Womens health Flashcards

Question

licehn scleross ey presntatons

Answer 1

* Vulval itching * Skin changes * Sorness and pain * Worse at night * Skin tightness * Pain during sex * Erosions * Fissures * The koebner phenomen - signs and symotos are mae worse by friction to to the skin. Skin looks: * Porcalin white * Shiny * Tight * Thin * Rainsed Pauples/plaques

Answer 2

potetnt topcal sterod - dermovate use every day for 4 wees then 2x a wee emollents 5% develop squamous cell carciomsa

Answer 3

Dryness and atrophy of the vaginal mucosa due to a lack of oestrogen. When exposed to oestrogen, the vagina and urinary tract become thicker, more elastic, and produce secretions. As oestrogen falls, its thinner, less elastic and more dry. This causes a tendency towards inflammation. There is also a change in pH and flora which leads to localised infections. Oestrogen also helps to keep connective tissue health and a lack of can lead to pelvic organ prolapse and stress incontinence. * Itching * Dryness * Dyspareunia - pain on sex * Bleeding Also consider it in women presenting with recurrent UTIs, stress incontinence, pelvic organ prolapse. Examination of vagina: * Pale mucosa * Think skin * Reduced folds * Erythema and inflammation * Dryness * Sparse pubic hair

Answer 4

* Vaginal lubricants * Topical oestrogen: * Topical oestrogen has lots of infractions with HRT - breast cancer angina and venous thromboembolism!! It may also lead to increaed ris pf endometrial hyoerplasia and endometrial cancer.

Answer 5

squamous cell cercinoma * Vulval intraepithelial neoplasia is a premalignant condition affection the squamous epithelium * High grade squamous intraepithelial lesion is associated with HPV infection that occurs in 35-50 YO Differentiated VIN is associated with lichen sclerosus

Answer 6

* Often incadendl presintaiton during catherisation * Lump * Ulceration * Bleeding * Pain * Itching * Lymphadenopathy of groin * Often affects the labia majora - irreguar mass * Bleeding # * Ulceration * Fungating lesion * 2 week wait * Biopsy of lesion * Sentinel node biopsy - demonstarte nodal spread * CT abdomen and pelvis for staging

Answer 7

For differentiated vulval intraepithelial neoplasia: * Watch and wait wide local excision * Imiqimod cream * Laser ablation * Local excisions * Goin lymog dissection * Checmotherapy Radiotherapy

Answer 8

75 YO HPV infection lupus lum in vagina and aroud skin ulcer bleeding after menopause ssmelly discahre bleeding between preieorsd itch pain when peeing radiotherpy surgert vaginal reconstruction chemotherapy

Answer 9

* Asymptomatic * Abnormal vaginal bleedig * Vaginal dishcccharge * Pelvic pain Dyspareunia Examine cervix with speculum * Smear * Colpposcopy and 2 week wait referal * Look for ulceration, inflamation, bleeding, visible tumour * Don’t use smear tests t exclude cervical cancer * Colposcopy - stains such as acetic acid and iodende solution can be used * Acetic acid makes the cells appear white (acetowhite) which happens in cells with increased nucleuer to cytoplasmic ratio * Schillers iodene test - healthy areas will tuen brown, unhealthyones won stain Punch biopsy or lareg loop excision of the transformational zone

Answer 10

* 80% are squamous cell carcinomas * Adenocarcinoma is the second most common * Dyskaryosis - cervical scressning test is HPV positive and there are abnormal changes in the cells fo the cervix HPV chance increase: * Early sexual activity * Increased sexua partners * Nto using condoms * Associated with HPV (human papillomavirus) 16 and 18, they are responsible for 70% of cancers * Smear tests to screen for precancerous cells P53 and pRb are tumour surpressor genes, HPV produces proiens whch inhibit these * Not engaging in cervical screening * Smoking * HIV * Combined pill >5 years * More full term pregnancies * Family history

Answer 11

* Happens every 3 years age 25-49 and every 5 50-64 * Cervical smear test - the juice is tested for HPV and then microscpoy for precancerous cell changes * Women with pevious HIV are screened annually * Women with previous CIN may need additional tests * The resuts are: * Inadequate * Normal * Boarderline changes * Low grade * High grade dyskaryosis * Possible invasive squamous cell carcinoma Inadequate sample – repeat the smear after at least three months HPV negative – continue routine screening HPV positive with normal cytology – repeat the HPV test after 12 months HPV positive with abnormal cytology – refer for colposcopy

Answer 12

80% are adenocarcinoma unoposed oestrogen early menses no pregannges obesty oestrogen only hormoen replacement therapy

Answer 13

Management and monitoring Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy Stage 2B – 4A: Chemotherapy and radiotherapy Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care * 5 year Survuval drops from 98% with 1 to 15% with stage 4 * Bevacizumab - monoclona antibody

Answer 14

* POST MENOPAUSAL BLEEDING!!!!!!!!!!!!! * Post coitao bleeing * Intermenstrual bleeding * Unusually heavy bleeding * Haematuria * Abnormal vag discharge * Anaemia Raised platemelt count

Answer 15

* 2 week wait if post menopausal bleeding (more than 12 months after last mensration * Transvaginal ultrasound in over 55 with - unexplained vag discharge, visible haemeaturia * Transvaginal ultrasoun for endometrial thickness * Pipelle biopsy * Hysteroscopy * Stages: Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis * 1 & 2 - total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa). * Progesterone * Chemo * Radio * Radical hysterectomy inclucing pelvic lymph odes and top of vag

Answer 16

An abnormal growth containing glands, stroma and blood vessels projecting from the lining of the uterus (endometrium) * Taximofen * Increased oestrogen levels * HRT

Answer 17

* Bleeding * Infertility * Malognant transformation * Transvaginla ultrasonography * Colour flow doppler * Sonohysterography * Histological diagnosis * Hysteroscopy * Dilatation and curettage * Watch and wait * levonorgestrel intrauterine system

Answer 18

* Some genetic compponenent * During mensturaiton it flows backewards (retrograde menstration) leading to te hcells seeding in the pelivs * Lymphatic spread * Cells change- metaplasia * Embryonic cells remain outsied the usterus and the devlop later on in life * Pelvic pain * The endometrial tissue also bleeds elsewheere wich causes irritation and inflamatin t the tissues elsewhrer, * This causes cyclicalm dull, heavy burnig pain * It can lead to adhesiosn * Reduced fertility

Answer 19

* Some genetic compponenent * During mensturaiton it flows backewards (retrograde menstration) leading to te hcells seeding in the pelivs * Lymphatic spread * Cells change- metaplasia * Embryonic cells remain outsied the usterus and the devlop later on in life * Pelvic pain * The endometrial tissue also bleeds elsewheere wich causes irritation and inflamatin t the tissues elsewhrer, * This causes cyclicalm dull, heavy burnig pain * It can lead to adhesiosn * Reduced fertility

Answer 20

* Pelvic ultrasoubnd - endometromas and chocolate cysts * Need gynea referal for laparoscopy * Laproscopc sugery s gold standard - biopsy needed. They can also remove bits which can help to relieve symptoms. *

Answer 21

Management and monitoring Initial: * Stablish clear diagnosis * Provide explanation, build partnership with patient * Analgesics for pain Hormonal * Combined oral contraceptive pill * Progesterone only pill * Injection * Mirena coil * Implant * GnRH agonists Surgical: * Laparoscopic to excise endometrial issues and remove adhesions * Hysterectomy * Hormonal medication can stop ovulation and reduce endometrial thickening * Induce a menopause like state - GnRH agonists * Infertility can sometimes be treated with surgery

Answer 22

Benign tumours of the smooth muscle of the uetere. * Affect 40-60% of women later on and are oestrogen sensiivt. * Intramural - within the myometrium, as they gro they change shape and distory the uterus * Subserosal - grow into the absmmoincal cavity * Submucosal - just belwo the endometrium * Pedunculated - on a stalk

Answer 23

* For fibroids less than 3cm, treat the same as heavy menstural bleeding * Mirenal coil * Tranexamix acid * Symtpmatic manegemnt - NSAIDs * Combined oral contraceptive * Cyclical oral progesterones * Endometrial ablation * Resection during hysteroscooy * Hysterectomy If over 3cm - refer to gynae - * Uterine artyer embolisation - block the blood supply causing ti to shrink * Myomectomy - laproscopic removal * Hyserectomy * Gnhr agonists can be used befroe surgery to reduce the size * Heavy blleeidn - aneamis * Reduced fertilitu * Consitpatoin * Pregnancy complications * Urinary obstruction * Torsoin * Malignant change t leiomyosarcoma * Red degeneration - infarction and necrosisof et hfibroid during pregnancy - severe abdominal pain, tachycardia, fever, vomiting

