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Medicine YEAR 1 > Phase 2 KPH - Week 3 (Breastfeeding) > Flashcards

Phase 2 KPH - Week 3 (Breastfeeding) Flashcards

1
Q

Breasts

A
  • Accessory organs of the female reproductive system
  • Develop during puberty
  • Mounds of variable size and shape
  • Lie on the front of the thorax, superficial to pectoralis major, extend up to axilla
  • Contain glandular, fatty and connective tissues
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2
Q

List the structures of the breast

A
  • Alveoli
  • Mammary glands
  • Lobes
  • Lobules
  • Lactiferous ducts
  • Lactiferous sinuses
  • Nipple
  • Lymphatic vessels
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3
Q

Describe the structure and function of mammary glands

A
  • Composed of alveoli
  • Enlarge during pregnancy, atrophy when breast-feeding ceases
  • Form 15-20 lobes that radiate around the nipple
  • Each lobe contains many smaller lobules, which end in dozens of tiny bulbs called acini
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4
Q

What is the function of the alveoli of the breast?

A

To produce milk (initially colostrum)

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5
Q

Describe the function of the lactiferous ducts

A

Drain the milk (or colostrum) from the lobes to the centre of the nipple where they open at the lactiferous sinuses

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6
Q

Describe the path taken by milk in the breast

A

Alveoli -> lobes -> lactiferous ducts -> lactiferous sinuses -> nipple

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7
Q

Describe the structure of the nipple

A
  • In centre
  • Mostly composed of smooth muscle fibres
  • Surrounded by pigmented area of skin = areola
  • Almost unpigmented before first menstruation, pigmentation increases around puberty then turns pink -> brown during pregnancy
  • Numerous sebaceous glands in areolae (independent of hair follicles except at periphery of areolae) = Montgomery tubercles
  • Secretion of areolar glands prevent irritation of nipple during nursing
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8
Q

Retromammary space

A

Layer of loose connective tissue between breast and pectoral fascia, potential space, often used in reconstructive plastic surgery

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9
Q

Describe the connective tissue stroma of the breast

A
  • Supporting structure which surrounds the mammary glands
  • Fibrous and fatty component
  • Fibrous stroma condenses to form suspensory ligaments (of Cooper)
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10
Q

What is the function of the suspensory ligaments (of Cooper)

A
  • Attach and secure breast to dermis and underlying pectoral fascia
  • Separate the secretory lobules of the breast
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11
Q

Describe the lymphatic drainage of the breasts. Why is this significant?

A
  • Drain into axillary lymph nodes

- Form a route for breast cancer to spread

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12
Q

Describe the vasculature of the breasts

A
  • Arterial supply to medial part = internal thoracic artery
  • Arterial supply to lateral part = lateral thoracic and thoracoacromial branches and lateral mammary branches
  • Veins drain into axillary and internal thoracic veins
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13
Q

Describe the nerve supply of the breasts

A
  • Innervated by anterior and lateral cutaneous branches of the 4th to 6th intercostal nerves
  • Contain sensory and autonomic nerve fibres (autonomic regulate smooth muscle and blood vessel tone)
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14
Q

Describe the histology of the breast

A
  • Ducts are lined by inner layer of cuboidal to columnar epithelial cells and an outer layer of myoepithelial cells
  • Connective tissue within lobules is composed of fibroblasts in a background of collagen and acid muscins with histiocytes and occasional lymphocytes
  • Interlobular stroma is hypocellular and composed of fibroadipose tissue
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15
Q

Define lactation

A

Secretion of milk from mammary glands and period of time that a mother lactates to feed her young

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16
Q

Define galactopoiesis

A

Maintenance of milk production, requires prolactin

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17
Q

Why is oxytocin needed in lactation?

A

Triggers milk let-down (ejection) reflex in response to suckling

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18
Q

When does development of breasts for lactation begin during pregnancy?

