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Phase 3A > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Ligaments of the uterus

A

o Broad ligament – double layer of peritoneum attaching sides of uterus to pelvis
o Round ligament – from uterine horns to labia majora via inguinal canal, maintains anteverted position of uterus
o Ovarian ligament – joins ovaries to uterus
o Cardinal ligament – from cervix to lateral pelvic walls, contains uterine artery and vein
o Uterosacral ligament – cervix to sacrum, supports uterus

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2
Q

phases of the menstrual cycle

A

follicular phase days 1-13/14, ovulation day 13/14, luteal phase days 14-28

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3
Q

follicular phase of egg before entering menstrual cycle

A
  • primordial follicle - 1 oocyte surrounded by granulosa cells (secrete oestrogen, progesterone and inhibin)
  • primary follicle - zona pellucida forms
  • preantral follicle - granulosa cells differentiate into Theca cells (oestrogen)
  • early antral follicle - oocyte full size, antrum forms and fills with fluid (from birth to when it enters cycle)
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4
Q

follicular phase during menstrual cycle

A
  • makes mature/Graafian follicle
  • after day 7 10-15 early antral follicles grow
  • 1 is dominant and antrum grows
  • LH surge - oocyte emerges out of meiotic arrest - first division into secondary oocyte
  • ovulation
  • enzymes rupture follicle and oocyte carried away in antral fluid
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5
Q

luteal phase

A
  • after ovulation granulosa cells increase in size becoming corpus luteum (oestrogen, prog, inhibin)
  • no fertilisation after 10d corpus luteum undergoes apoptosis = triggers menstruation
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6
Q

uterine changes during menstrual cycle

A
  • Days 1-5 – menstrual phase, decreased progesterone - endometrial degeneration and menstrual flow
  • Days 5-14 – proliferative phase, oestrogen makes endometrium thicken and stimulates myometrium and progesterone receptor generation
  • Days 15-28 – secretory phase, progesterone binds overriding oestrogen to prevent myometrium contraction and the endometrium secrets glycogen to nourish oocyte
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7
Q

oestrogen and the menstrual cycle

A

produced by granulosa cells in follicular phase and by corpus luteum in luteal phase

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8
Q

progesterone and the menstrual cycle

A

produced by granulosa and theca cells in small amounts in follicular phase, by corpus luteum in large amounts in luteal phase

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9
Q

FSH in menstrual cycle

A

o High early in follicular phase due to decrease in oestrogen and progesterone causing an increase in GnRH from hypothalamus
o Slow decrease during cycle due to dominant oocyte releasing more oestrogen
o Increase in FSH at day 10-11 causing LH receptors to develop on Theca cells

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10
Q

LH and the menstrual cycle

A

o Levels constant for most of follicular phase
o LH surge 18h before ovulation due to high oestrogen increasing sensitivity to GnRH – surge allows oocyte to complete meiosis 1
o LH decreases rapidly then slowly after ovulation due to increase in progesterone
o LH acts on Theca cells to produce androgens – converted to oestrogen and atrial fluid in granulosa cells

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11
Q

inhibin and the menstrual cycle

A

decreases FSH by inhibiting release at pituitary, peaks for ovulation, decreases as corpus luteum degenerates

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12
Q

meiotic divisions for oogenesis

A

females arrested in prophase of meiosis I – maturation during menstrual cycle – arrested in metaphase of meiosis II until ovulation, meiosis complete after fertilisation

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13
Q

route of sperm

A

seminiferous tubules – rete testis – efferent ducts – epididymis – vas deferens – ejaculatory duct – urethra

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14
Q

LH and FSH in males

A

o FSH – stimulates Sertoli cells to produce inhibin (inhibits release of FSH from pit) and promotes spermatogenesis
o LH – stimulates testosterone release from Leydig cells (negative feedback to hypothalamus and pit

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15
Q

fertilisation

A
  • day 1 - fusion, enzymes digest zona pellucida, sperm enters, mem pot change prevents more entering, 4-7h after meiosis II occurs and the DNA replication and mitosis
  • 2/3 - zygote, in fallopian tube, CLEAVAGE increases no. of totipotent cells
  • 4 - compaction
  • 5 - cavitation and expansion - fluid filled cavity expands, blastocyst >80cells
  • 6+ - hatch out of zona pellucida
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16
Q

implantation timing/changes

A
  • 21st day of menstrual cycle, 7 days post fertilisation
  • endometrial cells provide metabolic fuel for early grown for first 5 weeks until foetal heart is functioning
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17
Q

stages of implantation

A
  1. Apposition – day 9, hatched blastocyst orientates via embryonic pole, synchronises with endometrium
  2. Attachment – integrins between endometrial endothelium and trophoblast cells
  3. Differentiation – trophoblast layer splits into cytotrophoblast and synctiotrophoblast
  4. Invasion – synctiotrophoblast erodes spiral blood vessels by digestion of basal lamina via enzymes to increase blood flow
  5. Decidual reaction – differentiation of stromal cells adjacent to blastocyst
  6. Maternal recognition – secretion of IL-2 prevents rejection, day 11 post fertilisation
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18
Q

beta hCG (human chorionic gonadotrophin)

A
  • Produced by synctiotrophoblast cells and begins being released at endometrial invasion
  • Maintains corpus luteum and stimulates oestrogen and progesterone production; prevents menstruation
  • Levels peak 60-80 days after last menstruation then rapidly decreases
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19
Q

relaxin in pregnancy

A

– Increases early in pregnancy from ovaries and placenta, limits uterine activity, softens and ripens cervix

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20
Q

oxytocin in pregnancy

A

from posterior pituitary, secreted throughout, increases towards end to stimulate uterine contractions and caring behaviours

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21
Q

prostaglandins in pregnancy

A

– PGF2a most abundant, PGE2 10x stronger, initiate labour, produced by uterine tissue

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22
Q

maternal adaptations during pregnancy

A
  • weight gain 10-15kg
  • uterus hypertrophy and hyperplasia, cervix softens
  • blood vol 50% increase, RBC mass increase, hb concentration decrease, WBC increase
  • CV - CO 40% inc, peripheral resistance 50%decrease
  • lungs - tidal vol 40%inc, no rate change
  • renal - GFR 40% inc
  • GI - reduced motility, delayed gastric emptying, constipation
  • thyroid enlargement
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23
Q

diagnosis of labour

A

contractions with effacement and dilatation of the cervix

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24
Q

signs of labour

A
  • Show (mucus plug from the cervix)
  • Rupture of membranes
  • Regular, painful contractions
  • Dilating cervix on examination
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25
Q

first stage of labour

A
  • latent phase - 0-4cm, 0.5cm/h, irreg contractions
  • active phase - 4-7cm, 1cm/h, reg contractions
  • transition phase - 7-10cm, 1cm/h, strong contractions
  • head descends remaining flexed, rotation from OT to OA
  • membranes rupture
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26
Q

second stage of labour

A
  • Contraction continue, head descends and flexes further, rotation normally complete
  • Passive = before pushing starts
  • Active = Pushing starts when head reaches pelvic floor
  • Delivery – head extends as its delivered over perineum, rotates back to transverse before the shoulders deliver
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27
Q

third stage of labour

A
  • placenta, normally 15min with up yo 500ml blood loss
  • uterine muscle fibres contract shearing blood vessels to placenta
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28
Q

the passenger descriptions

A
  • Presentation – head (cephalic), buttocks (breech)
  • Position of the head – rotation – OT, OP, OA
  • Attitude of the head – degree of flexion – vertex (optimal), brow or face
  • Foetal lie – longitudinal (optimal), transverse (sideways), oblique (slight angle)
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29
Q

gestation

A

w+d since LMP (start of period)

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30
Q

gravidity and parity

A

gravidity is how many times they have been pregnant including this one, parity is how many deliveries past 24w despite the outcome (still birth included)

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31
Q

trimesters of pregnancy

A

1st 0-12w
2nd 13-26w
3rd 27-birth

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32
Q

investigations during routine antenatal appt

A
  • Symphysis–fundal height measurement from 24 weeks onwards
  • Fetal presentation assessment from 36 weeks onwards
  • Urine dipstick for protein for pre-eclampsia
  • Blood pressure for pre-eclampsia
  • Urine for microscopy and culture for asymptomatic bacteriuria
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33
Q

vaccines during pregnancy

A
  • Whooping cough (pertussis) from 16 weeks gestation
  • Influenza (flu) when available
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34
Q

pregnancy lifestyle advice

A
  • Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
  • Take vitamin D supplement (10 mcg or 25 for those at risk daily)
  • Aspirin 75mg for women at risk of pre-eclampsia
  • LMWH for risk of VTE
    etc…..
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35
Q

booking clinic

A
  • Blood group, antibodies, and rhesus D status
  • FBC for anaemia
  • Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
  • Also offered screening for HIV, Hep B, Syphilis antibodies
  • Measurements – weight, height, BMI, urine for protein and bacteria, BP
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36
Q

combined screening test during pregnancy

A
  • 10-14w (Down’s T21, Edwards’ T18, Patau’s T13)
  • USS for nuchal thickness (>6mm in downs)
  • bloods - HCG (high = risk), PAPPA (low = risk)
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37
Q

