1
Q
What is vasa praevia?
A
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.
2
Q
What are the RFs for vasa praevia?
A
The aetiology of vasa praevia remains unclear, but it has been associated with multiple gestations, in vitro fertilization, and velamentous cord insertion.
3
Q
What is the classic triad of vasa praevia?
A
Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)
4
Q
How is vasa praevia diagnosed and managed?
A
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.
5
Q
What are the risk factors for breast cancer?
A
- 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
6
Q
What are the types of breast cancer?
A
- 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.
7
Q
What are the signs and symptoms of breast cancer?
A
- 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
8
Q
What are the possible differentials for an unexplained breast mass?
A
- 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.
9
Q
What is the process of breast cancer screening in the UK
A
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.
10
Q
How is a suspected breast carcinoma investigated?
A
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).
11
Q
What are the management options for breast cancers?
A
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)
12
Q
What are the possible side effects of medications used to treat breast cancer?
A
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.
13
Q
What is a lactational breast abscess?
A
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.
14
Q
What is the cause of lactational breast abscess?
A
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.
15
Q
What are the clinical features of a lactational breast abscess?
A
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
16
Q
What are the differentials for a lactational breast abscess?
A
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.
17
Q
How is a diagnosis of lactational breast cancer confirmed?
A
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
18
Q
How is a lactational breast abscess managed?
A
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
19
Q
What is an amniotic fluid embolism?
A
An amniotic fluid embolism (AFE) is a life-threatening condition that occurs when amniotic fluid, or other debris enters the maternal circulation.
20
Q
What are the causes of amniotic fluid embolism?
A
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.
21
Q
What are the signs and symptoms of an amniotic fluid embolism?
A
- High respiratory rate
- Tachycardia
- Hypotension
- Hypoxia
- Disseminated intravascular coagulopathy
22
Q
What are the main differentials for amniotic fluid embolism?
A
- 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
23
Q
How is amniotic fluid embolism managed?
A
- 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
24
Q
What causes puerperal mastitis?
A
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.
25
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.
26
How is mastitis diagnosed?
1. Clinical evaluation: Puerperal mastitis is primarily diagnosed based on clinical symptoms and breast examination.
2. Ultrasonography: This may be used in cases where an abscess is suspected.
3. Cultures: If an abscess is present and drained, or if symptoms persist despite antibiotic therapy, cultures should be obtained.
27
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.
28
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.
29
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.
30
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
1. Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
2. Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
3. Bartholin's cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
31
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.
32
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.
33
What are the common causes for PID?
1. Chlamydia Trachomatis (14-35%)
2. 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.
34
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.
35
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.
36
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.
37
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.
38
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
39
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
40
What are the 3 types of ovarian cancer?
1. 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
2. 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).
3. 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.
41
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
42
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
43
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.
44
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.
45
How is placenta praevia managed?
1. 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
2. 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
3. In labour: caesarean section
4. 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
5. 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.
46
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.
47
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.
48
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
49
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.
50
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.
51
What are the signs and symptoms of fat necrosis of the breast?
The presentation of fat necrosis can vary, but typically includes:
- A firm or hard, irregular lump in the breast
- Overlying skin may show signs of inflammation, such as redness and warmth, or bruising
It's worth noting that these signs and symptoms can mimic those of breast cancer, making differentiation on clinical grounds alone challenging.
52
How is fat necrosis of the breast investigated?
1. Clinical examination
2. Imaging: Mammography and/or ultrasound
3. Tissue sampling: Fine needle aspiration cytology (FNAC) or core biopsy
53
How is fat necrosis of the breast managed?
Management of fat necrosis is primarily conservative, as intervention is usually not required. Patients should be reassured about the benign nature of the condition. Regular follow-up may be necessary to monitor any changes in the lump's characteristics or size. In case of persistent or enlarging lumps, or if there is diagnostic uncertainty, surgical excision may be considered.
54
What are the features of atrophic vaginitis?
