Things to Learn Flashcards
1
Q
what is the most common cancer in men
A
prostate
2
Q
What do LHRH analogues do
A
LHRH analogues (also called GnRH analogues) act by desensitizing LHRH receptors in the pituitary gland, which in turn prevents the secretion of luteinizing hormone (LH), causing the body’s androgen levels to drop in the long term
3
Q
How is prostate cancer linked to normal influences
A
Hormonal influences – prostatic adenocarcinoma is androgen sensitive because castration with surgery or LHRH analogues is associated with disease regression.
- binding of androgens induces the expression of growth factors and growth factor receptors which stimulate the progressive growth of the cancer
4
Q
what other conditions cause a raised PSA
A
Benign prostatic hypertrophy (BPH), prostatitis, urinary tract infections (UTI), trauma etc.
5
Q
what is the gold standard for diagnosis Prostate cancer
A
Trans Rectal Ultrasound Guided Biopsy
6
Q
How does the Gleason score work
A
Therefore a combined Gleason Grade score is used which is the sum of:
- The most common grade
- The highest/dominant grade
7
Q
what can CT be used to assess in cancer
A
- stage of the disease and how much it has spread
8
Q
what are the symptoms of a testicular torsion
A
Swollen, tender and erythematous testicle
Black internally
Black externally
Necrosis which also extends into the spermaticord
9
Q
what is an orchiopexy
A
– surgical attachment of testes to scrotum to fix them into position
10
Q
what do Sertoli cells do
A
– support cells involved in regulating spermatogenesis, spermiogenesis, blood-testes barrier, hormone production, tubular fluid secretion and phagocytosis of spermatid cytoplasm.
11
Q
what do leydig cells do
A
– are located in the intersitium and synthesise testosterone
12
Q
what are the risk factors for a seminoma
A
Undescended testes - poor histological development due to exposure to high temperature.
Infant hernia (indirect inguinal)
Rare genetic conditions
13
Q
describe seminoma
A
Macroscopic Hard Well circumscribed Pale/ White mass Lobular Homogenous
Microscopic
- Nuclear pleomorphism
- Prominent nucleoli
- Clear cytoplasm
- Well defined cell boundaries
14
Q
what serum marker are used for what tumours in men
A
Seminoma – PLAP (Placental Alkaline Phosphatase)
Choriocarcinoma – hCG (human chorionic gonadotrophin)
Yolk sac tumours – AFP (alpha-fetoprotein)
Embryonal carcinoma - Oct4
15
Q
What does cervical screening involve
A
Cervical screening involves taking a sample of epithelial cells from the transformation zone using a brush or a spatula, applying/smearing this to a slide and then staining with a Papanicolaou stain (Pap)
16
Q
what are the types of cervical cancer
A
80% squamous cell carcinoma
15% adenocarcinoma
17
Q
describe characteristics of kilobytes
A
Nuclear enlargement
Nuclear hyperchromasia (darker nuclei)
Peri-nuclear halo
18
Q
what does a women above 35 breast look like
A
Older women (>35 years) – undergo changes to breast tissue as fibrous tissue in the breast gets replaced by adipose tissue which is more radiolucent (passes more X-rays) through it, hence a mammogram increases the sensitivity for the detection of a lump.
19
Q
what two techniques are used to find an adenoma
A
ultrasound
mammogram
can also use a fine needle aspiration for cytology
20
Q
describe a fibroadenoma
A
Commonest benign breast tumour
<30 years
Arises in the breast lobule
Firm, smooth, mobile lump - ‘breast mouse’
Painless
Benign overgrowth of collagenous tissue within the lobule
Can have multiple in one breast
21
Q
What are the symptoms of ovarian cancer
A
- bloating
- feeling full quickly while eating
- pelvic or abdominal pain
- urinary urgency
- abdominal vaginal bleeding or discharge
- back pain
22
Q
Name the three types of epithelial tumours
A
Serous
Mucinous
Endometroid
23
Q
what are the three sex cord stomal cells
A
Granulosa cell tumour
Thecoma fibroma
Sertoli-Leydig cell tumour
24
Q
what is the surgery of ovarian cancer
A
Total Abdominal Hysterectomy and Bilateral Salpingo-oopherectomy
25
what HPV is associated with genital warts
6 and 11
26
what HPV is associated with carcinoma
HPV 16, 18, 31, 33,
27
How does HPV cause cancer
- Papillomavirus DNA is incorporated into the host genome
- this produces the proteins E6 and E7 which form complexes with anti-oncogenes such as p53 and retinoblastoma thereby inactivating the normal cellular response to DNA damage
- this results in accumulation of genetic abnormalities
28
when does an ovarian adenocarcinoma originate from
Fallopian tube
29
what are the type of cervical cancers
80% of being squamous cell carcinoma
15% adenocarcinoma
- the remainder are Aden-squamous and neuroendocrine carcinomas and these are caused by high oncogenic risk GPV
30
what is the transformation zone in the cervix and vaigna
- changes occur with the eversion (turning inside out) of then endocervical columnar epithelium onto the ectocervix
- the protrusion of the endocervical epithelium forms what is referred to as the endocervical columnar ectropion
- thus at punters the original squamous-columnar junction becomes relocated outside the external os
- in response to the acidic conditions of the vaginal vault areas of ectropion are replaced with stratified squamous epithelium by metaplasia involving stages of reverse cell hyperplasia and immature metaplastic epithelium
- this is transformation zone
31
what type of HPV causes what type of carcinomas in the cervix
Squamous cell carcinomas HPV16
adenocarcinomas HPV18
32
How does HPV infect
HPV infect immature basal cells through epithelial breaks caused by damage
- this can directly infect metaplastic squamous epithelium but it cannot infect mature superficial squamous epithelial cells
33
what are dyskaryotic changes of the nucleus
- disproportionate nuclear enlargement
- irregularity in form and contour
- hyperchromasia
- irregular chromatin condensation
- abnormalities in number, for, and size of nucleoli
- multinucleate
- nucleus to cytopaslm ratio increases as dyskaryosib prowesses so exfoliated cells with severe dysplasia most resemble immature basal cells
34
what two HPVs are associated with common warts
HPV 2 and 7
35
what are the two types of connective tissue that the breast stroma is made up of
1, interlobular stroma = this is comprised of a dense fibrocollagenous tissue mixed with adipose tissue
2, intra lobular stroma - this is comprised of a looser fibrocollagneous tissue contains hormonally responsive breast-specific fibroblasts important in mammary gland remodelling for example in pregnancy
36
What happens to the breast tissue with ageing
- with ageing from approximately age 30 and through menopause the breast lobules involute and can nearly complete atrophy in the elderly
- adipose is more prominent
- lobules decrease in size and in number
37
describe what epithelial tumours are like and where they project
- cystic with solid components
- smooth surface or be covered in papillary projections
- spread is often into the peritoneal cavity
38
What are the type of ovarian carcinomas
- serous adenocarcinoma
| - mucus adenocarcinoma
39
what plays a role in pathogenesis of prostate cancer
- androgens
- IGF-1 plays a role
- diet as well plays a factor
40
what is the only certain risk factor for development of germ cell tumours
cryptorchidism
- risk factor in germ cell tumours of the testsis mainly seminomas
- accounts for approximately 10% of cases
41
development of the testis does not...
