Quesmed wrong answers Flashcards
What is vasa praevia?
Vasa praevia is a condition seen in obstetrics where the foetal vessels, unprotected by the umbilical cord or placental tissue, run dangerously close to or across the internal cervical os. These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.
What are the RFs for vasa praevia?
The aetiology of vasa praevia remains unclear, but it has been associated with multiple gestations, in vitro fertilization, and velamentous cord insertion.
What is the classic triad of vasa praevia?
Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)
How is vasa praevia diagnosed and managed?
Investigations
Diagnosis of vasa praevia is usually made with transabdominal or transvaginal ultrasonography. Most cases can now be diagnosed antenatally, a significant improvement from prior times when the condition was usually only diagnosed post-delivery following a foetal death due to haemorrhage.
Management
The primary management strategy for vasa praevia is an elective caesarean section prior to the rupture of membranes, typically arranged for 35-36 weeks gestation. However, if the mother goes into labour or her membranes rupture, an emergency caesarean section should be carried out immediately to prevent foetal death.
What are the risk factors for breast cancer?
- Increased hormone exposure
- Early menarche or late menopause
- Nulliparity or late first pregnancy
- Oral contraceptives or Hormonal Replacement Therapy - Susceptibility gene mutations
- Most commonly BRCA mutations (BRCA1/BRCA2) - Advancing age
- Caucasian ethnicity
- Obesity and lack of physical activity
- Alcohol and tobacco use
- History of breast cancer
- Previous radiotherapy treatment
What are the types of breast cancer?
- Invasive ductal carcinoma (IDC): This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.
- Invasive lobular carcinoma (ILC): This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.
- Ductal carcinoma in situ (DCIS): This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.
- Lobular carcinoma in situ (LCIS): This is not a cancer but an area of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later.
- Inflammatory breast cancer (IBC): This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.
- Triple-negative breast cancer (TNBC): This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.
- HER2-positive breast cancer: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.
What are the signs and symptoms of breast cancer?
- Unexplained breast mass in patients aged 30 and above, with or without pain
- In those aged 50 and older, nipple discharge, retraction or other concerning symptoms
- Skin changes suggestive of breast cancer
- Unexplained axillary mass in those aged 30 and above
What are the possible differentials for an unexplained breast mass?
- Fibroadenoma: Typically presents as a solitary, painless, and well-circumscribed breast lump in young women
- Cyst: Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle.
- Mastitis: Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever.
- Lipoma: Presents as a soft, mobile, and painless lump.
What is the process of breast cancer screening in the UK
In the United Kingdom, the NHS Breast Screening Programme provides free breast screening services for all women registered with a GP. The programme invites women between the ages of 50 and 70 for breast screening every three years, with the first invitation to screening usually sent to women before they turn 53.
This screening process involves a mammogram, which is an X-ray of the breasts that can help detect breast cancers early, often before they can be felt. The aim of breast cancer screening is to find cancer at an early stage when treatment is most effective.
In 2018, the age range for screening was extended as part of a trial, and some women were invited for screening from the age of 47 up to the age of 73. Women over 70 can still ask for a screening every three years.
How is a suspected breast carcinoma investigated?
Triple assessment is used to investigate suspected breast carcinoma:
1. Clinical examination: of the breast and surrounding lymph nodes
2. Radiological examination: typically a mammogram, can also involve breast ultrasound and MRI
3. Biopsy: often a core needle biopsy or fine needle aspirate (FNA)
Staging involves the TNM system considering the size of the tumour (T), the spread to the lymph nodes (N), and the presence of metastases (M).
What are the management options for breast cancers?
The management strategy for breast carcinoma can vary based on several factors including the subtype of carcinoma, stage, hormonal receptor status, and the patient’s overall health and preferences.
- Surgical management: Wide local excision (WLE) or mastectomy, with sentinel node biopsies for invasive cancers and possible axillary node clearance for positive nodes. Breast reconstruction can be done concurrently or later.
- Radiotherapy: Adjuvant radiotherapy is commonly offered following WLE to reduce recurrence. It may also be given to patients with higher stage cancers post-mastectomy.
