Theme 9: Gynaecological and Breast Pathology Flashcards
True or false: there are more than 100 subtypes of Human Papillomavirus.
True
Many are considered ‘low risk’ and most women can clear high and low risk HPV via their immune system.
Which are the two main low risk subtypes of HPV?
HPV 6 and 11
Low risk HPV are linked with genital warts and other low-grade cytological abnormalities.
Which are the four main high risk subtypes of HPV?
HPV 16, 18, 31 and 33
High risk HPV are associated with high-grade pre-invasive and invasive diseases.
True or false: roughly 50% of cervical cancers contain HPV DNA?
False. The figure is much higher.
99.7% of cervical cancers contain HPV DNA.
HPV types 16 and 18 are associated with what percentage of cervical cancers?
HPV types 16 and 18 are associated with ~70% of cervical cancers.
What are the two main vaccines available for HPV? Which subtypes does each cover?
- Gardasil
Covers HPV 6, 11, 16 and 18
6 and 11 are low-risk types that cause condylomata (genital warts)
16 and 18 are high-risk types that cause cervical intraepithelial neoplasms and invasive carcinoma - Cervarix
Covers HPV 16 and 18
How do high risk subtypes of HPV cause cancer?
Express E6 and E7 genes.
E6 bind to and inhibits p53. As p53 usually triggers apoptosis when faulty DNA is detected, these cells no longer self-destruct.
E7 binds to RB1, a tumour suppressor gene. RB1 usually regulates cell proliferation, therefore these cells proliferate without control.
Accumulation of genetic damage plus uncontrolled proliferation leads to neoplasms.
Which area of the cervix is most susceptible to oncogenic effects of HPV?
Transformation zone - an area that undergoes metaplasia even in normal physiological conditions.
The pre-invasive stage of cervical squamous cell carcinoma is known as ____.
The pre-invasive stage of cervical squamous cell carcinoma is known as cervical intraepithelial neoplasia (CIN).
Detection of CIN is the aim of the cervical screening programme.
What is dyskaryosis?
Presence of squamous cells with abnormal cytological changes
If, at cervical screening, a woman is found to have a degree of dyskaryosis, what is the usual treatment option?
Large loop excision of the transformational zone (LLETZ)
What is the most important causative factor associated with cervical squamous cell carcinoma?
Infection by high risk HPV subtype (HPV 16, 18, 31, 33)
Although HPV is the number one cause of cervical cancer, what other risk factors are associated?
- Multiple sexual partners or male partner with multiple partners
- Young age at first intercourse
- High parity
- Low socioeconomic group
- Smoking (immunosuppressed as smoking lowers number of antigen presenting cells)
Cervical glandular intraepithelial neoplasia (CGIN) is the precursor to which cancer?
Cervical adenocarcinoma
True or false: Cervical squamous cell carcinoma is highly related to high-risk HPV, but cervical adenocarcinoma is not.
False.
While high risk HPV is the most important factor in cervical SCC, it is also related to cervical adenocarcinoma.
Stage for stage, which has the worst prognosis, cervical SCC or cervical adenocarcinoma?
Cervical adenocarcinoma has the worse prognosis as it is harder to treat, due to its radioresistance.
What system is used to stage cervical cancer?
FIGO
I: Confined to cervix
II: Invades beyond uterus, but not pelvic side
III: Extends to pelvic wall, lower third of vagina, hydronephrosis
IV: Invades bladder or rectum or outside pelvis
What are the usual sites of metastasis for cervical cancers?
Pelvic and para-aortic lymph nodes
Via blood to liver, lungs and bone
How is vulval intraepithelial neoplasia visualised?
Toluidine blue is painted over the area
What are the two subtypes of vulval intraepithelial neoplasia?
- Classical/warty/basaloid
2. Differentiated
How is classical/warty/basaloid VIN graded?
Classical/warty/basaloid VIN (vulval intraepithelial neoplasia) is graded as VIN 1-3
Which type of VIN is related to HPV infection?