occur normally at higher temperatures
- histological changes occur within the undescended testsis as early as 2 years of age and are evident as tubular atrophy with an arrest in germ cell development
- in the adult, tubules are lined by a preponderance of Sertoli cells instead of having normal cellular development
42
what is a choriocarcinoma made out of
- made out of giant syncytiotrophoblast cells and cytotrophoblasts
- this is why it secretes HCG
43
what can HCG give rise to
gynaecomastia
44
what risk is a biopsy of a testicular neoplasm associated with
a risk of tumour spillage and potential spread
- therefore standard management of a solid mass in the testis is a radical orchiectomy based on the presumption of malignancy
45
What leads to hyaline membrane disease
Architectural & functional immaturity of lungs ◦ preterm babies
◦ babies from diabetic mothers
◦ male gender, caesarean section
Deficiency of pulmonary surfactant
46
what causes an increase and decrease in pulmonary surfactant
glucocorticoids, thyroxine & labour increase
insulin & Caesarean section decrease
certain genetic polymorphisms SP-A, SP-B
47
what are the complications of hyaline membrane disease
◦ chronic lung disease (BPD)
◦ pneumothorax,
- pneumomediastinum,
- pneumopericardium
48
What are the causes of prematurity
PROM (premature rupture of membranes) 30-40%
Intrauterine infection 25%
Uterine anomalies (fibroids, bicornuate)
Cervical incompetence
Placental problems (abruption, pl. praevia)
Multiple gestation
IOL for maternal or fetal disease
49
What are the major causes of death in pre-term babies(important card)
Hyaline membrane disease (HMD)
Intraventricular haemorrhage (IVH)
Necrotizing enterocolitis (NEC)
Neonatal sepsis
◦ early onset (up to 1 week of age)
◦ late onset (>1 week of age)
50
What factors determine survival rates in premature babies
Gestational age (>35/40)
Size
◦ BW >2500g
◦ no growth restriction
Antenatally corticosteroids
Exogenous surfactant at delivery
Postnatally
◦ management
◦ treating the underlying disease
51
what happens in meningococcus septicaemia
◦ shock
◦ bilateral adrenal haemorrhage
◦ widespread purpura
◦ meningitis
52
what investigations do you perform to get a genetic diagnosis
Antenatally
◦ chorionic villous sampling CVS
◦ amniocentesis
Postnatally or at PM
◦ blood
◦ skin
◦ sternum
53
what does Apgar stand for
```
o Appearance - colour of the baby
o Pulse - heart rate
o Grimace - reflex
o Activity (muscle tone)
o Respiration effort
```
54
what happens in perinatal asphyxia
Tissue suffers hypoxaemia, ischaemia
| - hypercarbia, metabolic acidosis
55
What are the warnings of hypoxia ischameia
* Decreased fetal movement.
| * Sentinel events (placenta abruption, uterine rupture, cord prolapse).
56
What does encephalopathy refer to
Abnormal neurologic function and consciousness level
Abnormalities of tone and reflexes
Autonomic dysfunction
Seizures
57
What are the potential targets for neuroprotection
* Decrease energy depletion - increase glucose, use hypothermia and barbiturates.
* Glutamate (inhibition of release). = via calcium channel blockers, magnesia, adenosine, hypothermia, free radical scavengers
* Inhibition of leukocyte/microglial/cytokine effects. = hypothermia, free radical synthesis inhibitors
• Blockage of downstream cellular events.
o Free radical synthesis inhibitors
o Free radical scavengers etc…
58
what are the 5 effects that therapeutic hypothermia has
↓ cerebral metabolism
↓ energy use
↓ accumulation of excitotoxic amino acids
↓NO synthetase activity
↓free radical activity
59
What are the symptoms of early onset GBS
* Apnea
* Severe hypoxia
* Cardio-respiratory failure
* Hypotension
* Metabolic acidosis
* Tachycardia
* Poor perfusion
60
How do you investigate early onset GBS
* Full blood count – neutropenia
* CRP – acute phase reactant – rise may be delayed by 12 hours
* Blood cultures
61
What are the predisposing factors to early onset GBS
• 1% of babies born vaginally to mothers who carry GBS become infected
• Predisposing Factors
– Evidence of chorioamnionitis including maternal fever
– Prolonged labour
– Prolonged rupture of membranes
– Low birthweight
62
what are the organisms that cause late onset sepsis in the new-born
* Coagulase-negative staphylococci
* Staph Aureus
* Others
63
describe the genetic and acquired reasons for a small for gestational age
```
Genetics
• Normal small baby
• Chromosomal disorders.
o Edwards syndrome
o Trisomy 18.
• Inherited disorders.
```
Acquired
- Uteroplacental insufficiency - this is the most common
- congenital infection such as CMV
- smoking
- maternal chronic illness such as renal or sickle cell disease
- multiple pregnancy
64
How does utero-placental insufficiency happen
o Failure of syncytiotrophoblast invasion of the high resistance spiral arteries.
o Poor placental development with raised resistance in vascular bed.
65
Name some problems that neonates have if they are small for gestational age
- temperature control
- polycythemia
- poor nutritional status
- hypoglycaemia
- increased risk of necrotising enterocolitis
66
why do spontaneous preterm births happen
* Infection or ruptured membranes
* Cervical incompetence
* Polyhydramnios
67
what are the 3 main respiratory problems
structurally immature
- primaritve alveolar development
- susceptibility to oxygen toxicity
functionally immature
- surfactant deficient
- lack of respiratory drive - intercostal and diaphragm are weak
susceptibility to infection
Immature immune system.
