to insulin; 5 mg folic acidRefer to preconception diabetes service (NICE NG3)
HypothyroidismUnder-replacementCheck TFTs preconception and as soon as pregnancy is confirmed; seek specialist advice on dose adjustmentUse local endocrine/obstetric guidance for targets
Corrected: the previous "TSH <2.5 mIU/L target" is not a NICE recommendation and has been removed. "Switch warfarin when planning pregnancy" has been replaced with the RCOG timing. The heading "STOP before conception" was softened – several drugs (e.g. antiepileptics, lithium) must not be stopped without specialist advice.

Lifestyle Optimisation

FactorRecommendationRationale
SmokingStop completely; offer stop-smoking supportReduces miscarriage, fetal growth restriction, preterm birth, SIDS
AlcoholSafest approach is not to drinkNo known safe level – risk of fetal alcohol spectrum disorder
BMIAim for a healthy weight before pregnancyRaised BMI increases risk of gestational diabetes, pre-eclampsia and stillbirth
Exercise150 min/week moderate activityGeneral health; continue in pregnancy
Caffeine<200 mg/dayHigh intake linked to miscarriage and low birth weight
Vitamin D10 micrograms (400 IU) dailyNICE NG247: advise during pregnancy and breastfeeding, at least October–March; year-round for those with little sun exposure or darker skin (UK government advice)

Additional Lifestyle Advice

  • • Diet: balanced diet with plenty of fruit and vegetables
  • • Food safety: avoid unpasteurised products, raw/undercooked meat, high-mercury fish
  • • Occupational hazards: review workplace exposures (chemicals, radiation, infections)
  • • Mental wellbeing: ask about stress, anxiety and past mental illness

5️⃣ Antenatal Care

Booking Appointment (ideally by 10 weeks)

First full antenatal appointment, ideally by 10 weeks. Establishes a baseline, identifies risk factors and starts the care pathway.

History Taking

  • • Current pregnancy: LMP, EDD, symptoms
  • • Obstetric history: previous pregnancies, births, complications
  • • Medical history: chronic conditions, medicines, allergies
  • • Infection history: previous chickenpox/shingles or varicella vaccination (RCOG 2024) – if none, advise avoiding contact and reporting any exposure without delay
  • • Family history: genetic conditions, pregnancy complications
  • • Social history: smoking, alcohol, drugs, domestic abuse
  • • Mental health: Whooley + GAD-2; past severe mental illness; family history of perinatal mental illness
  • • Pre-eclampsia risk factors: to decide on aspirin (NICE NG133)

Examinations & Tests

  • • General: height, weight, BMI, blood pressure, urine for protein
  • • Blood tests: FBC, blood group & antibodies, HIV, hepatitis B, syphilis, sickle cell/thalassaemia screening
  • • Urine: culture for asymptomatic bacteriuria
  • • Cervical screening: if due, usually deferred until 12 weeks after birth
  • • Dating scan: 10–14 weeks (combined screening 11+2 to 14+1 weeks)
Key Actions: folic acid (400 micrograms, or 5 mg if high risk); vitamin D; aspirin 75–150 mg daily from 12 weeks if 1 high-risk or >1 moderate-risk factor for pre-eclampsia; lifestyle advice; arrange scans; give "Screening tests for you and your baby" information.

Sources: NICE NG201; NICE NG133; NICE NG247; RCOG GTG 13; NHS screening programmes.

Routine Antenatal Schedule (uncomplicated pregnancy)

More frequent review is needed for higher-risk pregnancies.

GestationWhoKey ActivitiesTests / Scans
By 10 weeksMidwife (booking)Full history, risk assessment, aspirin decisionBooking bloods, urine culture
10–14 weeksUltrasoundDating, viability, number of fetusesDating scan; combined test 11+2–14+1
16 weeksMidwifeReview results, BP, urine–
18+0–20+6 weeksUltrasoundStructural anomalies; placental siteMid-pregnancy (anomaly) scan
25 weeksMidwife (nulliparous)BP, urine, SFH–
28 weeksMidwifeBP, urine, SFH; routine anti-D prophylaxis if RhD-negativeFBC, antibodies; OGTT 24–28 weeks if indicated
31 weeksMidwife (nulliparous)BP, urine, SFH–
34 weeksMidwifeBP, urine, SFH; second anti-D dose if on a two-dose regimen–
36 weeksMidwifeBP, urine, SFH, presentation; birth and feeding plans–
38 weeksMidwifeBP, urine, SFH; discuss prolonged pregnancy options–
40 weeksMidwife (nulliparous)BP, urine, SFH–
41 weeksMidwifeOffer membrane sweep and induction of labourIncreased monitoring if induction declined (NICE NG207)
Corrected: anti-D prophylaxis is given as a single dose at 28 weeks or as two doses at 28 and 34 weeks depending on the product/local regimen (NICE TA156) – the previous table implied a dose at both visits for everyone. "FBC at 36 weeks if previous anaemia" was removed (not a routine NICE schedule item).

Sources: NICE NG201 Antenatal care; NICE TA156 routine antenatal anti-D prophylaxis; NICE NG3; NICE NG207 Inducing labour.

Screening for Down's, Edwards' and Patau's Syndromes

Understanding Down's Syndrome

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

Important: use respectful language. Avoid "defect", "abnormal" or "suffering from"; say "has Down's syndrome" or "a person with Down's syndrome". Say "higher chance / lower chance", not "high risk / low risk".