A

From week 18

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19
Q

Role of progesterone in lactation

A
  • Influences growth in size of alveoli ad lobes
  • High levels inhibit lactation before birth
  • Levels drop after birth, triggers the onset of copious milk production
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20
Q

Role of oestrogen in lactation

A
  • Stimulates milk duct system to grow and differentiate
  • High levels inhibit lactation
  • Levels drop at delivery, remain low for first several months of breastfeeding
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21
Q

Which type of contraception should be avoided by breastfeeding women and why?

A
  • Oestrogen-based contraception should be avoided

- Spike in oestrogen could reduce mother’s milk supply

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22
Q

Describe the role of prolactin in lactation

A
  • Contributes to increased growth and differentiation of alveoli
  • Influences differentiation of ductal structures
  • High levels during pregnancy and breastfeeding also increase insulin resistances, increased growth factors levels (e.g. IGF-1) + modify lipid metabolism in preparation for breastfeeding
  • During lactation, is the main factor in maintaining tight junctions of ductal epithelium and regulating milk production through osmotic balance
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23
Q

Describe the role of human chorionic sommatomammotropin in lactation

A
  • From month two, placenta releases large amounts of HCS
  • Closely associated with prolactin
  • Instrumental in breast, nipple and areola growth before birth
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24
Q

Describe the role of follicle stimulating hormone (FSH), lutenising hormone (LH) and human chorionic gonadotrophin in lactation

A
  • Control oestrogen and progesterone secretion

- Also control prolactin and growth hormone

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25
Q

Describe the role of growth hormone in lactation

A
  • Structurally similar to prolactin

- Independently contributes to galactopoiesis

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26
Q

Describe the role of adrenocorticotropic hormone (ACTH) and glucorticoids e.g. cortisol in lactation

A
  • Important lactation inducing functions

- Glucocorticoids play complex regulatory role in maintenance of tight junctions

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27
Q

Describe the role of thyroid-stimulating hormone and thyrotropin-releasing hormone in lactation

A
  • Very important galactopoietic hormones

- Levels naturally increase during pregnancy

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28
Q

Describe the role of oxytocin in lactation

A
  • After birth, contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze newly produced milk into the duct system
  • Necessary for the milk ejection or let-down reflex, in response to suckling
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29
Q

Describe secretory differentiation in lactation

A
  • Occurs during latter part of pregnancy
  • Breasts make colostrum
  • High levels of progesterone inhibit most milk production
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30
Q

Describe secretory activation in lactation

A
  • At birth, prolactin levels remain high
  • Delivery of placenta causes sudden drop in progesterone, oestrogen and HCS levels
  • Abrupt withdrawal of progesterone stimulates copious milk production of secretory activation:
  1. Breast is stimulated
  2. Prolactin levels in blood rise, peak in 45 minutes, return to pre-breastfeeding state 3 hours later
  3. Release of prolactin triggers cells in alveoli to make milk (other hormones such as insulin, thyroxine and cortisol are involved)
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31
Q

When does secretory activation occur?

A

30-40 hours after birth, although mothers may not feel until 50-73 hours after birth

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32
Q

Colostrum

A
  • First milk a baby receives
  • Contains higher amounts of white blood cells and antibodies than mature milk
  • Especially high in immunoglobulin A (IgA) - coats lining of baby’s immature intestines, helps to prevent pathogens from invading baby’s system
  • Secretory IgA also helps to prevent allergies
  • Over first 2 weeks after birth, colostrum production slowly gives way to mature breast milk (fore-milk then hind-milk)
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33
Q

Compare colostrum to mature breast milk

A

Colostrum:

  • Thick, creamy, yellow
  • Increased concentrations of calcium, potassium, fat-soluble vitamins, minerals and antibodies/WBC
  • High concentration of proteins but lower amounts of carbohydrates and lipids compared to breast milk
  • Lower in calories, so baby normally experiences small drop in weight in few days after birth (which quickly increases back to normal)
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34
Q

List the anti-infective agents found in colostrum

A

Macrophages, lymphocytes, immunoglobulins (esp. IgA), lactoferrin, lysozyme, complement, interferron, oligosaccharides, growth factors and enzymes

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35
Q

Describe the autocrine control of galactopoiesis

A
  • Hormonal endocrine control system drives milk production during pregnancy + first few days after birth
  • When milk supply is more firmly established autocrine (or local) control system begins
  • Milk supply strongly influenced by how often baby feeds and how well it is able to transfer milk from the breast
  • More milk removed from breast = more milk produced by the breast
  • Draining of breasts more fully also increases rate of milk production
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36
Q

What causes low milk supply?