Quadruple blood screening test during pregnancy

A
  • done for downs if >14w
  • beta-HCG (high is greater risk), Alpha-fetoprotein (AFP, low is risk), serum oestriol (low is risk), inhibin-A (high is greater risk)
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38
Q

further testing for screening during pregnancy

A
  • for higher chance result (risk >1/150)
  • second screening test - non-invasive prenatal testing (NIPT)
  • diagnostic test with amniocentesis (later on) or chorionic villus sampling (<15w) for DNA karyotyping
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39
Q

presentation o an ectopic pregnancy

A
  • Pregnancy symptoms, constant right or left iliac fossa pain, bleeding, cervical motion tenderness during examination, dizziness (blood loss), shoulder tip pain (peritonitis)
  • Gestational sac found on USS outside of uterus
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40
Q

pregnancy of unknown location and hCG changes

A
  • Positive pregnancy test, no pregnancy found of USS
  • Beta hCG used for monitoring and repeated after 48h (normally hCG would double)
    o Rise >63% likely indicates intrauterine pregnancy – should be visible on USS when hCG > 1500 IU/L
    o Rise <63% indicates ectopic
    o Fall >50% indicated miscarriage
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41
Q

management of ectopic pregnancy

A
  • expectant management
  • medical - IM methotrexate (highly teratogenic)
  • surgical - salpingectomy, salpingotomy (preserve tube)
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42
Q

management of miscarriage <6w

A

– expectant management if no complications then repeat urine pregnancy test after 7-10 days

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43
Q

management of miscarriage >6w

A
  • expectant
  • medical - oral or vaginal misoprostol (prostaglandin analogue making cervix soften and uterus contract)
  • surgical - manual vacuum aspiration <10w, D&C with electric vacuum
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44
Q

recurrent miscarriage

A

> 3
- Causes: idiopathic, older age, antiphospholipid syndrome (give low dose aspirin), thrombophilia’s, uterine abnormalities, genetic factors, chronic histiocytic intervillositis, chronic diseases (diabetes, thyroid disease, SLE)

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45
Q

medical abortion

A
  • Mifepristone (anti-progestogen – stops pregnancy and relaxes cervix)
  • Misoprostol (prostaglandin analogue – softens cervix and stimulates uterine contractions) 1 – 2 day later
  • Rhesus negative women above 10w should have anti-D prophylaxis
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46
Q

surgical abortion

A
  • Meds used before for cervical priming - misoprostol, mifepristone, or osmotic dilators
    o Cervical dilatation and suction of the contents of the uterus (up to 14w)
    o Cervical dilatation and evacuation using forceps (between 14 - 24 weeks)
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47
Q

post-abortion care

A

may experience vaginal bleeding and cramps for up to 2w, urine pregnancy test after 3w, support and counselling offered

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48
Q

nausea and vomiting of pregnancy

A
  • start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks
  • hCG thought to be cause - more severe in molar and multiple pregnancies due to higher levels
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49
Q

hyperemesis gravidarum

A
  • More than 5 % weight loss compared with before pregnancy
  • Dehydration
  • Electrolyte imbalance
  • assess severity using Pregnancy-Unique Quantification of Emesis (PUQE) score
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50
Q

treatment of hyperemesis gravidarum

A
  • antiemetics (prochlorperazine 1sr)
  • ranitidine/omeprazole for reflux
  • admission for IV fluid, antiemetics and thiamine supplements with daily U&Es
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51
Q

what are partial and complete molar pregnancies

A
  • complete mole - 2 sperm in an empty ovum (no genes)
  • partial mole - 2 sperm in a normal ovum - some fetal material may form
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52
Q

diagnosis of molar pregnancy

A
  • more severe morning sickness, bleeding, abnormally high hcg
  • snowstorm appearance on USS
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53
Q

treatment of molar pregnancy

A
  • remove mole - histology
  • referral to gestational trophoblastic disease centre
  • can occasionally metastasise needing chemo
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54
Q

types of multiple pregnancy

A
  • Monozygotic: identical twins (from a single zygote)
  • Dizygotic: non-identical (from two different zygotes)
  • Monoamniotic: single amniotic sac
  • Diamniotic: two separate amniotic sacs
  • Monochorionic: share a single placenta
  • Dichorionic: two separate placentas
  • diamniotic dichorionic best outcome
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55
Q

multiple pregnancy on USS

A
  • Dichorionic diamniotic twins - membrane between the twins, with a lambda sign
  • Monochorionic diamniotic twins - membrane between the twins, with a T sign
  • Monochorionic monoamniotic twins - no membrane separating
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56
Q

specific complications in twins

A
  • twin-twin transfusion syndrome (one twin receives majority of blood from placenta)
  • twin anaemia polycythaemia sequence (less acute- one becomes anaemic, other polycythaemia)
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57
Q

antenatal care for multiples

A
  • FBC at booking clinic, 20w, 28w (increased risk of anaemia)
  • Additional USS – 2 weekly from 16w with monochorionic, 4 weekly from 20w for dichorionic
  • Planned CS before spontaneous labour occurs, corticosteroids given before
  • Monoamniotic twins require CS between 32-33+6 weeks
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58
Q

definition of polyhydramnios

A

liquor volume increased, deepest liquor pool >10cm generally considered abnormal, should be around 1000ml at 38w

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59
Q

causes of polyhydramnios

A
  • Maternal disorders: GDM, renal failure
  • Twins: twin-twin transfusion syndrome
  • Fetal anomaly: upper GI obstructions/inability to swallow, CNS/cardiac/renal abnormalities, myotonic dystrophy
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60
Q

management of polyhydramnios

A
  • detailes USS
  • blood glucose monitoring
  • <34 w sever amnioreduction or NSAIDS (reduce fetal urine output)
  • vaginal delivery unless complications
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61
Q

oligohydramnios

A
  • develops when increased fluid loss or decreased production
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62
Q

investigations for oligohydramnios

A

Fluid analysis from speculum examination – ferning test (dried amniotic fluid forms fern-like crystals)
- vaginal swab for placental alpha macroglobulin-1 (PAMG-1) and insulin-like growth factor binding protein-1 (IGFBP-1))

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63
Q

management of oligohydramnios

A
  • Monitoring
  • Amnioinfusion (saline or Ringer’s lactate infused)
  • Induction of labour between 36-38w (risk of cord compression and limb deformities)
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64
Q

UTI in pregnancy and most likely bacteria

A

-Higher risk of pyelonephritis and miscarriage/ preterm birth
- most E.coli (gram-negative, anaerobic, rod), klebsiella pneumoniae (gram negative, anaerobic rod)

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65
Q

management of UTI in pregnancy

A
  • culture for sensitivities
  • 7d abx - nitro (not in 3rd trimester), amox, cefalexin, trimethoprim (not in 1st)
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66
Q

group B streptococcus infection in pregnancy

A
  • normal in flora of 20-40%
  • can cause neonatal sepsis/pneumonia/encephalitis or UTI in mother
  • screened at 35-37w if risk factors
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67
Q

treatment of GBS in pregnancy

A

3g IV Benzylpenicillin stat after onset of labour, followed by 1.5g IV Benzylpenicillin 4hourly until delivery (takes 4h to cross over into fetus)

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68
Q

chlamydia and gonorrhoea in pregnancy

A
  • preterm labour and neonatal conjunctivitis
  • Chlamydia treated with azithromycin or erythromycin (tetracyclines cause fetal tooth discolouration)
  • Gonorrhoea treated with cephalosporins
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69
Q

management of VTE in pregnancy

A
  • Prophylactic LMWH (dalteparin) from 28w if 3 risk factors, 1st trimester if >4
  • compression stockings
  • CTPA and doppler used for diagnosis - dalteparin immediately
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70
Q

what is pre-eclampsia

A
  • new htn with end-organ dysfunction (proteinuria)
  • occurs after 20w when spiral arteries of placenta form abnormally leading to a high vascular resistance in them
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71
Q

pre-eclampsia triad

A

htn, proteinuria, oedema

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72
Q

pregnancy-induced htn

A

htn occurring after 20w without end-organ damage (proteinuria)

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73
Q

symptoms of pre-eclampsia

A
  • Headache
  • Visual disturbance or blurriness
  • Nausea and vomiting
  • Upper abdominal or epigastric pain (this is due to liver swelling)
  • Oedema
  • Reduced urine output
  • Brisk reflexes
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74
Q

prophylaxis of pre-eclampsia

A
  • high risk (other chronic diseases) aspirin from 12w
  • moderate risk (>1 risk factor) aspirin from 12w
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75
Q

diagnosis of pre-eclampsia

A

BP >140/90
proteinuria, organ dysfunction, placental dysfunction
low placental growth factor

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76
Q

management of pre-eclampsia

A
  • urine dip, FBC,LFT, U&E weekly with serial growth scans
  • BP every 48h
  • scoring systems for admission (fullPIERS or PREP-S)
  • labetalol (1st line antihypertensive) then nifedipine
  • IV mag sulf during labour and in 24h after to prevent seizures
  • CS if uncontrolled
  • after delivery give enalapril
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77
Q

eclampsia

A
  • seizures associated with pre-eclampsia from cerebral vasospasm
  • IV magnesium sulphate
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78
Q