Classical/warty/basaloid VIN (vulval intraepithelial neoplasia)
Which type of VIN is more common in younger women?
classical/warty/basaloid VIN
How is differentiated VIN graded?
It isn’t graded
True or false: Differentiated VIN is unrelated to HPV
True.
Classical/warty/basaloid VIN is related to HPV and is more common in younger women.
Differentiated VIN is unrelated to HPV, but is associated with chronic dermatoses, especially lichen sclerosus. It is more common in older women.
Lichen sclerosus is associated with which genital neoplasia?
Differentiated vulval intraepithelial neoplasia
When a tumour is removed, positive margins suggest what about recurrence?
It is more likely to recur, because malignant cells were found at the margins of the excised tissue. This suggests some could be left in situ.
What is the most common type of vulval cancer?
Vulval squamous cell carcinoma
Accounts for 90% of vulval cancers
True or false: Vulval Intraepithelial Neoplasia (VIN) is more likely to become invasive in young, postpartum women.
False.
Invasion is most likely to occur in postmenopausal/immunocompromised women.
True or false: Spontaneous regression of vulval intraepithelial neoplasia (VIN) may occur, particularly in young, postpartum women.
True
Which of the following are incorrect:
A) Vulval squamous cell carcinoma is associated with inflammatory dermatoses, such as lichen planus and lichen sclerosus.
B) Inflammatory dermatoses are more likely to lead to vulval squamous cell carcinoma in over 70s
C) Vulval squamous cell carcinoma has very little link with HPV
D) Vulval intraepithelial neoplasia can lead to vulval squamous cell carcinoma
C) Vulval squamous cell carcinoma has very little link with HPV
There are two main types of vulval squamous cell carcinoma:
1] Associated with VIN, age <60, associated with lower genital tract neoplasia (CIN), HPV +
2] Associated with inflammatory dermatoses (lichen sclerosus, lichen planus), age >70
Which system is used to estimate the prognosis of vulval squamous cell carcinoma?
A) Dukes
B) Nottingham
C) FIGO
D) TMN
C) FIGO
grade, nodes, tumour size
What is the most important prognostic factor for malignant melanoma?
Depth of invasion
True or false: Extramammary Paget’s disease is linked with HPV
False
Which cancer is responsible for 5% of vulval tumours and is common around the age of 80?
Paget’s disease (extramammary)
How does extramammary Paget’s disease present?
Pruritic/burning/eczematous patch
Extramammary Paget’s disease begins as an in situ __1__ of the __2__ mucosa, but can develop into an invasive __3__.
1) adenocarcinoma
2) squamous
3) adenocarcinoma
Paget’s disease (extramammary) is associated with cancers of the __1__ and __2__
1) Bladder
2) Cervix
Which cancer is responsible for 5% of vulval tumours and is common between the ages of 50-60?
Malignant melanoma
Where is a very common site of spread for malignant melanoma of the vulva?
Urethra
In which condition do you find endometrial tissue where it shouldn’t be normally found?
Endometriosis
How is endometriosis diagnosed?
Laparoscopy to visualise the ectopic tissue
How might a patient present with endometriosis?
25% asymptomatic Dysmenorrhoea Dyspareunia Pelvic pain Subfertility Pain on passing stool Dysuria
How might you treat endometriosis?
Medical:
- Combined OCP
- GnRH agonist/antagonist
- Progesterone antagonist
Surgical
- Ablation
- Total abdominal hysterectomy
What other conditions are associated with endometriosis?
Ectopic pregnancy
Ovarian cancer
IBD
Inflammation of the endometrium is known as ____
endometritis
What is the most common cause of endometritis?
Pelvic Inflammatory Disease (PID)
What are the most likely causes of endometritis?
Pelvic inflammatory disease
Retained gestational tissue
Endometrial TB
IUCD infection (intrauterine contraceptive device)
What microscopic change would be seen on a biopsy of endometritis?