Answer 24

Key presentations * Asymptomatic * Menorrhagia * Prolonged menstruation - over 7 days * Bloating and feeling full * Urinary and bowel symptoms * Deep dyspareunia * Reduced fertility * Bimanual examination may reveal palpable pelvic mass Signs Symptoms Tests * Hysterospcpt for submucosal with heavy mensturla bleeding * Pelvic ultrasound * MRI scanner

Answer 25

* Pregnancy implants outside of the uterus such as in a fallopian tube, ovary, cervix or abdomen. * Previous ectopic pregnancy * Previous pelvic inflammatory disease * Previous fallopian tube surgery * Older age * Coils * Smoking * Endometriosis!! * IVF treatment

Answer 26

* 6-8 weeks gestation * Always ask about possibility of pregnancy * Missed periods * Constant lower abdominal pain * Vag bleeding * Lower abdo and pelvic tenderness * Cervical motion tenderness * Shoulder tip pain * Dizziness or syncope * Ultrasound scan will show adnexal mass moving separately to the ovary or comprising a gestational sac and yolk/fetal pole. * Transvag ultrasound * Gestational sac containt yolk or fetal pole might be found * Non specific mass iht be alled a blob sign * Empty uterus, fluid in uterus mistaken for gestational sack * Pregnancy of unknown location - positive pregnacy test but no evidance of pregency on ultrasound * A fall in HCG greater than 50% is likey to be a misscaragge

Answer 27

Management and monitoring * Referral to early pregnancy assessment unit * Expectant management - wait for normal termination * Medical management (methotrexate) * Surgical management (salpingectomy) Criteria for expectant management: * Follow up needed on day 2,4,7 * Ectopic is unruptured * Adnexal mass <35mm * No visible heartbeat * No pain and clinically stable * HCG level <1500 IU For methotrexate - HCG above 5000, confirmed pregnancy on ultrasound. It is very toxc to pregancy, women shouldn’t get pregnancy within 3 months of having it. * Surgical mamgement - pain, adnexal mass >35cm, visible heartbeat, hcg >500, signs of rupture, heamodynamically instable * Laproscpoic salpingectomy - general anasthetic, removal of fallopian tube * laparoscopic salpingotomy - fallopian tube is opened, pregancy is removed and then its sown back up again

Answer 28

* Mifepristone (anti-progestogen) - relaxes cervix, and terminates fetus * Misoprostol (prostaglandin analogue) 1 – 2 day later - softens cervix and stimulates contractions. From 10 weeks, additional doses are required * Rhessus negative women require anti D prophylaxis from 10 weeks gestation onwards * Less than 10 weeks - medication at home * Oramorph and morphine pain killers in pregnancy * Local anasthetic, sedation ot general * Cervical priming with misoprostol, mifepristone, osmotic dilators * Cervical dialation dn suction - up to 14 weeks. * Cervical dilation and exaltation using forceps Beyond 18 weeks its surgical.

Answer 29

rotterdam - 2/3 needed * Anovulation * Hyperandrogenism - hirsutism and acne Polycysitc overus on ultrasound

Answer 30

* Oligomenorrohea * Infertility * Obesity * Acne * Hirsutism * Male pattern hair loss * Insulin resistance * Acanthos nigricans * Hypercholesterima * Depressiona dn aanxiety * Obstructive sleep aponea * CVD disease * Sex issues Acanthosis nigricans

Answer 31

* Testosterone * Sex hormone binding globulin * Lunatizing hormone * Follicle stimulating hormone * Prolactin * Thyroid stimulating hormone * Raised lunatising hormone * Raised testosterone * Raised insulin * Normal or raised oestrogen levels * Raised LH:FSH ratio! * Oral glucose tolerance test, for diabeties checkign * Transvaginal ultrasound is gold standard!

Answer 32

* Manage risks associated - weight loss, exercise, stop smoking, statins, antihypertensives * Weight loss is a large management and can restore fertility * Orlistat may be sed to helpo weight loss in BMI >30. it is a lipase inhibitor. * They have increased risk of endometrial cancer - mirena coil, orla contraceptie pill, cyclical progesterones. * Managing infertilty - weight loss, Clomifene, Laparoscopic ovarian drilling, In vitro fertilisation (IVF) * Management of hiratusm - dianette OCP, topical eloflorinate, spirinolactone * For the hair growht - cominded pill (yasmin preferably or maybe dianette) * Spiranalactone can be used as an offliscence treatment Hiratusm can also be causeed by - medications ( phenytoin, ciclosporin, corticosteroids, testosterone and anabolic), ovarian/adrenal tumous Cushings * Inferetility * Diabeties (insulin resistance) * Hypercholesteremia * Cardiovascualr diesaes earlier? * Cancer - ovarian, endometrium

Answer 33

* Multiple partners * Young age * STIs * Previous inflammatory disease * Intrauterine device STIs: * Neisseria gonorrhoea * Chlaymidia trachomatis * Mycoplasma genitalium Non STIs * Gardenella vaginalis (BV) * Heamophilus influenzae * Estrichia coli

Answer 34

* Pelvic/lower abdominal pain * Abnormla discharge * Pain during sex * Fever * Dysuria Exam: * Pelvic tenderness * Cervcal motion tenderness * Purulent dishcarge Fever/ sepsis

Answer 35

* GUM medicniie refferal * Contact tracing A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea) Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis) Ceftriaxone and doxyxycline are also good!!! * They may require hospita admission and V antibiotis if there is sepsis or they are preggers. * May need surgery of tehre is an abcess * Sepsis * Abcess * Infertility * Chronic pelvic pain * Ectopic preg * Fitz- hugh- curtis syndrome - infection of glissons capsule (liver capsule) , spread thouhh blood, lymphatics or from pelvic cavity, * RUQ pain, laproscopy and treat adhesions.

Answer 36

The ovary twists in relation to the surroundign tissue, fallopian tube and blood supply. Pregnacny Before menarche Often occurs due to an ovarian mass >5cm such as a cyst or tumout. It can cause the blood supply to be cut off leadingto necrosis, it is an emergancy. * Severe sudden onset, unilateral pelvic pain. * Pain is constatnt, gets progressibly worse * Nausua and vomiting

Answer 37

Pelvic ultrasound - ideally transvaginal Whirlpool sign - free fluid in the pelvis and oedema of the ovary Doppler may show lack of blood flow Laproscopic surgeyr for removal or untwisting and fixing it in place. * Delay in treatment may lead to loss of function * The other one can normallyompensate fertility wise * Infection * Necrosis, rupture, sepsis * Peritonitis

Answer 38

Often diagnosed late as non-specific symptoms. 70% is diagnosed after it has spread beyond the pelvis. * Age 60 * Increased number of ovulations * Obestiy * Smoking * Recurrent clomifene use Protective - * Oral pill * Pregnancy * Breastfeeging * As these all stop ovulation for a while

Answer 39

* Epithelial cell tumours are the most common type - subtypes of this are - serous tumours, endometroid carcinomas, clear cell tumours, mucinous tumours, undifferentiated tumours * Dermoir cysts and germ cell tumours- tereatomas which come from ger cells. They are bengign. * Sex cord-stromal tumours - sertoli and leydig and granuola cell tumorus * Metastasis - krunken tumours are from GI cancer and look like signet rings in histology microscopy Non specific * Abdominal bloating * Early satiety * Loss of appetite * Pelvic pain * Urinary symptoms * Weight loss * Abdominal or pelvic pain * Ascites * It may press on the obturator nerve and cause referred hip or groin pain Refer to 2 week wait if they have ascities, pelvic mass or ambominal mass. In women over 50 with * New symptoms of IBS / change in bowel habit * Abdominal bloating * Early satiety * Pelvic pain * Urinary frequency or urgency * Weight loss Do CA125 blood test before referral.

Answer 40

CA125 blood test - >35 IU/ml is significant Pelvic ultrasound CT scan Histology Paracentesis Germ cell tumour * alfa fetoprotiesn * HCG CA125 - can be raised due to endometriosis, fibroids, adenomyosis, pelcin infection, liver disease, pregnancy.