HELLP syndrome in pregnancy

A
  • complication of pre/eclampsia
  • Haemolysis
  • EL elevated liver enzymes
  • LP low platelets
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79
Q

complications of gestational diabetes

A
  • large fetus, macrosomia
  • shoulder dystocia during delivery
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80
Q

oral glucose tolerance test for GD

A
  • at 24-28w if at risk
  • Normal results:
    o Fasting: < 5.6 mmol/l
    o At 2 hours: < 7.8 mmol/l
    o Anything higher is GM: cut off for gestational diabetes as simply 5 – 6 – 7 – 8
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81
Q

management of GD

A
  • education on lifestyle nd monitoring BM
  • 4 weekly USS from 28-36w
  • fasting glucose>7 = insulin +/- metformin
  • FG >6 plus macrosomia = insulin +/- metformin
  • glibenclamide (sulfonylurea) if refuse insulin
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82
Q

pre-existing diabetes in pregnancy

A
  • good control before
  • retinopathy screening after booking then at 28w
  • planned delivery at 37-38+6w
  • sliding scale insulin regime during labour
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83
Q

postnatal care with GD

A
  • resolves immediately after birth - stop meds
  • babies at risk of neonatal hypoglycaemia, polycythaemia, jaundice and congenital heart disease
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84
Q

obstetric cholestasis

A
  • reduced outflow of bile acids from liver dur to increased oestrogen and progesterone
  • resolves after delivery
  • increases risk of still birth
  • presents with jaundice
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85
Q

investigations for obstetric cholestasis

A

LFT (abnormal ALT, AST, GGT) and bile acids checked (raised)
normal for ALP to increase because also made by placenta

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86
Q

management of obstetric cholestasis

A
  • emollients for itching
  • Ursodeoxycholic acid improves LFTs
    planned delivery at 37w if severe
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87
Q

antepartum haemorrhage and most common causes

A
  • PV bleeding from 24w
  • most common causes - placenta previa, placental abruption, vasa previa
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88
Q

comparison of placenta previa, placental abruption and vasa previa

A
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89
Q

investigations for APH

A
  • CTG immediately, USS
  • if severe then catheterise and monitor hourly urine output
  • FBC, group and crossmatch, coag screen, U&E
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90
Q

management of APH

A
  • treat cause
  • IV access, analgesia, resuscitation
  • if in shock then enact massive haemorrhage protocol
  • may need urgent CS
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91
Q

definition of low-lying placenta and placenta praevia

A
  • low lying is within 20mm of internal cervical os
  • placenta praevia - placenta is over the internal os
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92
Q

diagnosis of placenta praevia

A
  • normally on 20w anomaly scan
  • bleeding normally starts around 36w
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93
Q

management of placenta praevia

A
  • transvaginal USS at 32 and 36w
  • corticosteroids between 24-35+6w
  • planned CS at 36-37w
  • emergency CS if haemorrhage or premature labour
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94
Q

what is placental abruption

A

placenta/part of it separates from uterus wall - area can bleed extensively

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95
Q

presentation of placental abruption

A
  • Sudden onset severe abdominal pain that is continuous
  • APT
  • Shock (hypotension and tachycardia)
  • Abnormalities on the CTG indicating fetal distress
  • Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
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96
Q

what is a concealed abruption

A
  • cervical os remains closed
  • severity can be underestimated
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97
Q

initial management of major/massive APH

A

o Urgent involvement of a senior obstetrician, midwife and anaesthetist
o 2 x grey cannula
o Bloods include FBC, UE, LFT and coagulation studies
o Crossmatch 4 units of blood
o Fluid and blood resuscitation as required
o CTG monitoring of the fetus
o Close monitoring of the mother

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98
Q

management of placental abruption

A
  • management of bleed
  • USS to diagnose
  • corticosteroids between 24-34+6w
  • may need anti-D
  • emergency CS
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99
Q

what is vasa praevia

A

foetal vessels within the membranes and travel across the internal cervical os - exposed due to lack of Wharton’s jelly
lead to bleeding which can be fatal for fetus due to small blood volume

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100
Q

presentation of vasa praevia

A
  • Ideally diagnosed by USS but not reliable
  • May present with antepartum haemorrhage or during labour when membranes seen or if fetal distress + dark red bleeding (high fetal mortality)
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101
Q

management of vasa praevia

A
  • Corticosteroids from 32 weeks then elective CS planned for 34-36 w
  • Emergency CS
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102
Q

what is placenta accreta

A

Placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery – PPH.
- accreta (surface of myometrium)
- increta (deeply into myometrium)
- percreta (past myometrium and perimetrium)

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103
Q

management of placenta accreta

A
  • diagnosis at USS
  • planned CS at 35-36+6
  • hysterectomy/uterus preserving surgery/expectant management (leaving to be reabsorbed but risk of infection and bleeding)
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104
Q

indications for continuous CTG monitoring

A

sepsis, maternal tachycardia, significant meconium, pre-eclampsia, APH, delay in labour, use of oxytocin

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105
Q

key features on a CTG

A
  • Contractions – per 10 minutes
  • Baseline rate – the baseline fetal heart rate, reassuring 110-160, non-reassuring or abnormal <100 or >180
  • Variability – how the fetal heart rate varies up and down, reassuring 5-25, non-reassuring, abnormal <5 for over 50mins or >25 for over 25mins
  • Accelerations – fetal heart rate spikes, generally a good sign
  • Decelerations - more concerning (response to hypoxia)
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106
Q

categories for CTG

A
  • Normal
  • Suspicious: a single non-reassuring feature
  • Pathological: two non-reassuring features or a single abnormal feature
  • Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
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107
Q

timescale for managing fetal bradycardia

A
  • 3 minutes – call for help
  • 6 minutes – move to theatre
  • 9 minutes – prepare for delivery
  • 12 minutes – deliver the baby (by 15 minutes)
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108
Q

fetal scalp blood sample - when and what does it measure

A
  • do if pathological fetal HR unless acute (immediate delivery)
  • Mostly to measure pH and lactate (fetal compromise and hypoxia) or anaemia from placental damage
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109
Q

fetal blood pH from scalp blood sample

A

> 7.25 – normal, can repeat in 1h
7.21-7.24 – borderline, repeat in 30min
<7.20 – abnormal, consider delivery

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110
Q

when to induce labour

A

41-42w, prelabour ROM, fetal growth restriction, pre-eclampsia, obstetric cholestasis, diabetes, intrauterine fetal death

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111
Q

score used to determine where to induce labour

A
  • Bishop score (total score of 13, score of >8 predicts successful induction)
    o Fetal station (scored 0 – 3)
    o Cervical position (scored 0 – 2)
    o Cervical dilatation (scored 0 – 3)
    o Cervical effacement (scored 0 – 3)
    o Cervical consistency (scored 0 – 2)
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112
Q

methods of labour induction

A
  • membrane sweep done at term
  • vaginal prostaglandin via gel, tablet or pessary
  • cervical ripening balloon
  • ARM +/- oxytocin infusion
  • oral mifepristone (anti-progesterone) + misoprostol for still birth
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113
Q

uterine hyperstimulation from induction of labour

A
  • main complication of induction
  • contractions lasting >2m or >5 in 10min
  • can lead to fetal distress, emergency CS and uterine rupture
  • stop inductions and give terbutaline for tocolysis
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114
Q

partogram

A
  • Used for monitoring first stage of labour
  • 2 lines on partogram that indicate when labour isn’t progressing:
    o Alert line – indication for an amniotomy (artificially rupturing the membranes) and repeat examination in 2h
    o Action line – needs to be escalated to obstetric-led care
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115
Q

4 P’s that influence progress in labour

A
  • Power (uterine contractions)
  • Passenger (size, presentation and position of the baby)
  • Passage (the shape and size of the pelvis and soft tissues)
  • Psyche (the support and antenatal preparation)
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116
Q

failure to progress in first stage of labour

A

<2cm in 4h
slowing of progress
partogram alert line (ARM), action line (further care)
if 2h after ARM no dilation then start oxytocin drip

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117
Q

failure to progress in second stage of labour

A

when pushing lasts >2h nulliparous/1h multiparous
- power - oxytocin for weak contractions
- passenger/passage - may be impossible needing CS
- change positions, encouragement, analgesia, oxytocin, episiotomy, instrumental delivery, CS

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118
Q

failure to progress in third stage of labour

A

> 30mins with active management, >60mins with physiological management

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119
Q

active management of third stage of labour

A

IM oxytocin and controlled cord traction

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120
Q

obstructed labour

A
  • labour dystocia
  • labour >24h, insurmountable barrier
  • can be fatal to both
  • complications - uterine rupture, infection, compression injuries
  • IV access, fluids, catheter, assisted delivery/CS
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121
Q

shoulder dystocia

A
  • anterior shoulder stuck behind pubis symphysis after head delivered
    EMERGENCY
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122
Q

presentation of shoulder dystocia

A
  • difficulty delivering face
  • failure of restitution (doesn’t rotate to OT)
  • turtle neck sign - head retracts back into vagina
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123
Q

management of shoulder dystocia

A
  • needs obstetrician, anaesthetist, paediatrician
  • episiotomy
  • McRoberts manoeuvre (knees to abdomen to provide posterior pelvic tilt)
  • pressure on anterior shoulder
  • Rubins manoeuvre - hand in vagina pressing baby shoulder
  • Wood’s screw manoeuvre
  • Zavanelli manoeuvre - push head back in for emergency CS
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124
Q

complications of shoulder dystocia

A
  • Fetal hypoxia (can cause cerebral palsy)
  • Brachial plexus injury and Erb’s palsy
  • Perineal tears
  • Postpartum haemorrhage
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125
Q

breech presentation

A
  • Complete/flexed breech (15%)
  • Frank/extended breech (70%)– with hips flexed and knees extended, bottom first
  • Footling breech (15%) – with a foot hanging through the cervix
  • External cephalic version (ECV) from 37w, 50% success
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126
Q

cord prolapse

A
  • cord descends below the presenting part into the vagina after ROM
  • high risk of compression causing fetal hypoxia
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127
Q

management of a cord prolapse

A
  • emergency CS - cord kept warm and wet but don’t touch (causes vasospasm)
  • if baby already compressing then push back in, woman in left lateral lie and tocolytic meds to minimise contractions
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128
Q

instrumental delivery

A

10% of births in UK
single dose co-amox after to prevent maternal infection
indicated when failure to progress, fetal distress, exhaustion