Lymphocytes/plasma cells
Which of these is not associated with endometrial polyps?
a) Often asymptomatic
b) Oestrogen-dependent
c) Often pre-cancerous
d) Medically treated with progesterone or gonadotropin-releasing hormone agonists
c) Often pre-cancerous
It is rare for endometrial polyps to become malignant (<1%)
What term describes a benign myometrial tumour with oestrogen/progesterone-dependent growth?
Leiomyoma
a.k.a uterine fibroids
What options are available for treating leiomyoma?
Medical:
- Intrauterine system (IUS, e.g. mirena coil)
- OCP
- Progesterone
- Fe2+
- NSAIDs
Surgical:
- artery embolisation
- ablation
- TAH (total abdominal hysterectomy)
What risk factors are associated with endometrial hyperplasia?
Obesity
Exogenous oestrogen
PCOS
Oestrogen-producing tumours
Tamoxifen
HNPCC
(PCOS = polycystic ovary syndrome; HNPCC = hereditary non-polyposis colorectal cancer)
Which of these is not a subtype of endometrial hyperplasia?
a) simple non-atypical
b) complex non-atypical
c) simple atypical
d) complex atypical
Trick question: they’re all subtypes of endometrial hyperplasia!
Endometrial hyperplasia is divided into 2 types: simple and complex. Each type has typical and atypical forms.
What term describes excessive proliferation of endometrium?
Endometrial hyperplasia
What causes endometrial hyperplasia?
Increased oestrogen, reduced progesterone
Left untreated, endometrial hyperplasia may develop into non-atypical hyperplasia, atypical hyperplasia and, finally, __?__.
endometrioid adenocarcinoma
type 1 endometrial adenocarcinoma
When endometrial hyperplasia has invaded into the myometrium it is termed __?__
Endometrioid adenocarcinoma
type 1 endometrial adenocarcinoma
What is the most common cancer of the female genital tract?
Endometrial adenocarcinoma
How many new cases of endometrial adenocarcinoma are there each year?
a) <500
b) 1000-2000
c) 5000-7000
d) >9000
d) >9000
Each year: Roughly 9,200 new cases of endometrial adenocarcinoma, roughly 2,500 deaths
Which staging system is used for staging endometrial adenocarcinoma?
FIGO (1-4)
What are the treatment options for endometrial adenocarcinoma?
Medical: progesterone
Surgical: Total abdominal hysterectomy (TAH)
Adjuvant: chemo, radio
What is the 5-year survival rate for a person diagnosed with stage 1 endometrial adenocarcinoma?
90%
A person with stage 2 or 3 endometrial adenocarcinoma has a 5-year survival rate of __?__
less than 50%
What types of endometrial adenocarcinoma are there?
Type 1: Endometrioid
Type 2: Serous
__?__ adenocarcinoma is a type of endometrial cancer that tends to affect postmenopausal women.
Serous adenocarcinoma
type 2 endometrial adenocarcinoma
__?__ adenocarcinoma is a type of endometrial cancer that tends to affect pre-/perimenopausal women.
Endometrioid adenocarcinoma
type 1 endometrial adenocarcinoma
Which type of endometrial adenocarcinoma develops from endometrial hyperplasia?
Endometrioid adenocarcinoma
type 1
Which type of endometrial adenocarcinoma develops from endometrial atrophy?
Serous adenocarcinoma
type 2
PTEN and KRAS mutations are associated with which type of endometrial cancer?
Endometrioid adenocarcinoma
What type of mutation is associated with endometrial serous adenocarcinoma?
P53
serous it type 2 endometrial adenocarcinoma. It is usually preceded by endometrial atrophy.
Which type of endometrial adenocarcinoma is linked to oestrogen?
Endometrioid
type 1
What is the Rotterdam criteria?
Tool for diagnosing polycystic ovary syndrome.
Patient must meet two out of the three below:
- polycystic ovaries
- hyperandrogenism (hirsutism/biochemical)
- Irregular periods (>35 days)
How would you expect PCOS to affect serum levels of FSH, LH, testosterone and DHEAS?