- Thinning of the vaginal mucosa
- Loss of pubic hair
- Narrowed introitus
- Loss of vaginal rugae (folds)
- Vaginal dryness and itching
- Dyspareunia
- Post-coital bleeding
- Vaginal discharge from inflammation
- Urinary symptoms such as dysuria and recurrent UTI
55
How is atrophic vaginitis managed?
1. Hormonal treatment:
- Systemic hormone-replacement therapy (oral or transdermal)
- Topical oestrogen preparations
2. Non-hormonal treatments:
- Lubricants, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
- Moisturisers, which should be used regularly
56
What is Paget's disease of the breast?
Paget's disease of the nipple, also known as Paget's disease of the breast, is a rare condition characterised by the presence of cancer cells in the skin of the nipple. This disease often suggests an underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.
57
What are the clinical features of Paget's disease of the nipple?
Common clinical features of Paget's disease of the nipple include:
- Eczema-like rash on the skin of the nipple and areola that is often itchy, red, crusty, and inflamed
- Bloody nipple discharge
- Burning sensation, increased sensitivity, or pain in the nipple
- Changes to the nipple, such as retraction or inversion
- Palpable breast lump (in some cases)
- Non-healing skin ulcer (in some cases)
58
How is Paget's disease of the nipple investigated?
To diagnose Paget's disease of the nipple, the following investigations are typically carried out:
- Physical examination of the breasts and lymph nodes
- Mammography or breast ultrasound
- Biopsy of the affected skin and nipple discharge cytology
- MRI may be used in certain circumstances to better assess the extent of disease
59
How is Paget's disease of the nipple managed?
Management of Paget's disease of the nipple primarily involves surgical intervention and is guided by the presence and extent of underlying breast cancer. Approaches can include:
1. Simple mastectomy: Removal of the entire breast, including the nipple and areola
2. Modified radical mastectomy: Removal of the entire breast along with some of the axillary (underarm) lymph nodes
3. Breast-conserving surgery (lumpectomy): If the underlying cancer is small and limited
Additionally, adjunctive treatments such as radiation therapy, chemotherapy, or hormonal therapy may be used depending on the characteristics of the underlying breast cancer.
60
What is the aetiology of postpartum depression?
1. Biological Factors: Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones, may contribute to PPD. Additionally, alterations in melatonin and cortisol rhythms, immune-inflammatory processes, and genetic predispositions are considered contributory.
2. Psychological Factors: A history of mood or anxiety disorders, previous episodes of postpartum depression, and certain personality traits such as neuroticism are associated with increased risk. Additionally, psychological stress from the transition to parenthood, and unrealistic expectations of motherhood may also contribute.
3. Social Factors: Lack of social support, relationship issues, life stressors, and low socioeconomic status can increase the risk of developing PPD.
61
What are the features of postpartum depression?
- Persistent lowering of mood and reduced enjoyment or interest in activities.
- Lowering of energy levels.
- Biological symptoms of depression like poor appetite and disturbed sleep patterns. It's important to distinguish between sleep that is disrupted due to the infant's sleep cycle and sleep disruption stemming from other causes.
- Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.
62
How is postpartum depression assessed and investigated?
1. The Edinburgh Postnatal Depression Scale (EPDS) is a widely accepted screening tool that consists of 10 questions and takes around five minutes to complete. It evaluates the intensity of depressive symptoms over the past seven days.
2. A detailed psychiatric history is essential to understand past episodes of depression or other mental health disorders, previous treatment regimens, and the family history of psychiatric conditions.
3. A complete physical examination and relevant laboratory investigations may be necessary to rule out other potential causes of depressive symptoms, such as hypothyroidism or anemia, especially if the patient presents with atypical symptoms or does not respond to standard treatment.
63
How is postpartum depression managed?
- First-line treatments typically involve self-help strategies and psychological therapies such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
- Pharmacological treatments, such as antidepressants, are considered in cases of high severity or distinct risks.
- In severe cases, admission to a mother and baby inpatient mental health unit might also be necessary.
64
What is premature ovarian insufficiency?
Premature ovarian insufficiency (POI) is a medical condition characterized by the onset of menopause in a woman aged below 40 years. The term ""premature"" is used to highlight the early onset of menopause compared to the normal age range.