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129
Q

risks to mother from instrumental delivery

A

PPH, episiotomy, perineal tears, anal sphincter injury, incontinence, nerve injury – obturator (weakness in hip adduction and rotation and numbness of medial thigh) or femoral nerve (weakness of knee extension, loss of patellar reflex and numbness of anterior thigh)

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130
Q

risks to baby during instrumental delivery

A
  • cephalohematoma (blood between skull and periosteum) with ventouse, facial nerve palsy with forceps
  • Serious risks to baby: subgaleal haemorrhage, intercranial haemorrhage, skull fracture, spinal cord injury
131
Q

causes of intrapartum haemorrhage

A

uterine rupture, placental abruption

132
Q

uterine rupture

A
  • incomplete (perimetrium remains intact) or complete (uterus contents into peritoneal cavity)
  • significant bleeding an high mortality for both
  • higher risk if VBAC
133
Q

presentation of uterine rupture

A

Acutely unwell mother and abnormal CTG – abdo pain, bleeding, ceasing of uterine contractions, hypotension, tachycardia, collapse

134
Q

management of uterine rupture

A
  • emergency CS then repair or hysterectomy
  • resuscitation and transfusions if needed
135
Q

classification of perineal tears

A
  • First-degree – injury limited to the frenulum of the labia minora and superficial skin
  • Second-degree – including the perineal muscles, but not affecting the anal sphincter
  • Third-degree – including the anal sphincter, but not affecting the rectal mucosa
  • Fourth-degree – including the rectal mucosa
136
Q

management of perineal tears

A
  • sutures above 1st degree
  • broad-spec abx
  • laxatives
  • physio
  • follow up monitoring
  • > 3rd degree offer subsequent CS
137
Q

long term complications of perineal tears

A
  • urinary and bowel incontinence
  • fistula between vagina and bowel
  • sexual dysfunction and dyspareunia
  • mental health
138
Q

classification of PPH

A
  • 500ml after vaginal delivery, 1000ML after CS
  • Minor PPH <1000ml
  • Major PPH >1000ml
    o Moderate PPH – 1000 – 2000ml
    o Severe PPH – over 2000ml
  • Primary (within 24h of delivery) or secondary (24h-12 weeks)
139
Q

causes of PPH (4 Ts)

A
  • T – Tone (uterine atony – the most common cause)
  • T – Trauma (e.g. perineal tear)
  • T – Tissue (retained placenta)
  • T – Thrombin (bleeding disorder)
140
Q

preventative measures for PPH

A
  • treat anaemias in pregnancy
  • empty bladder during birth
  • Active management of the third stage (10 units of IM oxytocin- increases uterus contraction)and controlled cord traction
  • IV tranexamic acid during CS if high risk
141
Q

management of PPH

A
  1. Resuscitation ABCDE
  2. Lie the woman flat, keep her warm and communicate
  3. 2 large-bore cannulas
  4. Bloods for FBC, U&E and clotting screen
  5. Group and cross match 4 units
  6. Warmed IV fluid and blood resuscitation as required
  7. Oxygen (regardless of saturations)
  8. Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
142
Q

mechanical treatment to stop bleeding in PPH

A
  • fundal massage
  • catheterisation
143
Q

medical treatment to stop bleeding in PPH

A
  • oxytocin 40 units in 500ml and ergometrine
  • carboprost IM - prostaglandin analogue
  • misoprostol sublingual (prostaglandin analogue)
  • tranexamic acid (antifibrinolytic)
144
Q

surgical treatment to stop bleeding in PPH

A
  • intrauterine balloon tamponade for 24h
  • B-lynch or Hayman suture around uterus to compress
  • uterine artery ligation
  • hysterectomy last resort
145
Q

secondary PPH

A

*Likely due to retained products of conception or infection (eg endometritis)
*Investigations – US, endocervical and high vaginal swabs
*Management – depends on cause (surgical evacuation, antibiotics)

146
Q

postpartum endometritis

A
  • inflammation of endometrium, mostly from infection
  • more common after CS
  • GAS (most common cause of puerperal sepsis), e.coli, staph
147
Q

presentation of postpartum endometritis

A

foul-smelling discharge or lochia, abnormal bleeding, pain, fever, sepsis

148
Q

management of postpartum endometritis

A
  • vaginal swabs
  • urine culture
  • USS if retained products of conception suspected
  • if septic needs admission
  • co-amox
149
Q

mastitis

A
  • inflammation of breast tissue
  • can be caused by milk blockage or infection
  • manage obstruction with continued BF, massage and heat packs
  • for infection milk sample for culture, flucloxacillin
150
Q

baby blues

A
  • most women in first week, last about 2w
  • mood swings, low mood, tearfulness
  • caused by hormonal changes, recovery, stress
151
Q

postnatal depression

A
  • low mood, anhedonia and low energy
  • peak around 3m after birth
  • mild - additional support
  • moderate - antidepressants and CBT
  • severe - may need input from specialist psych servoces
152
Q

scale used to assess severity of postnatal depression

A

Edinburgh postnatal depression scale
assesses how mother has felt over the past week, 10 questions with total score out of 30 points, score of 10 or more suggests PD

153
Q

puerperal psychosis

A
  • starts few weeks after birth
  • Delusions, hallucinations, depression, mania, confusion, thought disorder
  • emergency, may need admission to mother and baby unit
154
Q

perinatal mental health services

A
  • mental health conditions before pregnancy
  • plan and prepare
  • SSRI safe in pregnancy but beware of neonatal abstinence syndrome (poor feeding and irritability)
155
Q

premature labour

A

birth before 37 weeks gestation, considered non-viable below 23 w

156
Q

classification of premature labour

A
  • Under 28 weeks: extreme preterm
  • 28 – 32 weeks: very preterm
  • 32 – 37 weeks: moderate to late preterm
157
Q

prophylaxis of preterm labour

A

*Vaginal progesterone – prevents cervix remodelling and myometrium contraction
o offered when cervical length <25mm on USS between 16-24 weeks
*cervical cerclage – stitch into cervix to keep it closed (removed at term)
o offered when cervical length <25mm on USS between 16-24 w with history
- rescue cerclage if cervix dilated but no ROM

158
Q

preterm prelabour ROM

A
  • diagnosed by pooling amniotic fluid in vagina (ferning test or test of IGFBP-1 or PAMG-1)
  • management with erythromycin 250mg QDS for 10 days or until labour, induction of labour from 34w
159
Q

preterm labour with intact membranes

A
  • contractions and cervical dilatation without ROM
160
Q

management of preterm labour without ROM

A
  • fetal monitoring
  • tocolysis with nifedipine (short term use for transfer to special unit)
  • maternal corticosteroids (fetal lungs)
  • IV magsulf (helps protect baby’s brain)
  • delayed cord clamping or cord milking can increase blood vol for baby at birth
161
Q

antenatal steroids

A
  • corticosteroids help to develop the fetal lungs and reduce respiratory distress syndrome after delivery.
  • used in women with suspected preterm labour less than 36 w
  • two doses of intramuscular betamethasone, 24 hours apart.
162
Q

magnesium sulphate for premature delivery

A
  • reduces risk and severity of cerebral palsy
  • given within 24 hours of delivery of preterm babies of less than 34 weeks gestation
  • close monitoring for magnesium toxicity every 4h (obs and tendon reflexes)
163
Q

small for gestational age

A

measures below 10th centile for their gestation

164
Q

what is measured on fetal USS

A

estimates fetal weight (EFW), fetal abdominal circumference (AC)

165
Q

categories of SGA

A
  • constitutionally small (small family and growing normally)
  • fetal growth restriction (not growing as expected due to pathology)
166
Q

causes of FGR (fetal growth restriction)