↑ LH, testosterone, DHEAS
↓ FSH
(DHEAS = Dehydroepiandrosterone sulfate)
What investigations would be done to test for PCOS?
USS, fasting biochemical screen (↓FSH, ↑LH, ↑testosterone, ↑DHEAS ), OGTT
What treatment options are available for PCOS?
Lifestyle: weight loss
Medical: metformin, OCP, clomiphene
Surgical: ovarian drilling
PCOS increases the risk of which type of endometrial cancer?
Endometrioid adenocarcinoma
(type 1 endometrial adenocarcinoma)
PCOS can lead to endometrial hyperplasia, which can develop into this.
Which of the following is a cause of secondary gonadal failure (hypogonadotropic hypogonadism)?
a) Sheehan syndrome
b) Turner syndrome
c) Chemotherapy
d) Klinefelter’s syndrome
a) Sheehan syndrome
Postpartum haemorrhage causes the pituitary gland
to become ischaemic due to hypovolaemia. Failure of the gonads is secondary to failure of the pituitary.
What are the clinical features of gonadal failure?
Amenorrhoea/absent menarche, delayed puberty, ↓ sex hormone levels (+/- ↑ LH and FSH levels)
Which of these is associated with increased levels of FSH and LH?
a) PCOS
b) Hypogonadism
c) Endometrial TB
d) Fibrothecoma
b) Hypogonadism
Amenorrhoea/absent menarche, delayed puberty, ↓ sex hormone levels (+/- ↑ LH and FSH levels)
What treatment options are available for hypogonadism?
- Address the underlying cause
- HRT
What are the three potential origins of ovarian neoplasms?
- Surface epithelium
- Sex cord stroma
- Germ cell
Which are the most common origin of ovarian tumours?
Epithelium
Which is the most common histological type of ovarian tumour?
Serous (tubal) tumours. Originate from the ovarian epithelium.
True or false: Ovarian tumours are the most common type of gynae cancer.
False. They are 2nd commonest.
Endometrial adenocarcinoma is the commonest cancer of the female genital tract.
Which age group is usually more affected by serous tumours of the ovary?
Older women
What are the benign variants of epithelial tumours?
Cystadenoma
Adenofibroma
Cystadenofibroma
What term describes malignant epithelial tumours?
Cystadenocarcinoma
What are the subclassifications of germ cell tumours?
Germinomatous (arise directly from the germ cells)
Non-germinomatous (not directly from germ cells)
Which of the following is a germinomatous germ cell tumour?
a) Yolk sac tumour
b) Choriocarcinoma
c) Dysgerminoma
d) Teratoma
c) Dysgerminoma
Which of the following (if any) are benign germ cell tumours?
a) Dysgerminomas
b) Teratomas
c) Yolk sac tumours
d) Choriocarcinomas
b) Teratomas
The rest are malignant.
Teratomas are benign but there is a 1% risk of malignant transformation.
Which type of tumours arise from the primordial germ cells of the ovary?
Dysgerminomas
Arise from oogonia (primordial germ cells of the ovary)
Which of the following is not chemosensitive?
a) Dysgerminomas
b) Yolk sac tumours
c) Choriocarcinomas
d) They are all sensitive to chemotherapy
c) Choriocarcinomas
Which tumour originates from the extraembryonic yolk sac?
Yolk sac tumour
Which tumour arises from the placenta?
Choriocarcinoma
True or false: Sex cord stromal tumours are rare.
True
Thecoma, granulosa and Sertoli-Leydig are all types of cancer from what origin?
Ovarian tumours arising from sex cord stroma
What is Meig’s syndrome?
Triad of benign ovarian tumour, right-sided hydrothorax, ascites. Should resolve upon resection of the tumour.
Which of these do not produce oestrogen?
a) Fibroma
b) Thecoma
c) Fibrothecoma
d) Granulosa cell tumour
a) Fibroma
The others all produce oestrogen, but fibromas are hormonally inactive.