NHS Screening Pathway (England)

TestTimingComponentsResult
Combined test11+2 to 14+1 weeksNuchal translucency + PAPP-A + free βhCG + maternal ageHigher chance = 1 in 2 to 1 in 150 (at term); lower chance = 1 in 151 or lower
Quadruple test14+2 to 20+0 weeks (if combined test missed or NT not obtainable)AFP + hCG + uE3 + inhibin A + maternal age
NIPT (cell-free DNA)Offered after a higher-chance combined or quadruple resultCell-free DNA in maternal blood (placental origin)More accurate screening test; a higher-chance NIPT result still needs a diagnostic test to confirm
Corrected: in the NHS, NIPT is a contingent second-stage screen after a higher-chance result – not a first-line test "from 10 weeks". Unverified detection/false-positive percentages and the maternal-age chance boxes have been removed.

Diagnostic (Definitive) Tests

TestMethodMiscarriage risk
CVS (chorionic villus sampling)Needle sample of placental tissue (usually 11–14 weeks)About 1 in 200 (0.5%) quoted in NHS patient information; RCOG GTG 8 (2021) advises the additional risk is probably below 0.5%
AmniocentesisNeedle sample of amniotic fluid (from 15 weeks)
Key Points: screening tests give a chance, not a diagnosis. Diagnostic tests are definitive but carry a small miscarriage risk. All screening is optional and needs informed choice.

Sources: NHS Fetal Anomaly Screening Programme handbook (GOV.UK); RCOG Green-top Guideline 8 (Amniocentesis and CVS).

Common Antenatal Problems

Minor Symptoms

  • • Nausea/vomiting: reassurance, "little and often"; antiemetics per RCOG GTG 69 if needed (see Red Flags → Hyperemesis)
  • • Heartburn: lifestyle advice; antacids/alginates
  • • Constipation: fibre, fluids, activity
  • • Haemorrhoids: diet, avoid straining, topical treatments
  • • Backache: exercise, physiotherapy, paracetamol
  • • Leg cramps: stretching; check it is not unilateral swelling/pain (VTE)

Concerning Symptoms

  • • Vaginal bleeding: always assess – miscarriage, ectopic, placental causes
  • • Severe headache/visual symptoms: pre-eclampsia
  • • Abdominal pain: ectopic, miscarriage, abruption, labour
  • • Reduced fetal movements: same-day maternity assessment
  • • Persistent vomiting: hyperemesis gravidarum
  • • Itching (esp. palms/soles): intrahepatic cholestasis of pregnancy – LFTs and bile acids
  • • Chickenpox contact or rash: see Chickenpox section

When to Refer Urgently

Same-day referral: heavy bleeding, severe abdominal pain, suspected pre-eclampsia, reduced fetal movements, suspected rupture of membranes before 37 weeks, chickenpox in pregnancy (immediate specialist advice).
Corrected: "magnesium supplements for leg cramps" removed (not supported by NICE guidance); pre-eclampsia referral no longer requires BP >160/110 plus proteinuria plus symptoms – any suspected pre-eclampsia needs same-day assessment.

6️⃣ Problems in Pregnancy

Miscarriage (early pregnancy, up to 13+6 weeks)

7–14 days
expectant management – first-line for confirmed miscarriage (NICE NG126)
3 weeks
urine pregnancy test after expectant or medical management

GP triage of bleeding in early pregnancy (NICE NG126)

  • • Pain, abdominal/pelvic or cervical motion tenderness → immediate referral (exclude ectopic)
  • • Bleeding at 6 weeks or more (or uncertain gestation) → refer to early pregnancy assessment service
  • • Bleeding under 6 weeks, no pain, no ectopic risk factors → expectant management; repeat urine pregnancy test after 7–10 days; return if symptoms continue or worsen

Types of Miscarriage

TypeBleedingPainCervixManagement (secondary care)
ThreatenedLightMild/noneClosedViable pregnancy on scan: if bleeding worsens or persists beyond 14 days, reassess; if it stops, continue routine antenatal care
InevitableHeavyCrampingOpenExpectant, medical or surgical
IncompleteHeavy, ongoingCrampingOpenExpectant; medical – single dose misoprostol 600 micrograms (800 micrograms acceptable); or surgical. Mifepristone is not used
CompleteSettlingResolvingClosedUrine pregnancy test at 3 weeks; confirm location was intrauterine
MissedNone/minimalNoneClosedExpectant 7–14 days first-line; medical – mifepristone 200 mg orally, then misoprostol 800 micrograms 48 hours later (unless sac already passed); or surgical (MVA under local anaesthetic, or in theatre)

GP Role

  • • Assess: bleeding, pain, haemodynamic status; always consider ectopic
  • • Referral: as above; emergency if heavy bleeding with compromise
  • • Support: emotional support and information; ask about mental health afterwards
  • • Anti-D (first trimester, NG126): 250 IU to RhD-negative women having surgical management of miscarriage or ectopic; not needed for solely medical management, threatened miscarriage, complete miscarriage or pregnancy of unknown location. Beyond the first trimester, follow local/BSH anti-D policy.
  • • Recurrent miscarriage: 3 or more first-trimester losses (not necessarily consecutive) or 1 or more second-trimester losses → refer (RCOG GTG 17, 2023); clinicians may investigate after 2 losses if pathology is suspected
Corrected: "Anti-D if Rh-negative and bleeding >12 weeks" and "incomplete miscarriage = surgical evacuation" were out of date. NG126 (2023 update) added mifepristone + misoprostol for missed miscarriage. Age-specific miscarriage percentages have been removed as they could not be verified against a primary guideline source.

Sources: NICE NG126 (updated August 2023; mifepristone/misoprostol use in miscarriage is off-label); RCOG Green-top Guideline 17 Recurrent Miscarriage (2023).