A
  • Placenta mediated growth restriction – conditions that affect the transfer of nutrients across placenta – idiopathic, pre-eclapsia, maternal smoking, alcohol, anaemia, malnutrition, infection, maternal health conditions
  • Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
167
Q

long term complications of SGA

A

increased risk of – CVD, T2DM, obesity, mood and behavioural problems

168
Q

investigations when SGA identified

A
  • Blood pressure and urine dipstick for pre-eclampsia
  • Uterine artery doppler scanning
  • Detailed fetal anatomy scan by fetal medicine
  • Karyotyping for chromosomal abnormalities
  • Testing for infections
169
Q

management of SGA

A
  • Aspirin is given to those at risk of pre-eclampsia
  • Treating modifiable risk factors (e.g. stop smoking)
  • Serial growth scans to monitor growth
  • Early delivery where growth is static
170
Q

what is rhesus incompatibility

A
  • Rhesus-D negative mother has a rhesus positive baby – blood likely to mix at some point in pregnancy – mother has immune reaction against antigen on baby’s blood so becomes sensitised
  • normally only problem in subsequent pregnancies as antibodies can cross into fetal blood stream causing haemolytic disease of the newborn
171
Q

management of rhesus incompatibility

A
  • prevent sensitisation (IM anti-D for rhesus negative women) at 28w and birth
  • also given if any trauma/haemorrhage
172
Q

kleinhauer test

A
  • assess how much fetal blood in mothers during sensitisation event to quantify amount of anti-D
  • add acid to mothers blood sample - fetal blood more acid resistant so will survive
173
Q

menopause

A
  • retrospective diagnosis (made 12m after LMP)
  • av age 51
  • when periods stop due to lack of ovarian follicular function (no granulosa cells to produce oestrogen/progesterone)
174
Q

Postmenopause

A

from 12m after LMP

175
Q

perimenopause and the symptoms

A

->45y, the time around menopause with vasomotor symptoms and irregular periods
- hot flushes, emotional lability, joint pains, brain fog, vaginal dryness etc etc

176
Q

premature menopause

A
  • before 40
  • result of premature ovarian insufficiency
  • FSH levels done to aid diagnosis
177
Q

contraception needed during menopause

A
  • 2 years after LMP in women <50
  • 1 year in women >50
  • Progesterone based contraceptives (pill or Mirena) or non-hormonal
178
Q

HRT

A
  • Perimenopausal: cyclical combined HRT
  • Postmenopausal: continuous combined HRT
  • Takes 3-6 months to have full effect
  • risks of breast C, endometrial C, VTE, CVD, stoke
  • risk of VTE reduced by using patches>pills
  • need progesterone and oestrogen if they have uterus (stop endometrial proliferation)
  • improves QOL, reduces risk of osteoporosis
179
Q

premature ovarian insufficiency

A
  • menopause before 40
  • hypergonadotropic hypogonadism (high FSH/LH, low oestrogen)
  • idiopathic, iatrogenic (post chemo etc), autoimmune, genetic or post infection (TB etc)
180
Q

diagnosis and management of premature ovarian insufficiency

A
  • typical menopause symptoms + elevated FSH (2 samples 4w apart)
  • need HRT until at least average age of menopause
181
Q

atrophic vaginitis

A
  • Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen (menopause)
  • itching, dryness, dyspareunia, bleeding, inflammation, prolapse, recurrent UTI, thin skin
  • treat with moisturisers + topical oestrogens
182
Q

cervical cancer

A
  • mostly younger reproductive age women
  • 80% squamous cell carcinoma, next most common adenocarcinoma
  • strongly associated with HPV
183
Q

human papilloma virus

A
  • STI, type 16 and 18 cause 70% of cervical cancers
  • vaccine given in 13y/o
  • produces proteins that inhibit some tumour suppressor genes
184
Q

presentation of cervical cancer

A
  • Symptoms – abnormal vaginal bleeding, discharge, pelvic pain, dyspareunia
  • Appearance of cervix (needs urgent cancer referral for colposcopy)– ulceration, inflammation, bleeding, visible tumour
185
Q

cervical intraepithelial neoplasia

A
  • grading system for level of dysplasia diagnosed at colposcopy
  • CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
  • CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
  • CIN III: severe dysplasia, very likely to progress to cancer if untreated – cervical carcinoma in situ
186
Q

screening for cervical cancer

A
  • Cervical smear test – tested for high-risk HPV, if positive then microscopy for precancerous changes (dyskaryosis)
  • Every three years aged 25 – 49
  • Every five years aged 50 – 64
  • annually if immunocompromised or previous positive HPV
187
Q

colposcopy

A
  • used with stains - acetic acid (abnormal cells white), or Schiller’s iodine test (abnormal cells don’t stain)
  • punch biopsy or large loop excision
188
Q

international federation of gynaecology and obstetrics (FIGO) staging system for gynae cancers

A
  • stage 1 - confined to organ
  • stage 2 - invades part of adjacent organ
  • stage 3 - invades further into pelvic wall
  • stage 4 - invades other pelvic organs (bladder, rectum etc)
189
Q

management of cervical cancer

A
  • hysterectomy and local lymph node removal with chemo and radiotherapy
  • 15% survival for stage 4
  • bevacizumab monoclonal antibody to reduce development of new blood vessels
190
Q

endometrial cancer

A
  • 80% adenocarcinoma - oestrogen dependant
191
Q

endometrial hyperplasia

A

-precancerous thickening (5% become cancerous)
-treated with progestogens
- risk when increased oestrogen without progesterone
- can be caused by obesity (adipose cells make oestrogen) or PCOS

192
Q

presentation of endometrial hyperplasia/cancer

A

PMB (2ww), abnormal bleeding or discharge, anaemia, haematuria

193
Q

investigations for endometrial cancer

A
  • transvaginal USS (normal endometrial thickness <4mm post-menopause)
  • pipelle biopsy
  • hysteroscopy with biopsy
194
Q

ovarian cancer

A
  • often presnt late due to non-specific symptoms
  • > 70% present when spread beyond the pelvis
195
Q

ovarian cancer types

A
  • Epithelial cell tumours: most common – sub types (serous tumours most common)
  • Dermoid cysts/germ cell tumours: benign, teratomas (come from germ cells), contain various tissue types, can cause ovarian torsion, can cause raised hCG
  • Sex cord-stromal tumours: benign or malignant, arise from stoma (connective tissue) or sex cords – several types including Sertoli–Leydig cell tumours and granulosa cell tumours
  • Metastasis: A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer (stomach) – signet ring cells on histology
196
Q

risk/protective factors for ovarian cancer

A

Risk Factors – age, BRCA1/2, increased number of ovulations, obesity, smoking
Protective Factors – COC, breastfeeding, pregnancy

197
Q

presentation of ovarian cancer

A

– abnormal bloating, early satiety, loss of appetite, pelvic pain, urinary symptoms, weight loss, abdo/pelvic mass, ascites, may press on obturator nerve causing hip/groin pain (NON-SPECIFIC)

198
Q

investigations for ovarian cancer

A
  • CA125 blood test (>35 IU/mL is significant), pelvic USS
  • risk of malignancy index (RMI)
  • CT (stage), biopsy, paracentesis (ascitic tap to test cells)
  • <40y need alpha-FP and hCG for germ cell
199
Q

causes of raised CA125

A

tumour marker for epithelial cell ovarian cancer but not very specific – endometriosis, fibroids, adenomyosis, pelvic infection, liver disease, pregnancy

200
Q

vulval cancer

A
  • Rarer, 90% are squamous cell carcinomas
  • age, immunosuppression, HPV, lichen sclerosis (5% with this get vulval cancer)
  • skin changes - lump/ulcer/pain etc mostly labia majora
  • biopsy with node biopsy
  • wide excision, lymph node removal, chemo, radio
201
Q

vaginal cancer

A

mostly squamous cell carcinoma
like vulval cancer management
may present with dyspareunia

202
Q

structural causes of abnormal menstrual bleeding PALM

A

P – polyps (endometrial or cervical)
A – adenomyosis
L – leiomyoma (fibroid)
M – premalignancy (endometrial hyperplasia), malignancy

203
Q

non-structural causes of abnormal menstrual bleeding COEIN

A

C – systemic coagulopathy (thrombocytopenia, von Willebrand’s disease, leukaemia, warfarin
O – ovulatory dysfunction (PCOS, hypothyroidism, Cushing’s, hyper prolactinoma, congenital adrenal hyperplasia)
E – primary endometrial disorders (endometritis)
I – iatrogenic (contraceptives)
N – generally rare causes

204
Q

red flag signs for abnormal menstrual bleeding

A

Suspected cancer – PCB, PMB, pelvic mass, cervix lesion

205
Q

intermenstrual bleeding

A
  • ovulation causes spotting in 1-2%
  • uterine causes: iatrogenic (contraceptives), endometritis, uterine polyps, fibroids, adenomyosis, endometrial cancer
  • cervical causes: following examination, infection, cervical ectropion, cancer
  • vaginal causes: infection, cancer
206
Q

heavy menstrual bleeding

A
  • > 80ml but based on effect of QOL and symptoms
  • Exclude underlying pathology – anaemia, fibroids, bleeding disorder (will have been heavy bleeding since menarche), cancer
  • tranexamic acid if no pain, mefenamic acid if pain (NSAID + reduces bleeding), hormonal contraceptives (Mirena)
207
Q

postcoital bleeding

A

Non-menstrual genital tract bleeding immediately or shortly after intercourse
Mostly from cervical causes or vaginal atrophy (post menopause)

