Women's health Flashcards
What are the indications for mammagraphy?
- clinically suspicious lump in pts >40
breast cancer where mammography not previously performed (any age)
residual lump after cyst aspiration
single duct blood stained nipple discharge
nipple skin change
triennial mammograms between ages 47 and 73 as part of national breast screening programme
contra-indications to mammography
breast pain without lump
symmetrical thickning
before commencing hrt
women under 40 years unless diagnosed with previous breast cancer
What features are common in a mammaogram if the pt has neoplastic lesions?
mass, often spiculation or more subtle irregular
microcalcification may be present
distortion of surrounding breast parenchyma
a 24 yr old with palpable mass in breast should have what minimum investigation?
Ultrasound, then maybe biopsy depending on findings. Risk of malignancy neglible in this age group
a 25-39 yr old with palpable mass in breast should have what minimum investigation?
breast ultrasound plus histology or cytology. Triple assessment
a 40+ with palpable mass in breast should have what minimum investigation?
mammography and ultrasound and either histoloy or cytology. Triple assessment
What are the different types of tissue diagnosis in breast cancer?
Fine needle aspiriation cytology (FNAC)
Core biopsy (gives histological diagnosis)
vacuum assisted biopsy
open (surgical biopsy)
What is a triple assessment in breast cancer?
combination of:
1. clinical assessment
2. radiological assessment (US/MMG/MRI)
3. pathological assessment (FNA, core biopsy).
What is the NHS breast screening program?
uk, women aged 47-73 years invited every 3 years to have screening mammography.
indications for mastectomy
pt choice
large tumour relative to pts breast,
multifocal
sub-areolar tumour
contra-indication to radiotherapy (prev radiotherapy, unable to lie flat, ataxia)
failed conservation surgery
BRCA gene in young pt
bilateral prophylactic mastectomy
local reccurence after wide load excision and radiotherapy
inflammatory breast cancer
indications for breast conservation
pts choice
operable unifocal primary tumour where resection less than 20%
tumour at favourable site for conservation
suitable for radiotherapy
What are the surgeries to the axilla following breast cancer?
axillary node clearance
sentinel node biopsy
non-surgical management
complications of axilllary node clearance (ANC)?
seroma formation (60%)
shoulder stiffness
permenant or temp paraesthesia under arm due to damage to intercosto brachial nerves (60%)
lymphoedema to arm
damage to long thoracic nerve of bell
damage to nerve and blood supply to latisimus dorsi muscle
damage to axillary vein and very rarely brachial plexus
Radiotherapy for breast cancer indications
always given to remaining breast after wide local excision
after some mastectomies for poor prognosis, high risk tumours
to palliate a large or inoperable primary cancer
treat symptomatic bone mets where it may cause disease regression and reduces bone pain after a few weeks
treat axilla in woman instead of axillary clearance
reduces local recurrence rates
Hormonal therapy treatment for breast cancer in pre-menopausal women
1st line - tamoxifen
Hormonal therapy treatment for breast cancer in post-menopausal women
Aromatase inihibitors (exemestane, letrozole, anastrozole)
How does an intraductal papilloma normally present?
benign breast lesion grows within mammary ducts of breast.
typically presents; blood tinged nipple discharge, without any skin changes or palpable lumps.
31yr, lump in right breast. Recently stopped breast feeding.
o/e: firm, well circumscribed mass, subareolar region. mobile, non-tender, 2cm diameter. left breast no abnormalities.
Most likely diagnosis?
galactocele - most common in women who recently have ceased breast feeding. milk builds up and stagnates within lactiferous ducts, leading to formation of a mobile cyst like lesion which can be tender
56 yr old woman, breast clinic for 3 yearly breast screening app. no abnormalities on physical exam.
mammogrm shows star shaped pattern of scarring with translucent centre in left breast.
Most likely diagnosis?
radial scar - benign which can mimic breast carcinoma,=. Idiopathic sclerosing hyperplasia of breast ducts. pts are typically asymptomatic and usually picked up incidentally on mammogram showing a star or rosette-shaped lesion with translucent centre
mammary duct ectasia presentation
perimenopausal, thick, sticky green or yellow nipple discharge with nipple inversion
What’s gestational age?