A
  • Not feeding or pumping enough
  • Inability of the infant to transfer milk effectively - jaw or mouth structure deficits or poor latching technique
  • Rare maternal endocrine disorders
  • Hypoplastic breast tissue
  • Inadequate calorie intake or malnutrition of the mother
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37
Q

Describe the mechanism of the milk ejection reflex

A
  • Mechanism by which milk is transported from breast alveoli to nipple
  • Suckling by baby stimulates paraventricular nuclei and supraoptic nucleus in the hypothalamus, signals the posterior pituitary to produce oxytocin
  • Oxytocin stimulates contraction of myoepithelial cells surrounding alveoli, which already hold milk
  • Increased pressure causes milk to flow through duct system and be released through the nipple
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38
Q

Give examples of stimuli which can trigger the milk let-down reflex

A
  • Baby suckling
  • Hearing baby crying
  • Thinking about breastfeeding
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39
Q

What causes a poor milk ejection reflex?

A
  • Sore/cracked nipples
  • Separation from the baby
  • History of breast surgery
  • Tissue damage from prior breast trauma
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40
Q

What can help improve a woman’s milk ejection reflex?

A
  • Feeding in familiar and comfortable place
  • Massage of breast or back
  • Warming breast with cloth/shower
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41
Q

Which receptors are involved in the milk ejection reflex?

A

Slowly adapting and rapidly adapting mechanoreceptors densely packed around the areolar region

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42
Q

Describe the components of mature breast milk

A
  1. Lactose
    - Main sugar (carbohydrate) in breast milk
    - Composed of glucose + glalactose
    - Amount of lactose in milk increases over duration of breastfeeding to meet baby’s need
  2. Protein
    - Casein (2.6g/L) present - much lower than cow’s milk
    - Whey protein (6.4g/L)
  3. Lipids
    - 38g/L
    - Triglycerols
    - Phospholipids
    - Fatty acids (including essential fatty acids)
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43
Q

What is the energy content of mature breast milk

A

750kcal/L

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44
Q

Compare the nutritional components of breast milk to formula milk

A

Macromolecules v similar - created using breast milk as gold standard

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45
Q

List the compositional differences between breast milk and formula milk

A
  • Breast milk provides complex range of anti-infective components e.g. antibodies to help protect baby from infection
  • Breast milk is always right temperature and is microbiologically clean - bottle feeding requires careful sterilising and temperature control before feeding baby
  • Breast milk is more easily digested - baby often less constipated/gassy
  • Breast milk rich in digestive enzymes e.g. lipase/amylase - promote intestinal health
  • Breast milk contains probiotics which contribute to baby’s gut microflora
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46
Q

List the maternal benefits of breastfeeding

A
  • Reduces maternal risk of breast cancer, diabetes, heart disease, osteoporosis and ovarian cancer
  • Helps with spacing of pregnancies due to lactational amenorrhoea
  • Helps with weight loss after birth
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47
Q

Why may mothers have negative feelings towards breastfeeding?

A
  • Feelings of insecurity/guilt about not being able to produce enough milk
  • Concern over quality of their diet and effect on baby
  • Lack of education/support or little exposure to breastfeeding prior to pregnancy
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48
Q

Breastfeeding etc. (Scotland) Act 2005

A

It is an offence to:
- Prevent or stop a person in charge of a child from feeding milk (breast milk, cow’s milk or infant formula) to that child in a public place or on licensed premises - including breastfeeding and feeding from a bottle

Also stated to:

  • Support and encourage breastfeeding of children by their mothers
  • Spread information promoting and encouraging breastfeeding
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49
Q

In what ways can breastfeeding be promoted in communities?

