Womens Health (Ben) Flashcards

Question

How is chlamydia diagnosed?

Answer 1

**Nucleic acid amplification tests (NAAT)**. Which can involve a: * Vulvovaginal swab * Endocervical swab * First-catch urine sample (in women or men) * Rectal swab (after anal sex) * Pharyngeal swab (after oral sex)

Answer 2

First Line - **doxycycline 100mg twice a day for 7 days**

Answer 3

**Doxycycline is contraindicated in pregnancy and breastfeeding**. Alternatives include: * Azithromycin 1g stat then 500mg once a day for 2 days * Erythromycin 500mg four times daily for 7 days * Erythromycin 500mg twice daily for 14 days * Amoxicillin 500mg three times daily for 7 days

Answer 4

**No** Apart from in cases of: * Rectal Chlamydia * **Pregnancy** * when Symptoms persist

Answer 5

* Preterm delivery * Premature rupture of membranes * Low birth weight * Postpartum endometritis * Ectopic pregnancy * Neonatal infection (conjunctivitis and pneumonia)

Answer 6

* Pelvic inflammatory disease * Chronic pelvic pain * Infertility * Epididymo-orchitis * **Conjunctivitis** - is usually as a result of sexual activity, when genital fluid comes in contact with the eye. * Lymphogranuloma venereum * Reactive arthritis

Answer 7

Symptoms last for **longer than 2 weeks**: * Chronic erythema * Irritation * Discharge Most cases are **unilateral** It occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia.

Answer 8

It is a condition affecting the **lymphoid tissue around the site of infection with chlamydia**. It most commonly occurs in men who have sex with men. * **Primary stage** - Painless ulcer (primary lesion) that typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. * **Secondary stage** - lymphadenitis (swelling, inflammation and pain in the lymph nodes infected with the bacteria). The inguinal or femoral lymph nodes may be affected. * **Tertiary stage** - inflammation of the rectum (proctitis) and anus. This leads to anal pain, change in bowel habit, tenesmus and discharge.

Answer 9

1st Line - **Doxycycline 100mg twice daily for 21 days**

Answer 10

Syphilis is a **sexually transmitted infection** caused by the spirochete bacterium **Treponema pallidum**.

Answer 11

As stated, its caused by the bacterium Treponema pallidum. It can be transmitted by: * Through **direct contact with syphilis sores** during sexual activity. * Vertical transmission from an **infected mother to her unborn child**, resulting in **congenital syphilis** * Intravenous drug use * Blood transfusions and other transplants

Answer 12

There are three stages of Syphilis: **Primary Syphilis** * A painless genital ulcer (**chancre**). That spontaneously recovers within 3 – 8 weeks. The lesion is round, with an indurated base. * Local lymphadenopathy **Secondary Syphilis** - Typically starts after the chancre has healed. (Or 4-10 weeks post-primary infection). Presents with: * Symmetrical maculopapular rash, often involving the palms, soles, and face. * Condylomata lata (grey wart-like lesions around the genitals and anus) * Low-grade fever * Lymphadenopathy * Alopecia (localised hair loss) * Oral lesions **Tertiary Syphilis** - Can occur 20-40 years after the primary infection (in untreated patients). Presents with: * Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones) * Aortic aneurysms * Neurosyphilis **Neurosyphilis** - can occur at any stage if the infection reaches the central nervous system. Presents with: * Headache * Altered behaviour * Dementia * **Tabes dorsalis** (demyelination affecting the spinal cord posterior columns) * **Ocular syphilis** (affecting the eyes) * Paralysis * **Argyll-Robertson pupil**

Answer 13

* It is a **specific finding in neurosyphilis**. * It is a constricted pupil that accommodates when focusing on a near object but does not react to light. * They are often irregularly shaped. * It is commonly called a “**prostitutes pupil**” due to the relation to neurosyphilis and because “it **accommodates but does not react**“.

Answer 14

It can present shortly after birth or later in infancy with: * Rash on the palms/soles of feet * Mucous patches/lesions in the mouth/nose/genitals * Fever, hepatosplenomegaly * Anaemia * Bone developmental abnormalities ('**saber shins**') * Neurological sequalae (seizures, developmental delay).

Answer 15

Different types of **Serological testing** is used for screening and monitoring, and then for confirmation of the diagnosis: * Screening and Monitorring - **Non-treponemal tests (e.g., VDRL, RPR)** * Diagnostic - **treponemal tests (e.g., EIA, TPPA, FTA-ABS)** * **Dark-field microscopy**: Can be used to directly observe T. pallidum in samples from primary lesions or secondary rash. * **CSF examination**: Should be considered in tertiary syphilis to evaluate for CNS involvement.

Answer 16

Primary, secondary, and early latent syphilis: * A **single dose of intramuscular penicillin G (benzathine benzylpenicillin)** is the first-line therapy. Tertiary and late latent syphilis or syphilis of unknown duration: * Requires a longer course of **intramuscular penicillin G for 2-3 weeks**. Neurosyphilis: * Treated with **intravenous penicillin G for 10-14 days** * Patients allergic to penicillin may be given doxycycline or tetracycline.

Answer 17

Bacterial vaginosis is a **bacterial imbalance of the vagina** caused by an **overgrowth of anaerobic bacteria** and a **loss of lactobacilli** (the dominant bacterial species responsible for maintaining an acidic vaginal pH). It is not a sexually transmitted infection but it increases the risk of developing an STI

Answer 18

* Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). * The acidic environment prevents other bacteria from overgrowing. * When there are **reduced numbers of lactobacilli** in the vagina, the **pH rises**. This more **alkaline environment** enables **anaerobic bacteria to multiply**.

Answer 19

* **Gardnerella vaginalis** (most common) * Mycoplasma hominis * Prevotella species Bacterial vaginosis can occur alongside STIs like candidiasis, chlamydia and gonorrhoea.

Answer 20

It is the most common cause of abnormal vaginal discharge in women of childbearing age.

Answer 21

* **Multiple sexual partners** (although it is not sexually transmitted) * **Excessive vaginal cleaning** (douching, use of cleaning products and vaginal washes) * Recent antibiotics * Smoking * Copper coil * **Pregnant women** are at increased risk of bacterial vaginosis due to hormonal changes. Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

Answer 22

* **fishy-smelling watery grey or white vaginal discharge** (fishy smelling particularly after intercourse) * Increased vaginal discharge * Vaginal itching or irritation may be present but is less common Half of women are asymptomatic

Answer 23

* **Vulvovaginal Candidiasis** Characterised by itching, burning, dyspareunia, and white, curd-like discharge. * **Trichomonas Vaginalis Infection** Presents with purulent, frothy, greenish discharge, pruritus, dyspareunia, and dysuria. * **Chlamydia or Gonorrhoea infection** May present with increased vaginal discharge and possibly lower abdominal pain, but are often asymptomatic. * **Atrophic Vaginitis** Most commonly seen in postmenopausal women, presenting with dryness, burning, dyspareunia, and thin, watery discharge.

Answer 24

The **Amsel Criteria** - Three out of the following 4 features need to be present: * Vaginal pH >4.5 (Vaginal swab with pH paper) * Homogenous grey or milky discharge * Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour) * **Clue cells** present on wet mount (Microsopy)

Answer 25

* First line treatement - **Metronidazole** is given either orally or intravaginally. * Second line management - **Clindamycin** * Asymptomatic BV does not usually require treatment You should also assess for the risk of STIs, as well as providing education about how to reduce the risk of recurrence.

Answer 26

**Alcohol** This is because alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Answer 27

Increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV. During **Pregnancy**: * Miscarriage * Preterm delivery * Premature rupture of membranes * Chorioamnionitis * Low birth weight * Postpartum endometritis

Answer 28

Trichomoniasis is a **sexually transmitted infection (STI)** caused by the flagellated protozoan parasite, **Trichomonas vaginalis**. It primarily infects the urogenital tract, and has an incubation period of around 7 days.

Answer 29

It is the most common non-viral STI globally.

Answer 30

**Women**: * **Profuse, frothy, yellow-green vaginal discharge** * Vulval irritation * Dyspareunia (painful sex) * Asymptomatic presentation is also common (up to 50%) * **Strawberry Cervix** sign may be seen on examination * The vaginal pH will be raised (above 4.5) similar to bacterial vaginosis **Men** * Non-gonococcal urethritis * Balanitis (inflammation to the glans penis) * Also commonly asymptomatic

Answer 31

* Contracting HIV by damaging the vaginal mucosa * Bacterial vaginosis * Cervical cancer * Pelvic inflammatory disease * **Pregnancy-related complications** such as preterm delivery or low birth weight baby.

Answer 32

* **Bacterial vaginosis** Characterized by a fishy-smelling, grayish-white vaginal discharge and vaginal pH > 4.5 * **Candidiasis** Presenting with a thick, white, "cottage cheese" like vaginal discharge and vulval itching * **Gonorrhea or Chlamydia** These STIs may present with mucopurulent cervical discharge, cervical motion tenderness, and may also be asymptomatic.

Answer 33

* Diagnostic - **Charcoal swab with microscopy** This should be taken from the posterior fornix of the vagina (behind the cervix) * **Urethral swab** or **first catch urine** is used in men

Answer 34

**Oral metronidazole** Either **400–500mg twice a day for 5–7 days**, or a **single dose of 2g orally**. Its advised to abstain from sexual activity for at least one week, or until the patient and all partners have completed treatment.

Answer 35

**Lower Urinary Tract Infection** - Involves infection of the bladder, causing cystitis. **Upper Urinary Tract Infection** - Involves infection up to the kidneys, called pyelonephritis.

Answer 36

**Pregnant women are at higher risk** of developing both lower and upper UTIs UTIs during pregnancy increase the risk of: * Preterm delivery * As well as other adverse pregnancy outcomes, like low birth weight and pre-eclampsia.

Answer 37

* Asymptomatic bacteriuria refers to **bacteria present in the urine, without symptoms of infection**. * Pregnant women with asymptomatic bacteriuria are at a higher risk of developing UTIs, and subsequently at risk of preterm birth. * As a result, **pregnant women are tested at booking and routinely** throughout pregnancy (urine sample testing for microscopy, culture & sensitivity). * Urine testing of asymptomatic patients is not usually done (as it can lead to unescesary antibiotic use) but pregnant women are the exception due to the adverse outcomes associated with infection.

Answer 38

* Dysuria (pain, stinging or burning when passing urine) * Suprapubic pain or discomfort * Increased frequency of urination * Urgency * Incontinence * Haematuria

Answer 39

* Fever (more prominent than in lower urinary tract infections) * Loin, suprapubic or back pain (this may be bilateral or unilateral) * Looking and feeling generally unwell * Vomiting * Loss of appetite * Haematuria * Renal angle tenderness on examination

Answer 40

* **Mid-stream urine samples** are sent off for cultures and sensitivity testing.