1st day last menstrual period (LMP), + 7 days, = 9 months (280 days)
When is term in pregnancy?
37+0 weeks
What is gravidity?
number of times a woman has been pregnant regardless of outcome
what is parity?
the number of times a womaaan has delivered a fetus with gestational age greater than 24wks
what is parity?
the number of times a woman has delivered a fetus with gestational age greater than 24wks
Definition of pre-eclampsia
placental condition affecting pregnant women commonly from around 20weeks gestation
clinical features of pre-eclampsia
hypertension and proteinuria
other signs; peripheral oedema, severe headache, drowsiness, visual distrubances, epigastric pain, nausea/vomiting and hyperreflexia
Aetiology of pre-eclampsia
related to dysfunctional trophoblast invasion of the spiral arterioles leading to decreased uteroplacental blood flow and resultant endothelial cell damage.
Risk factors for pre-eclampsia
nulliparity, previous hx or fhx of pre-eclampsia, increasing maternal age, exisiting disease (hypertension, diabetes, renal disease, autoimmune disease). Obesity, multiple pregnancy.
Maternal complications of pre-eclampsia
eclampsia (seizures due to cerebrovascular vasospasm), organ failure, disseminated intravascular coagulation (DIC), HELLP syndrome (presence of haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
Foetal complications of pre-eclampsia
intrauterine growth restriction, pre-term delivery, placental abruption, neonatal hypoxia
Management of pre-eclampsia
Anti-hypertensive treatment, delivery of placenta only curative treatment.
Labetalol recommended 1st line anti-hypertensive.
Magnesium sulfate can be used as prevention and treatment of eclamptic seizures
Why should you do FBC and LFTs as an investigation once a woman has pre-eclampsia?
important to screen for HELLP syndrome
How frequent should pts with severe pre-eclampsia have blood tests and which blood tests should these be?
U&Es, FBC, transaminases, and bilirubin
3 times a week
- to anticipate if a pt is developing HELLP syndrome
Which is a high risk factor for pre-eclampsia: Family history of pre-eclampsia, 1st pregnancy, type 2 diabetes mellitus
type 2 diabetes
What is chorioamnionitis?
infection of the membranes in the uterus
Clinical features of chorioamnionitis
fever, abdo pain, offensive vaginal discharge, evidence of preterm rupture of membranes
typical signs - maternal and foetal tachycardia, pyrexia, uterine tenderness
Management of chorioamnionitis
indication for admission and delivery
require IV broad spectrum antibiotic therapy as part of sepsis six protocol
What’s the definition of baby blues?
transient lability in mood from around 3days after birth, usually resolving within 2 weeks
Characteristics of baby blues
irritability, anxiety about parenting skills and tearful
Management of baby blues
supportive, reassuring
Definition of cord prolapse
during labour, the umbilical cord exits the cervix prior to delivery of the infant. Causes acute compromise of umbilical blood supply to the infant and necessitates immediate delivery.
Risk factors for cord prolapse
abnormal lie, multiple pregnancy, polyhydramnios, high head, multiparity, low birth weight, prematurity
Management of cord prolapse
foetus should be delivered as rapidly as possible
prevent further prolapse by adopting knees to chest position
filling bladder with 500ml warmed saline
avoid exposure and handling of the cord, reduce cord into vagina
terbutaline to stop uterine contractions
What is HELLP syndrome?
presence of haemolysis (H),
elevated liver enzymes (EL),
low platelets (LP)
often manifests during 3rd trimester
Clinical features of HELLP syndrome
headache,
nausea/vomiting,
epigastric pain,
right upper quadrant abdo pain
blurred vision,
peripheral oedema
Maternal complications of HELLP syndrome
organ failure,
placental abruption,
disseminated intravascular coagulopathy (DIC)
Foetal complications of HELLP syndrome
intrauterine growth restriction,
preterm delivery,
neonatal hypoxia
What are the causes of antepartum haemorrhage and whats the definition
PV bleed after 24wks gestation
Causes: placental abruption, placenta praevia, vasa praevia, cervical ectropion, 50% unexplained
What is the definition of placental abruption
premature separation of placental bed
Presentation of placental abruption
acute abdo pain (but not always), contractions,
antepartum haemorrhage (but not always),
woody uterus on palpation
Investigations for placental abruption
bloods,
coagulation screen,
USS foetus,
CTG monitoring
Management of placental abruption
Expedite delivery (induction or C section dependent on foetal condition)
What is placenta praevia?
placenta lying in lower segment of the uterus - graded system
Presentation of placenta praevia
painless antepartum haemorrhage,
soft uterus
Investigations for placenta praevia
bloods, coag screen, USS foetus, CTG monitoring
Management for placenta praevia
elective c section
What’s the steps of delivering the baby in normal labour?
