Mixed TOGS Flashcards
Surgical causes abdo pain, nonepithalial ovarian cancers, IBD in pregnancy, vAMA, peripartum hyponatraemia, VIN
Presentation of leaking abdominal aneurysm in pregnancy?
Unexplained collapse preceded by severe acute abdo/back pain, typically intercapsular
Who is more at risk of abdominal aneurysm?
Marfan’s
What is murphy’s sign and what does it indicate?
Tenderness increased on inspiration while palpating RUQ
Acute cholecystitis
Typical presentation of pancreatitis?
Upper abdominal pain eased by leaning forward
Often history of biliary colic/cholecystitis
Types of non-epithelial ovarian cancer
Malignant ovarian germ cell tumours - dysgerminoma, embryonal, immature teratoma, choriocarcinoma, yolk sac tumour
Sex cord-stromal tumours - thecoma, granuloa cell, sertoli-leydig
Most common germ cell tumour?
Dysgerminoma
Features of dysgerminoma?
20-30s
Fish flesh cut surface
Haemorrhage and necrosis common
SOlid, round, lobulated
90% 5 year survival
LDH used to monitor disease
Tumour markers in immature teratoma?
AFP, LDH, DHEA can be raised
Features of endodermal sinus tumour/YS tumour?
Elevated AFP
Malignant
Radioresistant
Unilateral
Large, solid, lobulated
Schiller-Duvall bodies (glomerulois tufts)
Pathognomomic feature of granulosa cell tumour?
Call-exner bodies
Isosexual precococious puberty in 50%
Features of immature teratoma?
Malignant
Elements from all 3 germ cell layers
May coexist with mature teratoma
Features of mature teratoma?
95% benign, rarely undergo malignant transformation
Cystic masses with focal solid areas - rokitansky’s protuberance
hair, sebum, teeth
Features of choriocarcinoma (non-gestational type)
Very rare
Isosexual precocity
High hCG
Large haemorrhagic masses
Derived from syncytiotrophoblas and cytotrophoblast
Which NEOCs may have raised testosterone?
granulosa cell, sertoli-leydig
Which NEOCS have raised hCG?
choriocarcinoma, embryonal
Yolk sac tumour will have raised…
AFP, LDH
In which NEOC can you have raised AMH?
granulosa cell tumour
(inhibin also raised)
How are NEOCs managed?
Surgery and chemotherapy
Unilateral salpingo-oophorectomy if fertility preservation required
Which medications should be stopped prior to conception in women with IBD?
Mycophenolate mofetil and methotrexate
Drugs used for UC that are safe in pregnancy?
Sulfasalazine
Metronidazole short courses
Steroids
Sulfasalazine MoA?
interferes with folate synthesis by inhibiting dihydrofolate reductase
Therefore need to give high dose folic acid
Risks to fetus with sulfasalazine use?
Bloody diarrhoea in infant, avoid >3g/day due to fetal nephrotoxicity, theoretical risk kernicterus in newborn
What are the key challenges with use of biologics in IBD in pregnancy?
Minimal data
Infliximab crosses placenta at high rates in 3rd trimester which can cause immunosuppression in newborns for 6 months. Therefore often discontinued at 32w
Considerations for labour in IBD?
Avoid episiotomy as can trigger perinanal disease
Definition of very advance maternal age?
> 45 years at time of delivery
Main risks of pregnancy in women with very advanced maternal age?
Caesarean section delivery 50%
Hypertension/ PET - especially in egg donation conception
GDM
Fetal growth restriction
Pre-term delivery
Placenta praevia
Higher risk of admission to ICU
If Na 125-130 in labour- what should you do?
Fluid restrict to 80ml/h
Repeat Na in 4 hours
Inform obs team/NNU
If Na <125 in labour - what should you do?
Fluid restrict to 30ml/h
Stop oxytocin
Repeat Na in 2 hours
MDT involvement
If after initial measures Na <125 and worsening/symptomatic, what should you do?
CCU involvement
Consider 2.7% saline 200ml in 30mins
Consider furosemide 20mg IV if fluid overload
Post-natally, at what Na level should you fluid restrict/stop oxytocin?
<125
Restrict to 30ml/h
MDT involvement
Signs/symptoms of hyponatraemia
headache, nausea, no appetite, apathy
disorientation, agitation, seizures, coma, respiratory arrest, pulmonary oedema
Most common vulval malignancy?
vulval squamous cell carcinoma
What are the 2 main precursors to vulval squamous cell carcinoma?
HPV dependent - vulval high grade squamous intraepithelial lesion (vHSIL) >10% 10year risk ca
HPV independent - differentiated type vulval intraepithelial lesion (dVIN) >50% 10 year risk ca
Which HPV types are high risk for vulval ca?
HPV 16 and HPV 33
Main risk factors for HPV independent vulval ca?
lichen sclerosus and age
How to biopsy suspected VIN
Incisional punch biopsy 4mm width, 5mm depth
Ensure biopsy is mapped
Management of VIN
Surgical - local excision if small/defined OR vulvectomy if extensive disease
Medical management - imiquimod 5% cream
MoA imiquimod?
Immunomodulator - agonism of toll-like receptors 7+8
Risk of recurrence after treament of VIN?
26%
Features of usual type (HPV dependent) VIN?
basaloid, warty, multifocal
35-55 years old
RFs: HPV, smoking, immunodeficiency
Features of differentiated VIN?
Unifocal
Post-menopausal
Lichen sclerosis is associated with what other immune conditions?
Thyroid disease
T1DM
What is extra mammary paget’s?
Rare vulval lesion in 60-80yo
Associated with adenocarcinoma e.g. breast or GO
Strawberries and cream appearance - erythematous and scaly patches
Paget cells seen on biopsy
High recurrence - excision is treatment
Nodes affected in vulval cancer?
Inguino-femoral nodes
Incision type to remove vulval cancer?
Triple incision with primary closure
Appearance of squamous vulval ca?
Warty, rolled edges
Treatment for vulvodynia?
gabapentin
amitriptyline