The aetiology of POI can be idiopathic or iatrogenic. Iatrogenic causes include invasive procedures or treatments such as ovarian surgery, radiotherapy, or chemotherapy that directly impact the ovaries.
65
What are the features of premature ovarian insufficiency?
1. Vasomotor symptoms: hot flushes, night sweats
2. Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia
3. Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration
66
What are the differentials for premature ovarian insufficiency?
1. Hypothyroidism: fatigue, weight gain, cold intolerance, depression, hair loss
2. Hyperprolactinemia: irregular menstrual cycles, infertility, breast milk production not related to childbirth or nursing
3. Polycystic Ovary Syndrome (PCOS): irregular periods, hirsutism, obesity, infertility
67
How is premature ovarian failure diagnosed and managed?
The primary investigation for POI is to test for raised FSH levels, indicative of menopause. These levels should be repeated at least once more to confirm the diagnosis and ensure the first result was not anomalous.
Management
The primary management strategy for women with POI is to offer hormone replacement therapy (HRT) until at least the age of normal menopause, unless the risks of HRT treatment outweigh the benefits. Additionally, psychological support should be provided due to the potential mental health impacts of early menopause.
68
What is the mechanism of action of tamoxifen?
Tamoxifen is used in patients who have oestrogen receptor positive breast cancer who are pre or peri-menopausal. This selective oestrogen receptor modulator will inhibit the oestrogen receptors on the breast cancer thus reducing the growth drive from oestrogen. Tamoxifen is not used in patients who are post-menopausal because it is actually a partial agonist for oestrogen so for post-menopausal women it increases the risk of endometrial cancer. Tamoxifen increases the risk of thrombosis and endometrial cancer
69
What is the mechanism of action of anastrozole?
This aromatase inhibitor is used in post-menopausal patents with breast cancer that oestrogen receptor positive. This helps reduce the levels of oestrogen in post-menopausal women, who make the majority of their oestrogen via aromatisation
70
What is cord prolapse?
Cord prolapse refers to a situation during labour when the umbilical cord exits the cervix ahead of the infant. This position poses an acute risk to the umbilical blood supply to the infant and demands immediate delivery.
71
What are the risk factors for cord prolapse?
- Abnormal lie (e.g. transverse, breech)
- Multiple pregnancy
- Polyhydramnios
- High fetal head at delivery
- Multiparity
- Low birth weight
- Prematurity
72
What are the signs of cord prolapse?
The primary symptom of cord prolapse includes a sudden change in the fetal heart rate pattern, particularly variable or prolonged decelerations. Other signs and symptoms can include:
- Feeling of the cord in the vagina or visible cord after rupture of membranes
- Abnormal fetal heart rate detected on cardiotocography
73
How is cord prolapse managed?
When cord prolapse is diagnosed, swift action is vital to prevent fetal hypoxia and death. Management strategies include:
- Immediate delivery of the fetus, preferably via instrumental delivery or caesarean section if the cervix is not fully dilated
- The use of ""knees-chest"" position to prevent further prolapse
- Filling the bladder with 500ml warmed saline to aid in preventing further prolapse
- Avoidance of exposure and handling of the cord, reducing cord into the vagina
- Use of tocolytics, such as terbutaline, to stop uterine contractions
74
What are the acceptable values for symphysis fundal height from 24 weeks of pregnancy?
From 24 weeks of pregnancy, the SFH is equal to gestational weeks with the accuracy and precision of ± 2 cm. For example, if a patient's SFH is 30 cm, her gestational weeks should be in range of 28–32 weeks of pregnancy.
75
What is the definition of Postpartum haemorrhage and what is the aetiology?
Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery.
Aetiology
The aetiology of postpartum haemorrhage (PPH) can be remembered using the mnemonic of the 4 'T's:
1. Tone: The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.
2. Trauma: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries.
3. Tissue: Retained placental or foetal tissue can cause continued bleeding.
4. Thrombin: Coagulopathies can lead to continued bleeding due to a failure of clotting.
76
What are the risk factors for PPH?