Instrumentation of airway. - e.g. mechanical ventilation used can provide an easy way for pathogens to enter
68
what are the symptoms of respiratory distress syndrome
tachypnoea
expiratory grunting
recession
- happens within 4 hours of birth
69
How do you prevent respiratory distress syndrome
* Ante-natal steroids
* Avoidance of intrauterine hypoxia
* Prophylactic surfactant treatment
* Keep warm, avoid acidosis – acidosis can denatures surfactant
70
What happens in chronic lung disease of the infancy
Oxygen dependency in a preterm baby at 36weeks post menstrual age
Lung injury in the preterm infant
Inflammation, fibrosis, emphysema
71
what are the signs and symptoms for necrotising enterocolitis
- abdominal distension, tenderness, discolouration
- blood in stools
- generalised collapse
72
What are the risk factors for necrotising enterocolitis
- prematurity, hypoxia, infection, enteral feeding
73
what is the preterm central nervous system at risk of
Periventricular Haemorrhage (PVH)
Periventricular leucomalacia (PVL)
74
what are the risk factors for a periventricular haemorrhage
* Prematurity (very rare after 34 weeks)
* RDS
* Pneumothorax
* Hypercapnia
* Acidosis
* Hypotension
* Instability and handling
* Severe bruising at birth
75
overall what are the 4 main causes of death for children under 5 years
1. Preterm birth complications
2. Pneumonia.
3. Intrapartum related events.
4. Diarrhea.
76
How do you reduce chance of pneumonia
* Breastfeeding promotion
| * Hemophilus influenzae type b and pneumococcal vaccines
77
What does polymorphism mean
• they are polymorphic when the frequency of the minor allele in the population is >1%.
78
name the three ways how you can identify disease genes
positional candidates
• Identified through genome wide genetic linkage analysis.
functional candidates
- Identified by a functional association with previously identified disease genes
exome/genome sequencing
- Identified as having rare variants in multiple unrelated affected individuals – an allelic series
- for example you remove all the common variants and this leaves the candidates genes
- you then get multiple people with the same condition and compare the cases to see which genes are shared between the individuals
- eventually you end up with on candidate gene that causes the condition
79
What does diphtheria act on
Acts on:
o Heart: myocarditis and heart block.
o Nerves further difficulty swallowing, paralysis, diplopia.
80
what does the endotoxin do
Released during lysis of the organisms.
| Leads to macrophage activation
81
describe the pathogenesis of meningococcal disease
- Activation of inflammatory cascade via LPS
- Causes release of pro-inflammatory cytokines such as. IL-6 and TNF- alpha
- This causes myocardial depression
- Endothelial dysfunction which causes capillary leakage and shock
- Causes a coagulopathy – takes a long time for the blood to clot as the whole coagulation cascade is abnormal
= therefore this inflammatory reaction to LPS causes most the symptoms of septic shock
82
Name some slow bacterial infection
```
– Tonsillitis
– Otitis media
– Urinary tract infection
– Gastroenteritis
– Impetigo
```
83
What the three common causing meningitis and septicaemia
- streptococcus pneumonia
- neisseria meningitides
- haemophilus influenza B
84
What are the clinical symptoms of septicaemia
* Tachycardia.
* Tachypnoea.
* Prolonged capillary refill- blood being sent to organs
* Low BP (late sign) - common to drop blood pressure due to shock whereas in children this is a pericardia a rest and late sign that they are going to decompensate
* Rash - doesn't disappear usually, but you can have septicaemia without any rash
85
What are the clinical symptoms of meningitis
* High temperature
* Headaches
* Vomiting
* Not able to tolerate bright lights = photophobia
* Drowsiness
* Stiff Neck.
86
What are the symptoms of meningitis in infants
- Tense or bulging soft
- High temperature
- Breathing fast and difficulty breathing
- Extreme shivering
- Cold hands and feet
- Vomiting and refusing to feed
- Blotchy skin getting paler or turning blue
87
what vaccinations take place at
- 8 weeks old
- 12 weeks old
- 16 weeks old
- one year
8 weeks old
- Diphtheria, tetanus, peruses, polio, Hib, HepB,
- pneumoccoal (13 serotypes)
- Meningococcal group B
- rotavirus, gastroenteritis
12 weeks old
- Diphtheria, tetanus, peruses, polio, Hib, HepB,
- rotavirus
16 weeks old
- Diphtheria, tetanus, peruses, polio, Hib, HepB,
- pneumoccoal (13 serotypes)
- Meningococcal group B
one year
- Men B
- Hib and MenC
- pneumococcal
- MMR
88
What are the top 3 organisms that can cause problems in young infants before vaccination
- Group B streptococcus
- E.coli
- Listeria
89
what are the vulnerable groups of people that are predisposes to developing pneumococcal infection
• Absent / non-functional spleen
– Congenital asplenia – born without a spleen
– Traumatic removal
– Hyposplenism (eg sickle cell) – spleen gets ruined as well
* Hypogammaglobulinaemia
* HIV infection
90
what bacteria does not having a spleen leave you vulnerable to and how do you treat it
```
• Vulnerable to encapsulated bacteria
– Pneumococcus
– HiB
– Meningococcus
• Vaccination
• Lifelong penicillin daily
```
91
what are the invasive and non invasive features of pneumoccoal
```
Non invasive
• Acute otitis media
• Sinusitis
• Conjunctivitis
• Pneumonia
```
```
Invasive
• Septicaemia
• Meningitis
• Peritonitis
• Arthritis
• Osteomyelitis
```
92
What are the symptoms of neonatal tetanus
- Weak
- Lethargic
- Poor suck
- Spams
- Fits
93
what are the two types of fungi and give examples
Yeasts
- such as candida
Moulds
- such as aspergillum
94
what are common suerpiical mycosis
```
• Common
o Candidiasis: nappy rash.
o Tinea Corporis: ring worm.
Treat both with topical antifungal (nystatin).
• Occurs in Normal Hosts
```
95
what are invasive mycosis
o Candidaemia: extremely preterm infant, effects kidneys and brain.
o Pulmonary Aspergillosis: child with chronic granulomatous disease.
Impaired neutrophil function.
• Opportunistic infections in immunocompromised hosts.