Answer 41

* Mid-stream urine (as stated above) - In children, men and pregnant women * Urine Dipstick will be positive for nitrates and leukocytes (although this is unreliable in women older than 65 and those who are catheterised) * Blood tests if there are signs of systemic upset (FBC, U+E, and CRP, etc...) * Ultrasound scan of bladder/kidney (if there is concern about antecedents/complications (e.g.urinary retention/obstruction)

Answer 42

* **Escherichia coli** (E. coli) (Most common) * **Klebsiella pneumoniae** (gram-negative anaerobic rod) * Enterococcus * Pseudomonas aeruginosa * Staphylococcus saprophyticus * Candida albicans (fungal)

Answer 43

Urinary tract infection in pregnancy requires **7 days of antibiotics** * First Line - **Nitrofuratoin for 7 days** (although this needs to be avoided in the 3rd trimester) * Second Line - If nitrofuratoin is unsuitable then use **Amoxicillin or Cefelexin for 7 days**

Answer 44

As it is associated with an **increased a risk of neonatal haemolysis** (destruction of the neonatal red blood cells).

Answer 45

This is because it works as a **folate antagonist**. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.

Answer 46

If a non-immune woman contracts the varicella zoster virus (VZV) during the first trimester of her pregnancy, it can cause **Congenital varicella syndrome** in the foetus (as the virus can have **teratogenic effects**).

Answer 47

* If a non-immune pregnant woman comes into contact with a person infected with the VZV; **immunoglobulin can be given as a preventive measure**. * If maternal infection by VZV occurs, **Acyclovir** is the treatment of choice and should be **administered within 24 hours of the onset of the rash**. * Pregnant women who lack immunity to the VZV should be counseled to avoid exposure to the virus.

Answer 48

Premature ovarian insufficiency (POI) is a medical condition characterized by the **onset of menopause in a woman aged below 40 years**.

Answer 49

The causes can either be idiopathic or **iatrogenic** e.g.: * ovarian surgery * radiotherapy or chemotherapy that directly impact the ovaries.

Answer 50

Women with POI typically develop the same symptoms as those undergoing natural menopause, including: * **Vasomotor symptoms**: Hot flushes, night sweats * **Sexual dysfunction**: Vaginal dryness, reduced libido, problems with orgasm, dyspareunia * **Psychological symptoms**: Depression, anxiety, mood swings, lethargy, reduced concentration

Answer 51

* **Hypothyroidism**: Fatigue, weight gain, cold intolerance, depression, hair loss * **Hyperprolactinemia**: Irregular menstrual cycles, infertility, breast milk production not related to childbirth or nursing * **Polycystic Ovary Syndrome (PCOS)**: Irregular periods, hirsutism, obesity, infertility

Answer 52

* **Blood test for raised FSH levels**; indicative of the menopause (repeated on at least 2 separate occasions)

Answer 53

**Hormone Replacement Therapy** (HRT) until at least the age of normal menopause. * HRT is done, unless the risks of HRT outweigh the benefits * Psychological support should also be provided due to the potential mental health impacts of early menopause.

Answer 54

Oligohydramnios is defined as the presence of a **lower than normal volume of amniotic fluid within the uterus**.

Answer 55

There are various different causes: * **Uteroplacental insufficiency** This can lead to intrauterine growth restriction. Its usually due to maternal conditions like hypertension, pre-eclampsia, maternal smoking and placental abruption. * **Fetal urinary system abnormalities** The amniotic fluid is derived mainly from fetal urine, abnormalities in this system (such as renal agenesis, polycystic kidneys or urethral obstruction) can therefore lead to oligohydramnios. * **Premature rupture of membranes** * **Post-term gestation** * **Chromosomal anomalies** * **Maternal use of certain drugs including prostaglandin inhibitors and ACE-inhibitors.**

Answer 56

**Potter Syndrome** which includes: * Clubbed feet, facial deformity, congenital hip dysplasia (Due to **foetal compression**) * Pulmonary hypoplasia (Due to **lack of amniotic fluid**) Potter syndrome is largely the result of reduced ""space"" surrounding the fetus as well as the lack of amniotic fluid for fetal lung growth and development.

Answer 57

**Polyhydramnios** - which is an overabundance of amniotic fluid.

Answer 58

Diagnosis is made via **ultrasound**: * This will show a reduced amniotic fluid index (AFI) or single deepest pocket (SDP)

Answer 59

Management depends on the underlying aetiology; but options include: * **Maternal rehydration** This may help to increase the amniotic fluid volume in mild cases of oligohydramnios. * **Amnioinfusion** This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid. * **Delivery** In severe cases, or if the fetus is in distress, delivery may be the best option. This may be via induction of labour or caesarean section, depending on the clinical scenario.

Answer 60

Polyhydramnios is the presence of too much amniotic fluid within the uterus.

Answer 61

The causes of polyhydramnios can be split into causes due to **excessive production of amniotic fluid** or **insufficient removal of amniotic fluid**: **Execessive production** is caused by **increased foetal urination** which can be due to: * Maternal diabetes mellitus * Foetal renal disorders * Foetal anaemia * Twin-to-twin transfusion syndrome **Insufficient removal** is caused by **reduced foetal swallowing** which can be due to: * Oesophageal or duodenal atresia * Diaphragmatic hernia * Anencephaly * Chromosomal disorders

Answer 62

* A uterus that feels tense or is large for the date of gestation * Difficulty of feeling foetal parts upon palpation of the abdomen.

Answer 63

**Maternal complications**: * Maternal **respiratory compromise** due to increased pressure on the diaphragm * Increased risk of **urinary tract infections** due to increased pressure on the urinary system * Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks * Increased incidence of caesarean section delivery * Increased risk of amniotic fluid embolism (although this is rare)

Answer 64

**Foetal complications**: * Pre-term labour and delivery * Premature rupture of membranes * Placental abruption * Malpresentation of the foetus (the foetus has more space to “move” within the uterus) * Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Answer 65

* Management of the underlying cause (e.g. maternal diabetes) * **Amnio-reduction** in severe cases of polyhydramnios

Answer 66

Fetal presentation is the **orientation of the fetus** in the womb that determines which part of the fetus presents first at the pelvic inlet during childbirth.

Answer 67

**Cephalic Vertex presentation** Makes up 95% of pregnancies

Answer 68

This is when the foetus is in a different orientation other than facing head-first down the pelvic inlet as birth approaches.

Answer 69

**Breech Presentation** - Refers to the positioning of the fetus in a longitudinal lie with the buttocks or feet proximal to the cervix and the head near the fundus.

Answer 70

Around 20% of babies are in breech presentation at 28 weeks gestation. But the vast **majority of these revert to a cephalic presentation spontaneously**, and only 3% are breech at term. Other types of malpresentation (e.g. shoulder) are much rarer than breech presentations.

Answer 71

* **Complete (flexed) breech** – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’). * **Frank (extended) breech** – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation. * **Footling breech** – one or both legs extended at the hip, so that the foot is the presenting part.

Answer 72

**Uterine**: * Multiparity * Uterine malformations (e.g. septate uterus) * Fibroids * Placenta praevia **Foetal**: * Prematurity * Macrosomia * Polyhydramnios (raised amniotic fluid index) * Twin pregnancy (or higher order) * Abnormality (e.g. anencephaly)

Answer 73

It is usually identified upon clinical examination: * Upon palpation of the abdomen the **round fetal head will be felt in the upper part of the uterus**, and an irregular mass (fetal buttocks and legs) in the pelvis. * The foetal **heart may be auscultated higher** on the maternal abdomen than usual * Sometimes it's not diagnosed until labour, where it can present with signs of foetal distress such as **meconium-stained liquor**. Diagnosis of Breech presentation is of limited clinical significance before 32-35 weeks gestation; as most likely the foetus will revert to cephalic presentation by birth.

Answer 74

**Ultrasound Scan**

Answer 75

* **Oblique lie** The fetus is positioned diagonally in the uterus, with the head or buttocks in one iliac fossa. * **Transverse lie** The fetus is positioned across the uterus, with the head on one side of the pelvis and the buttocks on the other. The shoulder is usually the presenting part. * **Unstable lie** This is where the presentation of the fetus changes from day-to-day.

Answer 76

* **External Cephalic Version (ECV)** This is the is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. It is offered to primiparous women at 36 weeks, and to multiparous women at 37 weeks. There is a 50% success rate (40% in primiparous, 60% in multiparous); and if successful, it can enable an attempt at vaginal delivery. * **Caesarean Section** If ECV is unsuccessful, contraindicated, or declined by the woman, current UK guidelines advise an elective Caesarean delivery. * **Vaginal Breech Birth** Some women may still choose to aim for a vaginal breech delivery. A footling breech is contraindicated however as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.

Answer 77

* Transient fetal heart abnormalities (which revert to normal), * Persistent heart rate abnormalities (e.g fetal bradycardia) * Placental abruption.

Answer 78

* **Cord prolapse** - where the umbilical cord drops down below the presenting part of the baby, and becomes compressed. This occurs in 1% of breech presentations (Compared to 0.5% in cephalic presentations) Less common: * Fetal head entrapment * Premature rupture of membranes * Birth asphyxia – usually secondary to a delay in delivery. * Intracranial haemorrhage – as a result of rapid compression of the head during delivery.

Answer 79

Cephalopelvic disproportion occurs when there is **mismatch between the size of the fetal head and size of the maternal pelvis**, resulting in **"failure to progress"** in labor for mechanical reasons. This is a significant risk factor for post term pregnancies

Answer 80

* Uterine rupture is a complication of labour, where the **muscle layer of the uterus (myometrium) ruptures**. * Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Answer 81

There are two types: * **Incomplete (or uterine dehiscence) rupture** - The uterine serosa (perimetrium) surrounding the uterus remains intact. * **Complete rupture** - The serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Answer 82

* **Previous Caesarean section** (The most significant) * Vaginal birth after caesarean (VBAC) * Previous uterine surgery * Increased BMI * High parity * Increased age * Induction of labour * Use of oxytocin to stimulate contractions

Answer 83

* The **scar on the uterus becomes a point of weakness**, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). * It is **extremely rare** for uterine rupture to occur in a patient that is **giving birth for the first time**.

Answer 84

It presents with an **acutely unwell mother**. It may occur with induction or augmentation of labour with: * Abdominal pain * Vaginal bleeding * **Ceasing of uterine contractions** * Hypotension * Tachycardia * Collapse

Answer 85

* **Placental abruption** Presents with abdominal pain +/- vaginal bleeding. The uterus is often described ‘woody’ and tense on palpation. * **Placenta praevia** Typically causes a painless vaginal bleeding. * **Vasa praevia** Characterised by a triad of ruptured membranes, painless vaginal bleeding, and fetal bradycardia.