208
Q

causes of postmenopausal bleeding

A
  • Polyps 30%
  • Submucosal fibroids 20%
  • Endometrial atrophy 30%
  • Hyperplasia 10%
  • Endometrial carcinoma 5-8%
  • Ovarian, tubal, cervical malignancy 2%
209
Q

fibroids + types/symptoms/investigations

A
  • also called leiomyomas - tumour of smooth muscle
  • affect 40-60%, oestrogen sensitive (grow during cycle and pregnancy)
  • can be intramural, subserosal, submucosal or pedunculated
  • often asymptomatic, heavy and prolonged menstrual bleeding, pain, bloating, urinary or bowel symptoms, deep dyspareunia, reduced fertility
  • hysteroscopy, pelvic USS, MRI before surgery
210
Q

management of fibroids

A
  • For fibroids <3cm:
    o Mirena coil (first line), symptomatic management, COC, cyclical oral progestogens
    o Endometrial ablation, resection, hysterectomy
  • Fibroids >3cm: same but Mirena coil can’t be used
    o Uterine artery embolization, myomectomy, hysterectomy
    o GnRH agonist (Zoladex) may be used to reduce size before surgery
211
Q

red degeneration of fibroids

A
  • ischaemia and infarction when it outgrows its blood supply (mostly in 2nd/3rd trimester of pregnancy)
  • severe abdo pain, fever, tachycardia, vomiting
  • rest, fluids and analgesia
212
Q

what is endometriosis

A

Ectopic endometrial tissue (an endometrioma) outside of the uterus

213
Q

symptoms of endometriosis

A
  • cyclical dull heavy pain, blood in urine/stools (if in bladder/bowel), adhesions (chronic sharp pain), reduced fertility (adhesions block tubes), deep dyspareunia
214
Q

diagnosis of endometriosis

A
  • USS may reveal large endometriomas and chocolate cysts but often unremarkable
  • laparoscopy gold standard with biopsy
215
Q

management of endometriosis

A
  • Initial management: establish diagnosis, education, analgesia, listen to patient
  • Hormonal: any contraceptive hormones, GnRH agonists such as Zoladex only used short term (stop FSH/LH release)
  • Surgical: laparoscopy to remove or ablate lesions and adhesiolysis, hysterectomy
216
Q

adenomyosis

A
  • Endometrial tissue inside the myometrium of uterus, more common in multiparous women, 10% of women, hormone-dependant so normally resolve after menopause.
  • Associated with pregnancy complications (infertility, miscarriage, preterm birth, SGA, PROM, malpresentation, CS, PPH
  • painful/heavy periods, dyspareunia
  • USS
  • management varies (tranexamic/mefenamic acid, contraceptives, endometrial ablation, uterine artery embolization, hysterectomy)
217
Q

endometrial polyps

A
  • over growth of endometrium extending into uterine cavity
  • can be precancerous
  • most postmenopausal, oestrogen sensitive
  • irregular bleeding, IMB, PMB, infertility
  • transvaginal USS, hysteroscopy, biopsy
  • Treatment – watch and wait, hormonal medications, polypectomy during hysteroscopy
218
Q

what is an ovarian cyst

A
  • fluid filled sac
  • functional ovarian cysts related to fluctuating hormones - very common premenopause
  • postmenopausal cysts more concerning
  • multiple cysts or ‘string of pearls’ appearance still need other symptoms to be diagnosed with PCOS
219
Q

presentation of ovarian cysts

A

most asymptomatic, pelvic pain, bloating, fullness, palpable pelvic mass, may be acute pain due to rupture, torsion or haemorrhage

220
Q

functional ovarian cysts

A
  • follicular cysts most common - follicle fails to rupture - resolves after a few cycles
  • corpus luteum cysts - fails to break down, often seen in early pregnancy
221
Q

investigations for ovarian cysts

A
  • assessment of red flags
  • premenopausal with simple ovarian cyst <5cm on USS no further investigations
  • <40 with complex mass need tumour markers for germ cell tumour
222
Q

management of ovarian cysts

A
  • Simple ovarian cysts in premenopausal women:
    o Less than 5cm cysts - almost always resolve within three cycles. They do not require a follow-up scan.
    o 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
    o More than 7cm: Consider an MRI scan or surgical evaluation
  • Cysts in premenopausal women need referral to gynae and CA125
  • Ovarian cystectomy or oophorectomy in some cases
223
Q

Meig’s syndrome

A
  • Triad of ovarian fibroma, pleural effusion, ascites
  • Typically in older women, removal of tumour results in complete resolution of effusion and ascites
224
Q

polycystic ovarian syndrome

A
  • common condition causing metabolic and reproductive problems in women
  • Characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism (effects of high testosterone) and insulin resistance (most get diabetes)
225
Q

Rotterdam criteria for PCOS diagnosis

A

Needs at least 2 of – oligoovulation/anovulation, hyperandrogenism (hirsutism (male hair pattern) and acne), polycystic ovaries on USS

226
Q

insulin resistance and PCOS

A
  • crucial feature
  • more insulin produced - promotes release of more androgens (from ovaries and adrenal gland) and suppresses sex hormone-binding globulin (SHBG) production by the liver (normally reduces effects).
  • high insulin contributes to halting development of follicles
  • diet, weight loss and exercise can help
227
Q

investigations for PCOS

A
  • Raised LH
  • Raised LH to FSH ratio (high LH compared with FSH)
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
  • USS >12 cysts in each ovary
  • oral glucose tolerance test
228
Q

management of PCOS

A
  • Reduce associated risks – weight loss (can restore fertility and reduce symptoms), low GI diet, exercise, smoking cessation, antihypertensives, statins (if QRISK >10%)
  • mirena/ cyclical contraceptives to reduce endometrial cancer
  • Fertility – weight loss, clomifene, laparoscopic ovarian drilling (multiple punctures in ovary), IVF
  • hirsutism - COC, topical treatments, laser hair removal
229
Q

ovarian torsion

A
  • ovary twists - ischaemia and necrosis if not fixed
  • usually due to ovarian mass >5cm
  • acute severe unilateral pelvic pain, gets worse, may be intermittent, nausea. palpable mass
  • USS (whirlpool sign, oedema), doppler studies (lack of blood flow), laparoscopy
  • emergency detorsion or oophorectomy
  • may lose function if delayed or become infected
230
Q

Lichen sclerosis

A
  • Chronic autoimmune inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin, commonly on labia, perineum, perianal skin
  • age 45-60, itching, soreness, skin tightness, superficial dyspareunia, erosions, fissures, Koebner phenomenon (symptoms made worse by friction to skin
  • porcelain white in colour, shiny, tight, thin, slightly raised, may be papules
  • symptom management - topical dermovate titrated down gradually, emollients
231
Q

what is androgen insensitivity syndrome

A
  • lack of androgen receptors, extra androgens converted into oestrogen resulting in female secondary sexual characteristics
  • X-linked AR in genetically male (XY) but no response to testosterone so female phenotype externally with testes inside and no upper vagina onwards
  • infertile, increased risk of testicular cancer
  • normally raised as female
232
Q

presentation of androgen insensitivity syndrome

A
  • in infancy with inguinal hernias containing testes
  • in puberty with primary amenorrhoea
  • high LH, high FSH, normal/raises testosterone, raised oestrogen
233
Q

management of androgen insensitivity syndrome

A
  • MDT
  • orchidectomy - prevent testicular cancer
  • oestrogen therapy
  • vaginal dilators or surgery to create adequate length
234
Q

bicornate uterus

A
  • heart shapes - 2 horns
  • can be associated with miscarriage, premature birth, malpresentation
235
Q

imperforate hymen

A
  • Hymen is fully formed, blocking vaginal opening
  • May be discovered in infancy or during first menstruations with cyclical pain but no bleeding
  • Needs surgery to avoid blocking ureters and avoid infection
236
Q

transverse vaginal septum

A
  • a septum (wall) forms transversely across the vagina, can be perforate or imperforate
  • can lead to infertility and pregnancy complications
  • needs surgery
237
Q

vaginal hypoplasia and agenesis

A
  • Vaginal hypoplasia refers to an abnormally small vagina
  • Vaginal agenesis refers to an absent vagina
  • Due to failure of the Mullerian duct development
  • Treat with vaginal dilator over time or surgery
238
Q

what is turners syndrome

A

female has a single X chromosome, making them 45 XO

239
Q

features of turners syndrome

A
  • 3 classic features – short stature, webbed neck, widely spaced nipples
  • High arching palate, downwards sloping eyes with ptosis, broad chest, cubitus valgus (when arm extended the forearms are angled outwards), underdeveloped ovaries, late/incomplete puberty, most women are infertile
  • associated with autoimmune conditions and recurrent otitis media and UTI
240
Q

management of turners syndrome

A
  • GH therapy to prevent short stature
  • oestrogen and progesterone therapy
  • fertility treatment
    monitoring for associated conditions
241
Q

Asherman’s syndrome

A
  • adhesions form within uterus following damage to basal layer of endometrium (eg after D&C)
  • lighter/painful periods, infertility, recurrent miscarriage
  • hysteroscopy with adhesiolysis, recurrence is common
242
Q

prolactinoma

A
  • prolactin secreting pituitary tumour - micro <10mm, macro>10mm
  • causes hypogonadism (decreases oestrogen and testosterone)
  • Females – irregular/absent periods, milky discharge from nipple, vaginal dryness, acne
  • Males – erectile dysfunction, decreased body and facial hair, smaller muscles, enlarged breasts
  • Both – infertility, osteoporosis, loss of libido
  • Diagnosis – bloods for hormone levels, MRI or CT head, visual field tests
  • Treatment – dopamine agonists (cabergoline – decrease production of prolactin and decrease size of tumour), surgical removal
243
Q

what is the UKMEC criteria

A
  • UK medical eligibility criteria used for contraceptives
  • UKMEC 1: No restriction in use (minimal risk)
  • UKMEC 2: Benefits generally outweigh the risks
  • UKMEC 3: Risks generally outweigh the benefits
  • UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
244
Q

risk factors for COC (UKMEC 4)