Pre-eclampsia

75–150 mg
aspirin daily from 12 weeks until birth if at increased risk
PCR ≥30
mg/mmol (or ACR ≥8 mg/mmol) = significant proteinuria

Definition & Diagnosis (NICE NG133)

New-onset hypertension (≥140/90 mmHg) after 20 weeks with one or more of: significant proteinuria (PCR ≥30 mg/mmol or ACR ≥8 mg/mmol), maternal organ dysfunction (renal, liver, neurological or haematological), or uteroplacental dysfunction (e.g. fetal growth restriction). Don't rely on proteinuria alone – use a full clinical review. 24-hour urine collection is not routinely used.

Who should take aspirin?

Any ONE high-risk factor:

  • • Hypertensive disease in a previous pregnancy
  • • Chronic kidney disease
  • • Autoimmune disease (e.g. SLE, antiphospholipid syndrome)
  • • Type 1 or type 2 diabetes
  • • Chronic hypertension

MORE THAN ONE moderate-risk factor:

  • • Nulliparity
  • • Age 40 or over
  • • Pregnancy interval >10 years
  • • BMI ≥35 kg/m² at first visit
  • • Family history of pre-eclampsia
  • • Multi-fetal pregnancy

Aspirin for this use must be prescribed (community pharmacies cannot sell it for pre-eclampsia prevention in England) and is off-label.

Severity

Hypertension
  • • BP 140/90 to 159/109 mmHg
  • • May be asymptomatic – check urine and symptoms
Severe hypertension / severe features
  • • BP ≥160/110 mmHg
  • • Severe headache, visual disturbance
  • • Epigastric/RUQ pain, vomiting
  • • Hyperreflexia/clonus, breathlessness, reduced urine output

GP Management

  • • Prevention: aspirin 75–150 mg daily from 12 weeks until birth for women at increased risk (above)
  • • Suspected pre-eclampsia: same-day secondary care assessment (PlGF-based testing between 20+0 and 36+6 weeks is done there)
  • • Severe hypertension or severe features: emergency admission
  • • Treatment (specialist-led): labetalol first-line; nifedipine if labetalol unsuitable; methyldopa if neither suitable
  • • After birth: if proteinuria (1+ or more) persists at the 6–8 week check, review again at 3 months to assess kidney function
  • • Education: warning symptoms and when to seek help
Corrected: aspirin dose changed from "75 mg" to 75–150 mg; risk factors aligned with NG133 (molar pregnancy removed; BMI threshold is ≥35 at first visit; age is ≥40); unverified incidence and recurrence percentages removed; "mild pre-eclampsia" wording replaced with NG133 blood pressure bands.

Source: NICE NG133 Hypertension in pregnancy (2019, updated 2023); NICE NG201.

Low-lying Placenta & Placenta Praevia

Definition (RCOG GTG 27a, 2026 update)

Ultrasound finding (after 16 weeks)Term to use
Placental edge reaches or covers the internal osPlacenta praevia
Placental edge less than 20 mm from the internal os, not covering itLow-lying placenta
Placental edge 20 mm or more from the internal osNormal
Corrected: the old Grade I–IV / "minor/major/marginal" classification has been replaced by the RCOG ultrasound-based terms above. Mode-of-birth rules and the "0.5% incidence" figure were removed because they could not be verified against the current guideline.

Risk Factors

  • • Previous caesarean birth or uterine surgery (also raises risk of placenta accreta spectrum)
  • • Previous placenta praevia
  • • Assisted reproduction, multiparity, older maternal age, smoking

Clinical Presentation

  • • Painless vaginal bleeding in the second half of pregnancy – may be recurrent
  • • Malpresentation (breech, transverse lie) common
  • • Uterus soft and non-tender

GP Management

NEVER perform a digital vaginal examination if praevia is possible and placental site is unknown – it may provoke massive haemorrhage.
  • • Bleeding: ABC, same-day/emergency obstetric referral (999 if heavy)
  • • Low-lying/praevia at the anomaly scan: follow-up ultrasound including transvaginal scan at 32 weeks; if still low-lying/praevia and asymptomatic, another at around 36 weeks to plan birth
  • • Previous caesarean + anterior low-lying placenta/praevia: needs specialist assessment for placenta accreta spectrum
  • • Asymptomatic women can usually be cared for as outpatients; advise to attend immediately with any bleeding, pain or contractions

Source: RCOG Green-top Guideline 27a Placenta praevia and placenta accreta spectrum (2018; updated 2026).

Placental Abruption

Definition

Separation of a normally sited placenta from the uterine wall before birth. A major cause of maternal and fetal morbidity and mortality.

Risk Factors

  • • Previous abruption
  • • Hypertension / pre-eclampsia
  • • Abdominal trauma (including domestic abuse, road traffic collision)
  • • Smoking, cocaine use
  • • Polyhydramnios, multiple pregnancy

Clinical Features

Revealed
  • • Vaginal bleeding (often dark)
  • • Constant abdominal pain
  • • Uterine tenderness
Concealed
  • • Little or no visible bleeding
  • • Severe pain, hard ("woody") uterus
  • • Maternal shock out of proportion to visible loss
  • • Fetal compromise or death

GP Management

OBSTETRIC EMERGENCY: call 999 for immediate transfer. Do not delay for investigations.
  • • Immediate: ABC, oxygen if hypoxic, IV access if trained/equipped
  • • Transfer: blue-light to an obstetric unit, with pre-alert
Updated: unverified incidence and recurrence percentages removed. Hospital investigation lists trimmed to GP-relevant actions.

Source: RCOG Green-top Guideline 63 Antepartum haemorrhage.

Ectopic Pregnancy

<35 mm
unruptured tubal mass, no heartbeat – threshold used for expectant/methotrexate options (NG126)
250 IU
anti-D for RhD-negative women having surgical management

Risk Factors

  • • Previous ectopic pregnancy
  • • Previous pelvic inflammatory disease
  • • Previous tubal surgery or sterilisation
  • • Pregnancy with an IUD in situ
  • • Assisted conception
  • • Smoking

But: many women with an ectopic pregnancy have no risk factors – exclude it anyway (NICE NG126).