Answer 86

* **Intrapartum Cardiotocography** (first line) - It is continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. Changes in fetal heart rate pattern and **prolonged fetal bradycardia** are early indicators for uterine rupture. * **Ultrasound** - Is diagnostic; features include abnormal fetal lie or presentation, haemoperitoneum and absent uterine wall.

Answer 87

* Uterine rupture is an **obstetric emergency**. * Resuscitation and transfusion may be required. * **Emergency caesarean section** is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 88

* **Preterm Labour** - The onset of regular uterine contractions accompanied by cervical changes occurring before 37 weeks gestation. * **Preterm Birth** - The delivery of a baby after 20 weeks gestation but before 37 weeks gestation. Prematurity is classed as: * Under 28 weeks: **extreme preterm** * 28 – 32 weeks: **very preterm** * 32 – 37 weeks: **moderate to late preterm**

Answer 89

Regular uterine contractions, changes in cervical effacement or dilation (before 37 weeks gestation)

Answer 90

* **Overstretching of the uterus** Multiple pregnancy (commonly due to assisted conception) and polyhydramnios. * **Foetal risk conditions** Pre-eclampsia, intrauterine growth restriction, placental abruption. * **Uterus or cervical problems** Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery. * **Infections** Chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, sexually transmitted infections (e.g., Chlamydia), and recurrent urinary tract infections. * **Maternal co-morbidity** Hypertension, diabetes, renal failure, thyroid disease, etc.

Answer 91

* **Braxton Hicks contractions** Characterized by irregular, non-painful contractions that do not cause cervical dilation or effacement. * **Urinary tract infection** Presents with dysuria, frequency, suprapubic pain, and possibly preterm labour symptoms. * **Placental abruption** Presents with vaginal bleeding, abdominal pain, and hypertonic uterus. * **Uterine rupture** Signs include severe abdominal pain, vaginal bleeding, abnormal fetal heart rate, and cessation of contractions.

Answer 92

**Foetal fibronectin test (fFN test)** - is a screening test used to assess the risk of preterm delivery after the onset of pre-term labour. A negative fFN test indicates a low risk of delivery occurring within the next 7-14 days.

Answer 93

* **Corticosteroids** - (betamethasone or dexamethasone) should be administered to accelerate foetal lung maturation. * **Intravenous antibiotics** - if there is an increased risk of infection (evidence of Group B Streptococcus (GBS) in current or previous pregnancy, presence of maternal fever). (**Penicillin** is the antibiotic of choice if there is no allergy). * **Tocolytic agents** may be considered to delay labour, . (**Nifedipine** is the first-line tocolytic agent).

Answer 94

* PROM is a condition characterized by the **rupture of the amniotic membranes (or sac) before the onset of labour**. * If this occurs after 37 weeks gestation, it is know as **premature rupture of the membranes at term**. * If this occurs before 37 weeks however, it's known as **Preterm prelabour rupture of membranes (P‑PROM)**. * Most women with PROM at term will spontaneously start labour within 24 hours.

Answer 95

Exact cause isn't well understood; but can be due to a combination of: * Infection * Inflammation * Stress * Mechanical forces.

Answer 96

* Foul-smelling or greenish amniotic fluid * Maternal fever * Reduced foetal movements A digital vaginal examination should be avoided in the absence of labour. But the foetal heart should be monitored.

Answer 97

* **Urinary incontinence** This can be distinguished by the absence of amniotic fluid and the presence of urinary symptoms. * **Vaginal discharge or infection** This can be ruled out by the absence of foul-smelling or greenish discharge and the absence of other infection symptoms.

Answer 98

Investigations for PROM should focus on **assessing signs of infection and foetal distress**, including: * Monitoring maternal temperature * Assessing foetal movements * Monitoring foetal heart rate * Observing vaginal discharge

Answer 99

* If **labour does not commence within 24 hours**, **induction of labour should be offered**. * If there are any **signs of infection**, **immediate induction of labour should be commenced** under consultant guidance and a broad spectrum antibiotic should be given. * If there are any signs of foetal compromise, senior review is required to make a decision about whether immediate caesarean section is required. * Following delivery, even if both baby and mother are asymptomatic, they should be closely observed in hospital for 12 hours post-birth.

Answer 100

* **Chorioamnionitis** - due to ascending infection * **Preterm birth** - (and the associated complications) e.g. respiratory distress syndrome, necrotising enterocolitis, and foetal death * **Developmental problems** - E.g. pulmonary hypoplasia, facial and limb deformities due to compression in the uterus, and cord prolapse due to low levels of amniotic fluid.

Answer 101

* Cord prolapse is when the **umbilical cord descends below the presenting part of the foetus and through the cervix** into the vagina, after rupture of the fetal membranes. * There is a significant danger of the presenting part compressing the umbilical cord, resulting in fetal hypoxia.

Answer 102

* **Abnormal lie (Malpresentations)** (e.g. transverse, breech) * Multiple pregnancy * Polyhydramnios * High fetal head at delivery * Multiparity * Low birth weight * Prematurity

Answer 103

* **Sudden change in the fetal heart rate pattern**, particularly variable or prolonged decelerations. * Feeling of the cord in the vagina or visible cord after rupture of membranes * Abnormal fetal heart rate detected on cardiotocography

Answer 104

* **Cardiotocography** - Umbilical cord prolapse should be suspected when there are signs of foetal distress on CTG. * **Vaginal examination** - Can then be used to diagnose a prolapsed cord (by confirming the presence of the umbilical cord in the birth canal)

Answer 105

When cord prolapse is diagnosed, swift action is vital to prevent fetal hypoxia and death: * Immediate delivery of the foetus is required (by **Emergency Cesaerean section**). A vaginal delivery has a high risk of cord compression and significant hypoxia to the baby. * Use of the **left lateral position** (with a pillow under the hip) or the **knee-chest position** (on all fours) to prevent further prolapse. This uses gravity to draw the fetus away from the pelvis and reduce compression on the cord. * Filling the **bladder with 500ml warmed saline** to aid in preventing further prolapse * Avoidance of exposure and handling of the cord (as handling causes vasospasm) * Use of **tocolytics**, (e.g.terbutaline), to stop uterine contractions.

Answer 106

Instrumental delivery refers to a **vaginal delivery assisted by either a ventouse suction cup or forceps**. These tools are used to help in the delivery of the baby’s head.

Answer 107

10% of UK Births

Answer 108

* Failure to progress * Foetal distress * Maternal exhaustion * Control of the head in various fetal positions * The use of an epidural for analgaesia, increases the risk that an instrumental delivery may be nescesary.

Answer 109

* Postpartum haemorrhage * Episiotomy * Perineal tears * Injury to the anal sphincter * Incontinence of the bladder or bowel * **Nerve injury** (obturator or femoral nerve)

Answer 110

* **Cephalohaematoma** with ventouse * **Facial nerve palsy** with forceps Rarer (more serious complications): * Subgaleal haemorrhage (most dangerous) * Intracranial haemorrhage * Skull fracture * Spinal cord injury

Answer 111

* It is essentially a **suction cup on a cord**. * It goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina. * Its main complication is a **cephalohaematoma** - Which involves a collection of blood between the skull and the periosteum.

Answer 112

* The forceps come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina. * Main complication is **facial nerve palsy**, with **facial paralysis on one side**. * The forceps can also cause bruises on the baby's face

Answer 113

* Femoral nerve * Obturator nerve The nerve injury tends to recover over 6 – 8 weeks.

Answer 114

The Femoral nerve can be **compressed against the inguinal canal** during a forceps delivery resulting in nerve injury.

Answer 115

* Weakness of knee extension * Loss of the patella reflex * Numbness of the anterior thigh and medial lower leg.

Answer 116

The obturator nerve may be **compressed by forceps during instrumental delivery** or by the **fetal head during normal delivery**.

Answer 117

* Weakness of hip adduction and rotation * Numbness of the medial thigh

Answer 118

* Shoulder dystocia is a specific type of obstructed labour where the **anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis**, after the head has been delivered. * This is an obstectric emergency

Answer 119

* **Maternal gestational diabetes** * **Macrosomia** * Birthweight >4kg * Advanced maternal age * Maternal short stature or small pelvis * Maternal obesity * Post-dates pregnancy

Answer 120

* Difficult delivery of the foetal face or chin * Retraction of the foetal head back into the vagina, after its been delivered (**turtle-neck sign**) * **Failure of restitution** - where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. * Failure of descent of the foetal shoulders following delivery of the head.

Answer 121

Its an Obstetric emergency that needs prompt intervention to deliver the baby. There are various **manouvres** to help with this: * **McRoberts manoeuvre** * **Rubins manoeuvre** * **Wood’s screw manoeuvre** * **Zavanelli manoeuver** An episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. But this isn't always nescesary.

Answer 122

It involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.

Answer 123

It involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Answer 124

It is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery.

Answer 125

It involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Answer 126

* Placenta accreta refers to when the **placenta implants deeper than usual**, (through and past the endometrium), making it difficult to separate the placenta after delivery of the baby. * It is referred to as **placenta accreta spectrum**, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.

Answer 127

* **Superficial placenta accreta** - is where the placenta implants in the surface of the myometrium, but not beyond * **Placenta increta** - is where the placenta attaches deeply into the myometrium * **Placenta percreta** - is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder.

Answer 128

* Previous placenta accreta * Previous termination of pregnancy * Dilatation and curettage * Previous caesarean section * Advanced maternal age * Low lying placenta or placenta praevia * Uterine structural defects

Answer 129

* Usually the placenta attaches to the endometrium. This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby. * With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond. * This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as a caesarean section. * This **deep implantation** makes it **very difficult for the placenta to separate during delivery**, leading to extensive bleeding (postpartum haemorrhage).

Answer 130

* It typically **doesn't cause any symptoms during pregnancy**. * It can present with bleeding (antepartum haemorrhage) in the third trimester. * It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It can cause **significant postpartum haemorrhage**.

Answer 131

Ideally it is diagnosed before birth with an **Antenatal Ultrasound**

Answer 132

* Severe Postpartum Haemorrhage * Preterm delivery * Uterine rupture.

Answer 133

* **Elective Ceesarian Section with hysterectomy** is the safest management option. If preserving the patient's fertility is important to them, then the following can be attempted alongside the C-Section: * **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. But this comes with a significant risk of bleeding and infection.

Answer 134

* It's defined as the **placenta overlying the cervical os**. * This means that the placenta is attached in the lower portion of the uterus; lower than the presenting part of the fetus.

Answer 135

* **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 **NOTE** A 4 stage grading system used to be used, but it's now considered outdated.