Risk factors for postpartum haemorrhage (PPH) include:
- PPH in previous pregnancy
- BMI >35
- Multiple pregnancy
- Parity >4
- Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia
- Delivery via Caesarean section
- Induction of labour
- Instrumented delivery (forceps or ventouse) and episiotomy
- Prolonged labour (greater than 12 hours)
- Macrosomia (>4kg baby)
- Advanced maternal age
77
How is postpartum haemorrhage assessed and managed?
Investigations for PPH include blood tests for Group/Save and Crossmatch, and consideration of fresh frozen plasma if clotting abnormalities are present. In cases of secondary PPH, ultrasound looking for retained products and endocervical/high vaginal swabs looking for infection are recommended.
Management
Initial management of PPH involves:
1. Resuscitation with an ABCDE approach
2. Consideration of activation of a major haemorrhage protocol
3. Laying the woman flat
4. Inserting two large bore cannulas
5. Providing oxygen
6. Considering fresh frozen plasma if clotting abnormalities are present
Further management strategies may include:
- Mechanical methods such as rubbing the uterus and catheterisation
- Medical treatments including oxytocin, syntocinon, ergometrine, carboprost, misoprostol, and tranexamic acid
- Surgical treatments such as intrauterine balloon tamponade, B-lynch suture around the uterus, uterine artery ligation, or hysterectomy
For secondary PPH, management depends on the cause and can include surgical evacuation for retained products of conception or antibiotics for infection.
78
What are the steps for minor PPH due to uterine atony after the woman has been stabilised?
1. Uterine massage
2. Bimanual compression (fist inside uterus and pressure outside uterus)
3. Oxytocin
4. Ergometrine (though CI in Hx of HTN)
79
How is gestational hypertension and pre-existing hypertension differentiated?
gestational hypertension occurs after 20 weeks.
80
Which blood pressure is considered hypertensive in pregnancy? When is treatment recommended?
>140/90 is hypertensive
Treatment with labetalol is recommended when 150/100. Alternatives include methydopa (Alpha-2 agonist) and nifedipine (CCB)
Regularly monitor BP and urinalysis
81
What are fibroadenomas?
Fibroadenomas are benign tumours that consist of a mixture of fibrous and epithelial tissue. They originate from the lobules, the milk-producing glands in the breast.
Fibroadenomas are most commonly seen in young women, with the highest incidence occurring in the early 20s. They are particularly common during periods of reproductive hormonal change such as puberty, pregnancy, and perimenopause.
The exact cause of fibroadenomas is unclear. However, they seem to be influenced by reproductive hormones, as they often enlarge during pregnancy and shrink after menopause.
82
What are the clinical features of fibroadenomas?
Patients with fibroadenomas typically present with the following:
- A firm, non-tender breast mass
- The mass is rounded and has smooth edges
- The mass is highly mobile upon palpation, often referred to as having a "rubbery" consistency
- The mass typically does not grow beyond 3cm in diameter
83
How are fibroadenomas investigated and managed?
While fibroadenomas are benign, patients usually undergo a triple assessment to exclude more serious pathology. This includes:
1. Clinical examination
2. Imaging (usually ultrasound and/or mammogram)
3. Needle biopsy (fine needle aspiration or core biopsy)
Management
Management of fibroadenomas can vary depending on the size, number, patient age, and symptoms:
1. Conservative management: Many fibroadenomas do not require treatment and will regress naturally after menopause.
2. Surgical excision: This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment.
84
Which is the HPV vaccine and which types of HPV does it protect against?
Gardasil is the vaccination used and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58
85
What are the risk factors for VTE and when should postnatal thromboprophylaxis be given?
Risk factors:
- Previous VTE
- Thrombophilia
- Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions)
- Age >35
- BMI >30
- Parity >3
- Smoking
- Multiple pregnancy
- Pre-eclampsia
- Caesarean section
- Prolonged labour
- Operative delivery
- Preterm birth
- Stillbirth
- Postpartum haemorrhage >1000mL
- Other surgical procedure carried out
- Immobility
- Systemic infection
Those with four or more risk factors are usually recommended 6 weeks of postnatal thromboprophylaxis.
86
What is Bowen's disease?