96
what are the symptoms of malaria
• Can be non-specific
– Fever, lethargy, vomiting, diarrhoea
```
• Severe disease
– Anaemia
– Respiratory distress
– Cerebral malaria (coma, seizures)
– Hypoglycaemia
```
97
What is the presentation of toxoplasmosis in the neonate
- Hepatosplenomaegaly
- Funducosopy – nasty retinitis
- Ultrasound scan of the brain – ventricular dilation that can cause hydrocephalus
98
what does the frequency of a wheeze depend on
- degree of narrowing
- elasticity of airway wall
- local airflow
99
describe congenital lobar emphysema
* Over distension of lobe
| * Partial bronchial obstruction
100
describe what bronchogenic Cyst present
o Early with respiratory distress.
| o Later with infection.
101
What problems can cancers affect later on
```
Growth and development
Psychosical
Organ function
Cacner
Fertility and reproduction
```
102
what is the most common cancers in 0-14 year olds
* Leukaemia (31.1%),
* CNS (25.4%),
* Lymphomas (10%).
103
what is the most common cancer in 15-19 year olds
* Lymphomas (20.7%),
* Carcinomas and Melanoma (19.6%)
* CNS (18.7%)
* Leukaemia (13.8%).
104
if you have wilms tumour what syndromes are you predisposed to
WAGR
- Wilms tumour
- Aniridia
- Genito-urinary abnormalities
- Mental retardation
Can also have
- Beckwith-wiederman syndrome (BWS)
105
why is the WT1 gene linked to kidney tumours (wilms tumour)
- WT1 plays a crucial role in ureteric branching
- WT1 and the WNT pathway (activated by beta catenin) have key roles in epithelial induction of the metanephric mesenchyme
106
what are the symptoms to retinoblastoma
- Leukocoria – white pupil when light is shone onto it
- Eye pain
- Redness
- Vision problems
107
what are chemotherapy related complications
hearing loss, infertility, cardiac toxicity and second malignancies
108
How does the patient present with acute lymphoblastic leukaemia and where does it metastasis to
* Bruising/bleeding.
* Pallor or fatigue due to anaemia.
* Infection due to neutropenia.
- liver, spleen, lymph nodes and mediastinum
109
what are the causes of abdominal pain
* Constipation
* Functional/RAP (recurrent abdominal pain)/IBS
* Duodenal ulcers/Helicobacter Pylori
* Inflammatory Bowel Disease
110
what are the causes of chronic vomiting/haemetemesis
* GOR.
* Intestinal Obstruction (if bile) intermittent.
* DU (rare)
111
what are the causes of rectal bleeding/blood stools
* IBD
* Chron’s/UC
* Fissures/haemorrhoids
* Polyps/polyposis syndromes
* Infection (bacterial).
112
what are the symptoms of IBD
o Weight loss
o Abdominal pains
o Tiredness
o Rectal bleeding
113
what are organic causes of constipation and how would you investigate them
- Hirschsprungs - rectal biopsy
- hypothyroidism - growth failure so check TSH
- neurologic - examines the spine and lower limbs
- anal stenosis - examination
114
what does reflex present like with children who are greater than three years old
- heart burn
- brash
- vomiting
- oesophagi's
- usually have history of reflux as an infant
115
what are the RED flags and pink flags for GORS
```
Red Flags
o Haemetemesis
o Failure to thrive
o Sandifers syndrome (back arching in infants)
o Aspiration pneumonia.
```
Pink Flags
o Daily symptoms for longer than 12 months
o Failed empiric theraphy
116
name 3 ways in which you can assess GORD
- pH study/impedence
- barium swallow
- upper GI endoscopy
117
how do you use a clinical score to mark GORD
- the I-GERQ-R is used
- this is a list of 12 questions that can be filled out by carers
- measures how significant refluxes are at home over the last week
118
what is the treatment of eosinophilic oesophagitis
• Dietary
o Food exclusions
o Pragmatic trials.
* Oral budesonide
* Monteleukast.
119
what is the symptoms of gastritis
* Vomiting
* Abdominal pain
* Haemetemesis
* Anaemia.
120
How do you diagnose gastritis
- Endoscopy
- Stool antigen
- C13 breath test
121
what is the presentation of crohns disease
```
• Abdominal pain
• Weight loss
• Diarrhoea
• Insidious onset
• Growth failure
• Raised ESR/CRP/low albumin/Hb.
- raised calprotectin greater than 20
```
122
what is the presentation of ulcitis colitis
* Chronic bloody diarrhoea
* Abdo pain
* Weight Loss
* Usually diagnosed within 2 months
123
when should you use surgical treatment for iBD
– Medical treatment not working
– Obstruction or other surgical emergency
– Poor growth and localised disease in Crohn’s
124
who are the two groups of children that are most likely to die at the hands of their carers
- vulnerable children and children in need
125
what is vulnerable children
A vulnerable child is defined as being under the age of 18 years and currently at high risk of lacking adequate care and protection.
126
what are the risk factors for physical abuse
Unrelated adult male in the house
Single, young, unsupported parents
Mental health problems
Domestic violence
Drug and or alcohol Abuse
Previous parental police records
Disabled child
127
what can neglect include
Failure to provide adequate food, shelter and clothing
Failing to protect a child from physical harm or danger
Failure to provide adequate supervision
Failure to ensure access to appropriate medical assessment and treatment
Unresponsive to a child’s basic emotional needs
128
what can emotional abuse involve
It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person.
It may feature age or developmentally inappropriate expectations being imposed on children.
It may involve seeing or hearing the ill-treatment of another.
It may involve serious bullying (including cyber-bullying), causing children frequently to feel frightened or in danger
129
what is the role of a doctor in child protection
Complete a child protection report
Opinion-‐ Accidental/Non-‐accidental injury Maintain a holistic approach
Assess for other medical problems
Assess growth and development
Ensure siblings are assessed
Attend Strategy meeting
Contribute to Child Protection Conference
130
what is an impairment
any loss or abnormality of psychological, physiological or anatomical structure or function. ( e.g. paralysis of the legs)
131
what is a disability
any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. (e.g. Inability to walk)
132
what is a handicap
the impact of the impairment or disability on the person’s pursuit or achievement of the goals which are desired by him/her or expected of him/her by society. (e.g. unable to work in a job that requires mobility)
133
iN the international classification of functioning disability and health (ICF) what are the three levels of it
* Impairment in body function/structure.