Answer 41

Multiple cysts (string of pearls) is polycystic overian syndrome if they have no other conditions, it also requires two of anovulation, hyperandrogenism, polycystic ovaries on ultrasound. Follicular cysts are the most common and are when the egg is released they persist. Normally they disappear after a few menstural cycles Corpus luteumncysts - often seen in early pregnancy * Serous cystadenoma - epitherla cells * Mucison cystadenoma * Endometrioma * Dermoid cysts - teratomas Sex cord stromal tumous - sertoli, leydig and granulosa cell tumours

Answer 42

* Asymptomatic * Pelivc pain * Fullness in the abdomen * Palpable pelvic mass Distuinbigh if it is benign or malignant * Abdmonial bloating * Reduced appetite * Early satiety * Weight loss * Urinary symptoms * Pain * Ascities * Lymphadenopathy Risk factors: * Age * Postmenopause * Increased number of ovulations * Obesity * Hormone replacement therapy * Smoking * Breastfeeding (protective) Family history and BRCA1 and BRCA2 genes

Answer 43

* Premenopausal women with a simple cysts less than 5 cm on ultrasound can be left Blood: * CA125 - tumour marker for ovarian cancer to check Women under 40 with a complex ovarian mass look for germ cell tumour * Lactate dehydrogenase * HCG * Alfa-fetoprotien * For suspected cancer - 2 week wait Simple cycts on premenopausal wmen: * Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. * 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. * More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasoun * Enlarged cyts might need surgical intervention - remove cyst or ovary * Torsion * Haemorrhage * Rupture * Meigs syndrome - ovarnain fibroma, pleural effusion, ascieties. This is in older women. Requires removal of the tumour.

Answer 44

* Idiopathic * Antiphospholipid syndrome - low dose aspin and LMWH * Hereditary phrombophilias - factor V leidan, gactor II gebe mutation, protoein S deficancy * Uterine abnormalaties - * Genetics * Chronci histocytic intervillositis - very rarem histocytes and macrophaes build ip and causes inflamation. * Diabeties * Untreated thyroid disease * SLE Investiagete after three or more 1st trimester ones, or one second trimester one. Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic ultrasound Genetic testing of the products of conception from the third or future miscarriages Genetic testing on parents

Answer 45

* Missed - fetus is dead but there are no symptoms * Threatened - vag bleeding with closed cervix and alive fetus * Inevitable - vag bleeding with open cervix * incomplete - products of conception remain after miscarriage * Compete - full miscarriage has occurred and the uterus is empty Anembryonic pregnancy - gestational sack but no embryo * Inevitable - you do a vginal exma and the cervix is open, yo miht be able to see some sack, the misscarrige is going to happen. Delayed - the women have no symptoms, but the feotus is over 7mm and there is no heartbeat on ultrasound. This will have to come away. They often present to antenatal clinic unaware.

Answer 46

* Transvag ultrasound - three features used, as each appears the last one becomes less important - mean gestational sac diameter, fetal pole and crown rump length, fetal heartbeat. * When there is crown rump length of 7mm and no heartbeat after 2 weeks, it is non viable. * When the mean gestational sac is 25mm and there is no fetal pole, after a week it is an anembryonic pregnancy * A speculum exam can also be good to look at the cervix * bHCG levels need to be moniterd to ensure failing iUP * Normally bHCG should double every day, so if it is falling you know the feotus is coming away Vaginal ultrasound! * Ectopic pregnancy * Cervical caner! Alays just swab them as you don’t want to miss it!

Answer 47

* <6 weeks - if in no pain just leave them, repeat pregnancy test after 7 days, if negative it is a miscarrige * <6 weeks - refer to early pregnancy assesment unit, ultrasoun for location and viability of the pregnancy. Then expecanct manegment, medical management, surgical management. * Medical manegent - misoprostol - prostaglandin analouge which softens cervix and simulates uterine contractions, side effects of heavy bleeding, pain, vomiting, diarrhoea. * Manual vaccum aspiraition - local anasthetic, a tibe goes into eth cervix and then a syringe is used to manyually aspirate the contents of the uterus . <10 weeks gestation. * electric vaccum aspiration (general anasthetic) cervix is widedned a a vaccum put inn to suck out the contents, * Anti rhesus d MUST be given to resus negative women * Rretained products of conceotio can lead to infection, needs misoprostol or surgical managetment with vaccum and cutterage. A coplication of cutterage is endometritis.

Answer 48

32-336 for uncomplcated monochoronc monoamnotc twns before 35- 6 for trples monoamnotc are c secton

Answer 49

* Anaemia * Hypertension * Spontanous preterm birth * Cesarean * Potpartum hemmoarge * Polyhydramnios * Miscarrige * Fetal growth restiricion * Prematurit y * Twin twin transufuion syndreome- one twin recieves roe bllood getting heartfaliure and poluhydamnio, the other ets anama, olidohydramnios and growth restriction * Twin anaemia polycythermia sequance - less acute but same as above Congenital abnormalaties

Answer 50

path - tumour that grows le a pregnancy n teh uterus partal - 2 sperm fertalse a normla egg and it divides into a tuour but some fetal material may grow complete - 2 sperm fertalise an empty egg and form a tumour

Answer 51

* Miscarrige * Gestational diabeteis * High blood perssure and preeclampsi a * Blood clots * Shoulder dysocia * Heavy bleeding after birth * Need for forceos of ceasarean * Stillbirth Spinal bifida

Answer 52

snowstorm appearcne bunch of grapes exaculation and hisological examination chemo if metastasised

Answer 53

* Previous gestational diabeteis * Previosu macrosomic baby * BMI >30 * Black, middle eastern and south asian ethnicity Family histroy of diabeties

Answer 54

anyone wit risk factos shold have oral clugcole tolerance test at 24-28 weeks gestation Oral glucose toleracne test - * Fast, drink 75g glucose, measure blood after and before. * Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l

Answer 55

* Education to the women * 4 week ultrasounds * Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin * Fasting glucose above 7 mmol/l: start insulin ± metformin * Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin * They should monitor the blood sugar levels a few times a day, Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below * Resoloves immedatly after birth * Babies can be at risk of hypoglycaemia, cardiomyopathy, congenital ehart disease, jaundice, polycythaemia Macrosomia and hypoglycaemia are the 2 biggest coplicatiosn for the baby!!!!!

Answer 56

* Take 5mg folic acid untill 12 weeks gestation * Aim for the same targets as in gestational * Use insulin and metformin, other diabetic medications should be stopped * Diabetic retinopathy screening would take place! * Planned delivery 37 +6 weeks Sliding scale insulin reigeme during labour may be needed. Dextrsoe and insulin infusion.

Answer 57

* Chronic hypertension exists before 20 weeks gestation and is not caused by dysfunction of the placenta. * Gestatonal hypertention - hypertention that occurs after 20 weeks without protnudia * Pre-ecalmpsa - hypertention and end organ dmaage - protinuria

Answer 58

* The lacunae formed are inadequate and there is high vascular resistance with poor perfusion This causes oxidative stress on the placenta and inflammatory chemicals to be released leading to systemic inflammation and impaired endothelial function.

Answer 59

* Headache * Visual disturbances * Nausea and vomiting * Upper abdominal pain * Oedema * Reduced urine output * Brisk reflexes * Odema in hands and face!! * Hypertention + proinuria and at least one of: * Severe headache * Visual disturbaces * Papilloedema * Clonus * Liver tenderness * Abnrmal liver enzymes * Platelet couunt falls to <100 x 109 litre Blood pressure over 150 is very worrying!!!!!

Answer 60

* Diagnose if there is a systolic blood pressure above 140 or diastolic blood pressure above 90 PLUS * Proteinuria, organ dysfunction, placental dysfunction. Placental growth factor is a protein that stimulates development of new blood vessles. In preeclampsia the levels are low.

Answer 61

Prophylaxis * Asprin is used as a prophylaxis against preeclampsia if they have a high risk factor or 2 moderate risk factors. * Monitored with blood pressure, symptoms and urine dipstick for proteinuria. Diagnosed: * Scorint systems on if to admit or not * Blood pressure monitered at least evry 48 hours * Ultrasound every 2 weeks * Labetolol is first-line as an antihypertensive (beta blocker) * Nifedipine (modified-release) is commonly used second-line * Methyldopa is used third-line (needs to be stopped within two days of birth) * Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia * IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures * Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload as a lot of It can go into the 3rd space (oedema). Restrict to 80mls an hour. Bloood tets fo plateltes, renal and liver.