A form of skin cancer which presents typically as a red, scaly patch on the skin
87
What are the signs and symptoms of HELLP syndrome?
Headache
Nausea and/or vomiting
Epigastric pain
Right upper quadrant abdominal pain due to liver distension
Blurred vision
Peripheral edema
88
What are the maternal and foetal complications of HELLP syndrome?
Maternal complications include:
Organ failure
Placental abruption
Disseminated intravascular coagulopathy (DIC).
Foetal complications include:
Intrauterine growth restriction
Preterm delivery
Neonatal hypoxia
89
How is HELLP syndrome investigated and managed?
Investigations for HELLP syndrome may include:
1. Full blood count to assess for low platelet count and evidence of hemolysis
2. Liver function tests to assess for elevated liver enzymes
3. Coagulation studies to evaluate for disseminated intravascular coagulation
4. Ultrasound scans to assess for liver abnormalities and placental abruption
Management
The definitive treatment for HELLP syndrome is usually the delivery of the baby. In some cases, mothers may also require blood transfusions to manage anemia and thrombocytopenia or steroids to accelerate lung maturation in the fetus prior to delivery. After delivery, supportive care and close monitoring are essential.
90
What is oligohydramnios and what are the causes?
Oligohydramnios is defined as the presence of a lower than normal volume of amniotic fluid within the uterus.
Aetiology
The causes of oligohydramnios are numerous and include:
1. Uteroplacental insufficiency: This can lead to intrauterine growth restriction and is often due to maternal conditions such as hypertension, pre-eclampsia, maternal smoking and placental abruption.
2. Fetal urinary system abnormalities: The amniotic fluid is derived mainly from fetal urine, abnormalities in this system (such as renal agenesis, polycystic kidneys or urethral obstruction) can therefore lead to oligohydramnios.
3. Premature rupture of membranes
4. Post-term gestation
5. Chromosomal anomalies
6. Maternal use of certain drugs including prostaglandin inhibitors and ACE-inhibitors.
91
What are the complications of oligohydramnios?
The complications of oligohydramnios are largely due to the reduced ""space"" surrounding the fetus and the subsequent lack of amniotic fluid for fetal lung growth and development. These can include:
1. Due to fetal compression: clubbed feet, facial deformity, congenital hip dysplasia.
2. Due to lack of amniotic fluid: pulmonary hypoplasia in the fetus.
The combination of these features is commonly referred to as Potter syndrome.
92
How is oligohydramnios investigated and managed?
The diagnosis of oligohydramnios is usually made via ultrasound, which shows a reduced amniotic fluid index (AFI) or single deepest pocket (SDP). Additional investigations may be required to determine the underlying cause, such as maternal blood tests or fetal karyotyping.
Management
The management of oligohydramnios largely depends on the underlying cause, the gestational age, and the presence of fetal distress. Options may include:
1. Maternal rehydration: This may help to increase the amniotic fluid volume in mild cases of oligohydramnios.
2. Amnioinfusion: This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid.
3. Delivery: In severe cases, or if the fetus is in distress, delivery may be the best option. This may be via induction of labour or caesarean section, depending on the clinical scenario.
In all cases, close monitoring of the mother and fetus is required.
93
How is congenital rubella syndrome acquired?
Congenital Rubella Syndrome (CRS) occurs when a woman contracts rubella during her pregnancy, affecting the developing fetus. The risk of developing CRS is greatest in the first trimester. This serious condition is now rare due to the success of the MMR (measles, mumps, rubella) vaccine.
CRS is caused by maternal infection with rubella virus during pregnancy, particularly in the first trimester. The virus can cross the placenta and affect the developing fetus leading to a range of congenital abnormalities.
94
What are the features of congenital rubella syndrome?
Newborns with CRS commonly present with:
1. Sensorineural deafness
2. Cataracts or retinopathy
3. Congenital heart disease
Other symptoms include:
- Organ dysfunction
- Microcephaly
- Micrognathia
- Haematological abnormalities
- Low birth weight
- Developmental delay and learning disability in later life
- A characteristic petechial rash described as a “blueberry muffin” rash.