Clinical Presentation

Early / Unruptured
  • • Missed period, positive pregnancy test
  • • Abdominal or pelvic pain
  • • Vaginal bleeding
  • • Cervical motion or adnexal tenderness
Ruptured
  • • Sudden severe abdominal pain
  • • Shoulder-tip pain
  • • Collapse, shock, pallor
  • • Tachycardia, hypotension, guarding

GP Management

High index of suspicion: positive pregnancy test + pain or tenderness = ectopic until proven otherwise → immediate referral to early pregnancy assessment (or out-of-hours gynaecology). Signs of rupture → 999.

What happens in secondary care (NICE NG126)

  • • Expectant management may be offered if clinically stable and pain-free, tubal ectopic <35 mm with no visible heartbeat, serum hCG ≤1,000 IU/L, and able to return for follow-up
  • • Methotrexate may be offered if no significant pain, unruptured tubal ectopic with adnexal mass <35 mm and no heartbeat, serum hCG <1,500 IU/L, no intrauterine pregnancy, and able to attend follow-up
  • • Surgery otherwise; salpingectomy → urine pregnancy test after 3 weeks
  • • Anti-D 250 IU for RhD-negative women having surgical management; not for solely medical management
Updated: the "1–2%" and "10% recurrence" figures have been removed as they could not be verified against NICE; management options added from NG126.

Source: NICE NG126 Ectopic pregnancy and miscarriage (updated 2023).

7️⃣ Chickenpox (Varicella) in Pregnancy

What changed: since the national VZIG shortage in 2022, UKHSA guidance (January 2023, clarified January 2025) makes oral aciclovir or valaciclovir, given from day 7 to day 14 after exposure, the first-choice post-exposure prophylaxis (PEP) for non-immune pregnant women at any stage of pregnancy. VZIG is now reserved for women who cannot take oral antivirals. RCOG Green-top Guideline 13 was updated in 2024 to match.

Where NICE stands: NICE CKS (Chickenpox – scenario: pregnant woman) advises seeking immediate specialist obstetric advice and considering admission when a pregnant woman develops chickenpox. For exposure management and antiviral regimens, the named sources used below are UKHSA and RCOG GTG 13.

Exposure to Chickenpox or Shingles in Pregnancy

<100 mIU/mL
VZV IgG = susceptible (<150 mIU/mL if immunosuppressed for another reason)
Day 7 → 14
oral antiviral PEP – start on day 7, not straight away

Step 1 – Was it a significant exposure?

  • • Type of contact: chickenpox; or shingles that is disseminated, in an exposed area (e.g. ophthalmic), or in an immunosuppressed person. Localised shingles on a covered area (e.g. thoracolumbar) in an immunocompetent person carries a remote risk.
  • • Infectious period: UKHSA advises from 24 hours before the rash until 5 days after it appears in immunocompetent people (until all lesions crust if immunosuppressed).
  • • Closeness: same room for 15 minutes or more, face-to-face contact, or a large open ward.
  • • Pattern: continuous (household), repeated (e.g. visitor) or single.

Step 2 – Is she immune?

  • • Definite history of chickenpox or shingles, or 2 documented doses of varicella vaccine → reassure; no PEP
  • • No history, uncertain history, or grew up in a tropical/subtropical country → urgent VZV IgG (the booking blood sample can often be tested, usually within 24–48 hours). Most women tested are immune.

Step 3 – PEP if not immune (VZV IgG <100 mIU/mL)

OptionRegimenNotes
First choice: aciclovir (oral)800 mg four times daily from day 7 to day 14 after exposure (7 days)Preferred in pregnancy because it has more pregnancy safety data. Reduce dose in renal impairment (see BNF). Off-label for this use.
Alternative: valaciclovir (oral)1,000 mg three times daily from day 7 to day 14 after exposureConsider if adherence to four-times-daily dosing is a concern; less pregnancy safety data but no concerns identified. Off-label.
VZIG (intramuscular)Only if oral antivirals are contraindicated or not tolerated (e.g. renal toxicity, malabsorption); give within 10 days of exposureSupplied via UKHSA; check availability first. For continuous household exposure, the 10 days run from the index case's rash onset.
  • • Day 0 = rash onset in the index case if a household contact; otherwise the date of first (or only) contact
  • • Presenting late? A 7-day course can still be started up to day 14 after exposure
  • • Why wait until day 7? In a study of healthy children, 77% given aciclovir immediately developed chickenpox vs 21% when started on day 7
  • • Second exposure: repeat the risk assessment and VZV IgG; if still not immune, give another course starting 7 days after the new exposure
  • • Safety-net: PEP attenuates rather than guarantees protection – she must report any rash promptly
  • • Infection control: treat as potentially infectious from day 8 to 21 after exposure (8 to 28 if VZIG given); avoid other pregnant women and neonates, including in the waiting room
  • • Tell the maternity team about the exposure and outcome
Old practice replaced: "give VZIG as soon as possible (up to 10 days)" is no longer first-line for pregnant women. Earlier teaching limiting aciclovir PEP to later pregnancy has also been superseded – oral antivirals are first choice at any gestation.

Sources: UKHSA Guidelines on post-exposure prophylaxis for varicella or shingles (January 2023; dose/timing clarification January 2025); RCOG Green-top Guideline 13 (2015, updated 2024). Check the BNF for renal dose adjustment.

Pregnant Woman Who Develops Chickenpox

NICE CKS: seek immediate specialist (obstetric) advice and consider the need for admission. See her away from other pregnant women.