- descent and engagement
- flexion - narrowest diameter
- internal rotation of head into OA
- extension - crowning
- restitution - head aligns with shoulders
- external rotation - shoulders rotate
- delivery of shoulders - gentle traction
What is the definition of failure to progress in labour
insufficient rate of dilatation / foetal descent
What are the causes of failure to progress in labour?
Power - hypotonic uterine activity
Passage - pelvic dimensions
Passenger - position, attitude, head size
Management for failure to progress in labour
augmentation of labour - ARM, syntocinon infusion
Instrumental delivery - forceps or ventouse
C section
What are the 7 layers that must be cut through in a c section?
- skin
2 Camper’s fascia - Scarpa’s fascia
- Rectus sheath
- seperate rectus abdominus
- parietal peritoneum
- uterus
What is shoulder dystocia?
normal gentle axial traction insufficient to deliver shoulders after head is born
Risk factors for shoulder dystocia?
previous hx, macrosomnia (big baby), diabetes, high maternal BMI
Complications of shoulder dystocia
brachial plexus injury, cerebral palsy, perinatal mortalitiy, PPH
Management of shoulder dystocia
1 call for help
2 tell mum to stop pushing, lie flat on bed
3. McRobert’s + suprapubic pressure + axial traction
4. internal manourves, deliver posterior arm
5. all fours, repeat
6. third line: cleidotomy, Zanvanelli, symphysiotomy
What is primary and secondary post partum haemorrhage?
primary - 500ml loss within 24hrs delivery
secondary - 500 ml loss 24hrs - 12 weeks post delivery
What are the causes of post partum haemorrhage? (4Ts)
Tone - atonic uterus (prolonged labour, macrosomnia, twins)
Trauma - genital tract injury
Tissue - retained placenta / membranes
Thrombin - coagulopathy (DIC in pre-eclampsia)
Management of post partum haemorrhage
fundal massage + syntocinon + ergometrine
resus: fluids, oxygen, blood products
Which is the most common gynae cancer?
Endometrial
What age group is at risk for endometrial cancer?
post menopausal
What is endometrial cancer
adenocarcinoma of the endometrium
Risk factors for endometrial cancer
obesity, unopposed oestrogen, tamoxifen
Presentation of endometrial cancer
post menopausal bleeding means 2ww - endometrial cancer until proven otherwise
Investigations for endometrial cancer
Transvaginal USS, endometrial biopsy
Management of endometrial cancer
total hysterectomy + bilateral salpingo - oophorectomy +/- brachytherapu +/- carboplatin/paclitaxel
What is ovarian cancer and who does it affect?
adenocarcinoma (germinal epithelium)
postmenopausal women
risk factors for ovarian cancer
BRCA, family hx, never used COCP
Presentation of ovarian cancer
pelvic mass, ascites, IBS symptoms, urinary symptoms
Investigations for ovarian cancer
CA125 (>35), USS abdomen
Management of ovarian cancer
total abdominal hysterectomy + BSO + carboplatin / paclitaxel
What is cervical cancer?
squamous cell carcinoma of ectocervix
peak incidence 30-35
What is cervical cancer linked to cause?
HPV (strains 16 +18) - preventable by vaccine
Risk factors for cervical cancer
HPV infection
Presentation of cervical cancer
asymptomatic finding, post coital bleeding, intermenstrual bleeding, abnormal discharge
When is screening for cervical cancer done
25-49 3 yearly, 5-64 5 yearly.
Management for cervical cancer
dependent on stage, cone biopsy for CIN, hysterectomy + cisplatin + radiotherapy
What is dysmenorrhea?