95
What are some differentials for congenital rubella syndrome?
Differential diagnosis for CRS may include other TORCH infections such as:
1. Toxoplasmosis: Presents with chorioretinitis, hydrocephalus, and intracranial calcifications.
2. Other (Syphilis, Varicella-Zoster, Parvovirus B19): Symptoms vary, but may include rash, fever, and various congenital abnormalities.
3. Cytomegalovirus (CMV): Presents with microcephaly, periventricular calcifications, and sensorineural hearing loss.
4. Herpes Simplex Virus (HSV): Presents with vesicular lesions, encephalitis, and eye disease.
96
How is congenital rubella syndrome diagnosed and managed?
Diagnosis of CRS involves serology tests to confirm rubella infection. Other investigations may include audiology tests for hearing impairment, ophthalmology review for eye abnormalities, and echocardiography for congenital heart defects.
Management
Management of CRS is primarily supportive and symptomatic. Early intervention services may be beneficial for affected infants. Regular follow-up is important to monitor progress and manage any long-term complications.
97
What are the 4 types of miscarriage?
1. Threatened miscarriage
This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the ""threat"" of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.
2. Inevitable miscarriage
There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.
3. Complete miscarriage
There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.
4. Missed miscarriage
The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.
98
How is miscarriage managed?
Miscarriage often cannot be prevented or stopped. Management therefore revolves around ensuring complete removal of foetal material.
1. Expectant management = allowing the products of conception to naturally expel
2. Medical management with e.g. misoprostol
3. Surgical management e.g. dilatation and curettage
If the woman is rhesus negative they may require anti-D prophylaxis.
99
What are the 8 types of benign breast disease?
Benign breast diseases are a variety of non-cancerous conditions that cause breast symptoms such as lumps, pain, and nipple discharge.
1. Fibroadenomas arise from the breast lobule stroma. Highly mobile, encapsulated breast masses.
2. Breast cysts occur due to the overgrowth of glandular and connective tissue, leading to blocked breast ducts and subsequent fluid accumulation. Lump potentially with distension.
3. Mastitis is typically caused by bacterial infections, often related to breaks in the skin around the nipple. Breast redness, mastalgia, malaise and fever
4. Intraductal papilloma is a benign tumour of the breast ducts. Bloody discharge from the nipple without a palpable mass.
5. Radial scar is a benign sclerosing breast lesion. Presents on mammogram as a stellate pattern of central scarring surrounded by proliferating glandular tissue
6. Fat necrosis is a response to adipose tissue damage. Painless breast mass, skin thickening or radiographic changes on mammography
7. Fibrocystic breast disease is due to an exaggerated hormonal response causing inflammation, fibrosis, cyst formation, or adenosis. Breast lumps, pain and tenderness
8. Mammary duct ectasia is due to inflammation and dilation of the large breast ducts. Palpable peri-areolar breast mass, thick nipple discharge and potential mammographic similarities to cancer.
100
What are the features of vulval cancer?
- 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
101
What are the effects of Lithium use during pregnancy?
The primary signs and symptoms associated with lithium exposure in utero include:
1. Congenital anomalies, particularly Ebstein's anomaly
2. Increased risk of miscarriage
3. Neurodevelopmental impairments in the offspring
102
What are some risk factors for uterine fibroids?
Oestrogen and progesterone, the hormones that stimulate the development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more oestrogen and progesterone receptors than normal uterine muscle cells.
Risk factors:
- Afro-carribean
- Early menarche
- Obesity
- Nulliparity
- Increased age until menopause (peak incidence at 40 years)
103
How are uterine fibroids managed depending on size?
<3cm and no uterine distortion = Non surgical:
- NSAIDS
- Anti-fibrinolytics eg tranexamic acid
- COCP
- Mirena
Symptomatic due to mass effect = Surgical management:
- Myomectomy
- Ablation
- Uterine artery embolisation
- Hysterectomy
104
Who is offered screening for gestational diabetes?
Happens at 24-28 weeks
- BMI above 30kg/m2.
- Previous macrosomic baby (weighing 4.5kg or above).
- Previous gestational diabetes.
