Neuro, Gynae, Neoplasia Flashcards
What are the symptoms of an ovarian cyst?
Can be no symptoms or:
Lower abdo or pelvic pain - rupture, rapid growth, stretching, bleeding or tortion
Indigestion
Early satiety - feeling full sooner than normal
Urinary and bowel urgency
Painful bowel movements
dyspareunia
What is an ovarian cyst?
A fluid filled sac on the ovary.
How are ovarian cysts diagnosed and treated?
Diagnosed by palpation, utrasound, MRI or CT scan.
Normally resolve spontaneously, but may need laparoscopy or laparotomy to remove a complex cyst.
What is a Bartholin’s cyst?
A blockage in the ducts leading from the Bartholin glands.
How is a bartholin’s cyst treated?
Surgical draining and antibiotics.
What are fibroids?
Also known as leiomyoma or myomas, they are benign growths on the uterus wall.
What are the risk factors for fibroids?
Family hx, ethnicity (african), 30 - 40 years old, obese, hypertension.
What complications could arise due to fibroids?
Increased fetal malpresentation, labour dystocia, LSCS and PPH.
What symptoms may occur with fibroids?
Could be none or: constipation rectal pain abdo pain breakthrough bleeding in menstrual cycle, heavy clots
What is the most common neurological condition in pregnancy?
Epilepsy - 0.5% of pregnancies
What is the effect of pregnancy on epilepsy?
Generally increases seizure incidence but is unpredictable.
AED’s are teratogenic, with effects increasing with the number of drugs being taken. T or F?
True
What is the management of epilepsy in pregnancy?
Preconception care including folate supplement - 5 mg/day (AEDs increase risk of deficiency) and drug review.
Pregnancy - ongoing measurement of drug levels (due to haemodilution effects of pregnancy - doseage may need to be titrated), fetal survelliance for malformations, continue folate, Vitamin K in late pregnancy as AEDs can affect production.
Labour - avoid pethidine as may induce a seizure and avoid dehydration
Vit K for newborn! Review medication postpartum and advice on safety when caring for the newborn.
What can trigger an epileptic fit?
Stress, Sleep deprivation lack of food hypoglycaemia Excessive alcohol consumption Illegal drug abuse Non-compliance with medication regime Flickering lights (rare) Health condition that causes high temp Certain medications Hormonal changes with menstrual cycle
What is SUDEP?
Sudden unexpected death in epilepsy - where someone with epilepsy dies unexpectedly with no identifiable cause. Most important risk factor is uncontrolled generalised tonic clonic seizures
If a woman is seizure free for 9 months prior to pregnancy it is likely that she _______ have a seziure in pregnancy.
won’t have a seziure
A woman with epilepsy that is NOT taking any medications is at a ________ risk of fetal malformation compared to a low risk woman.
HIGHER risk - 3.5% compared to 1-2%.
Which drugs have the highest risk of major congenital malformations and which has the lowest?
Sodium valproate - highest risk
Carbamazepine - lowest risk
What is status epilepticus?
Medical emergency - A seizure that lasts longer than 30 minutes or a series of seizures without regaining consciousness inbetween.
During the first 24 hours postpartum, the risk of a tonic clonic seizure ________
Increases by 1 - 2%
Postpartum considerations for epilepsy?
AED serum levels may rise due to reversal of pregnancy changes;
Breastfeeding is recommended as low levels cross to milk;
Note combined OCP interferes with some AEDs;
New onset seizures should be investigated to rule out other causes such as eclampsia, infection, intracerebral haemorrhage;
What are the known causes of epilepsy?
birth injury metabolic disorder genetic predisposition infection postnatal trauma brain tumour/trauma motor syndromes congenital malformation
What is multiple sclerosis?
A chronic inflammatory autoimmune disease of the central nervous system.
Destruction of the myelin sheaths in the brain and spinal cord.
What is the effect of pregnancy on MS?
Protective effect - however increased chance of relapse postpartum.
Postpartum risk is mitigated by exclusive breastfeeding which suppresses menstruation.
What is Bell’s Palsy?
An idiopathic inflammatory reaction involving the facial nerve and resulting in facial paralysis.
May be caused by oedema, hypertension or secondary to infection.
Treatment - most resolve without treatment - eye care (due to inability to close one eye), high dose steriods and emotional support.
What are the three types of MS?
Relapsing-remitting - clearly defined relapses, with good recovery in between. Most common (85%)
Secondary progressive - initially as above, then progression with/without occasional relapse. 50% of above go on to develop this within 10 years.
Primary progressive - progresses from diagnosis with short/temporary improvements.
What is the treatment for MS?
Acute episodes treated with steriods. Other drugs depending on severity - antispasmodics, analgesics, and medication for bladder urgency.
Considerations for MS in pregnancy, labour and postpartum?
Regular screening for asymptomatic bacteriuria;
Likely to become exhausted quickly in labour
Urinary retention?
Immobile - risk of DVT and pressure ulcers
Increased risk of relapse postpartum
Infection can trigger relapse
Contraception!