Treatment

SituationAction
Presents within 24 hours of rash onset and ≥20+0 weeksPrescribe oral aciclovir – 800 mg five times daily for 7 days (valaciclovir 1,000 mg three times daily for 7 days is the UKHSA alternative)
Presents within 24 hours of rash onset and <20+0 weeksConsider oral aciclovir (same regimen) – discuss with specialist and the woman
Develops chickenpox despite PEPSwitch to the therapeutic regimen above from rash onset
Severe chickenpox (any gestation)Hospital admission and IV aciclovir
VZIGNo role once the rash has appeared

Aciclovir and valaciclovir are unlicensed in pregnancy but can be prescribed in the woman's best interest after discussion (RCOG). Symptomatic care: paracetamol, hygiene to prevent secondary bacterial infection; avoid contact with other pregnant women and neonates until lesions have crusted (usually about 5 days).

Refer immediately to hospital (with ICU access) if:

  • • Respiratory symptoms – cough, breathlessness, chest pain (varicella pneumonia)
  • • Neurological symptoms – photophobia, seizures, drowsiness
  • • Haemorrhagic rash or bleeding
  • • Dense rash with or without mucosal lesions

Consider hospital assessment even if uncomplicated if she:

  • • Smokes, or has chronic lung disease
  • • Is immunosuppressed (including systemic corticosteroids in the preceding 3 months)
  • • Is in the second half of pregnancy

Ask her to contact you immediately if she develops respiratory symptoms or deteriorates. Delivery during the viraemic phase is hazardous – timing and mode of birth are individualised by the obstetric team, ideally at least 7 days after rash onset.

Sources: NICE CKS Chickenpox – scenario: pregnant woman; RCOG Green-top Guideline 13 (2024 update); UKHSA PEP guidance (therapeutic regimen for those who develop a rash).

Fetal & Neonatal Risks

~1%
fetal varicella syndrome risk after maternal infection before 28 weeks (0.91% before 20 weeks in pooled data)
±7 days
maternal chickenpox 7 days before to 7 days after birth → baby needs prophylaxis

Fetal varicella syndrome (FVS)

  • • Reported from about 3 weeks up to 28 weeks' gestation; risk appears lower in the first trimester (0.55%)
  • • Features: dermatomal skin scarring; eye defects (microphthalmia, chorioretinitis, cataracts); limb hypoplasia; neurological abnormalities (e.g. microcephaly, cortical atrophy)
  • • Miscarriage risk does not appear to be increased by first-trimester chickenpox
  • • Refer to a fetal medicine specialist at 16–20 weeks, or 5 weeks after infection, for detailed ultrasound; amniocentesis (VZV PCR) may be discussed – good negative but poor positive predictive value, and only after skin lesions have healed

Varicella infection of the newborn

  • • Maternal infection in the last 4 weeks of pregnancy carries a significant risk of neonatal infection
  • • Avoid planned birth for at least 7 days after the maternal rash (allows transfer of maternal antibodies) if safe to do so
  • • Babies of mothers with chickenpox from 7 days before to 7 days after birth need prophylaxis as soon as possible – no testing needed (neonatal team)
  • • Inform the neonatologist of the birth of any baby whose mother had chickenpox at any stage of pregnancy
  • • Breastfeeding is encouraged if she is well enough; express from the affected breast if lesions are near the nipple until they crust

Source: RCOG Green-top Guideline 13 (2024 update).

Quick Pathway for the GP

ScenarioWhat to do
Booking / preconceptionAsk about previous chickenpox, shingles or varicella vaccination. If none: advise avoiding contact and reporting exposure without delay. Consider postpartum vaccination if seronegative (safe with breastfeeding).
Contact + definite past chickenpox/shingles or 2 vaccine dosesReassure – routine antenatal care
Contact + no/uncertain historyConfirm significant exposure → urgent VZV IgG (booking sample)
VZV IgG ≥100 mIU/mLImmune – reassure
VZV IgG <100 mIU/mLAciclovir 800 mg four times daily from day 7 to day 14 (or valaciclovir 1,000 mg three times daily); VZIG only if antivirals unsuitable; advise she is potentially infectious days 8–21; report any rash; inform maternity team
Rash appears (within 24 h), ≥20 weeksAciclovir 800 mg five times daily for 7 days; immediate specialist advice; isolate from other pregnant women
Rash appears (within 24 h), <20 weeksConsider aciclovir as above; immediate specialist advice
Severe features or high-risk womanHospital (IV aciclovir) – see red flags
Infection <28 weeksCounsel about ~1% FVS risk; fetal medicine referral at 16–20 weeks or 5 weeks post-infection
Prescribing check: antiviral regimens above are taken from UKHSA and RCOG GTG 13 and are off-label in pregnancy. Confirm doses and renal adjustments against the current BNF before prescribing.

Sources: UKHSA PEP guidance (2023/2025); RCOG GTG 13 Appendix I algorithm (2024 update); NICE CKS Chickenpox.

8️⃣ Postnatal Care

Postnatal Care Framework

Care for mother and baby from birth to 6–8 weeks: physical recovery, mental health, infant feeding and family adjustment.

Timeline of Care

TimingProviderFocus
Before transfer home and first daysMidwifeRecovery, bleeding, feeding, newborn checks
Around day 5MidwifeNewborn blood spot (heel prick) test; feeding and weight
First weeksMidwife / screening teamNewborn hearing screen if not done before discharge
10–14 daysHealth visitorNew birth visit – feeding, mood, family adjustment
6–8 weeksGPMaternal postnatal check (physical and mental health, contraception) and infant physical examination

Red Flags – Seek Urgent Help

Emergency/urgent assessment: sudden or very heavy increase in vaginal bleeding; fever, shivering, abdominal pain or offensive discharge (sepsis); severe headache or visual disturbance (postpartum pre-eclampsia); chest pain or breathlessness; unilateral calf pain/swelling; thoughts of self-harm or harming the baby; sudden confusion or psychotic symptoms.