* A limitation in activity. - such as the inability to read or move around
* A restriction in participation such as exclusion from school
134
describe the 4 development screening/assessment questionnaires
ASQ ages and stages questionnaire – at 9 months and 2 years, parents complete, paper based, and health visitor/community nurse
SGS – schedule of growing skills - simple toys, crayons etc up to 5 years, screening tool relay
Griffiths.- formal assessment up to 6 years – takes 1 hour
Baylye – up to 2 years often used for ex premature
135
what does fetal alcohol spectrum disorder look like
- small head
- flat face
- small eye opening
- short nose
- low nasal bridge
- underdeveloped jaw
- thin upper lip
- smooth philtrum
136
what is executive function
An ability to organize and plan
An ability to focus and maintain attention
An ability to store and retrieve memories
An ability to inhibit inappropriate actions
An ability to prevent emotions from getting out of control
An ability to understand social situations and social behaviour
137
How does fetal alcohol spectrum disorder present
- Sleep disturbances, poor wake/sleep cycle
- Poor sucking responses/feeding problems
- Failure to thrive
- Hyper/hypo sensitivity to light cold pain
- Delays in walking and talking
- Delayed toilet training
- Difficulty in following directions
- Temper tantrums and disobedience
- Distractibility
138
what is a conduct disorder
Disorder of behaviour characterised by repetitive and persistent pattern of dissocial, aggressive or defiant conduct
139
who'does conduct disorder affect usually
Boys >> girls
Inner cities > rural areas
Socio-economic disadvantage
Family conflict and poor communication in the family
Increased incidence in looked after children
“Difficult” temperament
Specific reading disability
140
what are the three symptoms of attention deficit hyperactive disorder (ADHD)
- Hyperactivity
- inattention
- impulsivity
Hyperactivity
- Restless and fidgety
- Unable to wait
Impulsivity
- Acts without thinking
- Answers before questions finished
Inattention
- Jumps from task to task
- Makes carless mistakes
- Doesn’t listen properly
141
what are the risk factors of ADHD
- Boys > girls (4:1)
- Genetic factors
- Neuro-developmental abnormalities
- Maternal depression
- Smoking during pregnancy
142
How do you monitor ADHD
Height and weight - drugs can cause growth restriction
CVS – HR and BP
Sleep - drugs can cause sleep disturbance
Tics - can develop tics with the medication so you change which medication you are giving
143
describe the 4 aspects that you use to evaluate short stature
1. Height centile vs weight centile.
• Failure to thrive vs failure to grow.
```
2. When started.
• In utero
• In infancy
• In childhood
• In puberty
```
3. Body proportions.
• Primary or secondary growth disorder
4. Presenting signs.
• Idiopathic
144
What an cause disproportionate growth
Skeletal dysplasia
- achondroplasia - FGFR3 mutation - due to inhibition of ossification at the growth plates resulting in the long bones not elongating
- hydrochondroplasia FGFR3 mutation - due to structural and function receptor affected - milder and noticed later
- leri-welli dyschonrosteosis - reduced subischial length and madelung deformitiy, due to modparts of the limb shortening
rickets - caused by Vitamin D deficiency
145
describe madelung deformity and what its consists of
- Bowing of the radius
- Dorsal dislocation of the ulna
- Premature epiphyseal fusion
146
what can cause propionate growth failure
- psychosocial assessment = psychical growth retardation
- Syndrome features karyotypes = such as turners syndrome, Noonan, Williams
- tests for systemic disorders = such as chronic renal insufficiency, gastrointestinal disease, nutritional deficiency
test for endocrine disorder s= hypothyroidism and hypercortisolism
147
what are the phenotypes of turner syndrome
- short stature due to SHOX haplo-insufficiency
- webbed neck
- shield chest, widely spaced nipples
- cubitus valgus
- lymphedema of the hands
- shortening of 4th/5th metacarpal
- knocked knees
- gonadal dysgensis
148
What are the key features of Larons syndrome
```
Normal size at birth
Severe growth
restriction in infancy
Distinctive facial features
Blue sclerae
Hypoglycaemia (Insulin sensitivity
```
149
How do you manage idiopathic short stature
• Administration of GH
• Oxandrolone - anabolic steroid used for a long time and extradites growth but doesn't increase adult height
o Very little change in most cases.
150
what are the symptoms of Kawasaki disease
Medium vessel vasculitis of childhood in those aged less than 5 years old
- fever for at least 5 days with 4 or the following
1. bilateral conjunctival injection, non-exudative
- cervical lymphadenopathy
- polymorphous rash (not petechial bulls or vesicular)
- oral inflammation and irritation (not discrete lesions or exuate)
- ertherma and oedema of extermetieis progression to desquamination int he second week
If not treated you end up with a giant coronary artery aneurysm
151
What are the triple risk for SIDS
- vulnerable infant (male, prematurity, low birth weight)
- cortical developmental period
- external stressor (prone position, bed sharing, minor illnesses e.g. URTI, overheating, parental smoking)
152
what are mimics of abuse that you have have which are not abuse
Fractures
- Sometimes seen in vaginal delivery
- Osteopenia of prematurity
- Vitamin D deficiency especially in breast fed babies
- Osteogenesis imperfecta
- Resuscitation
Shaken baby syndrome
- - Triad of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhages
- SDH - 25-46% of asymptomatic newborn babies;
- retinal haemorrhages 34% of newborn babies (clear up to 2 months?)