Very painful periods
Top differentials for dysmenorrhea
Primary dysmenorrhea 6-12months after menarche, no specific cause
endometriosis, adenomyosis, fibroids, PID
What is endometriosis
presence of endometrial stroma and glands outside the uterine cavity
Presentation of endometriosis
dysmenorrhea, cyclic pelvic pain, subfertility
Investigations for endometriosis
Transvaginal USS, laproscopy is gold standard
Management of endometriosis
1: COCP, mirena, medroxyprogesterone
2. endometriosis surgery
What is menorrhagia and what are top differentials
80ml loss per cycle/period lasting more than 7 days
dysfunctional uterine bleeding, fibroids, endometriosis, hypothyroidism, coagulopathy
What are fibroids?
benign neoplasia of uterine smooth muscle
Presentation of fibroids
menorrhagia, pelvic pressure, bloating, dysmenorrhoea
Investigations for fibroids
transvaginal USS, hysteroscopy
Management for fibroids
- mirena IUS, COCP, tranexmic acid, mefenamic acid
- leuprorelin (GnRH analogue) / mifepristone (anti-progestogen)
- myonectomy (fertility preserving), hysterectomy
What is oligomenorrhea and what are top differentials
infrequent periods
function hypothalamic amenorrhoea - stress, exercise, weight loss, eating disorders.
PCOS
hyperthyroidism
perimenopause + many others
Investigations for oligomenorrhea and amenorrhea
full gynae hx and obs hx
measure height and weight
FSH LH
serum testosterone
prolactin
TSH
What is PCOS
2/3 Rotterdam criteria:
1. oligomenorrhea
2. features of hyperandrogenism
3. polycystic ovaries
Pathophysiology of PCOS
- abnormal ovarian steroidgenesis leads to raised androgens
- increased GnRH frequency, high LH, low FSH, high androgens, low aromatase, high androgens, low oestrogen, no LH surge, no ovulation, cyst antral fluid remains
- insulin resistance, mitogenic on ovaries and adrenals, high androgens
Presentation of PCOS
oligomenorrhea, subfertility, acne, hirsutism
Investigations for PCOS
FSH/LH, SMBG, testerone, TFTs, prolactin, USS
Management of PCOS
COCP, metformin + clomiphene
What are the differentials of acute lower abdo pain and what would you investigate?
- appendicitis, ectopic pregnancy, ovarian torsion, miscarriage, cyst rupture, PID / tubal abscess
- urine pregnancy test
- Transvaginal USS - serum beta-hCG if no pregnancy found in positive UPT
What is an ectopic pregnancy
implantation of conceptus anywhere outside of uterine cavity (usually tubal)
Site - usually ampulla of fallopian tube
Presentation of an ectopic pregnancy
typically 6-8 weeks gestational age, acute iliac fossa pain, tenderness, guarding, PV bleed
Investigations for ectopic pregnancy
pregnancy test, transvaginal USS, serial beta-hCG if pregnancy not found
Management of ectopic pregnancy
- if not ruptured, methotrexate or laproscopic salpingectomy
- ruptured - laparoscopic salpingectomy / salpingotomy + resus +/- post op methotrexate
Contraindications to breastfeeding
infants of mothers with TB infection
Infants of mothers with uncontrolled/unmonitored HIV
Infants of mothers who are taking medication which may be harmful such as amiodarone (arrythmia med)
Which medication helps to stop a woman breastfeeding?
Cabergoline (dopamine receptor agonist, which inhibits prolactin production leading to suppression of lactation)
What other medications should be avoided when breastfeeding apart from amiodarone
lithium, tetracycline, sitagliptin, methotrexate
What is rhesus isoimmunisation
Occurs when a rhesus negative mother has a baby which is rhesus positive
if any foetal red blood cells enter maternal blood, mother will form anti-D antibodies against them.
