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3rd year medicine > repro 3 > Flashcards

repro 3 Flashcards

1
Q

triad of PET?

A

Hypertension

Proteinuria

Oedema

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2
Q

chronic HTN vs PET?

A

PET after 20 weeks gestation

HTN <20 weeks gestation

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3
Q

eclampsia?

A

Eclampsia is when seizures occur as a result of pre-eclampsia

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4
Q

high risk factors vs moderate risk factors PET?

A

High risk factors PET

  • Pre-existing hypertension
  • Previous hypertension in pregnancy
  • Existing autoimmune conditions e.g. SLE
  • Diabetes
  • CKD

Moderate risk factors PET

  • >40 y/o
  • BMI >35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • FHx of pre-eclampsia

Women are offered aspirin from 12 weeks until birth if they have one high risk factor or more than one moderate risk factor

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5
Q

symptoms pre-eclampsia?

A

Headache

Visual disturbance/blurriness

Nausea + vomiting

Upper abdominal or epigastric pain (this is due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

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6
Q

Dx PET?

A

Systolic BP >140mmHg

Diastolic BP >90mmHg

Plus any of:

  • Proteinuria ≥1+ on dipstick
  • Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, or haemolytic anaemia)
  • Placental dysfunction (e.g. FGR or abnormal doppler studies)
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7
Q

Tx gestational hypertension without proteinuria?

A

Aim for BP <135/85mmHg

Admission for women with BP >160/110mmHg

Urine dipstick testing at least weekly

Monitoring of blood tests weekly (FBC, liver enzymes and renal profile)

Monitoring foetal growth by serial growth scans

PlGF testing on one occasion

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8
Q

Tx PET?

A

Labetolol = 1st line

Nifedipine is 2nd line (1st line in asthma)

Methyldopa 3rd line (needs to be stopped within 2 days of birth)

IV hydralazine used in critical care in severe pre-eclampsia or eclampsia

IV MgSO4 given during seizures, labour and in the 24 hours after labour to prevent seizures

Fluid restriction used during labour in severe pre-eclampsia or eclampsia to avoid fluid overload

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9
Q

Tx PET after birth of baby?

A

Enalapril (1st line)

Nifedipine or amlodipine (1st line in black African or Caribbean patients)

Labetolol (3rd line)

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10
Q

Tx eclampsia?

A

Seizures associated with pre-eclampsia

Tx = IV MgSO4

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11
Q

HELLP syndrome?

A

Complication of pre-eclampsia and eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
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12
Q

where does breast lie?

A

sits anterior to pectoralis major

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13
Q

secretory tissue of breast made up of?

A

Secretory tissue of breast made up of 15-25 lobes

Each lobe consists of tubulo-acinar gland which drains via a series of ducts leading to the nipple

Adjacent to secretory lobules is dense fibrous tissue which is surrounded by adipose tissue

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14
Q
A

….

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15
Q

basic functional secretory unit of breast?

A

TDLU - terminal duct lobular unit

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16
Q

drainage of secretions from breast?

A

In non-lactating breast, TDLUs lead into intralobular collecting duct → lactiferous duct → nipple

(expanded duct region near nipple = lactiferous sinus)

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17
Q

which cells line acini in lobule?

A

cuboidal/columnar = secretory epithelium

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18
Q

lactiferous duct lined by?

A

as lactiferous ducts approach surface they become lined by stratified squamous epithelium

Deeper they are lined by stratified cuboidal epithelium

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19
Q

changes in breast during menstrual cycle?

A

Luteal phase

  • epithelial cells increase in height
  • Lamina of ducts become enlarged
  • Small amounts of secretions appear in ducts
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20
Q

changes to breast in pregnancy?

A

First trimester - elongation and branching of smaller ducts

  • Also proliferation of epithelial cells, glands + myoepithelial cells

Second trimester - glandular tissue continues to develop

  • Secretory alveoli differentiate
  • Plasma cells and lymphocytes infiltrate tissue

Third trimester

  • Secretory alveoli continue to mature with development of extensive rER

(these changes are accompanied by reduction in amount of connective + adipose tissue)

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21
Q

which hormones stimulate proliferation of breast secretory tissue in pregnancy?

