The 2015 BHIVA guidelines suggest that patients should commence HAART immediately upon HIV diagnosis, irrespective of pregnancy status, rather than delaying until a specific CD4 count, as was previously advised.

HIV and Pregnancy: Guidelines for Minimizing Vertical Transmission

With the increasing prevalence of HIV infection among heterosexual individuals, there has been a rise in the number of HIV-positive women giving birth in the UK. In London, the incidence may be as high as 0.4% of pregnant women. The goal of treating HIV-positive women during pregnancy is to minimize harm to both the mother and fetus and to reduce the chance of vertical transmission.

To achieve this goal, various factors must be considered. Guidelines on this subject are regularly updated, and the most recent guidelines can be found using the links provided. Factors that can reduce vertical transmission from 25-30% to 2% include maternal antiretroviral therapy, mode of delivery (caesarean section), neonatal antiretroviral therapy, and infant feeding (bottle feeding).

To ensure that HIV-positive women receive appropriate care during pregnancy, NICE guidelines recommend offering HIV screening to all pregnant women. Additionally, all pregnant women should be offered antiretroviral therapy, regardless of whether they were taking it previously.

The mode of delivery is also an important consideration. Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks. Otherwise, a caesarean section is recommended, and a zidovudine infusion should be started four hours before beginning the procedure.

Neonatal antiretroviral therapy is also crucial in minimizing vertical transmission. Zidovudine is usually administered orally to the neonate if the maternal viral load is less than 50 copies/ml. Otherwise, triple ART should be used, and therapy should be continued for 4-6 weeks.

Finally, infant feeding is another important factor to consider. In the UK, all women should be advised not to breastfeed to minimize the risk of vertical transmission. By following these guidelines, healthcare providers can help minimize the risk of vertical transmission and ensure that HIV-positive women receive appropriate care during pregnancy.

Chickenpox and Pregnancy

Chickenpox is a common illness that can affect pregnant women. It has an incubation period of 14 to 21 days and those affected are infectious for two days before the rash appears.

If the pregnant woman has a definite history of Chickenpox, there is no risk to the developing fetus. However, if there is uncertainty about past exposure, a blood test can be done to check for immunity.

If the test detects specific IgG, it confirms past exposure and the patient can be reassured. If not, VZ-immunoglobulin may be administered within 10 days from exposure to prevent infection.

Levonorgestrel dosage should be increased for individuals with a BMI greater than 26 or a weight exceeding 70 kg.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

Screening for Gestational Diabetes

A family history of diabetes in a first-degree relative is a risk factor for gestational diabetes. Therefore, women with this risk factor should be offered an oral glucose tolerance test (OGTT) at 24-28 weeks. The National Institute for Health and Care Excellence (NICE) recommends screening for gestational diabetes using risk factors in a healthy population. At the booking appointment, healthcare providers should determine the following risk factors: body mass index above 30 kg/m2, previous macrosomic baby weighing 4.5 kg or above, previous gestational diabetes, family history of diabetes, and family origin with a high prevalence of diabetes. Women with any of these risk factors should be offered testing for gestational diabetes using the two-hour 75 g OGTT. Diagnosis should be made using the criteria defined by the World Health Organization. Women who have had gestational diabetes in a previous pregnancy should be offered early self-monitoring of blood glucose or an OGTT at 16-18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes should be offered an OGTT at 24-28 weeks. By identifying and managing gestational diabetes, healthcare providers can improve outcomes for both the mother and baby.

The first-line management for nausea and vomiting in pregnancy/hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral antiemetics or fluids, symptoms are not controlled with primary care management, or hyperemesis gravidarum is suspected. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.

Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, preterm birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

Neonatal sepsis is primarily caused by GBS, with preterm and very low birthweight infants being at a higher risk. Coagulase-negative Staphylococci, Staphylococcus aureus, and Escherichia coli are also frequently identified as causative agents. Listeria monocytogenes and Streptococcus pneumoniae are also significant pathogens.

Understanding Group B Streptococcus (GBS) Infection in Neonates

Group B Streptococcus (GBS) is a common cause of severe infection in newborns during the early stages of life. It is estimated that 20-40% of mothers carry GBS in their bowel flora, making them potential carriers of the bacteria. Infants can be exposed to GBS during labor and delivery, which can lead to serious infections. Prematurity, prolonged rupture of the membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection.

The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management. The guidelines state that universal screening for GBS should not be offered to all women, and a maternal request is not an indication for screening. Women who have had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and then antibiotics if still positive. If women are to have swabs for GBS, this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date. IAP should be offered to women with a previous baby with early- or late-onset GBS disease, women in preterm labor regardless of their GBS status, and women with a pyrexia during labor (>38ºC). Benzylpenicillin is the antibiotic of choice for GBS prophylaxis.