A
  • Training community healthcare providers
  • Peer counsellors - healthcare workers or women who have given birth to a child and breastfed successfully
  • Women’s groups - support groups
  • Integration of breastfeeding with primary and preventative health services
  • Integration of breastfeeding and early childhood development strategies
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50
Q

List the reasons why breastfeeding may not be possible

A
  • Low breast milk supply
  • Dependency on drugs
  • Medication
  • Infection
  • If baby can’t breastfeed
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51
Q

Explain why drug dependency may not allow for breastfeeding

A
  • Drugs may pass to baby through breast milk
  • Can cause irritability, sleepiness, poor feeding, growth problems, neurological damage, death
  • Puts mother and baby at risk of contraction infectious diseases such as HIV
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52
Q

Explain why medication may not allow for breastfeeding

A
  • Some prescription drugs can cause harm to baby
  • E.g. chemotherapy drugs, antiretroviral drugs, radioactive iodine, some sedatives, seizure medications, medications that cause drowsiness/suppress breathing
  • Some cause reduction in milk supply
  • E.g. cold and sinus medications contains pseudoephedrine, some types of hormonal contraception
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53
Q

Explain why infection may not allow for breastfeeding

A
  • Some can pass to baby through breast milk

- E.g. HIV, human T-cell lymphotropic virus

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54
Q

Why would a baby not be able to breastfeed?

A
  • Classic galactosemia - inability to break down galactose
  • Phenylketonuria - may be able to combine breastfeeding with formula
  • Deformity of mouth/jaw - can drink expressed breast milk
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55
Q

Define weaning

A

Process of gradually introducing baby to adult diet and withdrawing supply of milk, fully weaned when it is no longer fed any breast milk (or bottle substitute)

56
Q

When is weaning recommended?

A
  • Begin weaning at 6 months (solely breast milk until then)
  • Continue breastfeeding until age 2 (with solid foods, milk etc.)
  • Based on fact that baby’s digestive system reaches maturity then
  • Baby will take less milk when start eating solid foods, but milk contains more energy, vitamins and nutrients necessary for growth and development so weaning should not be started before 6 months
57
Q

Explain baby-led weaning

A

Allow baby to pick up food and put in mouth - gives chance to develop motor skills to feed self and experience different types of food

58
Q

Describe the nutrient requirement of a new-born

A
  • For optimal growth requires 150ml/kg/day and 110kcal/kg/day
  • 40% from carbohydrate and 50% from fat
  • Also require minerals such as calcium + phosphate and vitamins/trace elements
  • Breastmilk is deficient in vitamin K, new-borns are given vitamin K at birth to prevent haemorrhagic disease
59
Q

Describe the health benefits of breast milk for the baby

A
  • Meets all nutritional needs (for first 6 months)
  • Provides immune protection
  • Promotes development of the brain
  • Promotes maturation of the gut
60
Q

Describe the macronutrient composition of breast milk

A
  • Sugars 7% - mainly lactose
  • Fat 4%
  • Protein 1.3% - Casein 0.4%
  • Minerals 0.2%
61
Q

Give examples of biologically active substances with roles in the gut found in breast milk

A
  • Alpha-lactalbumin - antibacterial and immunostimulatory properties
  • Lactoferrin binds iron in competition with bacterial pathogens
  • Oligosaccharides - selectively encourage the growth and probiotic organisms
62
Q

Describe the benefits of the protection given by breast milk

A
  • Protects baby from infection - reduces risk of GI, respiratory and other infections (otitis media, meningitis, UTIs)
  • Reduces risk of sudden infant death syndrome, childhood lymphomas, early allergic disease and type 1 diabetes
  • Protection against heart disease in adult-hood
63
Q

Explain how breast milk promotes maturation of the gut

A
  • Epidermal growth factor - promotes healing
  • Neuronal growth factors - promotes development of peristalsis
  • Prevents necrotising enterocolitis (complication of extreme premature birth)
64
Q

Explain how breast milk promotes development of the brain

A
  • Presence of long-chain polyunaturated fatty acids e.g. docosahexanoic acid
  • Inverse associated between IQ and formula feeding
65
Q

Describe the health economic impact of use of formula milk

A
  • Universal exclusive breastfeeding in poorer countries would prevent 14% of deaths of children under 2 years of age
  • Associated with lower intelligence and economic losses of $302 billion annually
  • Breastfeeding duration to 12 months per child in high-income countries would prevent 22,000 deaths from breast cancer
66
Q

Where is prolactin secreted?