A

oestrogen + progesterone

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22
Q

composition of human milk

A

88% water

1.5% protein (lactalbumin and casein)

7% carbohydrate (lactose)

3.5% lipid

Small quantities of ions, vitamins + IgA

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23
Q

mechanisms of milk secretion?

A

2 mechanisms!

Lipid droplets = apocrine secretion

  • Droplets secreted carrying small amount of cytoplasm with it

Proteins = merocrine secretion (also called exocytosis)

  • Proteins in milk made in rER
  • Secreted via vesicles which merge with apical membrane to release only their contents into duct system
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24
Q

changes to breast after menopause?

A

Secretory cells in TDLU degenerate leaving only ducts

In connective tissue, fewer fibroblasts and reduced collagen and elastic fibres

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25
Q

blood supply/drainage to breast

A
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26
Q

lymph drainage of breast

A
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27
Q

diagnostic Ix breast lump?

A

Needle core biopsy

Vacuum assisted (large volume) biopsy

Skin biopsy

Incisional biopsy of mass

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28
Q

therapeutic approaches breast cancer?

A

Vacuum assisted excision

Excisional biopsy of mass

Resection of cancer

  • Wide local excision
  • Mastectomy
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29
Q

needle core biopsy results?

A

B1 - unsatisfactory/normal (doesn’t rule out malignancy?)

B2 - benign

B3 - atypia, probably benign

B4 - suspicious of malignancy

B5 - malignant

  • B5a - CIS
  • B5b - invasive
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30
Q

which cell types line ducts + lobules?

A

Myoepithelial cells - CONTRACTILE

  • Assist in milk ejection + provide structural support to lobules

Epithelial cells

  • Produce milk

both lie on basement membrane

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31
Q

benign breast tumours?

A

Phyllodes tumour

Intraductal papilloma

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32
Q

Ax gynaecomastia male?

A

exogenous/endogenous hormones

Cannabis

Prescription drugs

Liver disease (metabolises oestrogen)

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33
Q

fibrocystic change affects?

risk factors?

Symptoms?

Macroscopic features?

Miscroscopic features?

Tx?

A

very common in women age 20-50

RF = early menarche or late menopause

symptoms = smooth discrete lumps, sudden pain, cyclical pain, or asymptomatic

macroscopic = usualy small + multiple

microscopic = apocrine metaplasia (change of ductal depithelium to apocrine)

Tx = exclude malignancy

  • reassure (most resolve after menopause)
  • excise if necessary
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34
Q

hamartoma?

A

Circumscribed lesion composed of cell types normal to breast but in excess

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35
Q

fibroadenoma?

risk factors?

clinical features?

histological features?

A

Common - peak incidence in 30s

RF = commoner in african women

Clinical features

  • Usually solitary
  • Painless, firm, mobile, discrete
  • “Breast mouse” because of how mobile they are
  • Solid on USS

biphasic tumour = epithelium + stroma

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36
Q

Tx fibroadenoma?

A

Reassure

Excise if patient wishes

37
Q

sclerosing lesions breast?

malignant?

A

Sclerosing adenosis and radial scar

benign but may mimic carcinoma! - esp radial scar

38
Q

sclerosing adenosis s/s?

A

often asymptoamtic but can present with pain, tenderness, lumpiness/thickening

39
Q

radial scar features?

A

<10mm

stellate shape

central puckering

radiating fibrosis

40
Q

Dx radial scar?

A

requires vacuum biopsy as can mimic + become carcinoma

41
Q

fat necrosis Ax?

features?

Tx?

A

local trauma (seat belt injury) + Warfarin

features = foamy macrophages + fibrosis

Tx = exclude malignancy + reassure

42
Q

duct ectasia?

clinical features?

risk factors?

Tx?

A

affects subareolar ducts

clinical features

  • pain
  • acute episodic inflammatory changes
  • bloody or purulent discharge
  • nipple retraction

associated wih smoking!!

Tx = treat acute infections, exclude malignancy, stop smoking, excise ducts

43
Q

Ax acute mastitis/abscess?