What term describes a tumour which includes a mix of granulosa cells and thecoma/fibroma?
Sertoli-Leydig cell tumour
These tumours produce androgens and are usually benign, although 10-25% are malignant
True or false: Thecoma, fibroma and fibrothecoma are all benign.
True
True or false: Granulosa cell tumours are benign.
False.
Granulosa cell tumours are low-grade malignant.
They also produce oestrogen.
Spindle cells are associated with which ovarian neoplasm?
Thecoma/fibrothecoma
In primary gonadal failure, where is the problem?
Within the gonad itself
In secondary gonadal failure, where is the problem?
In the hypothalamus or pituitary gland
What condition is being described:
oestrogenic stimulation of endometrial proliferation; continuous stimulation may lead to atypical hyperplasia and carcinoma
Endometrial hyperplasia
What condition is being described:
benign smooth muscle tumours of the myometrium
Leiomyomata
What condition is being described:
local endometrial overgrowth
Endometrial polyps
What condition is being described:
acute/chronic inflammation of endometrium (usually due to infection)
Endometritis
What condition is being described:
spread of endometrium into the pelvis
Endometriosis
What common condition is being described:
Multiple follicular cysts, hyperandrogenism, menstrual irregularity
Polycystic ovary syndrome (PCOS)
What is the breast screening triple assessment?
1) Clinical examination
(history and physical examination)
2) Radiological examination
(USS, mammography)
3) Pathological examination
(core-cut biopsy, fine-needle aspiration cytology FNAC)
All three need to agree before patient is returned to normal screening pool.
Describe the normal glandular parenchyma of the breast by filling in the gaps:
__1__ lobes of glandular tissue, drained by __2__. Lobes __3__ toward areola.
Near the areola the lactiferous duct __4__ to form the __5__.
1) 15-20
2) lactiferous duct
3) converge
4) dilates
5) lactiferous sinus
Which of the following are synonyms for fibrocystic disease of the breast?
a) Fibrous mastopathy
b) Mammary dysplasia
c) Schimmelbusch’s disease
d) Chronic cystic mastitis
All of them
They all describe fibrocystic change/disease in the breast.
Which group is generally affected by fibrocystic disease?
Pre-menopausal women
True or false: Fibrocystic changes are usually unilateral in the breasts
False
Usually they are bilateral and multifocal. Fibrocystic change is seen in roughly 60% of normal breasts
What is the biggest risk factor for women developing fibrocystic change in their breasts?
Hyperoestrogenism
HRT, oestrogen-secreting tumour etc
What is the risk of fibrocystic breasts developing into subsequent carcinoma?
No risk - FCC is completely benign.
What condition is being described?
a constellation of bening, hormone-mediated breast changes including cyst formation, stromal fibrosis and mild epithelial hyperplasia without atypia.
Fibrocystic disease
aka. Fibrous mastopathy, mammary dysplasia, Schimmelbusch’s disease, chronic cystic mastitis
How are triple assessment findings scored?
Clinical: P1-P5 (P = palpation)
Radiological: R1-R5 (R = radiology, or U for ultrasound)
Pathological: B1-B5 (B = biopsy, or C = cytology)
What do the triple assessment scores mean?
P/R/B 1-5
1: Normal; return to normal screening
2: Benign; reassure and return to normal screening
3: Malignant potential; excision
4: Suspected malignancy; rebiopsy/excision
5a: Carcinoma in-situ (DCIS); wide local excision/mastectomy
5b: Invasive carcinoma; WLE/mastectomy
What triple assessment score would be given to a patient with fibrocystic changes on histological examination?
B2
Benign changes. Reassure and return to regular screening.
What triple assessment score would be given to a patient with fibroadenoma?
B2
Benign changes. Reassure and return to regular screening.
What condition is being described:
A mobile, painless, well-defined breast lump that is most commonly found in afro-Caribbean women.
Fibroadenoma
These are common benign growths usually found in women aged 20-30yo.
