Case 14- Breasts and STI's

Question 1

Mammogenesis

Answer 1

Growth and development of the breast

Question 2

Lactogenesis

Answer 2

Functional changes to allow for milk secretion

Question 3

Galactopiesis

Answer 3

Maintaining milk production

Question 4

Involution

Answer 4

Termination of milk production

Question 5

The 4 hormones involved in Mammogenesis

Answer 5

• Oestrogen- growth and branching of the ductal system (where milk is stored). Increases fat storage in stroma, inhibition of milk production
• Progesterone- produced by the placenta, involved in the growth and increased number of alveolar cells. Where milk is produced
• Human Placental Lactogen (hPL)/Prolactin- hPL is produced by the placenta, prolactin is secreted by the pituitary gland. Both cause the development of secretory characteristics in alveolar cells. Allows milk components to be released by exocytosis when required.

Question 6

Visible changes to the breast during pregnancy

Answer 6

The breast enlarges due to alveolar lobule formation, subcutaneous veins also enlarge. The areolar darkens and the Montgomery glands produce lipoid fluid to moisturise the nipple.

Question 7

2 stages of Lactogenesis

Answer 7

• Stage 1- secretory differentiation, when the glands become sufficiently differentiated to secrete colostrum. Occurs in mid pregnancy till a few days after birth, it is triggered by a reduction in oestrogen and only a few mls is released. Colostrum production increases after birth till its replaced by mature milk
• Stage 2- Secretory activation, the onset of mature milk secretion. It is 3-8 days after birth. It is triggered by a reduction in Progesterone and volume increases to 0.75-1L. Prolactin stimulates milk production in the alveoli.

Question 8

Galactopoiesis

Answer 8

Milk production is initially dependent on Prolactin. From 9 days following birth, production of milk is under autocrine control, continued milk production depends on regular milk removal. There is continuous secretion of milk in the alveoli, if the milk isn’t removed there is accumulation of the feedback inhibitor of lactation and an increase in intramammary pressure. The feedback inhibitor regulates the amount of milk produced so its dependent on the infants needs. When the milk is removed the inhibitor is removed.

Question 9

Galactokinesis- milk ejection

Answer 9

Oxytocin stimulates milk ejection. When the infant suckles the nipple the touch sensitive mechanoreceptors are stimulated in the nipple. The sends nerve signals via the intercostal nerves to the dorsal root ganglion and then to the Hypothalamus. Oxytocin is made from Hypothalamic paraventricular cells and is secreted from the posterior pituitary gland into the blood stream and causes contraction of myoepithelial cells in the mammary glands. Pushes milk down the lactiferous duct and out through the nipple.

Question 10

Cause of onvolution in the breast tissue

Answer 10

Alveolar cells shrink and loose their secretory function due to an accumulation of inhibitory peptides. Occurs when the feedback loop described above stops and the baby stops suckling. Normally starts 40 days after last breastfeeding. Epithelial cells no longer require their secretory function so are removed by apoptosis and required by adipocytes.

Question 11

Variety in breast milk

Answer 11

The longer the intervals between feeds, the lower that fat content. The longer the baby suckles, the more fat and less lactose sugar in the feed. The fact content peaks mid-morning and is lowest overnight.

Question 12

Composition of Colostrum

Answer 12

Primary role may be immunological not nutritional. It contains higher amounts of white blood cells and antibodies, especially IgA which coats the lining of the infants immature intestine. High concentration Protein, growth factors, antimicrobial products and electrolytes. There are low concentrations in fat and carbohydrate

Question 13

Difference in mature breast milk

Answer 13

Produced in large volumes and predominantly nutritional role. High concentrations of carbohydrates (especially lactose), fat. Low concentration of proteins, growth factors, antimicrobial products, electrolytes. The composition of breast milk is dynamic and varies with feeding and over the lactation period