Tx?

A

Ax = 2 main causes

  • duct ectasia (mixed organisms + anaerobes)
  • lacation (staph aureus)

Tx = antibiotics, percutaneous drainage if abscess

  • treat underlying cause i.e. remove ectasia
44
Q

phyllodes tumour affects?

features?

Tx?

A

Age 40-50

features

  • Slow-growing unilateral mass
  • Biphasic tumour - unlike fibroadenoma, dominated by stromal overgrowth
  • leaf-like structure

Tx = prone to local recurrence if not adequetely excised

45
Q

intraductal papilloma s/s?

Tx?

A

Nipple discharge +/- blood

large lump near nipple + smaller lumps further from nipple

Treatment

  • Benign can be excised without margins
  • However, atypia or CIS needs completely excised with margins
46
Q

malignant tumours breast?

A

Malignant phyllodes tumour

Angiosarcoma - post radiotherapy (iatrogenic)

Lymphoma

Metastatic tumours

  • Carcinoma: lung, ovarian, clear cell of kidney
  • Melanoma
  • Soft tissue tumours - leiomyosarcoma
    • You can get primary leiomyosarcoma of the breast, precursor is phyllodes
47
Q

breast carcinoma refers to?

A

Specifically talking about epithelial cells

  • Glandular epithelium of TDLU

It is an adenocarcinoma but usually just referred to as breast carcinoma

48
Q

precursor lesions breast carcinoma?

A

Ductal

  • Epithelial hyperplasia
  • Columnar cell change +/- atypia
  • Atypical ductal hyperplasia
  • Ductal carcinoma in situ

Lobular

  • Lobular in situ neoplasia
    • Atypical lobular hyperplasia
    • Lobular carcinoma in situ
49
Q

in situ carcinoma?

A

Confined within basement membrane

Malignant but non-invasive

Precursors of invasive carcinoma

Classification

  • Lobular
  • Ductal
50
Q

lobular in situ carcinoma types?

features?

Tx?

A

2 types

  • Atypical lobular hyperplasia (<50% of lobule involved)
  • Lobular carcinoma in situ (>50% lobule involved)

features:

  • multifocal and bilateral
  • Incidence decreases after menopause
  • Not palpable, not visible grossly
  • May calcify - mammography

Tx = ????? excision not possible because multifocal and bilateral - so mastectomy??? since true precursor for carcinoma

51
Q

ductal carcinoma in situ (DCIS) features?

A

15-20% of breast malignancies are DCIS

Arise in TDLU

Single duct

malignant epithelial cells confined within basement membrane

May involve nipple skin (Paget’s)

52
Q

Paget’s disease of nipple?

S/s?

A

High grade DCIS extending along ducts to reach epidermis of nipple

Still in situ carcinoma!!!!

s/s = itchy, sore, discoloured, ulcerated

53
Q

DCIS risk?

Tx?

A

75% progress to carcinoma

Tx

  • surgery
  • radiotherapy (don’t use chemo)
54
Q

microinvasive carcinoma?

A

Rare

DCIS (high grade) with invasion <1mm

Treat as DCIS rather than carcinoma in terms of management

55
Q

risk factors breast cancer?

protective factors?

A
  • risk increases with age
  • COCP, HRT
  • early menarche, late menopause
  • nulliparous
  • precursor lesions
  • BMI, alcohol, smoking
  • genetics
    • 1st degree relative doubles risk
    • BRCA1, BRCA2, TP53, PTEN

exercise + NSAIDs lower risk

56
Q

mortality of breast cancer?

A
57
Q

commonest type of breast carcinoma?

A

ductal carcinoma

58
Q

breast carcinoma grading?

A

Objective assessment of

  • Tubular differentiation (1-3)
  • Nuclear pleomorphism (1-3)
  • Mitotic activity (1-3)

So total scores

  • 3, 4 or 5 = grade 1
  • 6 or 7 = grade 2
  • 8 or 9 = grade 3
59
Q

hormone receptors breast cancer?

Tx?