153
what are the risks of STIs
Age - depends on age, anyone can get one but shift towards younger ages
Sexual partner - male will depend on whether they have exclusively male or female parterres, sex between men has a higher risk of STIs
Sexual practice - type of sex that you have, certain sort of sex have a higher risk - anal and vaginal sex has a higher transmission than oral sex
Condom usage - present STIs
Ethnicity
Area of residence
154
What are the types of chlamydia trachomatis -
serovars D-K
| serovars L1-3 cause
155
what symptoms can serovars D-K
Males - Urethritis - clear watery discharge, epipdidymitis, prostatitis
Females - Cervicitis(increase in vaginal discharge, spotting after sexual intercourse), Pelvic Inflammatory Disease, Fitz-Hugh Curtis - intra-abdominal syndrome
Neonate - conjunctivitis and pneumonia
156
what symptoms can serovars L1-3 cause
```
Lymphogranuloma venereum (lymphatic issues)
- Buboes, proctitis
```
- usually rectally acquired, can cause abdominal pain and change in bowel habits
157
What are the symptoms of Neisseria gonorrhoea
- males
- females
- neonates
Males – Urethritis, proctitis (rectally acquired), sore throat, epididymitis, prostatitis
Females – Cervicitis, PID, Peri-hepatitis, septic abortion
Neonates – Conjunctivitis
158
How do you treat neisseria gonorrhoea
– Ceftriaxone
| Drug resistance increasing
159
How do you manage genital warts
Vaccination
Management
- Topical podophyllotoxon, imiquimod
- Cryotherapy - freeze them of
160
What is the treatment of HSV
Aciclovir
Famciclovir - prodrugs
Valaciclovir - prodrugs
161
what is another word for syphilis
Treponema pallidum
162
Describe primary syphilis
Chancre usually single, painless
Dark ground positive - see organisms under the microscope
Lymphadenopathy
Serology may be negative
Infectious++
163
Describe secondary syphilis
Rash, fever, lymphadenopathy
Condyloma lata
Serology positive
Infectious++
- effects soles of hand and feet can cause redness
164
name some DNA enveloped viruses
Herpes viruses
- Herpes simplex
- Varicella zoster
- CMV
- Epstein-Barr
- HHV 6/7/8
Hepatitis B
Poxviruses
165
name some non-enveloped DNA viruses
Papillomavirus
Adenovirus
Parvovirus (ssDNA)
- spell out PAP, cervical smar for papillomarvirus
166
how does Herpes simplex virus present in neonates
Disseminated HSV
- Sepsis-like syndrome
- Hepatitis, coagulopathy
HSV encephalitis
- Fever, seizures
- Haemorrhagic infarction of white matter and cortex
167
How do you treat disseminated HSV
- IV Aciclovir
168
what are the problems with the treatment of CMV
- Neutropenia,
- thrombocytopenia
- IV access
- Long term fertility/malignancy risk
169
what are the symptoms of CMV
- sensioruneal deafness
- calcification in the brain
- hydrocephalus
- extra medullary haemopoitesis
- hepatosplenomeagly
170
what are the symptoms of varicella zoster virus
- rash - lasts 4-5 days
| - once the lesions have crusted over they are no longer transmittable
171
what are the symptoms of EBV in early life versus older children
```
Usually asymptomatic in early life
Infectious mononucleosis (glandular fever), typically 15-25 yrs old
```
172
What cancer can EBV cause
Burkitts lymphoma
173
what are the symptoms of Roseola infantum
- caused by HHV 6 and 7
| - sudden onset of high fever which lasts a few days then suddenly stops and the rash disappears
174
what are the consequences of chronic Hep B infection
Cirrhosis
Hepatocellular carcinoma
175
How do you reduce the risk hipB of transmission at birth
- give Hep B virus vaccine at birth and then at 1 month of age
- and HBIG as well (hepatitis B immunoglobulin)
176
what does poxvirus cause
smallpox
| molluscum contagiosum - found in groin and axilla areas, spread by direct contact
177
what can adenovirus cause
URTI / pneumonia
Conjunctivitis
Diarrhoea
Disseminated disease in immunocompromised hosts
178
What are the symptoms of parovirus B19
Asymptomatic
‘Slapped cheek’ syndrome
Arthropathy (adults) - present with disabling arthritis
Aplastic crisis
Fetal loss in pregnant women
179
What are important RNA enveloped virus
Measles, mumps, rubella
RSV, influenza, parainfluenza
Hepatitis C
HIV
- MMR, RSV, influenza, parainfluenza - respiratory in presentation
- Hepatisis C, HIV - blood infections
180
What are non enveloped RNA viruses
Rotavirus
Enteroviruses (includes polio)
Hepatitis A
- broadly cause enteric infections and gut infections
181
what are the original symptoms of measles
| and then what happens after 2 days and then 2 days after
Fever
Cough
Conjunctivitis
Miserable
then after 2 days get kopek spots
then after another 2 days a rash develops - usually starts behind the ear and spread downwards
182
what are the symptoms of rubella
- Fever
- occipital lymphadenopathy
- Mild rash
183
what are the symptoms of congenital rubella
EYES: cataracts, micro-ophthalmia, glaucoma
EARS: sensorineural deafness
HEART: pulm artery stenosis, VSD
- Low birth weight, rash, microcephaly
184
How does bronchiolitis present
- cough
- respiratory distress
- wheeze
185
how do you measure the perinatal mortality rate
number of stillbirths and early neonatal deaths per 1000 total births
186
describe how prematurity can lead to neonatal death and perinatal mortality
- Surfactant deficiency
- Periventricular haemorrhage
- Infection
- Necrotising enterocolitis
187
What is meckel-gruber syndrome
Meckel-Gruber syndrome is a rare and lethal autosomal recessive disorder characterized by occipital encephalocele, postaxial polydactyly and bilateral dysplastic cystic kidneys
188
List the maternal causes of still birth
- diabetes
- hypertensive disorder
- lupus
- APS
- cholestasis
- drug misuse
189
what are external finings of SIDS
- Body well developed and nourished
- Frothy fluid around nose
- Cyanosis of lipids and nail beds
190
what ligament is important in preventing uterine prolapse
- utter-sacral ligament
191
where does a lumbar block happen
L4/L5
192
what is the Rotterdam criteria for PCOS
i)Clinical hyperandrogenaemia
ii) oligomenorrhoea (less than 6-9 menses per year)
Iii) 12 or more polycystic ovaries on ultrasound. Or ovaries greater than 10ml
193
describe PID symptoms
- Asymptomatic
- pelvic pain
- deep dyspareunia
- malaise
- fever
- purulent vaginal discharge
194
what are the symptoms of endometriosis
Pain, dysmenorrhoea, menorrhagia, dyspareunia
| Ex: pelvic tenderness or mass, fixed uterus
195
what are the NICE guidelines for referring someone with subfertility
“Offer an earlier referral for specialist consultation to discuss options for attempting conception, further assessment and appropriate treatment if:
1. The woman in aged 36 years or over, and
2. There is a known clinical cause of infertility or a history of predisposing factors for infertility
196
```
how do you assess
- ovarian function
- tubal function
- uterine function
in secondary care
```
To assess ovulatory function:
• Bloods not done in primary care;
• Ovarian reserve testing-how female would respond to Gonadotrophin stimulation in IVF;
To assess tubal function: Hysterosalpingogram – this is when dye is injected in the room to look at the patency of the fallopian tubes – this can be painful
To assess uterine function: laparoscopy – for endometrioses to understand how significant things are
197
what are the NICE guides for unexplained infertility
Do not offer clomiphene-no increased chance of pregnancy or live birth (NOTE INTERNET PURCHASES - watch out that they don't do these).