maternal anti-D antibodies can cross placenta and cause rhesus haemolytic disease
Sensitisation events in rhesus isoimmunisation
indications for anti-D prophylaxis
- antepartum haemorrhage
- placenta abruption
- abdominal trauma
- external cephalic version
- invasive uterine procedures; amniocentesis and chorionic villus sampling
- rhesus positive blood transfusion to a rhesus neg woman
- intrauterine death, miscarriage or termination
- ectopic pregnancy
- delivery (normal, instrumental, c section)
Mx of Rhesus negative mother
prophylaxis of anti-D antibodies given at sensitisation events, and at 28weeks
What is haemolytic disease of the newborn
immune condition which develops after rhesus negative mum becomes sensitised to rhesus positive blood cells of baby in utero
Features of haemolytic disease of the newborn
hydrops foetalis; foetal odema in at least 2 compartments
yellow coloured amniotic fluids due to excess bilirubin
jaundice and kernicterus in neonate
foetal anaemia causing skin pallor
hepatomegaly or splenomegaly
severe odema if hydrops foetalis present in utero
Paeds resus advice
5 rescue breaths followed by 15 chest compressions
What is placenta accreta spectrum?
spectrum of abnormalities of placental implentation into uterine wall
Placenta accreta?
adherence of placenta directly to superficialy myometrium but does not penetrate thickness of muscle
Placenta increta
Villi invade into but not through the myometrium
Placenta pecreta ?
villi invade through full thickeness of myometrium to serosa
increased risk of uterine rupture and in severe cases placenta may attach to other abdo organs such as bladder or rectum
Risk factors for placenta accreta spectrum
previous termination of pregnancy
dilatation and curettage
previous csection
advanced maternal age
placenta praevia
uterine structural defects
dx of placenta accreta spectrum
doppler USS
MRI
clinical dx difficult antenatally
Complications of placenta accreta spectrum
increased risk of severe post partum bleeding, preterm delivery and uterine rupture
mx of placenta accreta spectrum
elective c section and hyrestectomy
Features of preeclampsia
hypertension
proteinuria
peripheral oedema
headaches
drowsiness
visual disturbances
epigastric pain
nausea/vomiting
hyperreflexia
When are women offered a blood test to check for anaemia in pregnancy?
booking appointment and 28week appointment
other blood tests offered at these appointments: FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies, hep B, syphilis, HIV
Which investigation is used to detect foeto-maternal haeemorrhage in a suspected event to ensure enough anti-D immunoglobulin has been given to mum
Kleinhauer test
used to detect amount of foetal haemoglobulin in mother’s blood stream
concerning feature on a ctg?
deceleration of 15bpm beginning during and lasting 60s after a contraction has terminated
Pregnant lady with pre-eclampsia, what is 1st line antihypertensive?
1st line - labetolol
CI in asthma, heart failure and heart block so then 1st line would be nifedipine
What is magnesium sulfate used for in pregnancy
seizure prophylactic in severe pre eclampsia, and IV magnesium sulfate used to terminate eclamptic seizure
Which antihypertensives are CI in pregnancy?
Ramipril and other ACE inhibitors
What is a fibroadenoma
benign mass from fibrous tissue in breast
usually painless, small, rubbery mass that is mobile
common in 15-35
usually dissappears in menopause
What is fetal hydrops
abnormal accumulation of serous fluid in 2+ fetal compartments (pleural, pericardial effusions, ascites, skin oedema, polyhydramnios or placental oedema)
Causes of non-immune fetal hydrops
severe anaemia - congenital parvovirus B19 infection, alpha thalassaemia major, massive materno-feto haemorrhage
Cardiac abnormalities
Chromosomal - Trisomy 13,18,21 or Turners
Infection - toxoplasmosis, rubella, CMV, varicella
Twin - Twin transfusion syndrome
Chorioangioma
what is main cause of anaemia in pregnancy
iron deficient anaemia (95%)
Risk factors for developing pre-eclampsia
nulliparity
previous hx or family hx
increasing maternal age
exisiting disease (hypertension, diabetes, renal disease, autoimmune disease)
obesity
multiple pregnancy
What is obstetric cholestasis
build up of bile acids
Clinical features of obstetric cholestasis
pruritis (hands and feet worse, no rash)
fatigue or malaise
nausea or loss of apetite
rarely: dark urine, pale stools (jaundice)
upper R abdo pain
mx of obstetric cholestasis
ursodeoxycholic acid (UDCA)
chlorphenamine to reduce itch