Answer 136

It's associated with increased morbidity and mortality for both the mother and fetus. Risks include: * **Antepartum haemorrhage** * Emergency caesarean section * Emergency hysterectomy * Maternal anaemia and transfusions * Preterm birth and low birth weight * Stillbirth

Answer 137

* Placenta praevia * Placental abruption * Vasa praevia

Answer 138

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

Answer 139

* **Bright red painless vaginal bleeding**. Placenta praevia should be suspected if there's vaginal bleeding that occurs after 24 weeks of pregnancy. * Malpresentation of the foetus may be found on examination as a result of the abnormal placental position * Mothers may present with signs of shock if there is severe blood loss. * Many women are asymptomatic

Answer 140

* If there is painless bleeding after **13 weeks** or previous history of uterine incision, then **transvaginal ultrasound** is used to diagnose or exclude placenta praevia. * In known cases of Placenta Praevia, further ultrasounds should be taken at 32 and 36 weeks gestation; to reassess the placental position.

Answer 141

* Give **Corticosteroids between 24-34 weeks** of gestation (to mature the foetal lungs, given the increased risk of preterm labour) * **Planned cesarean section** is adviced **between 36 and 37 weeks gestation**. (Its planned early to reduce the risk of spontaneous labour and bleeding). * In cases were premature labour or where antenatal bleeding occurs; an emergency Cesarean section will be required.

Answer 142

* Emergency caesarean section * Blood transfusions * Intrauterine balloon tamponade * Uterine artery occlusion * Emergency hysterectomy

Answer 143

* Placental abruption is the **premature separation of the placenta from the uterine wall during pregnancy**. * The site of attachment can bleed extensively after the placenta separates. Resulting in significant **Maternal Antepartum Haemorrhage**.

Answer 144

* Previous placental abruption * Pre-eclampsia * Bleeding early in pregnancy * Trauma (consider domestic violence) * Multiple pregnancy * Fetal growth restriction * Multigravida * Increased maternal age * Smoking * Cocaine or amphetamine use

Answer 145

* **Sudden onset severe abdominal pain that is continuous** * **Vaginal bleeding** (However in concealed abruptions; the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. So the severity of the bleeding would be largely underestimated.) * Characteristic **'Woody' hard abdomen** (Uterus) - suggests a large haemorrhage * Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible * Abnormalities on the CTG indicating foetal distress

Answer 146

* **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 147

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

Answer 148

* There are no reliable tests for diagnosing placental abruption. * It is a **clinical diagnosis based on the presentation** * Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.

Answer 149

* **Emergency delivery** Is indicated in the presence of maternal and/or foetal compromise and is usually by **caesarean section** unless spontaneous delivery is imminent or operative vaginal birth is achievable. * Even if an **in-utero foetal death** has been diagnosed, a **caesarean section** may still be indicated if there is maternal compromise. * **Induction of labour** For haemorrhage at term **without maternal or foetal compromise**, induction of labour is usually recommended to avoid further bleeding. * **Conservative management** For some partial or marginal abruptions not associated with maternal or foetal compromise. * **Anti-D Prophylaxis** Is given to **all Rhesus D Negative women** within 72 hours of bleeding starting.

Answer 150

* Vasa praevia is a condition seen in obstetrics where the **foetal vessels**, (unprotected by the umbilical cord or placental tissue), **run dangerously close to or across the internal cervical os**. * These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.

Answer 151

* **Velamentous umbilical cord** (Type 1 Vasa Praevia) Is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. * **An accessory lobe of the placenta** (Type 2 Vasa Praevia) (Also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.

Answer 152

* Low lying placenta * IVF pregnancy * Multiple pregnancy

Answer 153

Classic **Triad** of: * Painless vaginal bleeding * Rupture of membranes * Foetal bradycardia (or resulting foetal death)

Answer 154

* **Placenta praevia** Characterized by painless vaginal bleeding, but without the accompanying foetal bradycardia or death seen in vasa praevia. * **Abruptio placentae** Typically presents with painful vaginal bleeding, abdominal pain, and uterine tenderness and rigidity. Foetal distress is common.

Answer 155

* **Transabdominal or Transvaginal Ultrasound** * The majority of cases are diagnosed antenataly. * Although, it may only be diagnosed during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. * The later this is diagnosed, the greater the risk of foetal mortality.

Answer 156

* **Corticosteroids**, given from 32 weeks gestation to mature the fetal lungs * **Elective caesarean section**, planned for **34 – 36 weeks** gestation When **antepartum haemorrhage** occurs: * **Emergency caesarean section** is required to deliver the fetus before death occurs.

Answer 157

Postpartum haemorrhage (PPH) refers to **bleeding after delivery of the baby and placenta** (within 24 hours). To be classed as a PPH, there need to be a loss of: * **500ml** after a vaginal delivery * **1000ml** after a caesarean section

Answer 158

It is the most common cause of significant obstetric haemorrhage.

Answer 159

Minor Vs Major: * **Minor PPH** – under 1000ml blood loss * **Major PPH** – over 1000ml blood loss Major PPH further classification: * **Moderate PPH** – 1000 – 2000ml blood loss * **Severe PPH** – over 2000ml blood loss Primary Vs Secondary: * **Primary PPH** - bleeding within 24 hours of birth * **Secondary PPH** - from 24 hours to 12 weeks after birth

Answer 160

The 4 Ts: * **Tone**: **Uterine atony** is the most common cause of PPH - which is the failure of the uterus to contract after delivery. * **Trauma**: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries. * **Tissue**: Retained placental or foetal tissue can cause continued bleeding. * **Thrombin**: Coagulopathies can lead to continued bleeding due to a failure of clotting.

Answer 161

* PPH in previous pregnancy * BMI >35 * Multiple pregnancy * Parity >4 * Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia * Delivery via Caesarean section * Induction of labour * Instrumented delivery (forceps or ventouse) and episiotomy * Prolonged labour (greater than 12 hours) * Macrosomia (>4kg baby) * Advanced maternal age

Answer 162

In **Primary PPH**: * Blood tests for Group/Save and Crossmatch In **Secondary PPH**: * Ultrasound looking for retained products * Endocervical/high vaginal swabs looking for infection

Answer 163

* Resuscitation with an ABCDE approach * Lie the woman flat, keep her warm and communicate with her and the partner * Insert two large-bore cannulas * Bloods for FBC, U&E and clotting screen * Group and cross match 4 units * **Warmed IV fluid** and **blood resuscitation** as required * **Oxygen** (regardless of saturations) * **Fresh frozen plasma** is used where there are clotting abnormalities or after 4 units of blood transfusion.

Answer 164

**Mechanical**: * **Rubbing the uterus** through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) * **Catheterisation** (bladder distention prevents uterus contractions) **Medical**: * **Oxytocin** (slow injection followed by continuous infusion) - 40mg in 500mls * **Ergometrine** (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) * **Carboprost**(intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) * **Misoprostol** (sublingual) is also a prostaglandin analogue and stimulates uterine contraction * **Tranexamic acid** (intravenous) is an antifibrinolytic that reduces bleeding **Surgical**: * **Intrauterine balloon tamponade** – inserting an inflatable balloon into the uterus to press against the bleeding * **B-Lynch suture** – putting a suture around the uterus to compress it * **Uterine artery ligation** – ligation of one or more of the arteries supplying the uterus to reduce the blood flow * **Hysterectomy** is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 165

It depends on the cause: * Surgical evaluation of retained products of conception * Antibiotics for infection

Answer 166

[](http://)This can occur when a **rhesus-D negative woman has a Rhesus-D positive baby**. (Rhesus incompatability) It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens.

Answer 167

Examples of these **sensitisation events** include: * Antepartum haemorrhage * Placental abruption * Abdominal trauma * External cephalic version * Invasive uterine procedures such as amniocentesis and chorionic villus sampling * Rhesus positive blood transfusion to a rhesus negative woman * Intrauterine death, miscarriage or termination * Ectopic pregnancy * Delivery (normal, instrumental or caesarean section)

Answer 168

* Usually, the **sensitisation process does not cause problems during the first pregnancy**. * During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). * The red blood cell destruction caused by antibodies from the mother is called **haemolytic disease of the newborn**.

Answer 169

All mothers should be tested for rhesus status and anti-D antibodies at booking **Prevention of sensitisation** - is the mainstay of management. This involves giving **intramuscular anti-D injections** to rhesus-D negative women. * Note that anti-D has no effect once sensitisation has already occurred. Anti-D injections are given **routinely** on two occasions: * 28 weeks gestation * Birth (if the baby’s blood group is found to be rhesus-positive) Anti-D injections should also be given at any time where sensitisation may occur, such as: * Antepartum haemorrhage * Amniocentesis procedures * Abdominal trauma Anti-D is given within **72 hours of a sensitisation event**..

Answer 170

* The Kleihauer test checks **how much fetal blood has passed into the mother’s blood during a sensitisation event**. * This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.

Answer 171

A Puerperal infection is defined as an **infection of the genital tract** occurring **at labour or within 42 days** of the postpartum period.

Answer 172

* Endometritis refers to **inflammation of the endometrium, usually caused by infection**. * It can occur in the postpartum period, as infection is introduced during or after labour and delivery. * The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.

Answer 173

* More common after caesarean sections compared with vaginal deliveries. * Prophylactic antibiotics are given during a caesarean to reduce the risk

Answer 174

* It can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. * It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.

Answer 175

It can present from shortly after birth to several weeks postpartum, with: * Foul-smelling discharge or lochia * Bleeding that gets heavier or does not improve with time * Lower abdominal or pelvic pain * Fever * Sepsis

Answer 176

* Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors) * Urine culture and sensitivities * Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

Answer 177

**Septic patients**: * Require hospital admission and the septic six * This includes blood cultures and broad-spectrum IV antibiotics * A combination of clindamycin and gentamicin is often recommended. * Blood tests will show signs of infection (e.g. raised WBC and CRP). **Milder Infections**: * Can be treated in the community with oral antibiotics. * A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

Answer 178

* Benign breast diseases are a **group of non-cancerous conditions affecting the breast**. * They often manifest as breast lumps, nipple discharge, or other abnormalities.

Answer 179

* **Fibroadenomas** - arise from the breast lobule stroma. * **Breast cysts** - occur due to the overgrowth of glandular and connective tissue, leading to blocked breast ducts and subsequent fluid accumulation. * **Mastitis** - is typically caused by bacterial infections, often related to breaks in the skin around the nipple. * **Intraductal papilloma** - is a benign tumour of the breast ducts. * **Radial scar** is a benign sclerosing breast lesion. * **Fat necrosis** is a response to adipose tissue damage. * **Fibrocystic breast disease** is due to an exaggerated hormonal response causing inflammation, fibrosis, cyst formation, or adenosis. * **Mammary duct ectasia** is due to inflammation and dilation of the large breast ducts.

Answer 180

* **Fibroadenoma** - Highly mobile, encapsulated breast masses. * **Breast cysts** - Presence of breast lumps, potentially with distension. * **Mastitis** - Breast redness, mastalgia, malaise, and fever. * **Intraductal papilloma** - Bloody discharge from the nipple without a palpable mass. * **Radial scar** - Presents on mammogram as a stellate pattern of central scarring surrounded by proliferating glandular tissue. * **Fat necrosis** - Painless breast mass, skin thickening, or radiographic changes on mammography. * **Fibrocystic breast disease** - Breast lumps, pain, and tenderness. * **Mammary duct ectasia** - Palpable peri-areolar breast mass, thick nipple discharge, and potential mammographic similarities to cancer.