A

Anterior pituitary

67
Q

What is the function of prolactin?

A
  • Signals lactocytes to make milk
  • Critical to maintenance of long term milk supply
  • Levels highest at night
68
Q

Where is oxytocin secreted?

A

Posterior pituitary

69
Q

Describe the local control of milk production

A
  • Feedback inhibitor of lactation is secreted into milk
  • As milk volume increases, FIL blocks milk production
  • Removing FIL allows further milk production
70
Q

Which demographic are

a) Most likely to start and continuing breastfeeding
b) Least likely to starts and continue breastfeeding

A

a) Educated, affluent, older mothers

b) Younger, less-educated mothers from lower socio-economic backgrounds

71
Q

List the methods used to help breastfeeding work

A
  • Skin to skin contact soon after birth
  • Keep mother and baby together
  • Allow unrestricted, frequent feeds
  • Support mothers to breastfeed at night
  • Use dummies with caution
  • Don’t ‘supplement’
72
Q

Why is correct positioning and attachment important in breastfeeding

A
  • Good positioning is essential to ensure that the baby can correctly attach at the breast
  • Correct attachment is essential to ensure effective milk removal and prevent nipple damage
73
Q

Describe the principles of responsive feeding

A
  • Mother keeps baby close and responds to baby when:
    1. Baby shows feeding cues
    2. Baby needs comforted
    3. When mother or baby need to rest and relax
  • Breastfed babies cannot be overfed by frequent feeding
74
Q

Describe the disadvantages of ‘mixed feeding’

A
  • When breastfeeding mothers use formula milk
  • Strongly associated with premature cessation of breastfeeding
  • Breast milk production reduces as more formula taken
75
Q

List the pros of bottle feeding

A
  • Large volumes available at all times
  • Enables separation from mother and for father to give feeds
  • Supplies roughly same macronutrients as breast milk
  • Bottle fed babies tend to sleep longer through night
76
Q

List the cons of bottle feeding

A
  • Formula milk is expensive
  • Bottles have to be cleaned and sterilised and milk made up
  • Inconvenient when out - need to carry equipment and find source of boiled water
  • Lacks all biologically active elements of breast milk
  • Places child at risk of infection, SID, reduced cognition etc.
77
Q

List the problems with breastfeeding and the solutions to these problems

A
  • Mother has to learn practical techniques - support essential in hours and days after birth
  • Lactation/feeding can be painful - optimising attachment should minimise nipple trauma
  • Feeding frequency tends to be greatest at night
  • Breastfeeding is demanding and tiring
  • Requires mother to be with baby 24 hours per day - expression of breast milk can be used to maintain supply and frozen for later use
78
Q

Describe the doctor’s role in breast feeding

A
  • Acknowledge that breastfeeding is a learned behaviour and may be difficult at first
  • Be patient and confident that true lactation failure is very rare
  • Explain why supplementary feeds are counterproductive and dangerous
  • Refer for skilled lactation support
  • Discount some risk (e.g. weight loss) against long term benefits of breast feeding
  • Don’t advise supplementary bottle feeding just to allay anxiety
  • Don’t prescribe medication for mother without checking safety for lactation
79
Q

What is stigma?