Answer 62

* Help syndreom - * Haemolysis * Elevated liver enzymes * Low platelets Onset of seizures in a woman with pre-eclampsia Seizures in a pregnant woman are always eclampsia until proven otherwise IV MgSo4 4gms given over 5 minutes, followed by an infusion of 1 g/hour maintained for 24 hours Recurrent seizures may require further doses Treat hypertension (labetalol , nifedipine , methyldopa, hydralazine) Stabilise mum first, then deliver baby

Answer 63

* Smoking * Parity >3 * Over 35 YO * Reduced mobility * Multiple pregnancies * Pre eclampsia * Varicose veins * Family history * Thrombophillia IVF pregnancy

Answer 64

* Start VTE proyphylaxis at 28 weeks if there are 3 risk factors * First trimester if tehre are 4 or more risk factors * Also start if there is hospital admission, surgical prodedures, previous VTE, cance or arthiritis. * Low molecular weight heparin - enoxaparin, daltaparin, tinzaparin. Start as soon as possible In very high risk patients. * Continue for 6 weeks postnatally but stop briefly during labour. Antiembolic compressoin stockings, intermittenet pneumatic compression

Answer 65

* Obesity * Diabetes * Impaired immunity / immunosuppressant medication * Anaemia * Vaginal discharge * History of pelvic infection * History of group B Strep infection * Amniocentesis and other invasive procedures * Cervical cerclage * Prolonged spontaneous rupture of membranes Group A Strep infection in close contacts / family members

Answer 66

IV magnesum sulphate!

Answer 67

V benzylpenclln

Answer 68

reduced outflow of ble acds from lver also ncreased oestrogoen and progesterone levels 1% of women develops after 2 wees

Answer 69

* Third trimester * Itching is the main symptom - palm and hands and soles of feet * Fatigue * Dark urine * Pale greasy stools * Jaundice There is no rash!!! If there is one present think about polympophic eruption of pregnancy o pemphigoid gestationis

Answer 70

FT - abnotmla ALT, AST, GGT * Bile acids - raised ALP is noramllyl raised in preganncy becuased the pakcenta makes some, so if only this is raised think again

Answer 71

* Emollients for the itching - chalmomile lotion * Antihistamines ot help with sleep - doesn’t help itching * Water soulble vitmain K can be given if prothrobin time is deragnced Early delivery may be needed if it is really bad

Answer 72

* e.coli is most common * Kelbsiella pneumnoiae * Enterococcus * Pseudomons aerginosa * Staphylococcus saphrohyticus Candida albicans

Answer 73

* Dysuria * Suprapubic pain * Increased frequency * Urgency * Incontinence * Haematuria Pyelonephritis: * Fever * Loin, suprapubic or back pain * Feeling unwell * Loss of appetite * Heamaturia * Renal angle tenderness

Answer 74

7 days antbotcs!!! ntrofuranton - avodn n 3rd trmesyyer * Amoxixillin Cefalecin

Answer 75

an lead to varicella pneumonitis, hepatitis and encephalitis, * Congenital varicella syndrome - 1% of chicken pox cases and happens whe the infection is in the first 28 weeks of gestation. There is fetal growth restriction, microcephaly, hydrocepahlus and learning disability. Scars, limb hypoplasia and cataracts.

Answer 76

* Varicella vaccine prior to pregnancy * IV varicella immunoglobulins within 10 days as prophylaxis if they have been exposed * If thery present with rash, treat with oral aciclovir if theyr resent withtin 24 hours and they are over 20 week gestaiton

Answer 77

Abnormally low voulme of amniotic fluid surrounding the fetus. * Fetal growth restriction * Maternal comorbidities - hypertension * Placental abnormalities * Placental abnormalities * Fetal urinal tract anomalies * Maternal drug use - NSAID, ACE inhibitors * Post term pregnancy

Answer 78

* Ultraousnd - * In the first method, the maximum vertical pocket (MVP) is identified and measured. A normal MVP is 2 cm to 8 cm. * The second method calculates the amniotic fluid index (AFI) and involves dividing the uterus into four quadrants and then adding together the MVP from each quadrant. A normal AFI is 5 cm to 25 cm.2 * Oligohydrosis is: * AFI <5 cm or MVP <2 cm

Answer 79

* Ferning test - cervical secretions are dried on a slide, amniotic fluid forms crystals. * Amnisure: a vaginal swab to screen for the presence of placental alpha microglobulin-1 (PAMG-1) which is found in high concentration in amniotic fluid. * Actim-PROM: a swab that screens for insulin-like growth factor binding protein-1 (IGFBP-1) which is found in high concentration in amniotic fluid.

Answer 80

* The earlier it is diagnosed, the worse the outcomes. * Limb deformitys * Pulmonary hypoplasia Cord compression an happen during labour.

Answer 81

multple pregancy dabetes gut atresa nfecton rehseus dease placentl ssues

Answer 82

breathlesness heartburn constpato oedema n hands and feet enlarged vulcva tihhttness n stomach

Answer 83

* Extra antenatal appointments * Blood test for diabetes * Amniocentesis * Change in diet * Idomethacin - lowers the amount of urine youre baby makes * Preterm birth * Waters break early * Prolapsed umbilical cord * Heavy bleeding after baby * Placental abruption * Stillbirth * Postpartum hemorrhage * Fetal malposition * Uterine atony * Macrosomnia

Answer 84

accreta - into the myometruu but not beyond incretta - deeply inoy the myometrum percreta - past the myomerum and permetroum, potentially invading other organs

Answer 85

* Ideally diagnosed antenatally by ultrasound to allow planning * MRI scans to asses depth and width * Complex uterine surgery * Blood transfusions * Intensive care for the mother * Neonatal intensive care * Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery. Caesarean with: * Hysterectomy with the placenta remaining in the uterus (recommended) * Uterus preserving surgery, with resection of part of the myometrium along with the placenta * Expectant management, leaving the placenta in place to be reabsorbed over time, this is very risky. * At 20w scan watch for anterior LLP if previous CS * Loss of definition between wall of uterus and Abnormal vasculature * MRI scan may be useful * Arrange elective CS at 36 to 37 weeks * Discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and intervention radiology) * Multidisciplinary involvement in pre-op and procedure: consultant obstetrician, consultant anaesthetist and blood bank/ Haematologists * Blood and blood products available Local availability of a level 2 critical care bed (HDU)

Answer 86

Placenta separates from the wall of the uterus during pregnancy, often leading to antepartum haemorrhage. * Previous placental abruption * Preeclampsi a * Bleeing in early pregancy * Trauma * Multiple pregnacy * Fetal growth restirction * Multigravida * Increased maternal age * smoking * Cocaine/amphetamine use * \ntiphospholid

Answer 87

Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Answer 88

* Sudden sever continous abdo pain * Vaginal bleeding * Shock - hypotnsio and tachycardia * Abnormalaties on CTG * Woody plpation of abdomen * Maternal shock out of proportion to bleeging Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: more than 1000 ml blood loss, or signs of shock There is also concealed abruption wheere the cervixal os remains closed and the bleeding can easilty be underestinated.

Answer 89

* Notify midwife, senior obstiatrician and anaesthetist * 2x grey cancula * Bloods - FBC, UE LFT, Coagulaiton study * Cross match 4 units of blood * Fluid and blood recusitation * CTG monitering of the feotus * Close monitering of mother Steroids if pretetm delivery Rhesus D Emergcyanc c section Active managemtn of third stage

Answer 90

*exposed feotal vessles cross the OS. The fetal vessels should always be protected by the umbilical cord or by the placenta. Whartons jelly is the connective tissue that makes up the outside of the umbilical cord. 2 thngs can leave the vessles exposed: * Velamentous umbilical cord is where the umbilical cord insets into the chorioamnitotic membrane and the fetal vessles travel unproteced though the membranes before joining the placenta * An accessory libe of the placenta is connected by fetal vessles that travels though the chorioamnitotic memebrane between the lobes. The exposed vessels are prone to bleeding, paritciualry whe the membrane rupture. Wheich leads to fetal blood loss and death

Answer 91

* Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord. ths s when it attaches into eh chorioamntiotic membrane and travel unprotected before jooing the placenta. * Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 92

Management and monitoring * Planned c section if found on ultraousnd - 34-36 weeks * Corticosteroids t 32 weeks to mature feotal lings * Fetal mrotality is 60% if not known about prior to birth