Answer 181

* **Breast cancer** Characterised by hard, immobile lumps, nipple retraction, skin changes (like peau d'orange), or bloody nipple discharge. * **Gynecomastia** Enlargement of male breast tissue, which may be tender or painful. * **Abscess** A collection of pus in the breast tissue, often painful and associated with redness, warmth, and fever. * **Lipoma** Soft, mobile, non-tender fatty lumps beneath the skin.

Answer 182

* **Clinical breast examination**: To identify any palpable abnormalities. * **Mammography and ultrasound**: To visualize the internal structures and evaluate any identified lumps or abnormalities. * **Fine-needle aspiration or biopsy**: To confirm the diagnosis of identified lumps or suspicious areas. * **Blood tests**: To identify signs of infection or hormonal imbalances in certain cases.

Answer 183

* **Reassurance**: Often, benign breast diseases require only monitoring and reassurance, especially when symptoms are minimal and there is no sign of complications. * **Antibiotics**: Used in case of infections such as mastitis. * **Analgesics**: To manage pain or discomfort associated with various conditions. * **Surgical intervention**: In some cases, like large fibroadenomas, persistent cysts, or symptomatic intraductal papillomas. * **Hormonal therapy**: May be considered in cases of fibrocystic breast disease.

Answer 184

* Mastitis is the **inflammation of the breast tissue**, which can be with or without an infection. * When associated with lactation in postpartum women, the condition is specified as puerperal mastitis.

Answer 185

* Mastitis, (particularly puerperal mastitis), is a common condition among **postpartum women** * It typically occurs within the first six weeks postpartum, particularly in the second and third weeks. * It usually affects **first-time mothers** and those with a **history of mastitis** in previous pregnancies.

Answer 186

* Mastitis often results from **milk stasis**, which can lead to an inflammatory response and potential secondary infection. * Milk stasis may occur due to **inadequate milk removal**, either from **poor breastfeeding techniques, infrequent feeding**. Which can result in blockage of the ducts. * Cracked or sore nipples can provide a point of entry for bacteria, leading to infective mastitis. * **Staph Aureus** is the most common causative organism

Answer 187

* Is a breast condition that occurs when a **milk duct in the breast widens and its walls thicken**. * This can cause the duct to become blocked and lead to fluid build-up. * This is a **non-lactational cause of blockage of the ducts** (which leads to non-infective mastitis). * It is a normal part of aging and is more common in perimenopausal women.

Answer 188

* Poor breastfeeding technique * Nipple damage * Maternal stress * Previous history of mastitis * First time pregnancy * Smoking

Answer 189

* **Localised symptoms**: Painful, tender, red, and hot breast. * **Systemic symptoms**: Fever, rigors, myalgia, fatigue, nausea, and headache. * The condition is usually **unilateral** and tends to present within the **first week postpartum**. * In some cases, mastitis may develop into a breast abscess, manifesting as a fluctuant, tender mass with overlying erythema.

Answer 190

* **Breast abscess** Fluctuant mass, tenderness, overlying erythema, systemic signs of infection. * **Inflammatory breast cancer** Swelling, skin changes resembling orange peel, nipple inversion, axillary lymphadenopathy. * **Breast engorgement** Typically bilateral and associated with milk stasis, painful, and tense breasts.

Answer 191

* Diagnosis of mastitis is **primarily clinical** * An ultrasound may be useful in identifying an abcess if that is suspected

Answer 192

**No infection** (and is simply caused by duct blockage (duct Ectasia): * Management is conservative involving * Continued breastfeeding * Expressing milk * Breast massage. * Heat packs, warm showers and simple analgesia can help symptoms. **Infection** (or when conservative management fails): * Antibiotics * Flucloxacillin is first line, or erythromycin if allergic to penicillin. * A sample of milk can be sent to the lab for culture and sensitivities. Women should be encouraged to **continue breastfeeding**, even when infection is suspected. It will not harm the baby and will help to clear the mastitis by encouraging flow.

Answer 193

* Candida infection of the nipple (often after a course of antibiotics). This can lead to **Recurrent mastitis** * Breast Abcess

Answer 194

* Sore nipples bilaterally, particularly after feeding * Nipple tenderness and itching * Cracked, flaky or shiny areola Its associated with oral thrush and candidal nappy rash in the infant.

Answer 195

**Both the mother and baby need treatment**, or it will reoccur. Treatment is with: * **Topical miconazole 2%** after each breastfeed * Treatment for the baby (e.g. miconazole gel or nystatin)

Answer 196

A breast abscess is a **collection of pus within an area of the breast**, usually caused by a bacterial infection. This may be a: * **Lactational abscess** (associated with breastfeeding) * **Non-lactational abscess** (unrelated to breastfeeding) It often occurs as a result of infectious mastitis.

Answer 197

* **Staphylococcus aureus** (the most common) * Streptococcal species * Enterococcal species * Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Answer 198

* Alongside the features of Mastitis * The key feature that suggests a breast abscess is a **swollen, fluctuant, tender lump within the breast**. * As well as more generalised symptoms of infection like; Muscle aches, Fatigue, Fever, Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion).

Answer 199

Breast Ultrasound

Answer 200

* Referral to the on-call surgical team in the hospital for management * Antibiotics * Drainage (needle aspiration or surgical incision and drainage) * Microscopy, culture and sensitivities of the drained fluid Women are advised to continue breastfeeding. They should regularly express breast milk if feeding is too painful, then resume feeding when possible.

Answer 201

* Fibroadenomas are **common benign tumours of stromal and epithelial breast duct tissue**. * They originate from the lobules (the milk-producing glands of the breast)

Answer 202

* More common in **younger women** (aged between **20 and 40**) * They're particularly common in periods of reproductive hormonal change such as **puberty, pregnancy, and perimenopause**.

Answer 203

* Exact cause is unclear * They respond to the **increased levels of female reproductive hormones** (oestrogen and progesterone). As they often grow in size during pregnancy, and shrink during menopause.

Answer 204

* A **firm, non-tender breast mass** * The mass is **rounded and has smooth edges** * The mass is **highly mobile** upon palpation, sometimes called a **“breast mouse”**, as they move around within the breast tissue. * Often referred to as having a "rubbery" consistency * The mass typically does not grow beyond 3cm in diameter

Answer 205

* **Breast cysts** These can be soft to firm, mobile, and round with distinct edges, similar to fibroadenomas. However, they may be tender and can fluctuate in size with the menstrual cycle. * **Invasive breast cancer** Typically presents with a hard, irregularly shaped, immobile mass. There may be associated nipple discharge, retraction or skin changes. * **Intraductal papilloma** Generally presents with nipple discharge, occasionally blood-stained, but may also have an associated palpable mass. * **Lipoma** Presents as a soft, mobile mass. Unlike fibroadenomas, lipomas can grow beyond 3cm and are typically painless.

Answer 206

While fibroadenomas are benign, patients usually undergo a **triple assessment** to exclude more serious pathology. This includes: * Clinical examination * Imaging (usually ultrasound and/or mammogram) * Needle biopsy (fine needle aspiration or core biopsy)

Answer 207

* **Conservative management** Many fibroadenomas do not require treatment and will regress naturally after menopause. * **Surgical excision** This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment.

Answer 208

**No** * They are not usually associated with an increased risk of developing breast cancer. * Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.

Answer 209

Breast cysts are benign, individual, fluid-filled lumps of the breast.

Answer 210

* They are the **most common cause of breast lumps** * Occur most often between ages **30 and 50**, more so in the perimenopausal period.

Answer 211

The Lumps can be: * Possibly painful * Smooth * Well-circumscribed * Mobile * Possibly fluctuant They can also fluctuate in size over the menstrual cycle

Answer 212

Same as a Fibroadenoma. **Triple Assessment** of (to exclude cancer): * Clinical examination * Imaging (usually ultrasound and/or mammogram) * Needle biopsy (fine needle aspiration or core biopsy)

Answer 213

* **Aspiration of the breast cyst** is the recommended treatment in symptomatic cases. * Repeat aspiration or excision may be required in cases of recurrent cysts * Non-symptomatic (non-painful) breast cysts do not need to be drained unless they bother the patient or cause concerns.

Answer 214

**Yes** Having a breast cyst may slightly increase someone's cancer risk

Answer 215

* An intraductal papilloma is a **warty lesion that grows within one of the ducts in the breast**. * It is the result of the proliferation of epithelial cells. * They are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Answer 216

Most common between 35-55 years

Answer 217

They may present with: * Nipple discharge (clear or blood-stained) * Breast tenderness or pain * A palpable lump They are often asymptomatic and can be picked up incidentally on mammograms or ultrasound.

Answer 218

Patients require **triple assessment** with: * Clinical assessment (history and examination) * Imaging (ultrasound, mammography and MRI) * Histology (usually by core biopsy or vacuum-assisted biopsy) **Ductography** may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Answer 219

* Intraductal papillomas require **complete surgical excision**. * After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 220

* Breast cancer or carcinoma refers to a **malignant tumor originating from the cells of the breast tissue.** * The carcinomas can be invasive, indicating they have broken through the basement membrane of the tissue of origin and have the potential to metastasize, or non-invasive (in situ), suggesting they are confined to the initial location.

Answer 221

* Breast cancer is the **most common form of cancer in the UK**. * It mostly affects women and is rare in men (about 1% of UK cases). * Around 1 in 8 women will develop breast cancer in their lifetime.

Answer 222

* Female (99% of breast cancers) * Increased oestrogen exposure (earlier onset of periods and later menopause) * More dense breast tissue (more glandular tissue) * Obesity * Smoking * Family history (first-degree relatives) * BRCA Gene Mutations The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill. Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).

Answer 223

* BRCA refers to the **BR**east **CA**ncer gene. The BRCA genes are tumour suppressor genes. * Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers).