- Chemotherapy: Suggested for hormone receptor-negative and HER2 over-expressing patients. Neoadjuvant chemotherapy may be given to downstage tumours before surgery.
- Biological Therapy: Trastuzumab (Herceptin) / Pertuzumab may be given to HER2 positive patients, either as neoadjuvant therapy to downstage the tumour or as part of the overall treatment regimen.
- Hormonal Therapy: Anastrozole (aromatase inhibitor) for postmenopausal or Tamoxifen (oestrogen receptor antagonist) for premenopausal patients with oestrogen receptor-positive breast cancer.
- Bisphosphonates: May be used for reducing occurrence in node-positive cancers.
(Also Neratinib, a tyrosine kinase inhibitor indicated in patients with HER-2-positive breast cancers)
What are the possible side effects of medications used to treat breast cancer?
Treatment for breast cancer often involves medication, including chemotherapy, hormone therapy, and targeted drug therapy. Each of these can have different side effects.
- Chemotherapy drugs are powerful medications that aim to destroy rapidly dividing cells, such as cancer cells. However, they can also affect healthy cells, leading to a range of side effects, including fatigue, hair loss, easy bruising and bleeding, infection, anemia, nausea and vomiting, appetite changes, and problems with concentration or memory.
- Hormone therapy drugs, such as tamoxifen and aromatase inhibitors, are used to treat hormone receptor-positive breast cancers. Common side effects include hot flashes, vaginal dryness or discharge, menstrual changes, fatigue, mood changes, and osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.
- Targeted drug therapies, such as trastuzumab (Herceptin), pertuzumab (Perjeta), and ado-trastuzumab emtansine (Kadcyla), are designed to interfere with specific proteins or processes that contribute to cancer growth. Side effects can vary but often include diarrhea, liver problems, heart problems, mouth sores, and high blood pressure.
What is a lactational breast abscess?
A lactational breast abscess refers to an accumulation of pus within an area of the breast tissue, often as a complication of infectious mastitis. It commonly occurs in lactating women.
What is the cause of lactational breast abscess?
The most common causative organism of lactational breast abscesses is Staphylococcus aureus, which enters the breast tissue via a crack in the nipple skin or through a milk duct. The accumulation of milk, called milk stasis, and trauma to the nipple skin from incorrect latch or pump use can contribute to the infection and subsequent abscess formation.
What are the clinical features of a lactational breast abscess?
Individuals with a lactational breast abscess may exhibit:
- Fever or rigors
- Malaise
- Pain over an area of the breast
- Erythema over the affected breast area
- Possible presence of a fluctuant mass, which may not always be palpable
- History of recent or ongoing mastitis
What are the differentials for a lactational breast abscess?
The differential diagnoses for a lactational breast abscess include:
1. Mastitis without abscess: Characterised by inflammation and infection of the breast tissue, often with flu-like symptoms but without the presence of a fluctuant mass.
2. Engorgement: Overfilling of the breasts with milk, causing discomfort, tightness, and sometimes fever. However, engorgement lacks the localized erythema and fluctuant mass typical of an abscess.
3. Mammary duct ectasia: This condition involves inflammation and blockage of milk ducts, but it usually lacks the systemic symptoms like fever seen in abscess formation.
4. Inflammatory breast cancer: Presents with rapidly progressive erythema, edema, and warmth over the breast, often mistaken for an infection. However, it is not typically associated with a palpable mass.
How is a diagnosis of lactational breast cancer confirmed?
The diagnosis of a lactational breast abscess may be confirmed with:
- Breast ultrasound: To visualise the abscess and guide the procedure for drainage
- Diagnostic needle aspiration: For both diagnostic and therapeutic purposes, i.e., to culture the causative organism and evacuate the abscess
How is a lactational breast abscess managed?
The primary strategies for managing a lactational breast abscess include:
- Incision and drainage or needle aspiration (with or without ultrasound guidance)
- Antibiotic therapy: Oral or intravenous antibiotics, according to local protocols, targeted towards the most common causative organisms
What is an amniotic fluid embolism?