What are the three types of stroke?
Ischaemic - from decreased blood flow
Thrombotic - from a venous event
Haemorrhagic - haemorrhage for example from ruptured vessel
What are the signs and management of stroke?
Sudden onset neurological symptoms.
Investigate with CT/MRI, thrombophilia screening, CSF studies and urine/blood toxicology.
Ischaemic stroke - treat with anti-platelet medication
Thrombotic - anti-coag medication and/or surgery to remove clot
Hemorrhagic - surgery if secondary to ruptured aneurysm.
Refer to neurologist/rehab services.
Stop anti-coags prior to labour and recommence postpartum.
What are the most common cancers in pregnancy?
Melanoma Hodgkin's lymphoma Breast Cervical Ovarian
How does pregnancy usually affect cancer?
Can worsen the progression - oestrogen is an established growth factor.
What is the usual approach when cancer is diagnosed in pregnancy?
If possible, elective preterm delivery between 32 - 34 weeks gestation to allow appropriate investigations and treatment.
Should cervical screening been done in pregnancy?
Yes - if the woman has never had a pap smear, or is not current.
What is the new cervical screening test in Australia?
Now tests for HPV and if normal, only retest every five years.
Screening now starts at age 25.
What are the stages of cervical cancer?
Stage 1 - Strictly confined to the Cx - 1a = microscopically invasive; 1b = clinically visible.
Stage 2 - Goes beyond Cx into immediate surrounding tissue including upper 2/3rds of vagina;
Stage 3 - Extends to pelvic wall and lower vagina
Stage 4 - Extends beyond pelvis to bladder, rectum or even the lungs.
What are the treatments when pre-cancerous cells are identified?
Remove or destroy the cells by:
Freezing (cryotherapy);
Laser ablation;
Hot probe (cold coagulation).
Large loop excision of the transformation zone (LLETZ) this allows a sample to be sent for histological examination
What are the treatment of cervical cancer?
Excision if early stages - full investigation with MRI under anaesthetic to ensure not further spread.
More advanced - chemotherapy and radiotherapy
How does previous treatment for cervical cancer impact on pregnancy?
Repeated treatments increase risk of preterm birth. Cervical cerclage may be needed.
Radiotherapy for invasive cancer precludes future pregnancy - may be able to do an IVF/Surrogate cycle.
What are symptoms of cervical cancer in pregnancy?
Bleeding
Labour considerations for cervical cancer?
Increased risk of haemorrhage if a tumour present.
Risk of cervical dystocia from scar tissue - active monitoring of progress required. Note augmentation in this case may increase risk of uterine rupture.
Monitor for intrapartum bleeding.
What is pregnancy associated breast cancer?
That which is diagnosed during pregnancy or within 1 year postpartum.
How is breast cancer detected and diagnosed?
Mostly through self-examination.
Ultrasound is more reliable (93% detection) than mammography (68%) in pregnancy.
Diagnosis is made by using fine needle aspiration or biopsy.
What are the s/s of breast cancer?
fatigue anaemia anorexia, depression sepsis pain metastasis
What are the main treatments for breast cancer?
Radiotherapy (usually delay until postpartum), chemotherapy (contraindicated in first trimester), hormonal therapy (delay to postpartum due to fetal outcomes), surgery (can be done during pregnancy).
Management considerations for breast cancer?
Consider delaying birth until 2 - 3 weeks after last chemo
Corticosteriods for preterm delivery
Breastfeeding contraindicated with treatment
What factors increase and decrease the risk of ovarian cancer?
Decrease: multiparity OCP tubal ligation hysterectomy
Increase: Nulliparity Endometriosis Obesity Infertility
What are the symptoms of ovarian cancer?
Bloating Abdo and pelvic discomfort increasing abdo girth decreasing appetite Severe pain if tortion of the tumour
How is ovarian cancer treated in pregnancy?
Aim for standard cancer treatment. If late stage cancer, then discuss TOP as delay in treatment can have poor maternal outcomes.
Standard treatment = hysterectomy and removal of ovaries. Chemo contraindicated early in pregnancy.
If complex mass identified - remove by surgery in second trimester - 19-20 weeks
If presents with tortion - emergency - urgent ultrasound assessment and surgery
Thrombo-prophylaxis postpartum!
What are the three classifications of epileptic seizures?
- Partial (focal) seizures: Originate from one part of the brain and may spread to become generalised - may or may not involve loss of conciousness.
- Generalised seizures: involve the brain diffusely at onset. Usually impaired conciousness and involuntary muscle movement.
- Unclassified: not either of above - includes neonatal seizures and febrile convulsions.
What might cause increases in epileptic seizure activities in pregnancy?
Hormonal changes - oestrogens are thought to decrease seizure thresholds, progesterone decreases neuronal excitability.
changes in concentration of AEDs in the blood stream
Non-compliance (fear of teratogenosis)
Sleep deprivation
Alcohol consumption
What is a tonic-clonic seizure?
One that involves loss of consciousness and involuntary muscle movement.