What triple assessment score would be given to a patient with invasive breast carcinoma?
B5b
What risk factors are associated with breast carcinoma?
Hyperoestrogenism
- Early menarche, late menopause, OCP and E2 HRT
Obesity (in postmenopausal women)
Alcohol
What triple assessment score would be given to a patient with DCIS?
B5a
DCIS = ductal carcinoma in-situ
These carcinomas show no signs of invasion.
__?__ is the precursor to invasive breast carcinoma
DCIS (ductal carcinoma in-situ)
What is most commonly seen on screening in patients with DCIS?
Microcalcifications
What are the red flags associated with a palpable lump in breast examination?
Older patient
Tethering (low mobility, puckered skin, retracted nipple)
Discharge
How is the histological grade of breast cancer assessed?
Nottingham Grading System (1-3)
- assesses tissue based on tubule formation, nuclear pleomorphism and mitosis.
Grade 1: Well differentiated. >75% tubule formation, mild degree of nuclear pleomorphism and low mitotic count
Grade 2: Moderately differentiated
Grade 3: No tubule formation, marked nuclear pleomorphism and frequent mitoses
What information should a pathology report tell you about a breast malignancy?
- In situ or invasive
- Type (ductal, lobular etc…)
- Grade (Nottingham system 1-3)
- Size
- Vascular invasion
- Nodal status
- Relationship to margins
- Molecular marker status (oestrogen/progesterone/HER2 receptors)
What is the most common type of breast cancer?
Ductal (75%)
Cribiform, medullary, mucoid and lobular are all types of which cancer?
Breast
What are the key prognostic factors when assessing breast cancer?
Tumour grade
Tumour size
Nodal status
What factors inform the Nottingham Prognostic Index?
Grade (Nottingham System 1-3)
Nodal status (scored 1-3)
Tumour size
(grade + nodal status + 0.2 x size)
What score boundaries define the prognosis of breast cancer?
Nottingham Prognostic Index score:
> 3.4 = good (80% 16y survival)
- 41-5.4 = moderate (46%)
- 41< = poor (10%)
What does the circumscription of a mass usually tell you about whether it is benign or malignant?
Good circumscription is usually a feature of benign masses
What does calcification tell you about whether a mass is benign or malignant?
Calcification is not a good indicator of whether a mass is benign or malignant - it only tells you there is an abnormality
What is meant by ‘triple negative’ breast cancer?
The tumour is negative for oestrogen, progesterone and HER2 receptors. This means it cannot be targeted easily by current therapies and is a bad sign.
What is trastuzumab used for?
Trastuzumab [herceptin] is a drug that targets HER2 positive tumours
What is tamoxifen used for?
Targeted breast cancer therapy, targets oestrogen receptors on tumours.
What targeted therapies are available for treating breast cancer?
Tamoxifen
Aromatase inhibitors
Bisphosphonates
Herceptin (trastuzumab)
Luminal A, luminal B, Basal and normal-like are all molecular subtypes of which type of cancer?
Breast
Classified based on their molecular receptor status (HER2, E2, P4 etc)
True or false: During pregnancy women are more resistant to infections.
False.
Pregnancy does not alter resistance to infection.
Which infections can be passed from mother to baby during pregnancy (in utero)?
TORCH
Toxoplasmosis
Other: coxsackie, HBV, HIV, syphilis, varicella zoster
Rubella
CMV
Herpes simplex
Why should pregnant women be careful around cat and dog faeces?
They can contract toxoplasmosis, which is more severe in pregnancy and can transfer to the foetus
Which neonatal infections are contracted during passage through the birth canal?
Group B strep, herpes simplex
Gonorrhoea, chlamydia
HIV, HBV
What screening test does NICE recommend to help reduce the risk of pyelonephritis in pregnant women?
Women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy.
Identification and treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis.
True or false: Antenatal screening for Group B Streptococci is not recommended in UK
True.