An amniotic fluid embolism (AFE) is a life-threatening condition that occurs when amniotic fluid, or other debris enters the maternal circulation.
What are the causes of amniotic fluid embolism?
It is hypothesized that during labour or shortly after, amniotic fluid can enter the maternal circulation and form an embolism. This fluid may then block the circulation much like a blood clot, particularly in the lung, leading to symptoms that resemble those of a pulmonary embolism. The fluid also triggers an inflammatory response within the mother’s immune system, which can result in disseminated intravascular coagulation.
What are the signs and symptoms of an amniotic fluid embolism?
- High respiratory rate
- Tachycardia
- Hypotension
- Hypoxia
- Disseminated intravascular coagulopathy
What are the main differentials for amniotic fluid embolism?
- Septic shock: Fever, increased heart rate, confusion
- Anaphylactic shock: Rash, swelling, shortness of breath, low blood pressure
- Pulmonary embolism: Chest pain, shortness of breath, irregular heartbeat
- Hypovolaemic shock (e.g. due to placental abruption): Rapid heartbeat, cold and sweaty skin, irregular heart rhythm
How is amniotic fluid embolism managed?
- Immediate transfer to an intensive care unit
- Continuous foetal monitoring if the embolism has occurred before delivery
- Provision of oxygen and fluid resuscitation
- Correction of any coagulopathy, including administration of fresh frozen plasma for prolonged PT, cryoprecipitate for low fibrinogen, and platelet transfusion for low platelets
What causes puerperal mastitis?
Puerperal mastitis is often caused by blocked milk ducts or bacteria entering the breast tissue, often through a cracked or sore nipple. Staphylococcus aureus is the most common bacterial pathogen implicated in infectious cases.
What are the signs and symptoms of mastitis?
- Localised symptoms: Painful, tender, red, and hot breast.
- Systemic symptoms: Fever, rigors, myalgia, fatigue, nausea, and headache.
- Other clinical features: The condition is typically unilateral and typically presents one week postpartum.
- Potential complications: In some cases, a breast abscess may develop, which presents as a fluctuant, tender mass with overlying erythema.
How is mastitis diagnosed?
- Clinical evaluation: Puerperal mastitis is primarily diagnosed based on clinical symptoms and breast examination.
- Ultrasonography: This may be used in cases where an abscess is suspected.
- Cultures: If an abscess is present and drained, or if symptoms persist despite antibiotic therapy, cultures should be obtained.
How is mastitis managed?
- Analgesia: Over-the-counter pain relievers and anti-inflammatories can help manage pain and inflammation.
- Continued breastfeeding or pumping: To promote milk flow and prevent stasis.
- Antibiotic therapy: Typically started empirically, with Staphylococcus aureus coverage. The choice of antibiotic may be guided by culture results if available.
- Surgical drainage: This may be required in severe cases where a breast abscess has developed.
What are the foetal complications of maternal diabetes?
- Macrosomia, or an unusually large birthweight (>4kg), due to excess maternal blood glucose crossing the placenta and inducing increased neonatal insulin production. Macrosomia can increase the risk of shoulder dystocia, birth injuries, and emergency caesarean section.
- Pre-term delivery, which may result in respiratory distress syndrome.
- Hypoglycaemia in the baby shortly after birth due to sustained high foetal insulin levels after delivery. Severe hypoglycaemic episodes may lead to seizures in the baby.
- Increased risk of the baby developing type 2 diabetes later in life.
What are the types of vulval cancer?
A variety of skin cancers can affect the vulva, with the most common being squamous cell carcinomas. Other types can include basal cell carcinomas and melanomas. The exact cause of vulval cancer is unknown, but risk factors include increasing age, exposure to the human papillomavirus (HPV), and conditions that cause chronic inflammation of the vulva.
What are the features of vulval cancer? Which other conditions can present with similar features?