Answer 93

* Low-lying placenta is used when the placenta is within 20mm of the internal cervical os Placenta praevia is used only when the placenta is over the internal cervical os

Answer 94

* Previous caesarean sections * Previous placenta praevia * Older maternal age * Maternal smoking * Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 95

* Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os * Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os * Partial praevia, or grade III – the placenta is partially covering the internal cervical os Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

Answer 96

* Emergency caesarean section * Blood transfusions * Intrauterine balloon tamponade * Uterine artery occlusion * Emergency hysterectomy * ABCDE * If major bleed: two 14/16 G cannulas, IV fluids (crystalloid), X match 6 units, inform senior team and Paeds ASAP

Answer 97

repeat transvaginal ultrasound scan at: 32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery) * Planned delivery at 36-37 weeks - c section * Steroids between 34-35+6 weeks to mature the foetal lungs * C sections incisions may have to be made vertically to avoid the placenta * Come to hospital if there is any bleeding * Avoid sex Give anti D

Answer 98

* Pessary - propess (contains dinoprostone) (put in for 24 hours) * Then you can do a second pessary or a balloon * Then you can rupture the membranes Start on an oxytocin dri

Answer 99

First 1–12 weeks Second 13–26 weeks Third 27–end of pregnancy

Answer 100

37-42 weeks

Answer 101

prostoglandin E2 (dinoprostone)

Answer 102

Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 103

* External cephalc version acan be used at 37 weeks to turn them, 50% sucesfu * . Given tocolysis to relax the uterus with subcut terbutaline. It is a beta agonist reduced contractility of the myometrum * Rhesus D negative women need anti D prophylaxis. Kleihaur test is used to quantify the does of anti D needed. * Elective C seciton If the first baby in twins is breach a C seciton is requred

Answer 104

* Fever * Chills * Body aches * Loss of appetie * Discomfot * Pain below waist * Pale slammy skin * Increased heart rate * Foul smelling vaginal dischage Heavy bleeding that doesn’t improve

Answer 105

* Temp * White cell count * Vaginal swabs * Urine culture and sensitivitues Ultrasoubn for eetained products of conception

Answer 106

* * Muscle layer of the uterus ruptures during labour * Incomplete rupture - the uterine serosa (perimetrium) remains intact * Complete rupture - all contents of the uterus are released itno the peritoneal cavity High mobidity for motehr and baby Revious C section, can rupture with excessive pressure * Rare for it to happen in first birth * Increased BMI * High parity * Increased age * Induced labour Use of oxytocin to simulate contractoins

Answer 107

* Abnormal CTG * Abdominal pain * Vaginal bleeding * Ceasing of uterine contractions * Hypotension * Tachycardia * Collapse

Answer 108

* 25-40% of preterm birhts are due to infection * Commonly ureaplasma urackyticum, e coli * The bactera can ascend from the vagina, be tranplacental t retrograde seeding from peritonea caviy through the fallopean tube. The proinflamatory cytokines which causes terine rubture * Ischeamia to the placenta * Uterine overdistention in twins Cervical weakness - congenital or traua

Answer 109

Screenign: * Previous preterm birth * Pervious cervical cerclage * Multipe pregnancy * Intrauterine adhesiosn * Uterine abnormlaties * Previous C section Cervical length is measured usinf a transvaginal ultrasond. Cervical length of less than 25mm between weeks 16-24 is a bad sign, and these mothers are at higer risk * Fetal fibromectin - extracellular matrix glucoprotien localozed at the maternal fetal interface of eth amniotic membrane Sould not be detectable at high levels in the cervicovaginal secretions at pretemr, its prescence is associated with decidual membrane activation

Answer 110

* Abso pain * Vaginal pressure * Increased vag discharge, bleeding, watery loss * GI disturbance * Urinary symptoms * Contractions * Vulvl chnages * Cercical softenign r dilation * Liquor drainage CTG changes

Answer 111

Prophylaxis of preterm labour: * Progesterone gel vaginally to maintain pregnancy by decreasing myometriun activity. Offerend to women with cervial length less than 25mm on vag ultrasound bewteen 16-24 weeks gestation * Cervical cercalage - a stich in the cervix to add support. For women with a cervix less than 25mm between 16-20 weeks or who have had a previous premature birth or cervical trauma Rescue cerclage can be offered when there is cervical dilation without rupture of membranes

Answer 112

* Tocolytic - stop uterne contractons. First line is nifedipine * Steriois - given when baby is abot to be beron withtin 24-48 hours * Magnesium - neuroprotective of hypoxia and redced cerebal palsy risk * Theroregulation - put them in a warm bag * Delayed cord clamping Maternal early breast milk

Answer 113

* prophylactic antibiotics - erythromycin 250mg 4xday, for 10 days Induction of labour might be offered

Answer 114

etal monitoring (CTG or intermittent auscultation) * Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour * Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality * IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain * Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth * Tocolysis is using medication to stop contractions * Nifedipine is a CCB, atosiban is a oxytocin receptor antagonist that can also be used. * Give corticosteroids to help the fetal lungs to develop in less than 36 weeks - 2x dose of intramuscular betamethasone 24 hours apart Magnesium sulphate IV - protect the foetal brain

Answer 115

Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the foetal head * 1% * Macrosomia (most cases occur in normally grown babies) * Maternal diabetes * Previous shoulder dystocia * Disproportion between mother and feotus * Post maturity and induction of labour * Maternal obesity * Prolonged 1st or 2nd stage of labour * Instrumental delivery

Answer 116

Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the foetal head H – Call for help (emergency buzzer) * E – Evaluate for episiotomy * L – Legs in McRoberts (90% will come at this point) * P – Suprapubic pressure * E – Enter pelvis * R – Rotational manoeuvres * R – Remove posterior arm (R – Replace head and deliver by LSCS -Zavanelli)

Answer 117

* Maternal * PPH * Extensive vaginal tear (3rd and 4th degree) Psychological * Neonatal * Hypoxia * Fits * Cerebral palsy Injury to brachial plexus

Answer 118

First-degree tears are small and skin-deep. Second-degree tears are deeper and affect the muscle of your perineum. Third-degree tears also involve the muscle that controls your anus (the anal sphincter) Fourth-degree tears goes further into the lining of your anus or bowel

Answer 119

Umbilical cord descends below the feotus into ethe vagina, after rupture of foetal membranes. There is a risk of compression leading to fetal hypoxia. t can also lead to vasospasm. * Fetus being in an abnormal position, with room for the cord to descend. * Rare: 0.2 – 0.6% Premature rupture membranes Polyhydramnios (i.e. a large volume of amniotic fluid) Long umbilical cord Fetal malpresentation (e.g. if baby’s head not down) Multiparity Multiple pregnancy

Answer 120

* Emergancy c section * Don’t push it back in or handle it * When there is compression, Lie in left lateral positionor knee chest to use gravity (exaggerated smms poston) * Tocolytic medication (terbtaline) can be used to minmise contractions. * emergency buzzer * Infuse fluid into bladder via catheter if at home * Trendelenburg position (feet higher than head) * Constant fetal monitoring * Alleviate pressure on cord Transfer to theatre and prepare for delivery

Answer 121

* Delay in the first stage is when there is eitehr less than 2cm dilation in 4 hours ot slowing of progress in a multiparous women When the active pushing stage lasts longer than: * 2 hours in a nulliparous woman * 1 hour in a multiparous woman More than 30 minutes with active management More than 60 minutes with physiological management Active management involves intramuscular oxytocin and controlled cord traction.