Until it is clear that antenatal screening for GBS carriage does more good than harm and that the benefits are cost effective, the National Screening Committee does not recommend routine screening in the UK.
What is IAP and to whom is it offered?
IAP = intrapartum antimicrobial prophylaxis
IAP offered to:
- Women with previous baby with neonatal Group B Strep disease
- Women with GBS in current pregnancy
- Women who are pyrexial in labour
How is early-onset neonatal group B strep disease (EOGBS) prevented?
Intrapartum antimicrobial prophylaxis, if indicated.
Which of the following is not associated with intraamniotic infections?
a) Affects 20-25% of pregnancies with pre-term labour
b) Can lead to chorioamnionitis
c) Primarily acquired haematogenously
d) Amniocentesis increases the risk of infection
c) Primarily acquired haematogenously
Haematogenous (via blood) infection is rare but can occur with bacteria such as listeria monocytogenes.
Primary mode of infection is from vaginal bacteria ascending through the cervix.
What is the most common risk factor for intra-amniotic infection?
Prolonged rupture of membranes
Other risk factors include: amniocentesis, cordocentesis, cervical cerclage (cervical stitch), multiple vaginal examinations, bacterial vaginosis.
What are the risk factors for intra-amniotic infection?
Most common after prolonged rupture of membranes.
Other risk factors include: amniocentesis, cordocentesis, cervical cerclage (cervical stitch), multiple vaginal examinations, bacterial vaginosis.
Where do intra-amniotic infections usually originate from?
Bacteria present in the vagina cause infection by ascending through the cervix.
Haematogenous infection is rare.
What are the most common causative organisms for intra-amniotic infections?
Group B Strep
E-Coli
Genital Mycoplasma
How are intra-amniotic infections managed?
Antimicrobials (started at time of diagnosis; not after delivery)
Delivery of foetus
Define puerperium
The period of approx six weeks following childbirth, during which time the mother’s reproductive organs return to their non-pregnant state.
What is being described:
Infection of the womb within 6 weeks of childbirth
Puerperal endometritis
Affects ~5% of pregnancies
What risk factors are associated with puerperal endometritis?
Risk factors: c-section, prolonged labour, PROM, multiple vaginal examinations
What are the clinical features of puerperal endometritis?
- Fever
- Uterine tenderness
- Purulent, foul-smelling lochia
- Raised WCC
- Malaise, abdo pain
What are the main causative organisms of puerperal endometritis?
Frexently a mix of:
- E-Coli
- B-Haemolytic Streptococci
- Anaerobes
How is puerperal endometritis managed?
Broad-spectrum IV Abx until is apyrexial for 48 hours
Define early-onset neonatal sepsis
Sepsis within 72 hours of birth
Usually from vertically-transmitted infection
Define late-onset neonatal sepsis
Sepsis after 72 hours of birth
Usually from hospital acquired infection
What is the mortality rate for early-onset neonatal sepsis?
1 in 4 babies who develop EOS will die, even if given Abx
How do neonates acquire the organism(s) that lead to early-onset sepsis?
Maternal genital tract
True or false: It is typical to have multisystem involvement and pneumonia associated with early-onset neonatal sepsis
True
Which organism is the commonest cause of late-onset neonatal sepsis?
Coagulase-negative staphylococci
Associated with prosthetic devices, such as feeding tubes, IV access etc.
Can also be caused by E-Coli
What is the leading cause of all childhood infections?
Streptococcus pneumoniae
Childhood infections most commonly affect which system?
Respiratory
What is the leading cause of sore throat in children?
70-80% viral
20-30% Group A B-Haemolytic Streptococcus
A mother brings in her toddler who has been unusually irritable, not sleeping, has a fever and is struggling to keep balance more than usual.
What is the most likely organism causing these symptoms?
Streptococcus pneumoniae
Other common causes of otitis media are haemophilus influenzae and moraxella catarrhalis.