- A lump, which may be associated with lymphadenopathy
- Itching or discomfort in the vulval area
- A non-healing ulcer
- Vulval pain
- Changes in the skin of the vulva, such as thickening or changes in color
- Bleeding or discharge not related to the menstrual cycle
- Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
- Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
- Bartholin’s cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
How is vulval cancer diagnosed and managed?
Investigations
The initial investigation of suspected vulval cancer includes a thorough examination of the vulva. If there is a suspect lesion, a biopsy is performed to confirm the diagnosis. Additional tests, such as imaging studies or blood tests, may be performed to assess the extent of the disease and to aid in staging.
Management
The primary treatment for vulval cancer is surgery. This can range from a radical or wide local excision in simple cases, to a radical vulvectomy for multi-focal disease. Reconstructive surgery may be performed to maintain the structure of the vulva. In cases of advanced vulval cancer, radiotherapy, with or without chemotherapy, is now being used as an adjunct to surgery.
What is PID?
Pelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.
What are the common causes for PID?
- Chlamydia Trachomatis (14-35%)
- Neisseria gonorrhoea (2-3%)
While Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.
What are the signs and symptoms of PID?
- Bilateral abdominal pain
- Vaginal discharge
- Post-coital bleeding
- Adnexal tenderness
- Cervical motion tenderness upon bi-manual examination
- Fever
Approximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome.
How is PID investigated and managed?
- Pelvic examination
- Pregnancy test
- Swabs for gonorrhoea and chlamydia
- Blood tests
- Transvaginal ultrasound
Management
Treatment of PID typically takes place in the outpatient setting and involves a combination of antibiotics, such as:
- Ceftriaxone (given intramuscularly) + doxycycline + metronidazole
- Ofloxacin + metronidazole
Analgesia may also be required, and the patient is generally reviewed after 4 weeks.
It is noteworthy that empirical treatment for PID is often initiated in sexually active young women presenting with bilateral lower abdominal pain and adnexal tenderness due to the substantial number of women with PID that remain undiagnosed.
What are the potential complications with PID?
- Chronic pelvic pain (in around 40% of cases)
- Infertility (approximately 15%)
- Ectopic pregnancy (about 1%)
- Fitz-Hugh-Curtis Syndrome
Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.
What is the definition of secondary amenorrhoea?
Secondary amenorrhoea is a common condition affecting approximately 4-5% of women of reproductive age. It is most frequently observed in women aged 20-39 years.
What are the causes of secondary amenorrhoea?
- Pregnancy (most common cause)
- Breastfeeding
- Menopause
- Intrauterine adhesions leading to outflow tract obstruction (Asherman’s syndrome)
- Polycystic ovary syndrome (PCOS)
- Drug-induced amenorrhoea (e.g. contraceptive use)
- Physical stress, excess exercise, and weight loss
- Pituitary gland pathology, such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
What is Asherman’s syndrome?
Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea. In this case, the cyclical abdominal pain may be a sign that menstruation is occurring. Ultrasound examination is not particularly sensitive for making the diagnosis so an HSG or hysteroscopy might be needed for confirmation
What are the 3 types of ovarian cancer?
- Epithelial ovarian tumours
- Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries
- Epithelial tumours are partially cystic, and the cysts can contain fluid
- The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm
- Around 90% of ovarian cancers are epithelial ovarian tumours.
- Germ cell tumours features - Originate from the germ cells in the embryonic gonad
- These tumours typically grow rapidly and spread predominantly via the lymphatic route
- Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer
- Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG). - Sex cord stromal tumours
- Originate from connective tissue
- They are rare, making up less than 5% of all ovarian tumours. They are malignant tumours, but are much less aggressive than epithelial tumours
- Additionally, ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a ““signet ring”” sub-type of tumour, typically gastrointestinal in origin, which has metastasised to the ovary.
What are the signs and symptoms of ovarian cancer?
The clinical features of ovarian cancer typically present late in the disease progression and include:
- Abdominal discomfort
- Bloating
- Early satiety
- Urinary frequency or change in bowel habits
In later stages, the disease may cause:
- Ascites (due to vascular growth factors increasing vessel permeability)
- Pelvic, back and abdominal pain
- Palpable abdominal or pelvic mass
What are the investigations for ovarian cancer?