Source: NICE NG194 Postnatal care (2021); NHS newborn screening programmes.

6–8 Week Postnatal Check

Maternal Assessment

  • • General wellbeing: energy, sleep, appetite
  • • Physical recovery: perineum, caesarean wound, bleeding
  • • Feeding: problems and support
  • • Bladder/bowel: continence, pelvic floor
  • • Sexual health: resumption of sex, dyspareunia, contraception
  • • Mental health: Whooley questions + GAD-2; bonding

Examination & Follow-up

  • • BP: especially after a hypertensive disorder; if pre-eclampsia with persisting proteinuria (1+ or more) → review at 3 months for kidney function (NG133)
  • • Abdomen/wound/perineum: as indicated
  • • Cervical screening: if due, usually from 12 weeks after birth
  • • Blood tests: FBC if anaemic; others as indicated
  • • MMR: offer if not documented as having 2 doses
  • • Varicella vaccination: can be discussed if known seronegative (RCOG GTG 13)

Infant Assessment

  • • Growth and feeding
  • • Development: social smile, head control, visual fixing/following
  • • Immunisations: 8-week vaccines
  • • Screening results: newborn blood spot, hearing
  • • Safety: safer sleep, car seat use
Corrected: "Rubella immunity – offer MMR if not immune" replaced by checking MMR vaccination history, as antenatal rubella screening no longer happens in England.

Perinatal Mental Health

4 hours
assessment target for suspected postpartum psychosis
First 2 weeks
be alert for psychosis in women with severe mental illness history

Postnatal Depression

Risk Factors
  • • Previous depression/anxiety
  • • Poor social support
  • • Relationship difficulties or domestic abuse
  • • Traumatic birth or complications
  • • Feeding difficulties
Symptoms
  • • Persistent low mood, anxiety
  • • Loss of interest or pleasure
  • • Fatigue, sleep disturbance beyond baby care
  • • Guilt, worthlessness
  • • Difficulty bonding with baby
  • • Thoughts of self-harm

How to Screen (NICE CG192)

  • • At first contact in pregnancy and in the early postnatal period, ask the Whooley questions (depressed mood; loss of interest in the past month) and consider the GAD-2 for anxiety
  • • If either depression question is positive, she is at risk, or there is clinical concern: consider the EPDS or PHQ-9 as part of a full assessment, or refer to her GP/mental health professional
  • • Ask about past or present severe mental illness and severe perinatal mental illness in a first-degree relative

Management

SituationApproach
Mild to moderate depression or anxietyFacilitated self-help or psychological intervention via NHS Talking Therapies (perinatal pathway); review
Moderate to severe depressionHigh-intensity psychological intervention (e.g. CBT) and/or medication – discuss benefits and risks, including in breastfeeding (check the BNF, UKTIS and the UK Drugs in Lactation Advisory Service)
Severe mental illness, or any history of itRefer to secondary (preferably specialist perinatal) mental health services
Suspected postpartum psychosisAssessment within 4 hours by secondary mental health services
Thoughts of suicide or self-harmUrgent risk assessment and same-day mental health input as indicated
Corrected: the previous EPDS score bands (10–12 mild, 13–17 moderate, ≥18 "urgent psychiatric referral") and the routine EPDS schedule are not NICE recommendations and have been removed. Unverified prevalence figures were also removed.

Source: NICE CG192 Antenatal and postnatal mental health (2014, updated).

Postnatal Contraception

Contraception is needed from day 21 after birth. Discuss before discharge and review at 6–8 weeks. A pregnancy interval of less than 12 months is linked to higher risks of preterm birth and small-for-gestational-age babies.

Timing of Methods (UKMEC 2025 & CoSRH)

MethodBreastfeedingNot breastfeedingNotes
CondomsImmediatelyImmediatelySTI protection
POPAny time after birth (UKMEC 1)Any time after birth (UKMEC 1)If started after day 21: exclude pregnancy and use extra precautions for 2 days
ImplantAny time after birth (UKMEC 1)Any time after birth (UKMEC 1)Licensed 3 years
DMPA injection<6 weeks: UKMEC 2<3 weeks: UKMEC 2 (3 with other VTE risk factors)UKMEC 2025 raised postpartum DMPA categories
CHC<6 weeks: UKMEC 4; 6 weeks–6 months (primarily breastfeeding): UKMEC 2<3 weeks: UKMEC 3 (4 with VTE risk factors); 3–6 weeks: UKMEC 2 (3 with VTE risk factors)Postnatal VTE risk assessment needed
Cu-IUD / LNG-IUDWithin 48 hours of birth (UKMEC 1) or from 4 weeks (UKMEC 1); 48 hours to <4 weeks = UKMEC 3; postpartum sepsis = UKMEC 4Applies after vaginal or caesarean birth
SterilisationPossible at caesarean or laterPermanent – counsel about LARC alternatives

Lactational Amenorrhoea Method (LAM)

Over 98% effective only if all criteria are met:

  • • Fully (or nearly fully) breastfeeding – no long gaps: at least every 4 hours by day and every 6 hours at night
  • • Amenorrhoeic
  • • Baby less than 6 months old

Special Considerations

  • • Emergency contraception: can be used while breastfeeding – see CoSRH EC guidance for ulipristal and breastfeeding advice
  • • Copper IUD: most effective EC, then ongoing contraception
  • • Return of fertility: unpredictable, especially with mixed feeding
  • • Pregnancy spacing: interval under 12 months carries increased risks (CoSRH)
Corrected: CHC at 6 weeks–6 months while breastfeeding is UKMEC 2 (not "6 weeks if not exclusive BF"); POP and implant can start any time postpartum whether or not breastfeeding; LAM feeding intervals were reversed on the previous page; the 18–24 month spacing figure has been replaced with CoSRH's 12-month statement.