Which of the following is least likely to be the cause of acute respiratory infection in children?
a) Chlamydia pneumoniae
b) Mycoplasma pneumoniae
c) RSV
d) Streptococcus pneumoniae
a) Chlamydia pneumoniae
Leading aetiology of acute resp. infections in children:
- RSV (63%)
- Mycoplasma pneumoniae (9%)
- Streptococcus pneumoniae (8%)
What condition is being described?
A seasonal viral illness characterised by fever, nasal discharge and a dry, wheezy cough. On examination there are fine inspiratory crackles and/or high-pitched expiratory wheeze
Bronchiolitis
Aetiology:
- RSV
- Metapneumovirus
- Adenovirus
- Parainfluenza virus
- Influenza
- Rhinovirus
What is pertussis more commonly known as?
Whooping cough
What are the 3 clinical stages seen in pertussis?
- Catarrhal phase
- Paroxysmal phase
- Convalescent phase
A child presents with fever, irritability and poor feeding. On examination you notice the fontanelle appears to be bulging slightly. What differentials are you most concerned about?
Meningitis and encephalitis
What are the most likely causes of bacterial meningitis in:
(i) Neonates?
(ii) Children 1m-5y?
(i) Neonatal bacterial meningitis: Group B Strep, E Coli, Listeria Monocytogenes
(ii) 1m-5ys: Streptococcus pneumoniae, Neisseria meningitidis
What is the most common cause of meningitis in children under one year?
Enteroviruses
What is meningococcemia?
The dissemination of meningococci (Neisseria meningitidis) into the bloodstream (see the image below). Patients with acute meningococcemia may present with:
(1) meningitis;
(2) meningitis with meningococcemia; or,
(3) meningococcemia without clinically apparent meningitis
What symptoms are associated with UTI in older children?
- Dysuria
- Increased frequency
- Increased urgency
- Small volume voids
- Lower abdo pain
What is the most common cause of UTI in children?
E Coli (60-80%)
Others: proteus, klebsiella, enterococcus, staph. saprophyticus
Which of these is not an appropriate method of urine sampling in a child with suspected UTI:
a) Clean catch sample
b) Sanitary towel
c) Suprapubic aspiration
d) Catheter sample
b) Sanitary towel
Also should not use cotton wool or gauze
Meningococcemia has a mortality rate of __1__% (90% if __2__). The morbity rate is __3__% (deafness, neurological problems, amputations).
1) 5-10%
2) DIC
3) 10%
Peak incidence of Meningococcemia is around what age?
Under 4 years
60% of bacterial meningitis in the UK is due to __?__
Meningococcal B
Why is it more difficult to diagnose UTI in infants?
Their symptoms are less specific: fever, irritability, vomiting, poor appetite
When should a child with UTI be referred to a paeds specialist?
If they have recurrent UTI or abnormal imaging
- If they don’t need imaging, they don’t need the specialist
Which of the following is most appropriate following asymptomatic bacteriuria in a child:
a) Antibiotic prophylaxis
b) Imaging
c) Specialist referral
d) No follow-up required
d) No follow-up required
Impetigo is caused by which organism(s)?
Staphylococcus aureus
Staphylococcus pyogenes
A child presents with ruptured vesicles and honey-coloured crusting. What is this a classic description of?
Impetigo
True or false: Impetigo is not very contagious.
False: Impetigo is very contagious, spread rapidly.
Which sites are normally first affected by impetigo?
Face, mouth
What prescription is usually offered to children with How is impetigo usually managed?
Topical Abx or oral flucloxacillin
Advice re nursery/school
What organism causes a condition characterised by:
- Fever, sore throat, flushed face
- Rough sandpaper skin, rash
- White strawberry tongue
Scarlet fever is caused by Group A beta-Haemolytic Streptococcus
After 5 days you may also see desquamation of the soles and palms
What tests are used to confirm scarlet fever diagnosis?
Throat swab
Antistreptolysin O titre (antibody against streptolysin produced by group A b-haemolytic strep)
What is usually prescribed to a patient with scarlet fever?
Penicillin (if NKDA)