- Blood test for CA-125
- Pelvic and abdominal ultrasound scan
These results can be used to calculate the Risk of Malignancy Index (RMI), which stratifies the likelihood of cancer.
Further investigations can include:
- CT scans for staging
- AFP and beta-hCG tests for younger women who may have germ cell cancers
- Laparotomy for tissue biopsy
How is ovarian cancer staged?
Stage I (limited to the ovaries):
- Stage IA: limited to one ovary, the capsule is intact
- Stage IB: limited to both ovaries, capsules intact.
- Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.
Stage II involving one or both ovaries with pelvic extension and/or implants:
- Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings
- Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings
- Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.
Stage III involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:
- Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)
- Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm
- Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.
Stage IV ovarian cancer is tumour involving one or both ovaries with distant metastasis.
How is ovarian cancer managed?
Surgery
If early disease surgery can include removal of the uterus, ovaries, Fallopian tubes and infracolic omentectomy
In advanced disease debulking surgery can be performed.
Chemotherapy:
Adjuvant chemotherapy in combination with surgery
Intraperitoneal chemotherapy may be performed at the time of operation
Biological therapies are being trialled.
How is placenta praevia managed?
- Bleeding with unknown placental position:
- ABC approach, resuscitation and stabilisation
- If stable, perform urgent transvaginal ultrasound
- If the bleeding is not controlled, immediate caesarean section required - Bleeding with known placenta praevia:
- ABC approach, resuscitation and stabilisation. If stabilisation is not achieved, send for emergency caesarean Section.
- Corticosteroids should be considered if between 24-34 weeks gestation and there is risk of preterm labour - In labour: caesarean section
- Placenta praevia with no bleeding and not in labour:
- Monitor with ultrasound scans
- Give advice about pelvic rest (no penetrative sexual intercourse) and advise to go to hospital if there is significant vaginal bleeding - At term:
- If there is any degree of placental overlap at 35 weeks, aim for an elective caesarean section at 37-38 weeks gestation. Urgent C-section if she goes in to labour (due to risk of significant bleeding)
- When the placental edge is greater than 20mm from the internal cervical os, women can be offered a trial of labour (if no bleeding and with careful intrapartum monitoring). If significant haemorrhage or foetal distress develops during trialled vaginal delivery, immediately take to theatre for caesarean section.
What are the stages of placenta praevia?
Stage 1: In stage I the placenta reaches the lower segment but does not reach the internal os. This can be treated conservatively, and a vaginal delivery can be attempted with stage I placenta praevia.
Stage 2: Stage II refers to marginal previa: placental tissue reaches the margin of the internal cervical os but does not cover it. Treatment is dependent on the stage and effect on birth. The later stages of placenta praevia require a planned caesarean section to prevent maternal and foetal risks.
Stage 3: Stage III is diagnosed when the placenta covers the internal os prior to dilation but not when the cervical os is dilated.
Stage 4: Stage IV is the category where the placenta completely covers the internal os.
When is Anastrozole used and what are the side effects?
Anastrozole is an aromatase enzyme inhibitor, which blocks the conversion of androgens to oestrogens. It is predominantly used as adjuvant therapy post surgery in the management of post-menopausal women with oestrogen receptor positive breast cancer. Anastrozole’s side effects include arthralgia, menopausal symptoms, hypercholesterolemia, osteoporosis, and rarely Henoch–Schönlein purpura, a form of vasculitis, which the patient is presenting with.
What criteria is used to diagnose PCOS?
Upon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met:
1. Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
2. Oligo-/anovulation
3. Clinical or biochemical features of hyperandrogenism
What test is carried out to check whether a woman has ovulated?
The serum progesterone blood test should be carried out 7 days before the end of the cycle, at the peak luteal level.
What is fat necrosis of the breast?
Fat necrosis refers to a non-malignant condition in which there is death of adipose tissue (fat cells) within the breast, typically leading to the formation of a lump. It is more frequently observed in patients with obesity and postmenopausal women. Trauma is often associated.