- First degree relative with diabetes.
- Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)
105
What are the features that point to shoulder dystocia?
- Difficult delivery of the foetal face or chin
- Retraction of the foetal head (turtle-neck sign)
- Failure of restitution
- Failure of descent of the foetal shoulders following delivery of the head
106
How is shoulder dystocia managed?
Once shoulder dystocia has been recognised, management is as follows:
1. Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required
- Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction
2. McRoberts manoeuvre
- Hyperflexion and abduction of the mother's legs tightly to the abdomen
- This may be accompanied with applied suprapubic pressure
- Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released.
3. All fours position
4. Internal rotational manoeuvres:
- Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
- Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest
*Note that episiotomy will not relieve shoulder dystocia as it is a bony obstruction, but may be indicated to allow space for internal rotational manoeuvres.
5. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
6. Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section
Following the delivery of a baby after shoulder dystocia:
- The mother should be examined and monitored for postpartum haemorrhage, severe perineal tears and other genital tract trauma.
- The baby should be examined by a neonatologist for injury including brachial plexus injury, hypoxic brain damage, humeral or clavicular fractures
107
How does lobular carcinoma in situ and invasive lobular carcinoma look on biopsy?
A lobular carcinoma in situ would most likely reveal an abnormal proliferation of small, round, lobular cells arranged in a uniform pattern. There would be no infiltration of the basement membrane.
An invasive lobular carcinoma would most likely reveal an abnormal proliferation of lobular cells which are small and round and arranged in a uniform pattern. They would also infiltrate the basement membrane.
108
How does ductal carcinoma in situ and invasive ductal carcinoma look on biopsy?
A ductal carcinoma in situ would most likely reveal irregularly distributed cells which form no obvious pattern, with atypically larger nuclei. The atypical cells exist within the milk ducts of the breast, and the basement membrane is not breached.
Invasive would be if the basement membrane had been breached.
109
What is uterine inversion and how is it diagnosed?
Uterine inversion is a severe obstetric complication in which the fundus of the uterus collapses downwards, passing through the uterine cavity and the cervix, essentially turning the uterus inside out.
The risk factors associated with uterine inversion include prolonged labour, rapid and forceful delivery, and fundal placental implantation.
The exact cause of uterine inversion is not entirely understood, but it is believed to be associated with excessive traction applied to the umbilical cord before placental separation. Other contributing factors may include relaxed or atonic uterus, short umbilical cord, or previous uterine inversion.
The primary symptom is a large post-partum haemorrhage.
Investigations
The diagnosis of uterine inversion is primarily clinical, based on the characteristic presentation. However, ultrasound imaging can be useful in confirming the diagnosis and ruling out other causes of post-partum haemorrhage.
110
How is uterine inversion managed?
The management of uterine inversion focuses on maternal resuscitation and repositioning of the uterus. The primary methods include:
- Johnson manoeuvre: This involves using the hand to push the fundus back into the abdomen.
- Hydrostatic methods: This method involves filling the vagina with fluid to inflate the uterus back to the normal position.
- Laparotomy: This surgical procedure is usually considered when conservative options fail.
111
Why does PCOS increase the risk of endometrial cancer?
In PCOS increased levels of androgens in the ovaries leads to anovulation. As a result, the corpus luteum does not develop and hence progesterone is not produced. Progesterone mediates the shedding of the endometrial lining each month and its absence increases the risk of endometrial hyperplasia. This, in turn, is a risk factor for endometrial cancer
112
What is fibrocystic disease of the breast?
Fibrocystic breast disease is a benign condition characterised by the presence of fibrous tissues and cysts in the breasts. This condition is not considered a disease but rather a variation of normal breast tissue.
Fibrocystic disease is the most common benign breast condition.
The condition predominantly affects the 20-50 year old age group.
Fibrocystic breast disease is the result of the cumulative effect of cyclical hormones. The primary hormones involved are oestrogen and progesterone, among others, leading to changes in the breast tissue, including the formation of multiple small cysts and proliferative changes.
113
What are the features of fibrocystic disease of the breast?
- Bilateral “lumpy” breasts, most commonly in the upper outer quadrant.