Answer 122

* Cervical dilatation (measured by a 4-hourly vaginal examination) * Descent of the fetal head (in relation to the ischial spines) * Maternal pulse, blood pressure, temperature and urine output * Fetal heart rate * Frequency of contractions * Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium Drugs and fluids that have been given

Answer 123

* Power - uterine contractions * Passage - shape and size of pelvis and soft tissue * Passenger - size - altitude - posture o fteh feotus (how rounded the back and flexed the limbs) - Presentation - cephalic, shoulder, breech Lie - longitudinal, transverse, oblique (angled)

Answer 124

Initial: * Food * Water * Pain relief * mobilisation Secondary: * Abdominal palpation * Vaginal exam * CTG Tertiary: * Rupture of membranes Oxytocin drip Interventions may be requires such as: - Changing positions - Analgesia - Oxytocin - Epesiotomu - Instarmenal delivery C section

Answer 125

61% mortality rate associated. * Multiple pregnancy * Maternal age >35 * Instrumental delivery * Placental abruption

Answer 126

* First priority is respiratory faliure - mask vent and call anaesthatist * Moniter for feotal distress * Pulmonary artery catherterization Treat DIC with whole blood, packed cells r fresh frozen plasma

Answer 127

* Faliure to progress * Fetal distress * Maternal exhaustion Contorl of head

Answer 128

* Postpartum haemorrhage * Epesiotomy * Peritineal tears * Injury to anal sphincter * Incontinance of bowel and bladder * Nerve injury to femoral or obturator. Normally resolves after 6-8 weeks * Obturato - weakness of hip adduction, rotation and numbness of medial thight * Femoral - weakness of extension, loss of patella reflex and numbness of anterior tigh and medial lower leg * Cephaloheamatoma (blood betwwen skull and periosteum) with ventours * Facial nerve palsy with forceps * Subgaleal heamorrhage * Intercranial haemorrhage * Skull fracture Spinal cord injury gve sngle dose of co amox when forceps are used

Answer 129

Definition Bleeding after delivery of baby and placenta . Must be over 500ml for vag delivery and 1000ml after caesarean * Minor - <1000ml * Major > 1000ml * Moderte 1000-12000 * Severe >2000 Primary -bleedign withtin 2 horus Secondary - 24 hours to 12 weeks

Answer 130

* Prebous PPH * Multipe pregnacy * Obestiy * Lrge bay * Faliure to preogress * Preolonged * Pre ecplasia * Placenta accreta * Retained placenta * Instramental delivery Perineal tear

Answer 131

* Tone - uterine atony (most common) * Trauma - perineal tear * Tissue - retained pacenta Thrombin - bleeding disorder

Answer 132

* Treat anaemai during antenatal * Empty bladder for birth * IM oxytocin for 3rd stage Intravenous tranexamic acid in hgh risk patients

Answer 133

* Recusitate with ABCDE * Lie flat * 2 large bore canulas * Blood for FBC, UE, Clotting # * Group and cross match 4 units * Warm IV fluid * Oxygen Fresh flozen plasam after 4 units have been given

Answer 134

* Intrauterine balloon tamponade - for atony B lynch suture - putting suture around urters to compress it

Answer 135

* Rub the uterus to stimulate contraction * Cathetrissation to empty bladder * Oxytocin - injectio and tehn infusion * Ergometrine - smooth muscle contrcation stimulator (contraindicated in those with hypertention) * Carboprost = prostaglandin analouge * Misoprostol - prostaglandin analouge Tranexamic acid - antifibrolytic that reduces bleeding

Answer 136

Secondary PPH is liekly due to infection or retianed priducts of conception * Ultraousn * Ensocervical and high vag swabs for inectino Surgical evacuation and antibiotics!!

Answer 137

* Resporatry distress syndrome * Intraventricular heamorrage * Patent ductus arteriosus * Jaundice * Retinoapthy * Infetison Later on condition: * Diabetes * Heart disease * High blood pressure * Intellectual and developmental disabilities * Metabolic syndrome Obesity

Answer 138

* Give anti rhesus D injections to rhesus negative motehers as prophylaxis. This is given 28 week gestation and at birh * It should also be give any time sensations could occur - antepartum haemorrhage, amniocentesis, abdominal trauma. * Given within 72 hours of exposure After 20 weeks, the Keilhauer test is used to asses how mych further anti d is needed. Add acid to a sample of motehr blood, the fetal is more resitatnt to acid and will remain fine but the moterhs cells will be destroyed.

Answer 139

Baby blues * Affects more than 50 % of women after birth * Mood swings, low mood, anxiety, irritability, tearfulness * Usually self resolves in 2 weeks * Caused by hormonal changes, added responsibilitys, fattigue, recovery from birth * It is a physiological change that happens in first week.

Answer 140

Postnatal depression 1/10 women * Triad of low mood, anhedonia (lack of pleasure), low energy * 3 montsh after birth, symptoms should last 2 weeks before its diagnosed * Mild cases - more support * Modertae - SSRI and CBT * Severe - psychiaty services and inpatient care sometiems * Edinbough postnatal depression scale has 10 question and 30 points, 10 or moe points is indicative

Answer 141

lthum and sodum valporate must be stopped SSR can be taen - fluoxatne us th best the baby needs to stay n 4 hours after brth to monter for seratonn ssues

Answer 142

Fluid filled lumps 30-50 * Most common cause of breat lumps * Painful sometiems * Smooth * Well circumscribed * Mobile * Pssibly fluctulant Furtehr to rule out cancer Aspiration

Answer 143

Common benign tumours of stromal/epithermal breast duct tissue. * 20-40 YO * Respond to hormones and often regress after menopause * Small and mobile within the tissue - sometimes called a breast mouse as they can be moved * Painless * Smooth * Round * Well circumsided * Firm * Up to 3cm

Answer 144

Local degeneration and scarring of fat tissue in the breast, leading to fibrosis and necrosis Localised trama Radiotheray Surgery * Painless * Firm * Irregular * Fixed * Maybe skin dimpling or nipple inversion * Ultraosun ro mammogram may be similar to breast cancerm fne needle aspiration and core biopsy is neede. conservatve or surgcal excson

Answer 145

Benign fat tumours * Soft * Painless * Mobile * No skin changes c onservative management Surgical excision

Answer 146

The stroma ducts and lobules respond to progesterone and oesterogen and so fluctuate wthn th e cycle * Fluctuate wth cycle - worse 10 days befroe menstruatng and symproms reslove after menstraton ocurs * Lumpness * Tenderness * Fluctaton of sze Supportve bra NSAD Avod caffne Apply heat Hormal treatment - tamoxfen

Answer 147

* Smoking * Damage to nipple - eczema, candida infection, piercings * Breat disease - cancer * Staph aureus (most common) * Streptococcal Enterococcal

Answer 148

* Swollen lump * Fluctuant lump - able to move the fluid around within the lump using palpation * It has to be fluctuant to be an abscess General infection symptoms too - muscle aches, fatigue, fever, sepsis

Answer 149

Management and monitoring ANTIOBIOTICS! * Fluxolxacillin for staph * Co amoxiclav or metronidazole for anerobic bacteria * Referral to the on-call surgical team in the hospital for management * Antibiotics * Ultrasound (confirm the diagnosis and exclude other pathology) * Drainage (needle aspiration or surgical incision and drainage) * Microscopy, culture and sensitivities of the drained fluid

Answer 150

Inflamation of the breast tissue, often related to breastfeeling but sometomes due to infection. Infection enters the nipples and backtracks up the ducts to cause inflammation and infection. Mastitis may precede an abscess. It can also be caused by obstruction of the sucts

Answer 151

Lactational : * Conservative management * Continue breastfeeding, express milk and breast massage * Heat packs, warm showers and simple analgesia * Antiobiotics (flucloxacillin or clarithromycin if symptoms rent improving Continue breast feeding, regularly express milk f feeding is painful, resume feeding when possible. Non - Lactational: * Analgesia * Antibiotics bread sprectrum - Co-amoxiclav Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes) * Treatment for underlying causes - eczema or candida infection Candida infections can occur after antibiotics. This elads to recurrent mastitis and causes cracked skin onteh nipple. Associated with oral thrush and candidal nappy rash. Sore niplpes bilaterally, craked and shiny areola, white patches around the mouth and on eh tounge of baby. You need to treat bothe the mother and baby: * Topical miconazole 2% after each breastfeed * Treatment for the baby (e.g. miconazole gel or nystatin)

Answer 152

* Nipple changes * Purulent nipple discharge (pus from the nipple) * Localised pain * Tenderness * Warmth * Erythema (redness) * Hardening of the skin or breast tissue * Swelling Fever

Answer 153

* Most common cancer in UK * 1/8 women affected * 1% of all cases are men * Female * Increased oestrogen exposure * More dense breast tissue obesty * Smoking * Family history * COCP * HRT - particularly combined * BRCA - breast cancer genes, they are tumor surpressor genes which are faulty * BRCA1- chromosone 17, 80% will develop breast cancer, 50% ovarian BRCA2 gene - chromosone 13 - 60% will develop breast and 20% ovarian