Before providing nicotine replacement therapy (NRT), it is recommended to conduct cognitive behavioral therapy (CBT) or motivational interviewing with pregnant women who smoke. Additionally, it is important to screen all pregnant women for smoking using a carbon monoxide monitor.

Smoking cessation is the process of quitting smoking. In 2008, NICE released guidance on how to manage smoking cessation. The guidance recommends that patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion, and that clinicians should not favour one medication over another. These medications should be prescribed as part of a commitment to stop smoking on or before a particular date, and the prescription should only last until 2 weeks after the target stop date. If unsuccessful, a repeat prescription should not be offered within 6 months unless special circumstances have intervened. NRT can cause adverse effects such as nausea and vomiting, headaches, and flu-like symptoms. NICE recommends offering a combination of nicotine patches and another form of NRT to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

Varenicline is a nicotinic receptor partial agonist that should be started 1 week before the patient’s target date to stop. The recommended course of treatment is 12 weeks, but patients should be monitored regularly and treatment only continued if not smoking. Varenicline has been shown in studies to be more effective than bupropion, but it should be used with caution in patients with a history of depression or self-harm. Nausea is the most common adverse effect, and varenicline is contraindicated in pregnancy and breastfeeding.

Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist that should be started 1 to 2 weeks before the patient’s target date to stop. There is a small risk of seizures, and bupropion is contraindicated in epilepsy, pregnancy, and breastfeeding. Having an eating disorder is a relative contraindication.

In 2010, NICE recommended that all pregnant women should be tested for smoking using carbon monoxide detectors. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services. The first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing, or structured self-help and support from NHS Stop Smoking Services. The evidence for the use of NRT in pregnancy is mixed, but it is often used if the above measures fail. There is no evidence that it affects the child’s birthweight. Pregnant women

Treatment for Lactational Mastitis

Lactational mastitis is a common condition that affects breastfeeding women. If symptoms fail to improve after 48 hours of first-line antibiotic treatment, it is important to check that the woman has taken the antibiotic correctly and consider the possibility of an alternative diagnosis such as breast cancer or a breast abscess. If an abscess is suspected, it is important to note that malaise and fever may have subsided if antibiotics have been started.

If an alternative diagnosis is unlikely, a sample of breast milk should be sent for microscopy, culture, and antibiotic sensitivity. A second-line antibiotic, co-amoxiclav 500/125 mg three times a day, should be prescribed for 10-14 days, with a review of this choice when breast milk culture results become available. It is important to seek specialist advice if the woman is allergic to penicillin.

Breastfeeding should continue from both breasts if possible, with the affected breast being expressed if feeding is too uncomfortable. In the absence of culture and sensitivity results, flucloxacillin is the usual first choice, with erythromycin for those who are penicillin allergic. Recurrences are best treated with co-amoxiclav. It is worth noting that some cases progress to an obvious abscess, which should be drained.

Epilepsy and Pregnancy: Considerations for Medication and Breastfeeding

Carbamazepine (CBZ) is present in breast milk, but only in small amounts. Breastfeeding mothers should be encouraged to continue breastfeeding as the levels of CBZ in breast milk are too low to cause any harm to the baby.

Prior to conception, it is recommended that women take folic acid at a dose of 5 mg daily to prevent neural tube defects in the fetus. However, it is not recommended for breastfeeding mothers.

For patients with well-controlled epilepsy, there is no increased risk of seizures during pregnancy or the postpartum period. While there is no routine need to monitor serum anti-epileptic concentrations, the NICE guidelines suggest monitoring levels in certain circumstances such as adjusting phenytoin dose, poor concordance, and suspected toxicity.

Overall, it is important for women with epilepsy to work closely with their healthcare provider to ensure the best possible outcomes for both mother and baby during pregnancy and breastfeeding.

To reduce the risk of neural tube defects, women who are trying to conceive and up to 12 weeks into their pregnancy are recommended to take 400 mcg of folic acid. If there are additional risk factors, such as diabetes or a personal or family history of neural tube defects, a higher dose of 5mg is recommended. For bone health, a daily supplement of 10mcg of vitamin D is advised throughout pregnancy and breastfeeding. If a woman chooses to take a multivitamin during pregnancy, she should ensure that it doesn’t contain high doses of vitamin A (retinol) as it can cause birth defects.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. THF plays a crucial role in transferring 1-carbon units to essential substrates involved in DNA and RNA synthesis. Green, leafy vegetables are a good source of folic acid. However, certain medications like phenytoin and methotrexate, pregnancy, and alcohol excess can cause folic acid deficiency. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, all women should take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if either partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with antiepileptic drugs or coeliac disease, diabetes, or thalassaemia trait, and those who are obese (BMI of 30 kg/m2 or more) are also at higher risk and should take the higher dose of folic acid.