A

80% oestrogen receptor (ER) positive

  • anti-oestrogen therapy
    • oophrectomy
    • tamoxifen
    • aromatase inhibitors (letrozole)
    • GnRH antagonists (goserelin)

Progesterone receptor

HER2

  • Tx = trastuzumab (herceptin)
60
Q

tumour staging breast cancer

A
61
Q

presentation breast cancer?

A

50% asymptomatic

50% symptomatic:

  • dimpled skin
  • visible lump
  • nipple change e.g. inversion
  • bloody discharge
  • texture change (peu d’orange)
  • colour change
62
Q

process breast clinic?

A

examination + mammogram + USS

63
Q

treatment breast cancer?

A

Local (surgery, radiotherapy)

General (chemo, hormonal therapies, targeted therapies)

  • Small tumours = lumpectomy
  • Large tumours = mastectomy
64
Q

systemic Tx breast cancer?

A

Chemo

  • Adjuvant
  • Neo-adjuvant

Hormonal therapy

  • Non-invasive (SERMs, AIs, GnRH)
  • Invasive (oophorectomy)

Targeted therapies

  • Trastuzumab (herceptin)
65
Q

nipple discharge that isn’t blood or yellow?

A

physiological

66
Q

mammogram vs USS for breast lumps?

A

Mammogram only useful >40 age

USS before that

67
Q

if size of lump fluctuates with mensrual cycle?

A

likely to be benign

68
Q

eczema of the nipple?

A

paget’s disease

69
Q

tomosynthesis?

A

3D mammography

70
Q

imaging modality of choice for women with palpable mass?

A

USS

71
Q

disadvantages USS?

A

low sensitivity DCIS (mammogram has high sensitivity)

72
Q

uses of MRI in breast disease?

A

lobular cancer

Paget’s disease of nipple

73
Q

commonest cause of breast lump age <30?

30-50?

>50?

A

<30 = fibroadenoma

30-50 = cyst

>50 = cancer

74
Q

Best imaging modality to assess breast masses?

then?

A

USS

then do mammorgaphy if US findings suspicious or age >40

75
Q
A

cyst

76
Q
A

cancer - irregular, taller than it is wide (fibroadenomas wider than they are tall)

77
Q

staging of advanced or recurrent breast cancer?

A

CT chest, abdomen, pelvis to look for metastasis

(not required in local operable breast cancer)

78
Q

worrying nipple discharge?

Ax?

A

unilateral single duct is worrying

Ax

  • Invasive cancer
  • DCIS
  • Duct ectasia
  • Papilloma
79
Q

breast asbcess/infection seen in?

A

Tend to see in 2 groups of patients

  • Breast feeding
  • Duct ectasia - smokers
80
Q

types of breast surgery for cancer?

A

breast conservation (just as effective)

mastectomy

81
Q

procedure breast conservation?

A

clear margins >1mm PLUS

breast radiotherapy

82
Q

axillary metastasis staging?

axillary treatment options?

complications?

A

USS axilla + core biopsy

axillary Tx = axillary clearance + radiotherapy

comps = axillary node clearance can result in lymphoedema

83
Q

neoadjuvant endocrine therapy?

A

pre or peri-menopausal (menstruation in last year)

  • tamoxifen 20mg daily for 12 months + goserelin implant
  • letrozole 2.5mg daily for 12 months + goserelin implant

post-menopausal

  • letrozole 2.5mg daily for 12 months
84
Q

side effects aromatase inhibitors?

A

joint pain

fatigue

weight gain

loss of libido

mood swings

85
Q
A

mammogram + biopsy

86
Q

Dx?

next step?

Tx?

sentinel node biopsy indicated?

A

Dx = suggestive of DCIS

vacuum biopsy

Tx = surgery + radiotherapy (no chemo)

no its DCIS so in-situ i.e. cant metastasise

87
Q

Dx?

next steps?

Tx?

A

Dx = cancer or radial scar

next steps = core biopsy (no need for vacuum as localised mass)

Tx = WLE

88
Q
A

Tx = neoadjuvant chemo - trastuzumab

then WLE + axillary node clearance

89
Q
A

3rd year medicine (13 decks)

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