- Breast pain.
- Symptoms that worsen with the menstrual cycle, typically peaking 1 week before menstruation.
114
How is fibrocystic breast disease investigated and managed?
Investigations for fibrocystic breast disease often start with a clinical breast examination. Other investigations may include:
1. Mammogram: Useful for identifying any abnormalities in the breast tissue.
2. Ultrasound: May be used to distinguish between solid masses and fluid-filled cysts.
3. Biopsy: May be required to exclude malignant changes if there is a suspicious finding on imaging or physical examination.
Management
Management of fibrocystic breast disease is primarily supportive and includes:
- Encouraging the use of a soft but well-fitting bra for comfort.
- Providing appropriate analgesia for pain relief.
- Most cases resolve after menopause, and reassurance can be provided about this natural course.
115
How should PROM be investigated?
Investigations for PROM should focus on assessing signs of infection and foetal distress, including:
1. Monitoring maternal temperature
2. Assessing foetal movements
3. Monitoring foetal heart rate
4. Observing vaginal discharge
116
How should PROM at term be managed?
- If labour does not commence within 24 hours, induction of labour should be offered.
- If there are any signs of infection, immediate induction of labour should be commenced under consultant guidance and a broad spectrum antibiotic should be given.
- If there are any signs of foetal compromise, senior review is required to make a decision about whether immediate caesarean section is required.
- Following delivery, even if both baby and mother are asymptomatic, they should be closely observed in hospital for 12 hours post-birth.
117
What are some potential complications of PROM at term?
PROM at term can lead to several complications, including:
- Chorioamnionitis due to ascending infection
- Preterm birth and the associated complications such as respiratory distress syndrome, necrotising enterocolitis, and foetal death
- Developmental problems such as pulmonary hypoplasia, facial and limb deformities due to compression in the uterus, and cord prolapse due to low levels of amniotic fluid.
118
What is the PAM1 test?
Placental-alpha-microglobulin-1 (PAM1) test
PAM1 test is performed during speculum examination to detect the premature rupture of membrane in women with no established labour. A positive test will be indicated with the presence of two red lines.
119
What is a malignant Phyllodes tumour?
A malignant phyllodes tumour is a type of breast cancer of fibroepithelial origin. It is composed of both epithelial and interlobular stromal components, and it is most frequently observed in women in their 40s or 50s.
It is established that these tumours predominantly affect pre-menopausal women, with peak incidence in the fifth decade of life.
The exact aetiology of malignant phyllodes tumours remains unclear. They do not appear to be strongly linked with typical breast cancer risk factors, such as family history or hormonal influences. Some genetic mutations have been suggested, but further research is needed in this area.
120
What are the features of a malignant Phyllodes tumour?
- Usually presents as a rapidly enlarging, smooth, hard, palpable breast mass, sometimes visible as a smooth bulge under the breast skin
- In advanced stages, an ulcer may form on the breast
- Despite their potential for rapid and aggressive growth, malignant phyllodes tumours rarely metastasise.
121
What is an Actim-PROM test?
An Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood. Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes.
122
What is a serious well-documented side effect of Trastuzumab?
Cardiotoxicity resulting in heart failure
- SOBOE
-Peripheral oedema
- Ascites
- Paroxysmal nocturnal dyspnoea
123
What is the BRCA2 gene and what are the risks associated?
The BRCA2 gene is a tumour suppressor gene and repairs double-stranded DNA.
Mutations in the BRCA2 gene increase the risk of prostate, pancreatic, gastric and breast cancer. In females, there is also an increased risk of developing ovarian cancer.
124
What are the criteria for genetic testing for BRCA genes?
The criteria for referral include:
* one first-degree relative < 40 with breast cancer
* one first-degree male relative with breast cancer
* one first-degree relative with bilateral breast cancer
* a first- and second-degree relative with breast or ovarian cancer
* three first- or second-degree relatives with breast cancer
125
What is the most effective method of preventing GBS infection?
Antibiotics, commonly penicillin, are administered intravenously during labour and delivery if risk factors for GBS infection are present.
126
Women's Health
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