Orlistat is a medication used to treat obesity by inhibiting gastrointestinal lipase and reducing fat absorption from the gut. However, it often causes loose stool or diarrhea unless the patient follows a low-fat diet. It is crucial to assess the suitability of orlistat for patients taking critical medications like antiepileptics and contraceptive pills, as it may decrease their effectiveness by increasing gut transit time. If the patient wants to continue taking orlistat, it is advisable to consider alternative contraception methods that are more reliable.

Obesity can be managed through a stepwise approach that includes conservative, medical, and surgical options. The first step is usually conservative, which involves implementing changes in diet and exercise. If this is not effective, medical options such as Orlistat may be considered. Orlistat is a pancreatic lipase inhibitor that is used to treat obesity. However, it can cause adverse effects such as faecal urgency/incontinence and flatulence. A lower dose version of Orlistat is now available without prescription, known as ‘Alli’. The National Institute for Health and Care Excellence (NICE) has defined criteria for the use of Orlistat. It should only be prescribed as part of an overall plan for managing obesity in adults who have a BMI of 28 kg/m^2 or more with associated risk factors, or a BMI of 30 kg/m^2 or more, and continued weight loss of at least 5% at 3 months. Orlistat is typically used for less than one year.

Disorders of Sex Development: Common Conditions and Characteristics

Disorders of sex development refer to a group of conditions that affect the development of an individual’s reproductive system. The most common disorders are androgen insensitivity syndrome, 5-α reductase deficiency, male and female pseudohermaphroditism, and true hermaphroditism. Androgen insensitivity syndrome is an X-linked recessive condition that results in end-organ resistance to testosterone, causing genotypically male children to have a female phenotype. 5-α reductase deficiency, on the other hand, is an autosomal recessive condition that results in the inability of males to convert testosterone to dihydrotestosterone, leading to ambiguous genitalia in the newborn period. Male and female pseudohermaphroditism are conditions where individuals have testes or ovaries but external genitalia are female or male, respectively. Finally, true hermaphroditism is a very rare condition where both ovarian and testicular tissue are present. Understanding the characteristics of these conditions is crucial in providing appropriate medical care and support for affected individuals.

Understanding Parity and Its Relationship with Gravity

Parity refers to the number of pregnancies a woman has had that have been carried to a viable age, which is typically 24 weeks in the UK. This number is represented by a digit followed by a plus sign and another digit, which indicates the number of pregnancies that did not reach viability. Essentially, parity reflects the number of babies a woman has given birth to, while gravida refers to the number of times a woman’s uterus has contained a fetus, regardless of whether the pregnancy resulted in a live birth.

It’s worth noting that parity only increases once a baby is born, whereas gravida increases from conception. For instance, if a woman has given birth to twins, her parity would be 2, while her gravida would be 1. Understanding the difference between parity and gravida is important for healthcare providers to accurately assess a woman’s obstetric history and provide appropriate care.

Frequent feeding in a breastfed baby doesn’t necessarily indicate low milk supply in the mother. It is uncommon for a mother to have low milk supply, and if the baby is growing well and producing enough urine, it is a good sign that the milk supply is sufficient. In fact, frequent feeding or cluster feeding is normal in the early weeks and helps to establish a good milk supply. Breastfeeding mothers should be encouraged to seek support from local and national breastfeeding groups and consult with a trained professional to ensure proper infant positioning and latch.

There is no need to refer the baby to a pediatrician at this stage. It is not recommended to supplement breastfeeding with formula, especially in the early weeks, as this can decrease milk supply. It is important to feed the baby on demand to stimulate milk production. If milk is not removed from the breast, milk production will decrease.

While maternal prolactin deficiency is a rare cause of low milk supply, testing for it is not necessary in this scenario. If there are signs of low milk supply, such as a baby failing to thrive or becoming dehydrated, and after addressing positioning and latch issues, maternal prolactin deficiency may be considered. Factors that increase the likelihood of this condition include a history of maternal thyroid disorder, eating disorder, hypoplastic breasts, or breast surgery.

For more information on breastfeeding problems, refer to the NICE clinical knowledge summary.

Breastfeeding Problems and Management

Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

The use of gel can provide relief from symptoms. However, the main goal of treatment is to minimize the risk of transmission to the newborn during delivery. This risk is particularly high if the woman experiences primary genital herpes simplex during the last six weeks of pregnancy. In such cases, a caesarean section is the recommended method of delivery.