A
  • Marks an individual as being unacceptably different from ‘normal’ people with whom they interact
  • An attribute that discredits or disqualifies an individual from full social acceptance
80
Q

List forms of stigma

A
  • Culture
  • Weight
  • Gender
  • Age
  • Race
  • Sexuality
  • Diseases
81
Q

List the dimensions of stigma

A
  • Concealable (what can be seen)
  • Course (prominence or consistency) over time
  • Disruptiveness (degree to which it impedes social interactions)
  • Aesthetics (and reactions of others) that impact on worth or dignity
  • Origin (present at birth, accidental, deliberate)
  • Peril (danger that others perceive is posed to them)
82
Q

Define stigma

A

An idea or thought, based (usually) on prejudice

83
Q

List the types of stigma

A

External - being treated differently to other people

Internal - the way a person feels about themselves

84
Q

List the impacts of stigma

A
  • Avoidance
  • Rejection
  • Moral judgement
  • Stigma by association (stereotypes)
  • Discrimination
  • Abuse
  • Victimisation
85
Q

List the impacts of internal stigma

A
  • Self-exclusion from services or opportunities
  • Perceptions of self - low self esteem
  • Social withdrawal
  • Overcompensation
  • Fear of disclosure
86
Q

Why is stigma a health issue?

A
  • Individuals (psychological, social impacts)
  • Individual’s access to/use of services
  • Development of services
  • Research, development of interventions
  • Costs of stigma
  • Morbidity and mortality
87
Q

Describe the main determinants of health

A
  1. Age, sex and hereditary factors
  2. Individual lifestyle factors
  3. Social and community networks
  4. Living and working conditions - unemployment, water sanitation, health care services, housing, work environment, education. agriculture and food production
  5. General socio-economic, cultural and environmental conditions
88
Q

What factor can the severity of health and social problems in countries be attributed to?

A

The extent of inequality within the country - not the average income

89
Q

How can health inequalities be reduced?

A
  • Give every child the best start in life
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives
  • Create fair employment and good work for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill-health prevention
90
Q

Proportionate universalism

A

Cannot only focus on the most disadvantages to reduce health inequalities - actions must be universal but with a scale and intensity that is proportionate to the level of disadvantage

91
Q

What determines health inequalities in our population?

A
  1. Fundamental causes (global forces, political priorities, societal values leading to unequal distribution of power, money and resources)
  2. Wider environmental influences (economic and work, physical, education and learning, social and cultural, services)
  3. Individual experiences (economic and work, physical, education and learning, social and cultural, services)
  4. Effects (inequalities in the distribution of health and wellbeing)
92
Q

List actions to address social determinants of health

A
  • Structural changes in the environment
  • Legislative and regulatory controls
  • Fiscal policies
  • Income support
  • Reducing price barriers
  • Improving accessibility of services
  • Prioritising disadvantaged groups
  • Offering intensive support
  • Starting young
93
Q

Give an example of a health inequality in Glasgow

A

Across Glasgow there is a 21 year gap in female healthy life expectancy at birth

94
Q

Give an example of a socio-economic inequality in Glasgow

A

Across Glasgow neighbourhoods there is a nine fold variation in the proportion of children in an area living in poverty

95
Q

Give an example of a learning inequality in Glasgow

A

Across Glasgow neighbourhoods there is 7 fold variation in attainment levels among S4 pupils

96
Q

Give an example of an action to address health inequality through income support

A

Healthier, wealthier children project

97
Q

Give an example of an action to address social determinants of health through structural changes in the environment/legislative and regulatory controls

A

Introduction of 20mph zone - 50% drop in number of children killed or seriously injured

98
Q

Define clinical audit

A

A quality process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change

99
Q

Why undertake clinical audit?

A
  • Ensure best possible care for patients
  • Ensure clinical practice is evidence-based
  • It is an integral part of clinical governance
  • Assists with the implementation of national initiatives
  • Improves working between multi-disciplinary groups
100
Q

List the essential elements of clinical audit

A
  • Patient focused
  • Direct impact on patient care
  • Assists to improve patients’ experience of NHS
  • Can highlight an area of concern
  • Based on evidence based practice
  • Helps to ensure an efficient use of resources
101
Q

What can be audited?