Answer 154

* Ductal carcnomas in situ - precancerou sor cancer osu cells of the breat ducts, localsed pced up on mammograms notmally good prognosis * Lobular carcnomas n situ - precancerous condton n premenopausal women, asymptomaic and pcked up on mammogram, increased risk of invasive braest cancer * Nvasve ductal carcnoma non specfc - orgnate n eh breast ducts * Nvasve lobular carcnomas - not always vsble on mammograms breat lobules * Nflamatory - 1-3% of breast cancers loos le mastts but wont repond to antibotcs Pagets disease of the nipple - looks like eczea on nipple, invasive

Answer 155

Screening: * Mammogram every 3 years ages 50-70 * 1/100 women are diagnosed after going for a mammogram * A first-degree relative with breast cancer under 40 years * A first-degree male relative with breast cancer * A first-degree relative with bilateral breast cancer, first diagnosed under 50 years * Two first-degree relatives with breast cancer * They are speciially montered have genetic councelg annual mammograms and may be offered tamoxfen n premenopausalor anastrazole f postmenopausal as preventative. Rsk reducing mastectomy or bilateral oophroectomy

Answer 156

* Lumps that are hard rrcgular paunless, fixed * Tetherd to skini to chest wall * Niipple retracioni * Skkin dimplinig ot oedema * Lymphadenopahy

Answer 157

* Refer for 2 week wat f there s an unexplained breast lupmp over age 30 or unlateral npple chage n over 50s * Also cobsder f tehr s an unexplaed lump n the axlla ot sn changes on brast * They should receve clncal assesment magng and potetnally bopsy * Ultrasoun scans are bettern n younger women * Mamograms are beter n older * MR for those wih higher risks or to further asses a tumour * Stage is the anatomcal extent - size, anatomical position, spread. * Grade is what it looks like down the mircroscope Tr[le assesment - examination, magng and hstologu (core needle bopsy).

Answer 158

* Often eh cancer cells hae receptors - oestrogen progeserone ot human epdermal growth factor. * Trple negatve breastcancer meanas that t doesn’t have any of the receotprs and are harder to treat * TNM staging - lymoh node bopsy MRU of breast and axilla laver ultrasound CT of abdomen thorax and pelvis, isotope bone scan. * Surgery - breast conserving or mastectomy * Axillerya clearance of lymoh nodes if cancer is in tehre * Radiotherapy - session every day for 3 weeeks, general fatigue, fibrosis, shrinking of tiissue, long term skin changes * Chemo - Neoadjuvant therapy – intended to shrink the tumour before surgery Adjuvant chemotherapy – given after surgery to reduce recurrence Treatment of metastatic or recurrent breast cancer Hormone treatments: * For oestrogen : Tamoxifen for premenopausal women - blocks OR in breats and stimulates in bones and uterus, prvents osteoproosis but increaed risk of endometrial cancer Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane) - aromatase normally is fond in adipose and vconverts androgens to oestrogen * Use for 5-10 years * Trastuzamab - herceptin - targets HER 2 receptors * Pertuzumab - targets HER2 recepros (monoclonal antibody) * Neratinib - tyrosine kinase inhibitor * Have yearly mammograms after for 5 years * Reconstructive surgery Lumpectomy unless there are multiple tumour,

Answer 159

* Lungs lver bones and bran are the most common place to metastases to. Chronic lymphoedema - massage techniques, compression bandages, weight loss, skin care

Answer 160

* There is dilation of the large ducts leading to intermittent discharge from the nipple * Ectasia means dilation * There is inflammation leading to intermittent discharge which may be white green to grey Perinenopausal women Smokers

Answer 161

* Nipple discharge * Tenderness/pain * Nipple retraction or inversion * Breast lump * Exclude breast cancer - clinical assessment, imaging, histology * Microcalcifications are a key fnidinig on mammogram * Ductograpy - contrast is injected ad then mammogram * Nipple discharge cytology * Ductoscopy - tiiny camera

Answer 162

* No trearment - can slef resolove * Antibiotics for any additional infections * Surgical exccons of eh affected duct * Symptomatic maganemen - supportive bra and warm compress Reassure about cancer

Answer 163

Reconstrucitve surgery is offered to eveyr who has a mastectomy Imidate or delayed * After breast conserving surgery there can be partial reconstruction using a flap or reduction and reshaping. Remocing tissue and reshaping both breasts to match * After masectomy - breast implants (synthetic) flap reconstruction (using tissue from a different part of the body) * Implants - minimal scarring, good appearance but can feel unateral and have issue with hardening, leaking ect * Latissumus dorsi flap - the tissue is tunneled under the skin - pediculated means it keeps the original blood supply, free flap means comepletly transplanting it to a new construction * Transverse rectus abdominas flap Seep infereor epigastric perforator flap - uses skin and subcutanoues fat as a free flap

Answer 164

Warty lesion in a breast duct, caused by proliferation for the epitherlial cells. Presents with clear no blood strained nipple discharge. 35-55 YO Asymptomatic Nipple discharge Tenderness/pain Palpable lump

Answer 165

* Clinical assessment * Imaging - ultrasoonb, mammography and MRI * Histology - core or vaccum assisted biopsy * Ductography - injecting contrast into eh duct, there will be a filling defect with papilloma's Surgical excision Tissue examined for cancer!

Answer 166

An overgrowth of bacteria in the vagina - specifically anerobic. It is cause by a loss of lactobacilli (good bacteria) in the vagina. * Multiple sexual partners * Excessive vaginal cleaning * Recent antibiotics * Smoking * Copper coil It occurs less in women using the combined pill or who use condoms. * Lactobacilli are the main good bacteria in the vagina and prodice lactic acid to create a low pH (4.5) for the vagina. When tehre are reduced numbers the pH rises and anaerobic bacteria begins to overgrow. The most common causes are Gardnerella vaginosis, mycoplasma hominis and prevotella. * Gardnerella vaginalis is the most common cause!

Answer 167

* Fishy smelling watery grey/white discharge * Asymptomatic If there is itching and pain it suggests a co infection or different causes * Sometimes a speculum examination to look at discharge * High vaginal swab * Vaginal pH swab - normal is 3.5-4.5. BV is when it is above 4.5 * Charcoal vaginal swab for microscopy (high one done with a speculum or a low one done by self) It gives CLUE CELLS on microscopy. These are epithelial cells with bacteria stuck inside of them

Answer 168

* May naturally resolve. * Metronidazole targets anaerobic bacteria - oral or vaginal gel * Clindamycin is alternative * Always assses additional infections - chlaymidia and gonhoreaa * Provide info for prevention When prescribing metronidazole, no alcohol otherise they will get really ill!!!! * Increase risk of STIs * Miscarrige * Postpartum endometritis * Preterm deilvery * Low borth weight Ask about use of soaps and vaginal douching, and then explain how this increases the risk of BV.

Answer 169

Vaginal yeast infection of the candida family - normally candidan albicans * Increased oestrogen - pregnancy * Poorly ocntrolled diabeites * Immunosurpression * Broad spectrum antibiotics Colonise the vagina and not cause symptoms unless tehre are enviromentla changes such as pregnancy or broad specturm antibiotics

Answer 170

* Thick white non smelly discharge * Vulval and vaginal itching, irritation and discomfort More severe can lead to: * Erythema * Fissures * Oedema * Pain during sex (dyspareunia) * Dysuria * Excoriation * * Treated based on the presntaton * Test vagnap ph to distuinguish between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5). * A charcoal swab and microscopy can confirm the diagnosis

Answer 171

* Antfungal cream (clotrmzole) into the vag * Antfungal pessary * Oral antifungal tablets (fluclazone) Nice suggests - * A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night * A single dose of clotrimazole pessary (500mg) at night * Three doses of clotrimazole pessaries (200mg) over three nights * A single dose of fluconazole (150mg) * Canesten Due can be bought over the counter * Recurrent nfectons can be treated with manitnance antfungals Antfungal creasms can damage latex condoms and prevent spermcdes form worng so use alternatve contracepton for at least 5 days.

Answer 172

* Asymptomatic * Vag discharge * Itcing * Dysuria * Dysparunia * Balanitis * Frothy and yellow green dischareg * Fish smell * Strawberry cervix Vag pH of above 4.5

Answer 173

* Charcole swab and microscopy, take from posteior fornix ofwomen or a self swab * Uretheral swab or first catch urin in men as it lives in the urethra * Refer to GUM specalist * Contact tracing * Metronidazole * Preterm delivery * Prelabour membrane rupture * Lwo brith weight * Pelvic inflamatory disease * Cervical cancer * BV * HIV risk increased

Answer 174

Inflammation of glans penis * Non-specific dermatitis with Candida albicans or bacterial infection. * Other infections such as anaerobes or sexually transmitted infections. * Inflammatory skin conditions such as irritant or allergic contact dermatitis, seborrhoeic dermatitis, psoriasis, lichen sclerosus, lichen planus, or Zoon's balanitis. * Mechanical irritation and poor hygiene. * Pre-malignant conditions (penile intraepithelial neoplasia).