To continue having regular unprotected intercourse for 2 years (investigations after 1 year).
Offer IVF after 2 years.
198
who should you offer IVF to
* Offer 3 cycles to Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI).
* Offer one cycle to 40-42 year old women if 2 years unprotected intercourse,12 cycles AI (6 or more IUI), never previously had IVF & no evidence of low ovarian reserve.
199
what are the symptoms of ovarian hyper stimulation syndrome
Mild: Lower abdo discomfort/distention, with or without nausea.
Severe: Abdo pain/distention, ascites, pleural effusion, venous thrombosis
200
when do you offer intracytoplasmic sperm injection (ICSI)
* Severe deficits in semen quality
* Obstructive azoospermia
* Non-obstructive azoospermia
* Couple in whom previous IVF treatment cycle has resulted in failed or very poor fertilisation
* Appropriate investigations (eg semen analysis) for dx.
* Consider genetic issues (karyotype for Kallman’s) and microdeletions on Y-chromosome.
201
Who do you offer intrauterine insemination IUI to
* People who are unable to have vaginal intercourse (disability).
* Requiring specific consideration (eg sperm wash in HIV pos men)
* Same-sex relationships
202
what is the difference between a primary post part haemorrhage and a secondary post part haemorrhage
Primary
>500ml blood loss from the genital tract within 24 hours of delivery
- commoner
secondary
abnormal bleeding from the genital tract, from 24 hours after delivery - 6 weeks
203
what are the 4 causes of primary PPH
T: Tone = uterus not contracting (70%)
T: Tissue = placenta/membranes left behind (20%)
T: Trauma = episiotomy/tear which keeps bleeding (9%)
T: Thrombin = clotting disorders that need to be corrected (1%).
204
What are the predisposing factors to a primary PPH
Antepartum haemorrhage in this pregnancy
Placenta praevia (15x risk)
Multiple pregnancy (5x risk)
Pre-eclampsia (4x risk)
Nulliparity (3x risk)
Previous PPH (3x risk)
Maternal obesity (2x risk)
Maternal age (increases with age)
Multiparity (parity > 4)
205
what are the intrapartum risk factors for a PPH
Emergency Caesarean section (9x risk)
Elective CS (4x risk)
Retained placenta (5x risk)
Episiotomy (5x risk)
Operative vaginal delivery (2x risk)
Labour >12 hours (2x risk)
>4kg baby (2x risk)
Maternal pyrexia in labour (2x risk)
206
What are pre-exisitng and pregnancy risk factors for thromboembolic disease
```
1, Previous VTE
2, Thrombophilia Congenital /Acquired
3, Age over 35 years
4, Obesity (BMI >30)
5, Parity >4
6, Gross varicose veins
7, Paraplegia
8, Sickle cell disease
9, Inflammatory disorders
```
```
Pregnancy related complications
1, Surgical procedure eg LSCS, MROP
2, Dehydration
3, Sepsis e.g. pyelonephritis
4, Pre-eclampsia
5, Excessive blood loss
6, Prolonged labour
7, Immobility after delivery
```
207
when does post partum psychosis happen
o Usually first 10 days following childbirth.
208
Explain the mechanism of action behind proliferation versus apoptosis of the cells in the prostate gland
- in the stomal cell testosterone is converted to estradiol via aromatase this causes cell proliferation when estradiol binds to ER alpha
- some of the oestradiol leaks across into the basal and luminal epithelium through the basement membrane and this causes apoptosis when the estradiol binds to ERbeta
- But Testosterone is converted to DHT via 5 alpha reductase in the basal epithelium, then testosterone can either bind directly to AR or bind to AR by DHT
- the binding to AR prevents epithelial cell apoptosis
- but in old age too much DHT and testosterone is produced therefore there is too much proliferation and not enough oestraiol causing apoptosis
209
What is the three finger test for hernias
index finger on DIR, middle finger on SIR and ring finger on saphenous opening. Ask cough:
Indirect: deep inguinal ring
Direct: superficial inguinal ring.
Femoral: at the saphenous.
210
describe the mechanism fo action of the smooth muscle relaxation during an erection
- Parasympathetic neurone which is non adrenergic and non cholinergic allows calcium to enter the synapse and causes the release of nitric oxide
- the nitric oxide then diffuses across the smooth muscle
- NO binds to soluble gauntly cylases and produces cGMP this causes the smooth muscle to relax and decreases calcium inflow
- then signals from the sympathetic neurone does the opposite
211
what are the effects of congenital varicella syndrome
```
Skin lesions (73%)
• leading to limb hypoplasia
```
CNS (62%)
• microcephaly, hydrocephaly, neurodevelopmental delay
• cataracts/other eye problems
* also GI, genitourinary & cardiac abnormalities
* miscarriage
212
what does toxoplasmosis cause
• IUGR
- hydrocephalus,
- cerebral calcification
- microcephaly
- hepatosplenomegaly
213
What are the symptoms of congenial syphilis
* Early i.e. 0 to 2 years
* rash
* rhinorrhoea
* osteochondritis
* perioral fissures
* lymphadenopathy
* GN
* Late i.e. > 2 years
* Hutchinson’s teeth
* Clutton’s joints
* high arched palate
* deafness
* saddle nose deformity
* frontal bossing
214
What are the risk factors of gestational diabetes
Previous GDM
FH of Diabetes
Previous macrosomic baby - babies are larger as they receive more glucose for growth, baby can produce a large amount of amniotic fluid
Previous unexplained stillbirth
Obesity
Glycosuria
Polyhydramnios - larger baby can produce more urine and therefore cause polyhydraminos
Large for Gestational Age (LGA) in the current pregnancy
215
what are the maternal complications of gestational diabetes and type two diabetes (more likely complications if you have gestational diabetes)
1) Hyperglycaemia/hypoglycaemia
2) Pre-eclampsia
3) Infection
4) Thromboembolic disease
216
What are the foetal complications of gestational diabetes and type 2 diabetes
1) Macrosomia (birth asphyxia and traumatic birth injury)
2) Respiratory Distress Syndrome
3) Hypoglycaemia - used to an rich sugary environment and then when there born they are not exposed to as much sugar
4) Hyperbilirubinaemia (Jaundice)