Question 14

Composition of breast milk

Answer 14

• Proteins- over 400 different proteins. Low casein fraction. High soluble whey fractions i.e. immunoglobulins, lactoferrin and lysozyme. Maternal antibodies- most important secretory IgA.
• Carbohydrate- high lactose, Human milk oligosaccharides (HBO)- prebiotics they function to nourish gut microbiota.
• Fats- major energy source (50%), mainly triglycerides, carry fat soluble vitamins, fat content increases through feed
• Vitamins and minerals- low concentration of these, including iron, efficiently absorbed

Question 15

Breastfeeding benefits

Answer 15

• Infant- species specific and can be adapted to meet the needs of the baby. Reduces morbidity and mortality from some infectious diseases i.e. respiratory infections. Reduced rates of SIDS
• Mother- reduces uterine bleeding, reduces risk of breast cancer, reduces rate of ovarian cancer, improves birth spacing due to lactational amenorrhoea

Question 16

Difference in composition between breast milk a

Answer 16

1) Breast milk has low concentrations of vitamin D.
2) There is less efficient absorption of the components of formula milk.
3) Formular milk might not provide the right type of macronutrients and lacks in variety, in fats formula milk lacks DHA, cholesterol and lipase.

Question 17

Problems with breast feeding

Answer 17

• Not enough milk being produced- the infant struggles

* Too much milk being produced

Question 18

What makes a bad latch

Answer 18

A poor latch could be due to Cleft lip/palate or Tongue tie (Ankyloglossia) where there is unusually short/thick lingual frenulum. Sore or cracked nipples can be caused by a poor latch, this can cause a fistula

Question 19

Candidal infection

Answer 19

Thrush of the nipples. Overgrowth of Candida albicans within the nipple and duct. Its caused by sore or cracked nipples and recent antibiotic use

Question 20

Presentation of Candidal infections- nipple

Answer 20

• Sore nipples with pain continuing between feeds
• There may be a red, flaky rash on the areola which is itchy
• The nipple will be tender to touch

Question 21

Complications of having too much milk

Answer 21

Breast engorgement -> Blocked milk ducts -> Mastitis -> Abscess

Question 22

Breast engorgement

Answer 22

When the breast becomes swollen, hard, tight and painful. Usually affects both breasts. Occurs in the first few days of breastfeeding when milk is not removed adequately, this could be due to delayed initiation of breastfeeding, poor latching or ineffective suckling. Pressure within the breasts can damage the cell
Management- improve removal of milk

Question 23

Mastitis

Answer 23

Inflammation of the breast, usually occurs 2-3 weeks following birth. Due to milk stasis, which causes inflammation which can develop infection. Most infective cases are due to organisms from the infant’s nasopharyngeal or umbilical area – staphylococci or streptococci, normally Staphylococcus aureus. Caused by incomplete emptying of the breast and prolonged gaps between feeds.

Question 24

Presentation of Mastitis

Answer 24

• Mother develops a fever and feels systemically unwell
• Tender, firm area in the breast with overlying redness (often wedge-shaped)
• Severe pain in the breast
• Only affects a part of one breast

Question 25

Breast Abscess

Answer 25

Develop if mastitis is left untreated or doesn’t respond. A localised collection of pus. Presentation; painful swelling in the breast which feels full of fluid, discolourisation of the skin over a painful swelling. Mother can still feed if not painful. Management- incision and drainage of the abscess and antibiotics

Question 26

What issues can arise from the under/over production of milk

Answer 26

Underproduction of milk- sore/cracked nipples which can lead to an oppurtunistic thrush infection Overproduction of milk- mastitis which can sometimes lead to an abscess

Question 27

Diagnosis and treatment of Chlamydia

Answer 27

D: sample and nucleic acid amplification test T: Doxycycline 100mg 2x/day 1/52

Question 28

Chlamydia

Answer 28

Causative agent is Chylamydia trachomatis. An obligate intracellular parasite. 70% of infected women and 50% of infected men no obvious symptoms

Question 29

Symptomatic features of Chlymidia

Answer 29

* Nongonococcal urethritis (NGU) (mucoid discharge) * Cervicitis * Vaginal discharge * Endometritis * Epididymitis * Proctitis * Salpingitis * Neonatal conjunctivitis (50% of children born to infected mothers)