Sources: UKMEC 2025 (CoSRH); CoSRH (FSRH) Contraception After Pregnancy (2017, amended 2020).

9️⃣ Fertility & Subfertility

New guideline: NICE NG257 Fertility problems: assessment and treatment (31 March 2026) updates and replaces CG156. Recommendations on PCOS-related ovulatory dysfunction were removed pending a separate NICE guideline, and several IVF-procedure topics now signpost to ESHRE guidance.

Definition & Initial Assessment

>80%
of couples conceive within 1 year of regular unprotected intercourse (if the woman is under 40)
36+
offer specialist referral at presentation (NG257)

When to assess and refer (NICE NG257)

  • • Under 36: after 12 months of regular unprotected vaginal intercourse (or 6 cycles of artificial insemination)
  • • 36 or over: at presentation
  • • Any age: at presentation if either partner has a known or suspected cause of infertility, or if planned treatment (e.g. cancer therapy) may cause infertility
  • • Primary = never conceived; secondary = previously conceived, whatever the outcome

Initial History

Person trying to conceive
  • • Age, duration of trying
  • • Cycle length and regularity
  • • Previous pregnancies, contraception
  • • PCOS, endometriosis, PID/STIs
  • • Pelvic surgery
  • • Medicines
  • • BMI, smoking, alcohol
Partner (if male)
  • • Age, previous children
  • • Mumps orchitis, diabetes, cancer treatment
  • • Hernia repair, testicular surgery, vasectomy
  • • Medicines (e.g. anabolic steroids, chemotherapy)
  • • Heat/occupational exposures, tight underwear
  • • Smoking, alcohol, recreational drugs
  • • Erectile/ejaculatory function

General Advice

  • • Intercourse: every 2–3 days – timing to ovulation is not needed
  • • Folic acid: 400 micrograms daily (5 mg only if NG247 high-risk criteria)
  • • Lifestyle: healthy weight, stop smoking, limit alcohol, avoid recreational drugs
  • • Age: female fertility declines with age – use age to counsel on chances
  • • Stress: acknowledge the emotional impact; offer counselling
Corrected: early referral is now at presentation for those 36 or over (the previous page said "after 6 months if woman >35"). The "1 in 7 couples" statistic was removed as it could not be verified against NG257.

Source: NICE NG257 Fertility problems (March 2026); NICE NG247 (folic acid).

Fertility Investigations (Primary Care)

Investigate both partners in parallel to avoid delay.

Female Investigations

InvestigationWhenPurpose / NICE position
Mid-luteal serum progesteroneDay 21 of a 28-day cycle (later in longer cycles, e.g. day 28 of a 35-day cycle, repeated weekly if irregular)Confirms ovulation – offer even if cycles are regular
FSH and LHEarly follicular phaseIf cycles are irregular
ProlactinAny timeOnly if ovulatory disorder, galactorrhoea or pituitary tumour
Thyroid functionAny timeOnly if symptoms of thyroid disease
AMH / antral follicle countSecondary carePredict response to assisted conception – do not use AMH to predict spontaneous conception
Rubella susceptibility / MMR historyAny timeOffer vaccination if susceptible, before trying to conceive
Cervical screeningIf dueEnsure up to date

Male Investigations – Semen Analysis

Before the test: abstain from ejaculation for 2–7 days (WHO laboratory standard).

If abnormal: repeat ideally 3 months after the first test – spermatogenesis takes about this long. If there is a gross deficiency (azoospermia or severe oligozoospermia), repeat as soon as possible (NICE NG257).

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

ParameterLower reference limit (WHO 2021, as adopted in NG257)Term if below
Volume≥1.4 mLHypospermia
Concentration≥16 million/mLOligozoospermia
Total sperm number≥39 million per ejaculateOligozoospermia
Total motility≥42%Asthenozoospermia
Progressive motility≥30%Asthenozoospermia
Vitality≥54% liveNecrozoospermia
Morphology≥4% normal formsTeratozoospermia
Corrected: reference values updated from WHO 2010 (e.g. volume 1.5 mL, concentration 15 million/mL, motility 40%) to the WHO 2021 limits in NG257. "Severe abnormality → repeat at 1 month" replaced with NG257's "as soon as possible". Concentration (16 million/mL) and total number (39 million) are the WHO 2021 limits; confirm against the NG257 table and your laboratory's reference ranges.

Further Investigations (usually secondary care)

  • • Tubal patency: hysterosalpingography, HyCoSy or laparoscopy and dye, depending on comorbidities
  • • Pelvic ultrasound: ovaries, uterus, fibroids
  • • Genetic counselling: for specific genetic defects associated with male factor infertility
  • • Not recommended routinely: antisperm antibody testing, sperm DNA fragmentation testing, post-coital testing, basal body temperature charts

Source: NICE NG257 Fertility problems (March 2026).