The herpes simplex virus (HSV) comes in two strains: HSV-1 and HSV-2. It was once believed that HSV-1 caused cold sores and HSV-2 caused genital herpes, but there is now significant overlap between the two. Symptoms of a primary infection may include severe gingivostomatitis, while cold sores and painful genital ulceration are also common. Treatment options include oral aciclovir and chlorhexidine mouthwash for gingivostomatitis, topical aciclovir for cold sores (although the evidence for its effectiveness is limited), and oral aciclovir for genital herpes. Pregnant women with herpes should be treated with suppressive therapy, and those who experience a primary attack during pregnancy after 28 weeks gestation should have an elective caesarean section. The risk of transmission to the baby is low for women with recurrent herpes. Pap smear images can show the cytopathic effect of HSV, including multinucleation, marginated chromatin, and molding of the nuclei.

Infertility Management and Referral Criteria

Infertility is a common issue that affects many couples. According to the Clinical Knowledge Summaries, if a couple has been having regular unprotected sexual intercourse for one year and are without comorbidities that affect fertility, investigation into the cause of infertility should be initiated. If no cause is found, the couple should be referred for specialist input.

The referral criteria for infertility may vary between health authorities, so it is important to refer to local guidelines. However, in general, if the woman is younger than 36 years and history, examination, and investigations are normal in both partners, referral should be considered if the couple has not conceived after one year. If the woman is aged 36 years or older, referral should be considered after six months. Earlier referral may be necessary if there is a known cause for infertility, a history of factors that predispose to infertility, or if treatment is planned that may result in infertility.

It is important to ensure that the couple has been offered counselling before, during, and after investigation and treatment, regardless of the outcome. Infertility and its investigation and treatment can cause psychological stress, and infertility counsellors are provided by all licensed clinics in the UK through the British Infertility Counselling Association.

Typically, cervical screening is postponed until 3 months after giving birth, unless there was a missed screening or previous abnormal results. Smear tests are not conducted while pregnant, and there is no reason to refer for colposcopy based on the patient’s history. It is standard practice to delay smear tests until 3 months after delivery.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Monitoring hCG Levels After Molar Pregnancy

After a molar pregnancy, it is important to monitor hCG levels to detect any persistent gestational trophoblastic disease (GTD) that may require treatment. During this monitoring period, women should avoid becoming pregnant as it is difficult to differentiate between hCG levels that are increasing due to a new pregnancy or persistent GTD. The first hCG measurement is taken four weeks after uterine evacuation.

For complete hydatidiform mole, hCG monitoring is required for six months from the first normal hCG level or six months from evacuation of the uterus if the hCG level normalizes by eight weeks after evacuation. On the other hand, partial molar pregnancy has a lower risk of persistent GTD, and hCG follow-up is only necessary until two consecutive monthly levels are normal.

If a woman undergoes chemotherapy for gestational trophoblastic neoplasia, she should avoid pregnancy for at least one year. It is crucial to monitor hCG levels after molar pregnancy to ensure early detection and treatment of any persistent GTD.

Management of Lower Urinary Tract Infection

Guidance from SIGN1 recommends that in cases of lower urinary tract infection (UTI), a dipstick test is not necessary if typical symptoms are present. However, if minimal symptoms or signs are present, a dipstick test should be performed. If the test is positive for leukocytes and nitrites, treatment should be commenced. If it is negative, clinical judgement should be used to determine whether to offer empirical treatment and/or send a mid-stream urine (MSU) sample.

In cases where there are signs or symptoms of upper UTI infection, such as loin pain and systemic symptoms, admission should be considered. Non-pregnant women of any age with symptoms or signs of acute LUTI should be treated with a three-day course of trimethoprim or nitrofurantoin.

By following these guidelines, healthcare professionals can effectively manage lower UTIs and provide appropriate treatment to patients. Proper management can help prevent the spread of infection and improve patient outcomes.

The guidelines indicate that there is no requirement to delay further, even if a caesarean section was performed.

Contraindications for Insertion of Intrauterine Contraceptive Devices

When it comes to the insertion of intrauterine contraceptive devices (IUDs), there are very few contraindications. However, it is important to note that some conditions may increase the risks associated with the procedure. According to the Faculty of Family Planning and Reproductive Health Care, there are certain conditions that fall under UKMEC Category 3, where the risks outweigh the benefits. These include insertion between 48 hours and 4 weeks postpartum, as well as initiation of the method in women with ovarian cancer.

On the other hand, UKMEC Category 4 lists conditions that pose an unacceptable risk for IUD insertion. These include pregnancy, current pelvic infection, puerperal sepsis, immediate post-septic abortion, unexplained vaginal bleeding, and uterine fibroids or anatomical abnormalities that distort the uterine cavity.

In addition, NICE guidelines from 2005 recommend screening for sexually transmitted infections (STIs) before IUD insertion. Women at risk of STIs should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae, especially in areas where the latter is prevalent. Women who request it should also be tested for any STIs. For those at increased risk of STIs, prophylactic antibiotics should be given before IUD insertion if testing has not yet been completed.

It is important to consider these contraindications and guidelines before undergoing IUD insertion to ensure the safety and effectiveness of the procedure.