Question 30

Complications of chlamydia

Answer 30

Repeated infections can cause infertility | Lymphogranuloma venereum- rare infection of the lymphatic system

Question 31

Clinical manifestations of Gonorrhoea

Answer 31

Thick yellow/green discharge, pain when urinating In women: bleeding between periods, pelvic inflammatory disease In men: urethritis, dysuria

Question 32

Treatment of Gonorrhoea

Answer 32

Ceftriaxone 500mg IM as a single dose w/ azithromycin 1g oral

Question 33

Opthalmia neonatorum

Answer 33

Infection of the babies eyes, when the mother infects the baby during birth. Gonorrhoea

Question 34

Causative agent of Syphilis

Answer 34

Treponema pallidum, a gram negative Spirochete.

Question 35

Stages of Syphilis- can last 30 years

Answer 35

• Primary syphilis- a primary lesion (Chancre) forms as the site of inoculation (where you came into contact with bacteria), it forms 3 weeks after exposure. Heals without treatment after 2-6 weeks, organism spreads through lymphatics and bloodstream • Secondary syphilis- 6 weeks after primary lesion. Red, maculopapular rash on any part of the body normally palms or soles of the feet. Lesions known as Condylomata lata form in the anogenital region Tertiary syphilis- 80% enter latent phase, 40% of these individuals will then develop tertiary syphilis. dementia, wild proclamations and irrational behavious. You get Gummata, inflammatory nodules or plaques, locally destructive and typically found on bones but can occur in any organ.

Question 36

Treatment for Syphilis

Answer 36

Intramuscuar benzathine benzylpenicillin

Question 37

Papillomaviruses

Answer 37

Double stranded, non-enveloped DNA viruses. Causative agent of anogenital warts (condylomata acuminate). All serotypes of HPV causes hyperplastic epithelial lesions. Most causes of anogenital warts are caused by low risk oncogenic genotypes 6 and 11, these serotypes have a low risk of causing cancer.

Question 38

HPV and cervical cancer

Answer 38

HPV is found in >95% of cervical cancers. Cervical cancer is now recognised as an STI. HPV serotypes 16-18 cause 80% of all HPV cancers in the UK. The vaccine targets HPV 16-18 and has reduced genital wart cases by 86%.

Question 39

Condylomata acuminata

Answer 39

Benign, proliferative growths occurring in the genital, perineal, anal, and perianal areas. Lesions can also occur in the urethral meatus, vagina, cervix, and anal canal.

Question 40

The HPV vaccine

Answer 40

The HPV vaccine has been given to women in the UK since 2008, from 2019 it will also given to boys. The HPV vaccine helps protect against cervical cancer, some mouth and throat (head and neck- nasopharyngeal) cancer, some cancers of the anal and genital area.

Question 41

The Gardasil vaccine

Answer 41

Protects against 4 strains of HPV, types 6, 11, 16 and 18.

Question 42

Preventing STI's

Answer 42

* Prevention should focus on high risk groups * Consistent and correct use of condoms * Rapid access to treatment and notifying partners can reduce spread * Anyone under 25 who is sexually active should be screened for chlamydia annually and when changing sexual partners. * High risk groups should be tested every 3 months if they are having unprotected sex.

Question 43

The emotional issues with the termination of pregnancy

Answer 43

1) Depression is highly linked 2) Women may feel like they are killing their child 3) May feel highly anxious about the possibility of a pregnancy 4) May be against their religion

Question 44

Ethical arguments for abortion

Answer 44

Autonomy- the women has the right to choose what happens to her body Beneficence- may ensure the mother's physical and psychological health Non-maleficience- mothers life may be at serious risk if pregnancy continues Justice- promotes gender equality

Question 45

Arguments against abortion

Answer 45

Autonomy- foetus is unable to give or refuse consent for an abortion Beneficience- by aborting babies with learning disabilities are we saying their lifes have less value Non-maleficience- want to minimise harm to the foetus, abortion goes against this Murder

Question 46

Sperm donation

Answer 46

Can be paid £35 per visit. Sperm sample can be frozen for 180 days. Donors are tested for serious disease’s. Age 18-41.