Common Causes of Subfertility

Female Causes

CategoryConditionKey Features
OvulatoryPCOSIrregular cycles, hyperandrogenism (hirsutism, acne), polycystic ovarian morphology
Hypothalamic dysfunctionLow BMI, excessive exercise, stress
Premature ovarian insufficiencyUnder 40, raised FSH, oligo/amenorrhoea
Tubal / peritonealPID / chlamydiaHistory of STI, pelvic surgery
EndometriosisDysmenorrhoea, deep dyspareunia
UterineFibroids distorting the cavity, polyps, adhesionsHeavy periods, pelvic pressure

Male Causes

CategoryConditionKey Features
Sperm productionIdiopathic oligozoospermiaOften no identifiable cause
VaricoceleScrotal swelling ("bag of worms")
ObstructionCongenital absence of the vas deferensAssociated with CFTR gene variants
HormonalHypogonadismLow testosterone, small testes; ask about anabolic steroids
GeneticKlinefelter syndrome47,XXY; azoospermia

Unexplained Fertility Problems

A diagnosis of exclusion when standard investigations are normal.

  • • Management (NG257): advise continuing regular unprotected intercourse for a total of 2 years (including the time before investigation); IVF is then offered under the access criteria
  • • Age: prognosis worsens with increasing female age
Corrected: "expectant management, then ovulation induction" is not NICE practice for unexplained infertility and has been removed. Prevalence percentages for causes were removed as they could not be verified against NG257.

Source: NICE NG257 (March 2026).

Referral Criteria & IVF

When to Refer

ScenarioTiming
Trying to conceive, under 36After 12 months of regular unprotected intercourse (or 6 cycles of artificial insemination)
Trying to conceive, 36 or overAt presentation
Known or suspected cause of infertility (either partner)At presentation
Planned treatment that may cause infertility (e.g. cancer)At presentation – fertility preservation
Recurrent miscarriage3+ first-trimester losses or 1+ second-trimester loss (RCOG GTG 17)

NICE IVF Access Criteria (NG257, England)

  • • Offer IVF to women (and trans men and non-binary people with female reproductive organs) before their 42nd birthday if: there is a diagnosed cause not suited to or not helped by other treatments; or unexplained fertility problems and no conception after 2 years of regular unprotected intercourse (with or without IUI); or no conception after 12 cycles of artificial insemination (6 or more by IUI)
  • • Under 40: offer an initial 3 full cycles; if still not pregnant, discuss chances and consider up to 3 further full cycles. At the 40th birthday, complete the current cycle but do not start more
  • • Aged 40–42: separate criteria apply – see NG257 section "Access criteria for IVF"
  • • A "full cycle" = one episode of ovarian stimulation plus transfer of all resulting fresh and frozen embryos
  • • Take ovarian reserve into account when discussing IVF
Commissioning reality: NHS funding is set by Integrated Care Boards (not "CCGs" – replaced in 2022), and many ICBs fund fewer cycles than NICE recommends. Always check your local ICB fertility policy.

IVF Success Rates

Live birth rates fall steeply with age. Use the HFEA's current national data (hfea.gov.uk) when counselling – the previous age-band table on this page has been removed because its figures could not be verified against a current source.

Alternative Options

  • • Donor gametes: sperm, egg or embryo donation
  • • Surrogacy: when pregnancy cannot be carried
  • • Adoption / fostering
  • • Counselling: before, during and after treatment

Source: NICE NG257 (March 2026), "Access criteria for in vitro fertilisation (IVF)"; RCOG GTG 17.

Ovarian Hyperstimulation Syndrome (OHSS)

What it is

An iatrogenic complication of ovarian stimulation: enlarged ovaries and increased capillary permeability cause fluid shifts into the third space (ascites, pleural effusion), haemoconcentration and a prothrombotic state. "Early" OHSS follows the hCG trigger; "late" OHSS is driven by hCG from an implanting pregnancy and tends to be more severe and prolonged.

Risk Factors

Patient Factors
  • • Young age
  • • PCOS / high antral follicle count
  • • High AMH
  • • Previous OHSS
  • • Pregnancy (especially multiple)
Treatment Factors
  • • High response to gonadotrophins (many follicles)
  • • hCG trigger
  • • Fresh embryo transfer

RCOG Severity Classification

SeverityFeatures
MildAbdominal bloating, mild abdominal pain; ovarian size usually <8 cm
ModerateModerate abdominal pain, nausea ± vomiting, ultrasound evidence of ascites; ovarian size usually 8–12 cm
SevereClinical ascites (± hydrothorax); oliguria (<300 mL/day or <30 mL/hour); haematocrit >0.45; hyponatraemia (Na <135); hypo-osmolality; hyperkalaemia (K >5); hypoalbuminaemia (<35 g/L); ovarian size usually >12 cm
CriticalTense ascites/large hydrothorax; haematocrit >0.55; WCC >25,000/mL; oliguria/anuria; thromboembolism; ARDS

Any single feature of severe or critical OHSS places the woman in that category. Ovarian size may not match severity after egg collection.

GP Management

Red flags: severe abdominal pain, breathlessness, reduced urine output, rapid weight gain or increasing girth, calf pain/swelling, chest pain. Contact the fertility unit urgently or send to hospital.
Mild / moderate (outpatient)
  • • Liaise with the treating fertility unit – ongoing contact until resolved
  • • Oral fluids to thirst; paracetamol for pain (avoid NSAIDs)
  • • Daily weight and girth; watch urine output
  • • Stay mobile – VTE risk
Severe / critical
  • • Hospital admission via fertility unit or gynaecology
  • • FBC (haematocrit), U&E, LFTs, coagulation, imaging
  • • Thromboprophylaxis decided by the specialist team

Prevention

Specialist responsibility. NICE NG257 signposts to the ESHRE guideline on ovarian stimulation for IVF/ICSI (2025 update), part G, for OHSS prevention strategies.

Corrected: ovarian size bands were wrong on the previous page (mild is usually <8 cm, moderate 8–12 cm). Unverified incidence figures were removed.

Sources: RCOG Green-top Guideline 5 The Management of OHSS (updated 2026); NICE NG257. The "avoid NSAIDs" advice comes from RCOG GTG 5 – check the current version.