Congenital abnormalities ( this is to do with poor glucose control (due to pre-exisiting diabetes) in the first 12 weeks of the pregnancy)
217
Group B streptococous effects on the neonate
* Pneumonia
* Meningitis
* Non-focal sepsis
* death
218
what makes up the risk pro-life for group B streptococcus
* Preterm ruptured membranes
* Prolonged ruptured membranes
* Previous GBS neonatal infection
* Intrapartum fever
* GBS bacteruiria in pregnancy
219
what can cause macrosomia
- macrosomia is when the baby is larger than the 95% percentile
causes
Maternal diabetes – espically if not diagnosed or controlled
Maternal obesity
Previous large babies
Prolonged pregnancy
220
what are the problems with passage
Contracted pelvis – malnourished or have babies younger when the pelvis haven’t formed yet
Placenta praevia – haemorrhage
Soft tissue tumours = fibroids blocking the way or a big fibroid in the lower part of the uterus
Pendulous abdomen- those that have lots of babies before have lost the muscle tone in the tummy it is not as easy for the baby to come out
221
what are the different problems you can have with the power of contraction
Uterine inertia
Inco-ordinate contractions
Hypertonic contractions
Uterine Rupture
222
what are the signs of a poor fit when giving brith
Failure of progressive cervical dilatation
Failure of descent of the presenting part
Moulding
Caput
223
what are the two signs of fatal distress in labour
- Meconium-stained liquor - made out of bowel contents and disquemnetated cells
- fetal heart rate abnormalities
224
what are the problems with the 3rd stage of labour
Retained placenta – placenta should be out before an hour and normally within 30 minutes if not out in this time then manaual removal of the placneta
Uterine atony – cytosnoe?, emptying the bladder
Soft tissue lacerations
Uterine inversion
225
what are the 6 types of miscarriage
Threatened
- cervical os is closed
- bleeding light
Inevitable
- cervical OS open
- bleeding heavier than threatened
Incomplete
- cervical os is open
- some fetal tissue has passed
Complete
- cervical os shut and uterus is no longer open
- not fetal tissue remaining
- no longer bleeding
Septic
- tender uterus, fever may be absent
- contents of the uterus is infected
Missed
- cervical OS closed
- fetus has not developed and died in utero
226
what are the symptoms of a septic miscarriage
- Contents of uterus infected causing endometritis
- Vaginal loss offensive
- Tender uterus
- May be present with sings of pelvic infection
227
what are the investigations that you do in a miscarriage
Ultrasound scan
- Detects the location and viability – may show retained tissue, if any doubt repeat scan after 1 week (NICE)
Serum B HCG
- Increases in greater than 66% in 48 jrs in viable pregnancy
Other bloods
- FBC
- G+ S
- Rhesus status - give Anti D to rhesus negative women
228
How do you manage a miscarriage
Expectant
Wait for spontaneous resolution
o Resuscitation if blood loss is substantial
Medical Management
Removal of fetal tissue (using prostaglandins such as misoprostol).
Surgical Management
Curettage (scraping instrument)/surgical aspiration.= this can cause scarring of the womb which will cause fertility problems
= done under ultrasound guidance
229
What are the causes of a recurrent miscarriage
- problems in the uterine cavity e.g. large fibroids
Autoimmune disease (e.g. anti-phospholipid syndrome): 25%.
Chromosomal defects (4%).
Hormonal factors
Infection.
Others (obesity, smoking, maternal age, drug abuse
230
What are the risk factors for an ectopic pregnancy
- Smoking
- Scarring in womb and previous structures
- Previous ectopic – 10-15% chance that you will have another
- STIs
- Emergency contraction
- IVF
- Pelvic surgery
- IUCD in situ
231
How do women present with ectopic pregnancies
Women of reproductive age
- Positive pregnancy test/ Amenorrhoea 4-10 weeks
- PV bleeding
- Low abdo pain
- Collapse +/- shoulder tip pain
find
Tachycardia, abdominal tenderness.
Uterus is smaller than expected gestation
Cervical os is closed.
232
what do you manage the complete molar pregnancy
- surgery to remove the molar tissue
- 15% of molar tissue remains in the deeper tissue of the body and this can result in a gestational tumour
- need to have chemotherapy to get rid of it
233
How do you manage a partial molar pregnancy
- surgery to remove the molar tissue
- only 1% will have abnormal cells remaining in the deep tissue and have a persistent gestational tumour - this will need to have chemotherapy to get rid of it
234
What are the clinical features of a molar pregnancy
PV Bleeding
HG (excess HCG production)
o HCG secreted by syncytiotrophoblast.
Passage of vesicles per vaginum.
Examination
Large uterus
Early pre-eclampsia and hyperthyroidism may occur.
235
what are the causes of an antepartum haemorrhage
```
Placenta abruption
Placental praevia
Incidental genital tract pathology
Uterine rupture
Vasa praevia
```
236
what are the risk factors for placenta abruption
- Prev abruption,
- ↑ BP, Trauma
- Smoking
- idiopathic
- Multiparity
- ECV
- Polyhydramnios
237
Why are the clinical features of placental abruption
- Intense constant abdo pain
- +/- PV bleeding
- Shock, Oliguria, DIC
- Tense ‘woody’ uterus
- Fetal heart rate weak or absent
238
what are the risk factors of a placenta praevai
Prior praevia
Multiparity
Multiple pregnancy
Advanced maternal age
Prev LSCS
Smoking
239
what are the clinical signs of a placenta praevia
- Painless vaginal bleeding: usually between 32-37 weeks
- Uterus soft and non tender
- Malpresentation is common
- Requires c section delivery
- May result in pre-term delivery
240
What are the risk factors for pre-eclampsia
- age
- previous
- diabetes
- obesity
- hypertension
- autoimmune diseases
- sickle cell disease
- high age gap between pregnancies e.g. not having a pregnancy for 10 years
placental abnormalities
- hypoxia
- ischemia repercussion injury
- damage to the placental vili
241
what are the signs and symptoms of pre eclampsia
- Headaches
- Seeing spots
- Stomach pain
- Feeling nausea and throwing up