Answer 175

Penile discomfort and itch, bleeding, skin splitting, urethral discharge, urinary symptoms and/or sexual dysfunction. Redness and swelling of the glans penis and/or foreskin with possible sub-preputial discharge, fissuring, or ulceration. May presnt as uti but with only the pain symptom.

Answer 176

* Good hygine * Topicla corticostreoid * Poteintally an antifungal cream as well Safety net about sweeling occuring so much it prevents urintaiot - go to hospital.

Answer 177

urosodeoxycholuc acid

Answer 178

ulcers rased lumps red shuny skin leaage of pus and flud heamphlus ducreyi azthromycn

Answer 179

Causes swollen lymph glands n the groin on one or both sides, also ulcers * Lood * Pain in anal area * Consipation * Incomplete bowel emptying Test for chlamydia, if positive and there are smptms above, it is LGV. * Doxycycline 2x a day for 3 weeks. * Permennt geniatl swelling * Long term bowel complications * Bloodstreaminfeciton cuasing inflamtion of joints and liver

Answer 180

* Vascular: hypertension, atherosclerosis, hyperlipidemia, smoking * Neurological: Parkinson’s disease, multiple sclerosis, stroke, spinal cord injury, peripheral neuropathy * Hormonal: hypogonadism, hyperprolactinaemia, thyroid disease, Cushing’s disease * Drug-induced: antihypertensives, beta-blockers, diuretics, antidepressants, antipsychotics, anticonvulsants, recreational drugs * Systemic disease: diabetes mellitus, renal failure * Structural: pelvic trauma, penile trauma, Peyronie’s disease Psychogenic: depression, anxiety, performance anxiety, schizophrenia

Answer 181

FBC LFTs U&Es TFTs Lipid profile Fasting glucose and/or HbA1C Serum total testosterone: if testosterone is reduced, serum prolactin will then be checked to screen for secondary hypogonadism * Doppler to see blood flow Nocturnal penile tumescence - measures erections tougout the night to see if it psychilogica or not.

Answer 182

* Weight loss * Stop smoking * Less alcohol * Psychosexual councelling * Phosphodiesterase 5 inhibitors - relexation fo peniel blood vessles * Hormone therapys - refer to specalist Penile prosthesis - inflatable implants or semirigid rods

Answer 183

UPSII: * Understand * Parents * Suffer * Intercourse anyway Interests * Fraser guidelines: * He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment * He/she cannot be persuaded to tell her parents or to allow the doctor to tell them * He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment * His/her physical or mental health is likely to suffer unless he/she received the advice or treatment The advice or treatment is in the young person’s best interests.

Answer 184

* Not suitable for quite a few groups of people - VTE risk, high blood pressure, obese patients, smokers, ex-smokers >35, migraine with auras. Anti-epileptics

Answer 185

* weight gain * reduced bone mineral density * Acne, reduced libido, hair loss, mood changes, headache Irregular bleeding

Answer 186

* weight gain * reduced bone mineral density * Acne, reduced libido, hair loss, mood changes, headache Irregular bleeding

Answer 187

doxycyclne 7 dyas azthromycn n pregnancy

Answer 188

* Main sight of infection if urethra * Dysuria and ureteral discharge * Asymptomatic * Empdydimo-orichitis and reactive arthritis complications * high transmission to females FEMALES: * Main infection sight is endocerviacl canal * Non specific symptoms - dischage, menstra irragularity, dysuria * Asymtpatic * High transmission * Complications: pelvic inflammatory disease, ectopic preganc, chronic pelvic pain, infertility Neonatal transmission

Answer 189

Nuclec acd amplfcaton test - NAAT

Answer 190

Infect the non squamous epithelia - urethra, endocervical canal, rectum, pharynx, conjunctiva In neonates it affects the conjunctiva and sometimes can causes atypical pneumonia Infect the non squamous epithelia - urethra, endocervical canal, rectum, pharynx, conjunctiva

Answer 191

Symptoms in women In women, symptoms of gonorrhoea can include: an unusual vaginal discharge, which may be thin or watery and green or yellow in colour pain or a burning sensation when passing urine pain or tenderness in the lower abdominal area – this is less common bleeding between periods, heavier periods and bleeding after sex – this is less common Symptoms in men In men, symptoms of gonorrhoea can include: an unusual discharge from the tip of the penis, which may be white, yellow or green pain or a burning sensation when urinating inflammation (swelling) of the foreskin pain or tenderness in the testicles – this is rare

Answer 192

Partner notification Test for other STI’s Continuous surveillance of antibiotic sensitivity Single dose treatment preferred Aim to cure at least 95% of people at first visit Current regime – Ceftriaxone IM injection Ciprofloxavin oral if senstivty

Answer 193

Treponema pallidum sub species - spiral gram negative bacteria Early infectious syphilis (within 2 years of infection) Primary, Secondary and Early Latent Late syphilis (over 2 years since infection) Late latent, CNS, gummatous Male High risk in male to male intercourse * Primary syphilis: painless ulcer called a chancre on genitals, local lymphadenopath * Secondary - sysetmic symptoms on musouc memebrane, rash, low grade fever, alopecia, oral lesions * Latent -phase * Terriary - gummas development, cardiovascualr and neurological complications, aortic anyerisms, neurosyphilis - headache, dementia, altered behaviour, paralysis, sensory imparement

Answer 194

Early moist lesions Genital ulcers Dark fiel microscopy, polymerase chair reaction SEROLOGY- look for antibodies against T pallidum antigens * there are primary sceeenign tests and then tests done in more detail for those which test postive * Treponema pallidum particle agglutination test (TPPA) * Penicillin IM * Efficant follow up and partner notification * A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.

Answer 195

6 monts before for both men and women

Answer 196

oral glucsoe tolerance test

Answer 197

debltatngfatgue for >6 months wth cogntve dysfuncton total body pan unrefreshng sleep and post exertonal malaise.

Answer 198

* onset of persistent disabling fatigue * post-exertional malaise (PEM)/exertional exhaustion * unrefreshing sleep * cognitive and autonomic dysfunction, * Myalgia * Arthralgia * headaches * sore throat * tender lymph nodes (without palpable lymphadenopathy) symptoms lasting at least 6 months.

Answer 199

* DePaul symptom questionnaire is the screening tool * Blood tests - FBC, ESR, CRP to rule things out * Thyroid function test * ANA and RF test * Individulised therapy - cnsellig and supportive care. They learn to conserve energy, break dow large tasks, individulised excercse programs * Mindfulness and sleep hygine * CBT * Occupational therapy * Can amanage symtoms with sleeping tablets

Answer 200

photophoba pain changes in vision

Answer 201

viral, allergic bacterial - H influenzea or s pneumonia * Bacterial will have purulent discharge which is worse in the morning, highly contagious viral conjunctivitis - clear discharge, also other symptoms of viral infetio - sore throat blocked nose ect

Answer 202

bleeeding fomr teh genitla tract after 24 weeks gestations

Answer 203

bleeding form teh dgenital tract wit in 24 hours of delivery bleeding form teh gential tract between 24 hours and 6 weeks after delivery

Answer 204

early sex nreased sexual partners not usng condoms not engainig with cervial screening COCP use more full term pregannces FH smong HV

Answer 205

dagnosed at colposcopy!! I - mild only affecting 1/3 thcenss ley to resolve II - moderate dysplasia - liekyl to pregress to cancer, affecitng 2/3 III - server dysplasia - very lek to progress to cacner

Answer 206

colposcopy used acetic acid turns ells white (acetowhite) then add iodene, abmormal cells wll stay white and not turn brown

Answer 207

1 - in cervix 2 - invades upper 2/3 of vagina or lower uterus 3 - invades oelvic wall or lowe 2/3 of vagina 4 - invaes bladder recutm or beyond pelvis

Answer 208

* Emollients for the itching - chalmomile lotion * Antihistamines - chlorphenamine ot help with sleep - doesn’t help itching * Water soulble vitmain K can be given if prothrobin time is deragnced * Induce pregancy at 37-3 weeks Ursodeocycholic acid