A

uncontrolled HTN, migraine with aura, VTE history, age >35 and smoking, surgery with prolonged immobility, CVD, stroke, liver cirrhosis or tumours, SLE, clotting abnormalities

245
Q

Fraser criteria for contraception under 16y

A
  • can be prescribed if: she understands advice, cant be persuaded to tell parents, likely to continue being sexually active, likely to mentally or physically suffer without, best interest
246
Q

pretesticular causes of male infertility

A

anything that reduced testosterone – pathology of pituitary or hypothalamus, stress, chronic conditions, Kallman Syndrome

247
Q

testicular causes of male infertility

A
  • From damage – mumps, undescended testes, trauma, radiotherapy, chemotherapy, cancer
  • Genetic conditions – Klinefelter syndrome, Y chromosome deletions, Sertoli cell-only syndrome, anorchia (absent testes)
248
Q

post testicular causes of male infertility

A

damage from trauma, ejaculatory duct obstruction, retrograde ejaculation, scarring from infection, Young’s syndrome

249
Q

Klinefelter syndrome

A
  • Males born with XXY, often not diagnosed until adulthood
  • Small testes, reduced muscle mass/facial hair, enlarged breast tissue
  • Many complications/related conditions
  • Treatment of symptoms, testosterone replacement therapy, fertility treatment
250
Q

IVF process

A
  • 25-30% success rate
  • supress natural cycle (GnRH agonists or antagonists) – ovarian stimulation (FSH SC for 10-14 days then hCG given then after 36h oocytes collected) – oocyte collection (needle through vagina, US guided) – insemination or intracytoplasmic sperm injection – embryo culture (until blastocysts, day 5) – embryo transfer (after 2-5 days, one/ 2 in older woman)
251
Q

urge incontinence/overactive bladder

A
  • overactivity of the detrusor muscle of the bladder
  • suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs
  • significant impact of QOL
252
Q

stress incontinence

A
  • weakness of the pelvic floor and sphincter muscles allowing urine to leak during times of increased abdominal pressure
253
Q

investigations for urinary incontinence

A
  • bladder diary
  • urine dipstick
  • post-void residual bladder scan
  • urodynamic testing if not responding to treatment
254
Q

management of stress incontinence

A
  • lifestyle changes
  • supervised pelvic floor exercises for >3m before surgery
    -surgery: tension-free vaginal tape, autologous sling, colposuspension, intramural urethral bulking
  • duloxetine (SNRI) when surgery is less preferred
255
Q

management of urge incontinence

A
  • bladder retraining
  • anticholinergics (oxybutynin)
  • more invasive procedures: Botox A injections, sacral nerve stimulation etc
256
Q

vault prolapse

A

after hysterectomy, vaginal vault descends

257
Q

rectocele

A

defect in posterior vaginal wall so rectum prolapses forwards, associated with constipation, can develop faecal loading leading to constipation and urinary retention, may feel lump in vagina

258
Q

cystocele

A

defect in anterior vaginal wall, bladder prolapse into vagina, prolapse of urethra (urethrocele), both (cystourethrocele)

259
Q

presentation of pelvic organ prolapse

A
  • dragging or heavy sensation
  • urinary symptoms
  • bowel symptoms
  • sexual dysfunction
  • lump or mass in vagina
260
Q

grading system for pelvic organ prolapse

A
  • pelvic organ prolapse quantification (POP-Q) system
  • Grade 0: Normal
  • Grade 1: The lowest part is more than 1cm above the introitus
  • Grade 2: The lowest part is within 1cm of the introitus (above or below)
  • Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
  • Grade 4: Full descent with eversion of the vagina
261
Q

management of prolapse

A
  • conservative - physio, lifestyle, oestrogen cream
  • vaginal pessary
  • hysterectomy
262
Q

STD investigations

A
  • Everyone – bloods to check for HIV, Syphilis and Hep B or C
  • Males – urine sample (chlamydia, gonorrhoea, and mycoplasma), possible swabs (throat, penis, and anal canal)
  • Females – high vaginal swab
    o Triple swab:
     1 (HVS) – TV, BV, candida
     2 (ECS) – GC
     3 (chlamydia)
263
Q

thrush/candidiasis

A
  • yeast infection with candida (most common candida albicans)
  • thick white discharge, no smell, irritation
  • vaginal pH (<4.5 suggests), charcoal swab with microscopy
  • antifungal (clotrimazole) cream/pessary, fluconazole oral antifungals if severe
264
Q

Bacterial vaginosis

A
  • overgrowth of anaerobic bacteria caused by loss of lactobacilli (normally produce lactic acid to keep pH <4.5)
  • Gardnerella vaginalis most common
  • fishy-smelling watery grey/white discharge
  • charcoal swab for microscopy
  • asymptomatic don’t need treatment
  • metronidazole oral/vaginal (no alcohol)
  • education of female hygiene
  • can cause complications in pregnancy
265
Q

chlamydia

A
  • gram negative intracellular bacteria
  • can cause infertility
  • national screening programme - test <25 annually/aftre new partner, retest after 3m if +
  • charcoal swabs for microscopy/culture/sensitivities, nucleic acid amplification test (NAAT)
  • abnormal discharge, dyspareunia, LUTS, reactive arthritis
  • doxy 100mg twice a day for 7 days (azithromycin in pregnancy)
  • abstain from sex for 7d, refer to GUM for contact tracing
266
Q

Lymphogranuloma Venereum

A
  • condition affecting the lymphoid tissue around the site of infection with chlamydia, most common in men who have sex with men
  • primary stage – painless ulcer
  • secondary stage – lymphadenitis
  • tertiary stage – inflammation of rectum (proctitis) – pain, change in bowel habit, tenesmus, discharge
  • Doxycycline 100mg twice daily for 21 days
267
Q

chlamydial conjunctivitis

A
  • usually when genital fluid encounters the eye
  • chronic erythema, irritation and discharge lasting more than two weeks, most are unilateral
268
Q

gonorrhoea

A
  • gram-negative diplococcus infecting mucous membranes with columnar epithelium (endocervix, urethra, rectum, conjunctiva, pharynx)
  • high level of abx resistance (ciprofloxacin, azithromycin)
269
Q

presentation of gonorrhoea

A
  • Odourless purulent discharge, possibly green or yellow, dysuria, pelvic or testicular pain
  • Gonococcal conjunctivitis in neonate if infected mother (medical emergency, related to sepsis, perforation of the eye, and blindness)
270
Q

diagnosis of gonorrhoea

A

NAAT diagnoses but need charcoal swab for culture and sensitivities

271
Q

Management of gonorrhoea

A
  • refer to GUM for treatment and contact tracing
  • abx depends on sensitivities
    o 1 dose IM ceftriaxone 1g if the sensitivities are NOT known
    o 1dose of oral ciprofloxacin 500mg if the sensitivities ARE known
  • Follow up test of cure – NATT if asymptomatic, cultures if symptomatic
272
Q

disseminated gonococcal infection

A

*Complication of untreated infection – bacteria spreads to skin and joints
*Skin lesions, polyarthralgia, migratory polyarthritis (moves between joints), tenosynovitis, systemic symptoms

273
Q

mycoplasma Genitalium

A
  • bacteria causing non-gonococcal urethritis - STI
  • presents similar to chlamydia but with urethritis
  • NAAT
  • doxy 100mg BDS for 7d then azithromycin
  • follow up test of cure
274
Q

causes of PID

A

*Most from STI – gonorrhoea, chlamydia, mycoplasma genitalium
*Non-STI – BV, haemophilus influenza, E.coli

275
Q

presentation of PID

A
  • Pelvic pain, abnormal discharge or bleeding, dyspareunia, fever, dysuria
  • On examination – pelvic tenderness, cervical motion tenderness (cervical excitation), cervicitis, purulent discharge
276
Q

investigations for PID

A
  • full STI screen
  • High vaginal swab for BV, candidiasis, trichomoniasis
  • Microscopy to look for pus cells
  • Pregnancy test to exclude ectopic
  • Inflammatory markers raised in PID
277
Q

management of PID

A
  • treat any infections (GUM)
  • 1 dose IM ceftriaxone 1g (cover gonorrhoea)
  • Doxycycline 100mg BDS for 14 days (to cover chlamydia and Mycoplasma genitalium)
  • Metronidazole 400mg BDS for 14 days (to cover anaerobes such as Gardnerella vaginalis)
  • may need admission if severe or pregnant
278
Q

Fitz-hugh-curtis syndrome

A
  • Complication of PID, inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum
  • Bacteria can spread via peritoneal cavity, lymphatics or blood
  • Right upper quadrant pain (can have shoulder tip pain)
  • Laparoscopy to visualise and adhesiolysis to treat adhesions
279
Q

trichomoniasis

A
  • trichomoniasis vaginalis - sexually transmitted parasite
  • protozoan (single celled organism with flagella)
  • urethra of men and urethra/vagina of women
  • can increase risks of other infections and pregnancy complications
280
Q

presentation of trichomoniasis

A
  • 50% of cases are asymptomatic
  • Vaginal discharge (frothy, yellow-green), dysuria, itching, dyspareunia, balanitis (inflammation of gland penis)
  • On examination – strawberry cervix (colpitis macularis)
  • Raised vaginal pH
281
Q

diagnosis of trichomoniasis

A
  • Can be confirmed on charcoal swab with microscopy – taken in posterior fornix or urethra/first-catch urine
282
Q

management of trichomoniasis

A
  • Referral to GUM
  • Metronidazole
283
Q

genital herpes

A

HSV - both cold sores (herpes labialis) and genital herpes, 2 types HSV-1 HSV-2
- after infection it becomes latent in sacral nerve ganglia