Answer 224

**BRCA1 gene** is on chromosome 17 * 70% will develop breast cancer by aged 80 * 50% will develop ovarian cancer * Also increased risk of bowel and prostate cancer **BRCA2 gene** is on chromosome 13 * 60% will develop breast cancer by aged 80 * 20% will develop ovarian cancer

Answer 225

**Ductal Carcinoma In Situ (DCIS)** * Pre-cancerous or cancerous epithelial cells of the breast ducts * Localised to a single area * Often picked up by mammogram screening * Potential to spread locally over years * Potential to become an invasive breast cancer (around 30%) * Good prognosis if full excised and adjuvant treatment is used **Lobular Carcinoma In Situ (LCIS)** * A pre-cancerous condition occurring typically in pre-menopausal women * Usually asymptomatic and undetectable on a mammogram * Usually diagnosed incidentally on a breast biopsy * Represents an increased risk of invasive breast cancer in the future (around 30%) * Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms) **Invasive Ductal Carcinoma – NST** * Most common type of breast cancer * NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous) * Also known as invasive breast carcinoma of no special/specific type (NST) * Originate in cells from the breast ducts * 80% of invasive breast cancers fall into this category * Can be seen on mammograms **Invasive Lobular Carcinomas (ILC)** * Around 10% of invasive breast cancers * Originate in cells from the breast lobules * Not always visible on mammograms **Inflammatory Breast Cancer** * 1-3% of breast cancers * Presents similarly to a breast abscess or mastitis * Swollen, warm, tender breast with pitting skin (peau d’orange) * Does not respond to antibiotics * Worse prognosis than other breast cancers **Paget’s Disease of the Nipple** * Looks like eczema of the nipple/areolar * Erythematous, scaly rash * Indicates breast cancer involving the nipple * May represent DCIS or invasive breast cancer * Requires biopsy, staging and treatment, as with any other invasive breast cancer **Rarer Types of Breast Cancer** * Medullary breast cancer * Mucinous breast cancer * Tubular breast cancer * Multiple others

Answer 226

**Mammogram** is offered **every 3 years** to women aged **50-70 years** The screening aims to detect breast cancer early, which improves outcomes.

Answer 227

* Anxiety and stress * Exposure to radiation, with a very small risk of causing breast cancer * Missing cancer, leading to false reassurance * Unnecessary further tests or treatment where findings would not have otherwise caused harm

Answer 228

People who have: * 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 **Annual mammogram** screening is offered to women with increased risk. Potentially starting from aged 30, if high risk.

Answer 229

**Chemoprevention** may be offered: * Tamoxifen if premenopausal * Anastrozole if postmenopausal (except with severe osteoporosis) **Risk-reducing bilateral mastectomy** or **bilateral oophorectomy** (removing the ovaries) is also an option for women at high risk; but this is only suitable for a small subset of women.

Answer 230

* 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

Answer 231

**Two week wait referral** for: * An unexplained breast lump in patients aged 30 or above * Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes) * An unexplained lump in the axilla in patients aged 30 or above * Skin changes suggestive of breast cancer

Answer 232

* **Fibroadenoma** Typically presents as a solitary, painless, and well-circumscribed breast lump in young women * **Cyst** Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle. * **Mastitis** Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever. * **Lipoma** Presents as a soft, mobile, and painless lump.

Answer 233

Initial Investigations are with a **Triple Diagnostic Assesment**: * **Clinical assessment** (history and examination) * **Imaging** (ultrasound or mammography) * **Biopsy** (fine needle aspiration or core biopsy) Then once the woman has been diagnosed with breast cancer, then an **assesment of the Lymph nodes** is required: * Ultrasound of the axilla (armpit) * Ultrasound-guided biopsy of any abnormal nodes * A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Answer 234

**Ultrasound scans**: * Are used to assess lumps in younger women (e.g., under 30 years). * They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps. **Mammograms**: * Are generally more effective in older women. * They can pick up calcifications missed by ultrasound. **MRI Scans** may be used: * For screening in women at higher risk of developing breast cancer (e.g., strong family history) * To further assess the size and features of a tumour

Answer 235

The **TNM System** is used to stage breast cancer (Tumor, Nodes, Metastases). The following investigations are required to stage the cancer: * Triple Assesment * Lymph node assessment and biopsy * MRI of the breast and axilla * Liver ultrasound for liver metastasis * CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis * Isotope bone scan for bony metastasis

Answer 236

Breast cancer can spread to anywhere in the body, whoever the most common locations are: **2Ls and 2Bs** * L – Lungs * L – Liver * B – Bones * B – Brain

Answer 237

* Oestrogen receptors (ER) * Progesterone receptors (PR) * Human epidermal growth factor (HER2) These receptors can be targeted with breast cancer treatments

Answer 238

**Triple-negative breast cancer** is where the breast cancer cells do not express any of the three typical receptors. (ER, PR or HER2) This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Answer 239

* Gene expression profiling involves **assessing which genes are present within the breast cancer** on a histology sample. * This helps predict the **probability that the breast cancer will reoccur** as a distal metastasis (away from the original cancer site) within 10 years. * The NICE guidelines recommend this for women with early breast cancers that are **ER positive but HER2 and lymph node negative**. * It helps guide whether to give additional chemotherapy.

Answer 240

**Surgical** (The aim is removal of the tumour). There are 2 main types: * **Breast-conserving surgery** (e.g. wide local excision), usually coupled with radiotherapy. * **Mastectomy** (removal of the whole breast), potentially with immediate or delayed breast reconstruction. * **Axillary Clearance** - Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. (although this increases the risk of lymphoedema) **Radiotherapy** * Adjuvant Radiotherapy is given to patients following breast-conserving surgery to reduce the risk of recurrence. **Chemotherapy** * Suggested in patients with hormone receptor-negative and HER2 over-expressing patients. Its used in 1 of 3 scenarios: * **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 Treatment**: * Is used in patients with oestrogen-receptor positive breast cancer. There are 2 main first line options: * **Tamoxifen** for premenopausal women * **Aromatase inhibitors** for postmenopausal women (e.g., letrozole, anastrozole or exemestane) * Tamoxifen or an aromatase inhibitor are given for **5 – 10 years** to women with oestrogen-receptor positive breast cancer. **Biological Therapy** * **Trastuzumab** (Herceptin) is a monoclonal antibody that targets the HER2 receptor. So is used in HER2 positive cancers. * Trastuzumab can be used in conjunction with **Pertuzumab**. * **Neratinib** (Nerlynx) is a tyrosine kinase inhibitor and is another option for HER2 positive cancers.

Answer 241

* General fatigue from the radiation * Local skin and tissue irritation and swelling * Fibrosis of breast tissue * Shrinking of breast tissue * Long term skin colour changes (usually darker)

Answer 242

* Fatigue * Hair loss * Easy bruising and bleeding * Infection * Anaemia * Nausea and vomiting * Appetite changes * Problems with concentration or memory.

Answer 243

* Hot flashes * Vaginal dryness or discharge * Menstrual changes * Fatigue * Mood changes * Osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.

Answer 244

* Tamoxifen is a **selective oestrogen receptor modulator (SERM)**. * It either blocks or stimulates oestrogen receptors, depending on the site of action. * It **blocks oestrogen receptors in breast tissue**, and stimulates oestrogen receptors in the uterus and bones. * This means it **helps prevent osteoporosis**, but it does **increase the risk of endometrial cancer**.

Answer 245

* Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. * After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. * Aromatase inhibitors **work by blocking the creation of oestrogen in fat tissue**. * Examples include: letrozole, anastrozole or exemestane

Answer 246

Breast reconstructive surgery is offered to **all patients having a mastectomy**. There are two options: * **Immediate reconstruction** - done at the time of the mastectomy * **Delayed reconstruction** - which can be delayed for months or years after the initial mastectomy

Answer 247

After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are: * **Partial reconstruction** (using a flap or fat tissue to fill the gap) * **Reduction and reshaping** (removing tissue and reshaping both breasts to match.

Answer 248

* **Breast implants** (inserting a synthetic implant) * **Flap reconstruction** (using tissue from another part of the body to reconstruct the breast)

Answer 249

**Advantages** * Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. * It gives an acceptable appearance **Disadvantages** * Implants can feel less natural (e.g., cold, less mobile and static size and shape). * There can also be long-term problems, such as hardening, leakage and shape change.

Answer 250

* Latissimus Dorsi Flap * Transverse Rectus Abdominis Flap (TRAM Flap) * Deep Inferior Epigastric Perforator Flap (DIEP Flap)

Answer 251

* **Pain**: Persistent or worsening pain at the surgical site. * **Bleeding**: Increased wound drainage, decreased blood pressure, increased heart rate. * **Infection**: Wound redness, swelling, pain, pus discharge, and fever. * **Seroma**: Swelling at the surgical site, fluid-filled lump. * **Displeasure with cosmetic outcome**: Patient dissatisfaction with the appearance of the breast after surgery.

Answer 252

* **Stroke**: Sudden onset of neurological deficits such as weakness, speech impairment, visual changes. * **Venous thromboembolism**: Swelling, pain, and redness in the leg (deep vein thrombosis); shortness of breath, chest pain, and rapid heart rate (pulmonary embolism). * **Myocardial infarction**: Chest pain, shortness of breath, sweating, nausea, and lightheadedness. * **Aspiration**: Sudden onset of coughing, wheezing, and difficulty breathing.

Answer 253

* **Lymphoedema**: Swelling of the arm, feeling of heaviness or tightness, restricted range of motion. * **Damage to brachial plexus**: Numbness, tingling, or weakness in the arm. * **Axillary artery/vein injury**: Swelling, pain, pallor, and decreased pulse in the arm.

Answer 254

* Lymphoedema is a **chronic condition caused by impaired lymphatic drainage of an area**. * Lymphoedema can occur in an entire arm **after breast cancer surgery on that side**, with removal of the axillary lymph nodes in the armpit. * lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become **swollen with excess, protein-rich fluid (lymphoedema)**. * Areas of lymphoedema are prone to infection

Answer 255

* Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) * Compression bandages * Specific lymphoedema exercises to improve lymph drainage * Weight loss if overweight * Good skin care

Answer 256

* Paget's disease of the nipple, also known as Paget's disease of the breast, is a rare condition **characterised by the presence of cancer cells in the skin of the nipple**. * This disease often suggests an underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.

Answer 257

* Most common in Postmenopausal women * Only accounts for around 5% of breast cancers

Answer 258

* **Epidermotropic theory** - suggests that cancer cells from an underlying breast tumour migrate to the nipple. * **Intraepidermal origin theory** - which proposes the disease originates in the nipple itself.

Answer 259

* Eczema-like rash on the skin of the nipple and areola that is often itchy, red, crusty, and inflamed * Bloody nipple discharge * Burning sensation, increased sensitivity, or pain in the nipple * Changes to the nipple, such as retraction or inversion * Palpable breast lump (in some cases) * Non-healing skin ulcer (in some cases)

Answer 260

* **Atopic dermatitis (eczema)** Characterised by itchy, red, and inflamed skin, usually occurring in patches * **Contact dermatitis** Caused by irritants or allergens, presents with a red rash, itching, and possibly blisters * **Intraductal papilloma** Produces bloody nipple discharge but typically does not involve skin changes * **Mastitis or breast abscess** Presents with breast redness, swelling, pain, and possible fever; often related to breastfeeding * **Psoriasis** Presents with silvery scales on red, raised patches, often with itching or burning

Answer 261

* **Physical examination** of the breasts and lymph nodes * **Mammography** or **breast ultrasound** * **Biopsy** of the affected skin and nipple discharge cytology * **MRI** may be used in certain circumstances to better assess the extent of disease

Answer 262

Management of Paget's disease of the nipple primarily involves **surgical intervention**. Approaches can include: * **Simple mastectomy**: Removal of the entire breast, including the nipple and areola * **Modified radical mastectomy**: Removal of the entire breast along with some of the axillary (underarm) lymph nodes * **Breast-conserving surgery** (lumpectomy): If the underlying cancer is small and limited Additionally, adjunctive treatments such as radiation therapy, chemotherapy, or hormonal therapy may be used depending on the characteristics of the underlying breast cancer.