vit K reduce risk of haemorrhage
scheduling early delivery
Clinical features of eclampsia
hypertension
proteinuria
peripheral oedema
severe headache
drowsiness
visual disturbances
epigastric pain
nasuea/vomiting
hyperreflexia
seizures
Clinical features of eclampsia
hypertension
proteinuria
peripheral oedema
severe headache
drowsiness
visual disturbances
epigastric pain
nasuea/vomiting
hyperreflexia
seizures
Risk factors for eclampsia
nulliparity
previous hx or family hx
increasing maternal age
exisiting disease: HTN, diabetes, renal disease, autoimmune disease
obesity
multiple pregnancy
maternal complications of eclampsia
seizures
organ failure
HELLP syndrome (haemolysis, elevated liver enzymes, low platelets
foetal complications of eclampsia
intrauterine growth restriction
pre term delivery
placental abruption
neonatal hypoxia
mx of eclampsia
magnesium sulphate for seizures
labetalol 1st line anti hypertensive
if asthma, labetalol CI - nifedipine 2nd line
what is Gilbert’s syndrome
autosomal recessive decreased activity of enzyme that conjugates billirubin with glucaronic acid
Clinical features of Gilbert’s syndrome
intermittent mild jaundice in relation to stress, fasting, infection or exercise
mildly increased bilirubin but normal FBC
Indications for Induction of labour
post dates (>41 wks gestation)
preterm prelabour rupture of membranes
intrauterine foetal death
abnormal CTG
pre eclampsia, diabetes, cholestasis
CI for Induction of labour
previous classical incision during C section
multiple lower uterine segment C section
transmissable infections: herpes simplex
placenta praevia
malpresentations
severe foetal compromise
cord prolapse
vasa pravia
MEthods of Induction of labour
membrane sweep
vaginal prostaglandins (PGE2)
amniotomy
balloon catheter
reasons for each method of Induction of labour
membrane sweep 1st line
then vaginal pge2 unless CI of increased risk uterine hyperstimulation
oxytocin not used alone as primary unless CI to prostaglandins
misoprostol and mifepristone only used if indication is intrauterine foetal death
Freya, a 42-year-old woman, presents to the GP complaining of increasingly frequent,
prolonged and heavy periods. She states she has been passing more clots than usual. Freya
also complains of some constipation which has developed recently, as well as some
discomfort in her lower abdomen. On abdominal examination, there is a palpable, non-tender
mass arising from the pelvis. What is the most likely cause of Freya’s heavy menstrual
bleeding?
fibroids - common cause heavy menstrual bleeding and making palpable mass (uterus) on examination
Clinical features of endometriosis
cyclical pain
dysmenorrhoea
dysparuinia
subfertility
pelvic exam: tender, nodular masses on ovaries or ligaments surrounding uterus
gold standard diagnostic for endometriosis
laparoscopy
mx for endometriosis
analgesics
hormonal therapies:
COCP
medrixyprogesterone acetate
gonadotrophin-releasing hormone agonists
Presentation of fibroids
asymptomatic
menstrual dysfunction - menorrhagia and dysmenorrhoea
may be palpable on examination if big enough - non-tender uterus
You meet a 37-year-old woman on labour ward who is 40+5 weeks gestation and has elected to be induced. You return shortly after induction to find the patient is barely responsive and visibly dyspnoeic.
Your colleage takes some observations which show the patient is hypoxic and hypotensive. You suspect an amniotic fluid embolism.
Which of the following is the most appropriate next step in management?
give pt 15L O2 via non-rebreathe mask and call anaesthetist
What is the commonest cause of anovulation in women?
PCOS
definition of infertility
diminished ability of a couple to conceive a child or unexplained failure to conceive over a 2 year period
Statistically a couple stands an 80% chance of conceiving within 1 year if:
woman under 40
do not use contraception
have regular intercourse
factors affecting natural fertility
increasing age
obesity
smoking
tight fitting underwear (males)
excessive alcohol consumption
anabolic steroid use
ilicit drug use
Genetic causes of infertility
Turner’s syndrome
Kleinfelter’s syndrome
ovulation/endocrine disorders causing infertility
PCOS
pituitary tumours
Sheehans syndrome
Hyperprolactaemia
cushing’s syndrome
premature ovarian failure
tubal abnormalities causing infertility
congenital anatomical abnormalities
adhesions following PID
uterine abnormalities causing infertility
bicornate uterus
fibroids
asherman’s syndrome
Whats most likely causative agent for Bartholin’s cyst
E. coli