A
  • Structure - resources and personnel available
  • Process - amount and type of activities of clinical care
  • Outcome - result of an intervention
102
Q

Define the placebo effect

A

Improvements in patients symptoms that are attributed to their participation in the therapeutic encounter, with its rituals, symbols and interactions

103
Q

Describe the mechanism of action of the placebo effect

A

Related to complex neurobiologic mechanisms involving neurotransmitters (e.g. endorphins, cannabinoids and dopamine) and activation of specific, quantifiable and relevant areas of the brain (e.g. prefrontal cortex, anterior insula, rostral anteror cingulate cortex, and amygdala in placebo analgesia

104
Q

What extrinsic circumstances does the placebo effect rely on?

A
  • Emotional and cognitive engagement with clinicians, esp. trust
  • Social and physical value of interaction/intervention
  • Setting
  • Anticipation and expectation of clinical improvement
  • Conditioned response
  • Type of placebo e.g. larger pills, colour of pills, number of pills, injection etc.
105
Q

List the ethical issues surrounding the use of placebos

A
  • Not approved by FDA or NICE
  • Deceiving patients unethical
  • Safety and regulation concerns
  • Not always successful in helping patients’ symptoms
106
Q

Explain the use of placebos in RCT

A
  • Used to prove a new treatment effective above and beyond the psychological results of a simple belief in the ability of the drug to cure
  • Compares the results of the experimental treatment for an illness with those obtained from the placebo - gold standard for testing the efficacy of new treatments
107
Q

What is the average life expectancy of someone who is long-term homeless?

A

42

108
Q

What percentage of people who are long-term homeless show symptoms of malnutrition?

A

70%

109
Q

Why are homelessness health services necessary?

A
  • Health is last priority
  • Unstructured lifestyles
  • Distrust/stigma
  • High levels of alcohol consumption
  • High risk injection practices
  • Unmet physical and mental health needs
110
Q

List types of long-acting reversible contraceptive (LARC) methods and explain why their use is encouraged

A
  • Intrauterine devices
  • Contraceptive implant
  • Depoprovera (contraceptive injection)

Have low user input, high efficacy and can be reversed

111
Q

List the types of contraceptive methods

A
  1. Hormonal - oestrogen and progesterone or progesterone only
  2. Barrier
  3. Copper intrauterine device (coil)
  4. Natural methods
  5. Sterilisation
112
Q

Describe hormonal methods of contraception

A

Oestrogen and progesterone = combined pill, patch and vaginal ring (>99% efficacy)

Progesterone only pill (99% efficacy)

Injectable = Depoprovera (>99% efficacy)

Implant = Nexplanon (99% efficacy)

Progesterone releasing IUD = Mirena coil (>99% efficacy)

113
Q

Describe barrier methods of contraception

A
  • Condom - male and female (male = 98% efficacy, female = 95% efficacy)
  • Diaphragm and cervical caps (92-96% efficacy)

Efficacy very dependent on use, quoted efficacy for perfect use

114
Q

What is the efficacy of the copper intrauterine device

A

> 99%

115
Q

Describe natural methods of contraception

A

Based on:

  • Billings (mucus)
  • Temperature
  • Rhythm
  • Withdrawal
  • Persona

Efficacy is very variable but if combination of methods is used can be up to 97% with perfect use

116
Q

Describe sterilisation

A

Tubal ligation (female), vasectomy (male)

Tubal ligation has 1:300 failures over lifetime

Vasectomy has 1:2000 failures over a lifetime

117
Q

List the methods of emergency contraception

A
  1. Oral
    - Levonorgestrel (progesterone) - Levonelle
    - Ullipristal - EllaOne
  2. Intrauterine, copper IUD
118
Q

How effective are oral emergency contraceptives?

A

Levonelle - will prevent approx. 95% of expected pregnancies but efficacy reduces over time - must be used within 72 hours after unprotected sex

EllaOne - similar to Levonelle, for use within 120 hours after unprotected sex

119
Q

How effective is the copper IUD when used as an emergency contraceptive?

A

99%, must be inserted within 120 hours after unprotected sex

120
Q

How do hormonal methods of emergency contraception work?