Answer 263

* Vulvovaginal candidiasis, often referred to as a yeast infection, is an **inflammation of the vagina and the vulva** due to an **overgrowth of the yeast fungus**, primarily Candida Albicans. * Recurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic.

Answer 264

* **Candida Albicans** is the main causative organism (causing 85-90% of cases) * Transmission is usually **non-sexual**

Answer 265

* Pregnancy * Antibiotic use * Immunosuppression

Answer 266

**Symptoms**: * Itching * white curdy or lumpy discharge * sour milk odour * dysuria * superficial dyspareunia * pruritus * tenderness * burning sensation. **Signs**: * Redness * fissuring * swelling * intertrigo * thick white discharge. In **Men**: Symptoms: Soreness, pruritus, redness. Examination findings: Dry, dull, red glazed plaques and papules.

Answer 267

* **Bacterial vaginosis** Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation. * **Trichomoniasis** Presents with yellow-green, frothy discharge, dysuria, and itching. * **Chlamydia or Gonorrhoea** These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding. * **Genital herpes** Characterised by painful blisters or open sores in the genital area.

Answer 268

Routine **investigations are not typically required** for acute, uncomplicated vulvovaginal candidiasis cases. However, in instances where the **clinical presentation is unclear** or **recurrent episodes occur**, the following investigations may be necessary: * **Microscopy** - Detection of blastospores, pseudohyphae and neutrophils suggests Candida infection. * **Culture** - Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.

Answer 269

1st Line management is **Antifungal treatment**: * Oral (-azoles) e.g., fluconazole, itraconazole * Intravaginal e.g., clotrimazole pessary * Vulval e.g., topical clotrimazole cream Common regimens include: * **Fluconazole oral capsule 150mg** as a single dose. * **Clotrimazole intravaginal pessary 500mg** as a single dose. * **Clotrimazole intravaginal cream (10%) 5g** as a single dose. * Clotrimazole intravaginal pessary 200mg at night for 3 consecutive nights.

Answer 270

Is managed with a **Induction and Maintainence regimen**: * Induction with Fluconazole oral capsule 150mg every 72 hours for a total of three doses * Maintainence with Fluconazole oral capsule 150mg once weekly for six months

Answer 271

* Balanitis is **inflammation of the glans penis**. * If the foreskin is also inflamed, the correct term is balanoposthitis, although balanitis is commonly used to refer to both.

Answer 272

* More common in Men than boys * It's uncommon in circumcised boys and men (circumcision reduces the risk of inflammatory skin conditions which may cause balanitis).

Answer 273

* **Diabetes mellitus**. * Use of oral antibiotics. * Poor hygiene in uncircumcised males. * Immunosuppression. * Chemical or physical irritation of glans.

Answer 274

**Infectious Causes**: * Candida infection * Staph Aureus * Anaerobic Bacteria **Dermatological Causes** * Circinate balanitis (Associated with reactive arthritis) * Psoriasis * Fixed drug eruption (especially with sulfonamides and tetracycline) **Other causes** * Intertrigo (alot of cases) * Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms. * Trauma * Severe oedema due to right heart failure. * Morbid obesity

Answer 275

Intertrigo is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture.

Answer 276

* **Sore, inflamed and swollen glans/foreskin** * **Non-retractile foreskin (phimosis)**. * Penile ulceration. * Penile plaques. * Satellite lesions. * May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic infection). * Dysuria. * Interference with urinary flow in severe cases. * Obscuration of glans/external urethral meatus. * Impotence or pain during coitus. * Regional lymphadenopathy.

Answer 277

* Blood/urine testing for glucose if diabetes mellitus is possible. * Swab of discharge for **microscopy, Gram staining, culture and sensitivity**.

Answer 278

**Caused by contact dermatitis**: * Avoid Triggers * Topical hydrocortisone 1% once daily (consider adding an imidazole cream), for up to 14 days. **Caused by Candidal infection** * Clotrimazole cream 1% or miconazole cream 2%; apply twice daily until symptoms have settled. * Alternative regimens: fluconazole 150 mg stat orally * Topical imidazole with 1% hydrocortisone if there is marked inflammation **Caused by Bacterial infection** * Common bacterial infection - flucloxacillin (or erythromycin in penicillin-allergic patients). * Anaerobic infection - metronidazole 400 mg twice-daily for one week **Surgery** * Is not often done, but surgical referral for consideration of circumcision if balanitis is recurrent or pathological phimosis is present.

Answer 279

* Chancroid is a **sexually transmitted infection (STI)** of the genital skin. * It is primarily caused by the **gram-negative bacillus Haemophilus ducreyi**.

Answer 280

* Most common in **tropical and subtropical regions** as well as **Greenland** * Sexual behaviour, poor living conditions, and a lack of public health infrastructure contribute to the increased incidence in these areas

Answer 281

* Chancroid is caused by an infection with the **gram-negative bacillus Haemophilus ducreyi**. * The bacterium is sexually transmitted and can cause a genital ulcer and inflammation of the inguinal lymph nodes. * Given its higher prevalence in other parts of the world, its important to ask patients about **recent travel**.

Answer 282

* Presents as a **painful, potentially necrotic genital lesion**; that may **bleed on contact**. * Painful lymphadenopathy, commonly known as "bubo," which may rupture and discharge pus. Symptoms often develop within 4-10 days after exposure to the bacterium.

Answer 283

* **Herpes Simplex Virus (HSV)** Presents with multiple, small, vesicular lesions that become ulcers, accompanied by systemic symptoms such as fever and malaise. * **Syphilis** Presents with a painless ulcer (chancre) and generalized non-tender lymphadenopathy. * **Lymphogranuloma Venereum (LGV)** Presents with a small painless ulcer or papule that often goes unnoticed, followed by painful inguinal lymphadenopathy ("bubo") similar to chancroid.

Answer 284

Diagnosis is usually based upon the clinical picture. But the following can confirm the diagnosis: * **Culture** - H. ducreyi is a fastidious organism and culture is often difficult and time-consuming. * **PCR (Polymerase Chain Reaction)** - PCR for H. ducreyi can be performed on genital ulcer specimens, providing a more rapid diagnosis.

Answer 285

The infection is typically managed using **antibiotics**, including: * Ceftriaxone * Azithromycin * Ciprofloxacin **Adjunctive therapy** can include: * Analgesics for pain control * Incision and drainage of buboes

Answer 286

* Lymphogranuloma venereum (LGV) is a **sexually transmitted infection**. * Predominantly caused by the **L1, L2, or L3 serovars of Chlamydia trachomatis**.

Answer 287

More common in Men who have sex with Men

Answer 288

Its caused by infection with the L1, L2, or L3 serovars of Chlamydia trachomatis, typically through sexual contact.

Answer 289

* **Painless genital ulcer** - Typically appears 3-12 days after infection. It might go unnoticed, particularly if it occurs inside the vagina * Inguinal lymphadenopathy, often noticeable * Proctitis, associated with rectal pain and discharge (in case of rectal infections) * Systemic symptoms can include fever and malaise

Answer 290

* **Primary syphilis** Presents with a solitary, painless genital ulcer (chancre) and regional lymphadenopathy * **Herpes simplex virus infection** Characterised by multiple painful vesicles or ulcers, systemic symptoms, and occasional inguinal lymphadenopathy * **Chancroid** Caused by Haemophilus ducreyi, it presents with painful genital ulcers and painful inguinal lymphadenopathy

Answer 291

**Polymerase chain reaction (PCR)**, are employed to detect C. trachomatis from a swab of the genital ulcer.

Answer 292

Its managed by anitibiotics. Common regimes include: * **Oral doxycycline** - 100 mg administered twice daily for 21 days * **Oral tetracycline** - 2 g administered daily for 21 days * **Oral erythromycin** - 500 mg given four times daily for 21 days

Answer 293

* Genital herpes is an **infectious disease** characterized by the appearance of **painful sores or ulcers on the genitals**. * It is caused by infection with the **herpes simplex viruses**, either HSV-1 or HSV-2.

Answer 294

More common in 15 - 24 year olds

Answer 295

* **HSV-1** - Is traditionally associated with oral herpes, but it is now the **most common cause of genital herpes** in the UK. * **HSV-2** - Was reviously the most common cause of genital herpes in the UK, it is more likely to cause recurrent anogenital symptoms.

Answer 296

* Asymptomatic presentation in some individuals * Multiple painful genital ulcers * Dysuria * Vaginal or urethral discharge * Crusting and healing of lesions, marking the end of viral shedding * Fever, malaise, headache, and urinary retention in some cases Recurrent episodes are usually less severe and may not have an identifiable trigger. They may be preceded by a prodromal phase characterized by tingling.

Answer 297

* Clinical history and examination * Swab from the base of the ulcer analysed using nucleic acid amplification tests (NAATs), the most effective method

Answer 298

**Oral antivirals are the mainstay of treatment**. Ideally initiated within 5 days of symptom onset or while new lesions are forming: * **Aciclovir 400 mg** three times daily for 5 days * **Valaciclovir 500 mg** twice daily for 5 days * **Aciclovir 200 mg** five times daily for 5 days * **Famciclovir 250 mg** three times daily for 5 days For symptomatic relief, analgesia such as **topical lidocaine** may be beneficial.

Answer 299

* Referral to a GUM clinic * Immediate treatment initiation (**400 mg Aciclovir three times daily for 5 days**) for a first-time HSV episode * Inform the mother that **neonatal risk is low** even with lesions present at delivery. * If lesions are short lasting and resolve within 7-10 days, supportive treatment with **saline bathing** and **paracetamol** may suffice.

Answer 300

* Genital warts, or anogenital warts, are a type of sexually transmitted infection characterised by **small, skin-colored or grey growths in the genital area**. * They are typically painless and present in regions traumatised during sexual intercourse.

Answer 301

* Unprotected sex * Multiple sexual partners * Immunosuppression * Starting sexual activity at a young age.

Answer 302

* They are caused by the **human papillomavirus (HPV)** * 90% of cases are attributed to attributed to **serotypes 6 and 11** * Transmission primarily occurs through direct skin-to-skin contact during sexual activity.