284
Q

presentation of genital herpes

A
  • Ulcers or blistering lesions affecting the genital area
  • Neuropathic type pain (tingling, burning or shooting)
  • Flu-like symptoms (e.g. fatigue and headaches)
  • Dysuria (painful urination)
  • Inguinal lymphadenopathy
  • First infection normally lasts 3 weeks and is the worst
285
Q

management of genital herpes

A
  • diagnosis via viral PCR
  • Referral to GUM
  • Aciclovir
  • Methods to ease symptoms (paracetamol, loose clothing, topical lidocaine etc.)
286
Q

pregnancy and genital herpes

A
  • risk of neonatal HSV (high mortality)
  • treatment with aciclovir for first infection then prophylactic aciclovir from 28w, may need CS if symptomatic
  • if latent then may not need aciclovir
287
Q

HIV

A

RNA retrovirus
HIV-1 most common, HIV2 rare outside west africa

288
Q

AIDS defining illnesses

A
  • when CD4 count has dropped significantly = opportunistic infections and malignancy
  • Kaposi’s sarcoma, Pneumocystis jirovecii pneumonia (PCP), Cytomegalovirus infection, Candidiasis (oesophageal or bronchial), Lymphomas, TB
289
Q

screening for HIV

A
  • test anyone in hospital with infectious disease
  • test everyone with risk factors
  • can take up to 3m for abs to develop so may need repeat test
  • need verbal consent documented
290
Q

tests for HIV

A
  • antibody testing – blood test
  • p24 antigen (specific HIV antigen in blood) – can give positive result earlier in infection
  • PCR testing for HIV RNA (viral load)
291
Q

treatment for HIV

A
  • specialist HIV, infectious disease or GUM centres
  • Combination of antiretroviral therapy (ART) medications offered to everyone with a HIV diagnosis - starting regime of two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent
  • aim to have normal CD4 count and undetectable viral load
  • prophylactic co-trimoxazole if low CD4 count
292
Q

preventing HIV transmission during birth

A

o Normal vaginal delivery if viral load < 50 copies / ml
o CS if > 50 copies/ ml and in all women with > 400 copies / ml
o IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml
- low risk babies given 4w zidovudine, high risk given 3 drugs

293
Q

breastfeeding and HIV

A

can be transmitted in breast milk even if viral load undetectable

294
Q

post-exposure prophylaxis for HIV

A
  • start within 72h
  • ART tx - truvada and raltegravir for 28d
295
Q

syphilis

A

called Treponema pallidum – spirochete, gets in through skin or mucous membranes, mainly a sexually transmitted infection, incubation period of 21 days

296
Q

primary syphilis

A
  • painless ulcer (chancre) 3-8w
  • local lymphadenopathy
297
Q

secondary syphilis

A

lasts 3-12w then into latent phase
- systemic symptoms
- o Maculopapular rash
o Condylomata lata (grey wart-like lesions around the genitals and anus)
o Low-grade fever
o Lymphadenopathy
o Alopecia (localised hair loss)
o Oral lesions

298
Q

tertiary syphilis

A
  • many years after infection it can affect many organs
    o Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
    o Aortic aneurysms
    o Neurosyphilis (headache, dementia, altered behaviour, demyelination, ocular syphilis, paralysis, sensory impairment)
299
Q

diagnosis of syphilis

A

*Antibody testing – screening
*Dark field microscopy and PCR can confirm presence of T.pallidum

300
Q

management of syphilis

A
  • specialist or GUM service - contact tracing, full STI test
  • Single deep IM dose of benzathine benzylpenicillin
301
Q

genital warts

A
  • HPV affecting moist tissues of genitals (flesh coloured bumps or cauliflower-like)
  • Cream: imiquimod
  • Laser removal
  • Freezing therapy – liquid nitrogen
302
Q

risk factors for breast cancer

A

female, increased oestrogen exposure, more dense/glandular breast tissue, obesity, smoking, family history, COC (small risk then reverses after 10 years), combined HRT?

303
Q

BRCA genes

A
  • tumour suppressor genes
  • BRCA1 gene chromosome 17- 70% get breast cancer by 80, 50% get ovarian, increased risk of bowel and prostate
  • BRCA2 on chromosome 13 – 60% get breast cancer, 20% get ovarian
304
Q

types of breast cancer - ductal carcinoma in situ

A
  • pre/cancerous epithelial cells of breast ducts
  • localised to single area
  • often found at mammogram
  • 30% become invasive
  • good prognosis with full excision and adjuvant tx
305
Q

types of BC - lobular carcinoma in situ

A
  • pre-cancerous
  • pre-menopausal
  • usually asymptomatic and undetectable on mammogram
  • increased risk of bc in future
  • close monitoring - 6m examination, 1y mammogram
306
Q

types of bc - invasive ductal carcinoma

A
  • from cells in breast ducts
  • 80% of invasive cancers
  • seen on mammogram
307
Q

types of breast cancer - invasive lobular carcinoma

A
  • 10% of invasive bc
  • from cells in breast lobules
  • not always visible on mammogram
308
Q

types of bc - inflammatory bc

A
  • 1-3% of bc
  • presents similarly to breast abscess or mastitis (swollen, warm, tender, peau d’orange), doesn’t respond to abx
  • worse prognosis
309
Q

types of bc - Paget’s disease of the nipple

A

Looks like eczema on nipple/areola, erythematous/scaly rash, indicated breast cancer involving the nipple, may represent DCIS or invasive breast cancer

310
Q

breast cancer screening

A

*NHS screening – mammogram every 3y for women between 50-70y
*1 in 100 diagnosed with breast cancer from screening

311
Q

high risk patients for bc

A
  • First degree relative with: bc under 40y/o, or male bc, or bilateral bc under 50, or two with bc
  • Need genetic counselling and pre-test counselling before genetic tests
  • Annual mammogram (potentially starting at 30)
  • Chemoprevention – tamoxifen (premenopause), anastrozole (postmenopause)
  • Bilateral mastectomy or oophorectomy
312
Q

presentation of bc

A
  • Lumps that are hard, irregular, painless or fixed in place
  • Lumps may be tethered to the skin or the chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
  • Lymphadenopathy, particularly in the axilla
313
Q

triple diagnostic test for bc

A
  • clinical assessment
  • imaging - USS (younger women), mammogram , MRI
  • biopsy - fine needle aspiration or core biopsy
314
Q

lymph node biopsy for bc

A
  • Ultra-sound guided biopsy
  • Sentinel lymph node biopsy – during breast surgery, isotope contract and blue dye injected into tumour area then travels to lymph node then can biopsy
315
Q

breast cancer receptors

A
  • gene expression profiling
  • Oestrogen receptors (ER)
  • Progesterone receptors (PR)
  • Human epidermal growth factor (HER2)
316
Q

most common metastasis for bc

A

lungs, liver, bones, brain

317
Q

staging used for BC

A
  • TNM
  • Nottingham score - prognostic
318
Q

treatment for bc

A
  • surgery: mastectomy, lumpectomy+adjuvant therapy, axillary clearance of lymph nodes
  • radiotherapy: can cause damage to breast tissue so only one round done
  • chemo: neoadjuvant (shrink), adjuvant and treatment of metastatic/recurrent bc
  • hormone therapy: if ER+ tamoxifen and aromatase
  • targeted treatment - Trastuzumab (Herceptin) and Pertuzumab (Perjeta) – monoclonal antibodies that target HER2 receptor
319
Q

benign breast lumps - fibroadenoma

A
  • common benign tumours of stromal/epithelial breast duct tissue
  • typically small and mobile, more common between 20-40 because they respond to the female hormones
  • painless, smooth, round, well circumscribed, firm, mobile, usually up to 3cm
320
Q

benign breast lumps - fibrocystic breast changes

A
  • variation of normal, fluctuate with cycle - tissues respond to sex hormones and become fibrous and cystic
  • manage symptoms
321
Q

benign breast lumps - breast cysts

A
  • benign, individual, fluid-filled lumps – most common cause of lumps between 30-50
  • can be painful and fluctuate in size over the menstrual cycle
  • smooth, well circumscribed, mobile, possibly fluctuant
  • often need further assessment to rule out cancer, may slightly increase risk
  • aspiration can ease symptoms
322
Q

benign breast lumps - fat necrosis

A
  • localised degeneration and scarring of fat tissue
  • from trauma, radiation, inflammatory reaction
  • may need biopsy to rule out bc
  • painless, firm, irregular, fixed, possible skin dimpling or nipple inversion
  • resolve spontaneously or surgery
323
Q

benign breast lumps - galactocele

A

occur after stopping breastfeeding, breast milk filled cysts from lactiferous duct blockage, usually resolve without intervention

324
Q

benign breast lumps - Phyllodes tumour

A
  • rare tumours of the connective tissue (stroma) of the breast, mostly in 40-50s
  • large and fast growing
  • can be benign (~50%), borderline (~25%) or malignant (~25%).

Phase 3A (6 decks)

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