A

Inhibit or delay ovulation

121
Q

List the factors which influence contraceptive choice

A
  • Knowledge and understanding of method
  • Personal features e.g. forgetfulness, fear of needles
  • Method characteristics - side effect profile, efficacy, ease of use
  • Lifestyle and occupation
  • Motivation not to be pregnant (e.g. educational attainment, environment, peer influence etc.)
  • Alcohol and drug use - particularly influences decision not to use contraception
  • Peer/partner pressures
  • Embarrassed to discuss with partner or health professional
  • Concerns re confidentiality at GP/clinic
  • Poor access to services
  • Cultural/religious influences
122
Q

List common sexually transmitted infections

A
  1. Genital warts
  2. Chlamydia
  3. Genital herpes
  4. Trichomonas vaginalis
  5. Gonorrhoea
  6. Hepatitis B virus
  7. Syphilis
  8. HIV
123
Q

Genital warts

A
  • Most common STI seen in sexual health clinics
  • Caused by human papillomavirus (HPV) type 6 and 11
  • Often have another STI
  • Some types associated with cervical cancer
  • Girls vaccinated in school
124
Q

Chlamydia

A
  • Most common bacterial STI
  • Frequently asymptomatic, esp. in women
  • Cause of dysuria and discharge in men and pelvic inflammatory disease and cervicitis in women
  • May cause infertility in women
125
Q

Genital herpes

A
  • Caused by herpes simplex virus
  • Type 1 or type 2
  • Produces painful ulcers that heal completely but may recur
126
Q

Trichomonas vaginalis

A
  • Flagellated protozoan
  • Up to 50% cases asymptomatic
  • May produce vaginal discharge + odour in women and discharge or dysuria in men
127
Q

Gonorrhoea

A
  • Neisseria gonorrhoea is Gram negative diplococcus
  • Men typically develop purulent urethral discharge + dysuria
  • Women may have vaginal discharge
  • Men and women may be asymptomatic
  • Problems with drug resistant strains
  • More common in men who have sex with men
  • Complications include PID, conjunctivitis and disseminated gonococcal infection
128
Q

Hepatitis B virus (HBV)

A
  • Is a Hepadnavirus
  • Transmitted through sexual contact, blood contact and vertical transmission
  • Can lead to cirrhosis, liver failure and rarely liver cancer
129
Q

Syphilis

A
  • Recent epidemic across UK
  • Particularly seen in MSM
  • Frequently seen alongside HIV infection
  • Commonly presents with ulcer or rash depending on stage
  • Can have significant consequences if left untreated - neuropathy, aneurysm, tabedorsalis
  • Fully curable with long-acting penicillin
130
Q

HIV

A
  • Typically in specific at-risk populations e.g. MSM
  • Treatment has increased life expectancy to almost normal, still significant morbidity and mortality due to late diagnosis
  • Anyone presenting with recognised indicator condition should have HIV test, all pregnant women offered routine testing
131
Q

Describe a sexual health screen for women

A
  • NAAT for chlamydia and gonorrhoea - self take vaginal swab

- Blood for syphilis serology and HIV

132
Q

Describe a sexual health screen for heterosexual men

A

NAAT for chlamydia and gonorrhoea - first void urine sample

133
Q

List the groups at increased risk of sexual ill health

A
  • Adolescents
  • MSM
  • People from, or who have had sex with partners from, countries with high rates of HIV/other STIs
  • Frequent partner change or sex with multiple concurrent partners
  • Previous bacterial STI
  • Early onset sexual activity
  • Alcohol or substance abuse
134
Q

Sexual Offences (Scotland) Act 2009

A
  • Sexual activity under 16 years old is illegal

- Those under the age of 13 are considered unable to give consent, penetrative sexual activity is therefore rape

135
Q

Age of Legal Capacity (Scotland) Act 1991

A

Confers on any person, without a lower age limit, the right to give consent to his or her own medical treatment, provided that the clinical judgement of the doctor attending the young person is that the latter is competent to understand the nature and consequences of the treatment

Medicine YEAR 1 (18 decks)

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