Answer 303

* **Painless lumps** on the genitals or anal area * The lumps are either skin coloured or grey * Lumps that are either **keratinised** (hard) or **non-keratinised** (soft) * Areas of the body that are traumatised during sexual intercourse are commonly affected

Answer 304

* **Molluscum contagiosum** Characterised by small, firm, round bumps with a central indentation. * **Condyloma lata (secondary syphilis)** Presents as large, flat, grey-white lesions, often with a moist surface. * **Genital herpes** Presents with painful blisters or open sores in the genital area. * **Skin tags** Small, soft, skin-colored growths that hang off the skin and can appear anywhere.

Answer 305

* Diagnosis is primarily clinical made through a detailed history and visual inspection of the warts. * But in uncertain cases the diagnosis can be confirmed through **biopsy and histopathological investigation**.

Answer 306

Management depends on the patient's wishes and concerns about their appearance. If the patient is not concerned about the aesthetic aspect, a conservative approach can be adopted. But active treatment options include: * **Podophyllotoxin** - a plant-based antiviral that can destroy wart tissue * **Imiquimod** - an immune response modifier that stimulates the body's immune system to fight the virus * **Cryotherapy** (a process that freezes the wart using liquid nitrogen) or **ablative therapy** can be used to treat keratinised warts * **Trichloroacetic acid** - a chemical treatment that burns off warts. There is a high chance of reccurrence regardless of treatment.

Answer 307

* Primary HIV infection, or acute retroviral syndrome, is the phase that commences immediately after the **initial exposure to the Human Immunodeficiency Virus** (HIV). * This phase is characterised by a surge in viral replication and often coincides with the onset of clinical symptoms.

Answer 308

* HIV, specifically **HIV-1 and HIV-2**, are **RNA retroviruses** that cause primary HIV infection. * The virus enters and destroys the CD4 T-helper cells of the immune system. They are **transmitted through**: * Unprotected anal, vaginal or oral sexual activity * Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission) * Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)

Answer 309

Typically presents experience as a **mild flu-like illness 2-6 weeks post-exposure**. But it can widely range in the serverity of symptoms. Classic presentation includes: * Fever * Lymphadenopathy * Maculopapular rash (commonly found on the upper chest) * Mucosal ulcers * Myalgia * Arthralgia * Fatigue * Some people can remain asymptomatic After this initial flu-like illness within the first few weeks of infection. The **infection is then asymptomatic until the condition progresses to immunodeficiency**. Disease progression may occur years after the initial infection.

Answer 310

* Symptom onset within 3 weeks of infection * Symptoms lasting longer than 2 weeks * Symptoms involving the central nervous system (CNS)

Answer 311

* **Influenza** Characterised by sudden onset fever, cough, headache, muscle and joint pain, severe malaise, sore throat, and a runny nose. * **Mononucleosis** (Epstein-Barr virus or cytomegalovirus) Typically presents with fever, pharyngitis, lymphadenopathy, and fatigue. * **Acute streptococcal pharyngitis** Symptoms include sore throat, fever, headache, abdominal pain, nausea, and vomiting. * **Viral hepatitis** May present with jaundice, fatigue, nausea, fever, and muscle aches.

Answer 312

**Serum HIV enzyme-linked immunosorbent assay (ELISA)** A positive result must be confirmed using a second test.

Answer 313

* HIV viral load * Full blood count * Lymphocyte subset panel (including **CD4 count**) * Screening for other sexually transmitted infections such as chlamydia, gonorrhoea, and syphilis * Screening for viral hepatitis * Kidney function tests * Liver function tests * Glucose * Lipids

Answer 314

**Fourth-generation laboratory test for HIV** * Checks antibodies to HIV and the p24 antigen * It has a window period of 45 days, meaning it can take up to 45 days after exposure to the virus for the test to turn positive. * A negative result within 45 days of exposure is therefore unreliable **Point of care tests for HIV** * Only checks for HIV antibodies * Has a window period of 90 days

Answer 315

**CD4 Count** - gives the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection (and the development of an AIDs defining illness). * **500-1200 cells/mm3 is the normal range** * **Under 200 cells/mm3** puts the patient at high risk of opportunistic infections **HIV RNA per ml of blood** indicates the **viral load**. And is another way to monitor how well controlled a HIV infection is. An undetectable viral load means the level is below the recordable range (usually 20 copies/ml)

Answer 316

Every patient is offered ** Combination Antiretroviral Therapy** regardless of their viral load or CD4 count. There are several classes of ART drugs: * Protease inhibitors (PI) * Integrase inhibitors (II) * Nucleoside reverse transcriptase inhibitors (NRTI) * Non-nucleoside reverse transcriptase inhibitors (NNRTI) * Entry inhibitors (EI) The usual starting regime is: * **Two NRTIs** (e.g. **tenofovir plus emtricitabine**) * Plus a **third agent** (e.g. **bictegravir**). The aim of treatement **achieve a normal CD4 count and undetectable viral load**.

Answer 317

**Prophylactic co-trimoxazole** is given to **protect against pneumocystis jirovecii pneumonia (PCP)**

Answer 318

* AIDS is the **terminal stage of HIV infection** where combination antiretroviral therapy (cART) has not halted the spread of the virus. * It is defined by the **presence of an AIDS-defining illness alongside a CD4 count of less than 200 cells/mm³**.

Answer 319

Most common in Sub-Saharan Africa

Answer 320

* Kaposi’s sarcoma * Pneumocystis jirovecii pneumonia (PCP) * Cytomegalovirus infection * Candidiasis (oesophageal or bronchial) * Lymphomas * Tuberculosis

Answer 321

It depends on the specific AIDS defining illness that is present, which can include: * **Gastrointestinal symptoms** Such as dysphagia or odynophagia in oesophageal candidiasis * **Respiratory symptoms** In cases of Pneumocystis pneumonia or recurrent pneumonia * **Neurological symptoms** In cases of HIV encephalopathy, toxoplasmosis, or progressive multifocal leukoencephalopathy * **Skin lesions** In cases of Kaposi's sarcoma or lymphoma * **Visual symptoms** In cases of cytomegalovirus (CMV) retinitis.

Answer 322

* **HIV testing**: Primary diagnosis of HIV infection * **CD4 cell count**: To determine the progression of the disease * **Tests specific to AIDS-defining illnesses**: For example, bronchoscopy for suspected Pneumocystis pneumonia or biopsy for Kaposi's sarcoma

Answer 323

* **Combination antiretroviral therapy (cART)** To suppress HIV replication and slow disease progression * **Prophylaxis against opportunistic infections** Including Pneumocystis pneumonia and toxoplasmosis * **Treatment of AIDS-defining illnesses** Specific to the illness, for example, antifungal therapy for candidiasis or chemotherapy for lymphoma

Answer 324

* Correct use of condoms * Effective treatment combined with an undetectable viral load appears to prevent the spread of HIV, even during unprotected sex. * **Post-Exposure Prophylaxis (PEP)** - Can be used after exposure to reduce the risk of transmission. Its not 100% effective however and must be commenced within a short window of opportunity (less than 72 hours). * **Pre-exposure prophylaxis (PrEP)** is also available to take before exposure to reduce the risk of transmission.

Answer 325

* It involves a combination of Anti-retroviral therapy * **emtricitabine/tenofovir** (Truvada) and **raltegravir** for **28 days**. * The sooner PEP is started after exposure, the greater the chance it will work.

Answer 326

**Emtricitabine or tenofovir** (Truvada).

Answer 327

The HIV virus can transfer from mother to child at any stage of the pregnancy; however the **greatest risk is during delivery** (particularly a **vaginal delivery**) The mother's viral load affects what delivery type is reccomended: * **Under 50 copies/ml** - Normal vaginal delivery * **Over 50 copies/ml** - Pre-labour Cesaerean section is recommended **IV zidovudine** is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.

Answer 328

**Post Exposure Prophylaxis** * Low-risk babies (mother’s viral load is under 50 copies per ml) are given zidovudine for 2-4 weeks * High-risk babies are given zidovudine, lamivudine and nevirapine for four weeks

Answer 329

* **HIV can be transmitted during breastfeeding**. * Therefore the safest option is to **avoid breastfeeding alltogether** and to **use formula milk** (even if the mother's viral load is undetectable).

Answer 330

Erectile dysfunction (ED) is defined as the **consistent or recurrent inability to attain and/or maintain penile erection** sufficient for satisfactory sexual performance.

Answer 331

* It is more common in older men * It affects more than 50% of men aged over 60

Answer 332

* **Vascular disease** Atherosclerosis can lead to impaired blood flow to the penis, leading to ED. * **Autonomic neuropathy** This can cause penile denervation, most commonly seen in conditions like diabetes or with excessive alcohol intake. * **Medications** Certain drugs, such as antihypertensive agents, can cause ED. * **Psychogenic** Anxiety, depression, and other psychological factors can contribute to ED. * **Endocrine causes** Conditions like prolactinoma and hypogonadism can cause hormonal imbalances leading to ED. * **Pelvic surgery** Procedures involving the bladder, prostate, or other pelvic structures can damage nerves and blood vessels, leading to ED. * **Anatomical abnormalities** Conditions like Peyronie's disease, characterized by fibrous scar tissue inside the penis, can cause ED.

Answer 333

Primary symptom of erectile dysfunction is the **inability to achieve or maintain an erection sufficient for sexual intercourse**. This can also lead to: * Reduced sexual desire * Difficulty in ejaculation * Anxiety or depression related to sexual performance **Signs which suggest an organic cause**: * lack tumescence * slow-onset * normal libido. **Signs which suggest a psychogenic cause** * If situational * Acute onset * High levels of stress * Still having early morning erections.

Answer 334

* **Premature ejaculation** Characterized by uncontrolled ejaculation either before or shortly after sexual penetration. * **Hypogonadism** Characterized by low testosterone levels, resulting in low sex drive, fatigue, and mood changes. * **Peyronie's disease** Presents with a significant bend in the penis during erection, which can interfere with sexual function.

Answer 335

* **Detailed sexual and psychological history** to identify potential contributing factors. * **Blood tests** - Full blood count, urea and electrolytes, thyroid function tests, lipid profile, testosterone, and prolactin to evaluate overall health and hormonal status. * It can sometimes be the first presentation of sequalae of cardiovascular disease and so presentation should prompt investigation of cardiovascular health.

Answer 336

* **Psychosexual therapy** To address any underlying psychological factors. * **Oral phosphodiesterase inhibitors** (e.g. **Sildenafil**) To enhance the effect of nitric oxide, increasing blood flow to the penis. * **Vacuum erection devices** To draw blood into the penis by applying negative pressure. * **Intra-cavernosal injections** To directly increase blood flow. * **Penile prostheses** For cases resistant to other treatments.

Answer 337

* Headache * Flushing * Hypotension * Blue tinge to vision (little blue pill).

Answer 338

* Individuals taking nitrates * Hypertension/hypotension * Arrhythmias * Unstable angina * Stroke * Recent myocardial infarction.