1
Q
What is colostrum?
A
First milk produced by mammary glands in breast (for about a week)
2
Q
Why is “breast is best” for the baby?
A
- Reduced incidence of GI, respiratory & middle ear infection
- Decreased risk of childhood diabetes, asthma & eczema
- Reduced risk of lactose intolerance
- Improved intellectual & motor development
- Decreased risk of obesity in later life
- Possible reduced autoimmune diseases
- 27% reduced risk of sudden infant death syndrome
3
Q
What does WHO/UN advise women to do regarding breast feeding?
A
Breast feed exclusively for 6 months for optimal lifetime benefits
4
Q
Why is “breast is best” for the mother?
A
- Promotes recovery from childbirth
- Promotes return to “normal” body weight
- Promotes a period of infertility
- Reduces risk of premenopausal breast cancer
- Possibly reduces risk of ovarian cancer
- Possibly improves bone mineralisation
5
Q
What is the physiology behind lactational amenorrhoea?
A
- Prolactin suppresses hypothalamic release of GnRH & therefore pituitary FSH & LH
- Prevents follicular growth, ovulation & menstruation
6
Q
Describe breast development at birth?
A
Breast consists of lactiferous ducts without any alveoli (also male breast)
7
Q
Describe breast development at puberty?
A
Under influence of oestrogen the ducts proliferate & masses of alveoli form at the ends of the branches
8
Q
Describe breast development at each menstrual cycle?
A
Involves proliferative changes in alveoli & there may be some secretory activity
9
Q
Describe breast development during pregnancy?
A
Under influence of oestrogen, progesterone & prolactin the glandular portion of breast undergoes hypertrophy replacing adipose tissue
10
Q
Describe breast development from week 16 of pregnancy?
A
Breast tissue is fully developed for lactation but is quiescent awaiting activation
11
Q
Describe breast development after parturition?
A
Breast produces colostrum before mature milk production begins
12
Q
What are the 5 stages to breast alveoli development during pregnancy?
A
- Prior to pregnancy , ducts with few alveoli
- Early pregnancy, alveoli grow
- Midpregnancy, alveoli enlarge & acquire lumen
- During Lactation, alveoli dilate
- After weaning, gland regresses
13
Q
Describe the anatomy of the breast?
A
- Nipple surrounded by pigmented skin (areola)
- Modified sebaceous glands (alveoli) empty via lactiferous ducts that are dilated to form lactiferous sinuses which open on surface of nipple
- Each alveolus surrounded by contractile myo-epithelial cells
14
Q
What tissue is dominant in the non-lactating breast?
A
Adipose tissue
15
Q
When does glandular tissue develop fully in the female breast?
A
During pregnancy (replaces adipose tissue)
16
Q
What are the milk producing cells & what are they stimulated by?
A
- Secretory alveoli/acini
- Stimulated by prolactin
17
Q
What stimulates contractile myo-epithelial cells?
A
Oxytocin
18
Q
What 2 things does lactation consist of?
A
- Milk production
2. Let down (milk ejection reflex) as infant cannot suck milk out of alveoli where it is produced
19
Q
What is lactation controlled by?
A
Neurohumoral reflexes, prolactin is the hormone
20
Q
How is lactation initiated & controlled?
A
- Initiated by precipitous drop in oestrogen & progesterone after delivery
- Prolactin surges when mother nurses baby due to nerve impulses from nipples to hypothalamus
- When not nursing, hypothalamus produces prolactin inhibitory hormone
21
Q
How is lactation inhibited during pregnancy?
A
- Prolactin is inhibited by high levels of progesterone, oestrogen & hPL (human placental lactogen)
- These steroids fall after parturition & milk production begins
22
Q
Describe the suckling reflex (role of prolactin)?
A
Suckling stimulus inhibits hypothalamic release of dopamine (PIF) & prolactin is released in proportion to the strength & duration of suckling
23
Q
Describe the milk ejection reflex (role of oxytocin)?
A
- Suckling stimulates neurones in hypothalamus to synthesis oxytocin which is carried to posterior pituitary
- Release of oxytocin into blood stream acts on myo-epithelial cells in alveoli causing “let down” of milk
24
Q
What is oxytocin release inhibited by?
A
Catecholamines, stress can inhibit the reflex
25
Why is correct attachment important to suckle effectively for baby & mother?
- Avoid engorgement/blocked ducts for mum
| - Ensure sufficient intake for baby
26
What 4 things make up a mammary gland?
1. Breast
2. Secretory lobules
3. Alveoli
4. Lactiferous ducts (milk ducts)
27
How is milk made & excreted?
- Synthesised milk fat moves through cell to surface membrane
- Enclosed lipid droplet is pinched off into the duct lumen
- Milk protein passes though Golgi apparatus & released by exocytosis
28
Describe the composition of Colostrum (100ml)?
- 58 calories
- 5.3g carbohydratess
- 2.9g fat
- 3.7g protein
- Fewer water-soluble vitamins
- More fat-soluble vitamins (A)
- More zinc & sodium
- Greater amounts of immunoglobulins (IgG...) & growth factors
29
Describe the composition of mature milk (100ml)?
- 70 calories
- 7.4g carbohydrates
- 4.2g fat
- 1.3g protein
- Relatively low protein & fat compared to other mammals means human babies do not grow as fast
30
What happen over 2 or 3 weeks to the composition of milk?
- Transitional --> Mature milk
- Total calorific value increasing
- IgG & total proteins declining
31
How much milk does a woman produce per day?
- 800ml
| - Energy content of 27kJ/L (vary through lactation)
32
What are the specific composites of Mature milk?
- Energy source fat (easily digested emulsified globes)
- Lactose main carb
- Proteins casein & lactalbumin
- Fat soluble vitamins A,D,E,K
- Water soluble vitamins B6, B12, C, Folate, Niacin, Riboflavin, Thiamine
33
What does Lactose in mature milk (main carbohydrate) promote in a baby?
- Growth of Lactobacillus bifidus
| - Galactose for myelin formation
34
Describe the gut of a newly born child?
Initially sterile & 1st feeds will contain acute dose of antigens & bacteria (600sp of bacteria identified in breast milk including beneficial Bifidobacterium sps)
35
Describe Benign Breast diseases?
Heterogeneous group including developmental abnormalities, inflammatory lesions, epithelial & stromal proliferations & neoplasms
36
Describe the frequency pattern of benign breast disease?
Increases towards menopause then decreases
37
How can diagnosis of benign breast disease be accomplished without surgery in majority of patients?
- Mammography
- Ultrasound
- Magnetic resonance imagine of breast
- Extensive use of needle biopsies
38
Describe the characteristics of a normal cell on cytology?
- Large cytoplasm
- Single nucleus
- Single nucleolus
- Fine chromatin
39
Describe the characteristics of a cancerous cell on cytology?
- Small cytoplasm
- Multiple nuclei
- Multiple & large nucleoli
- Coarse chromatin
40
What type of needle is used to get a specimen of breast tissue for histology?
Core biopsy (Tru-cut) needle
41
What is the Fibrocystic change (FCC) which occurs in benign breast disease?
- Exaggerated physiologic response
- Nonproliferative, includes gross & microscopic cysts, apocrine metaplasia, mild epithelial hyperplasia, adenosis & increase in fibrous stroma
- Multifocal & bilateral
42
How common is Fibrocystic change (FCC)?
- Over 1/3 of women 20-50 yrs old
| - Declines after menopause
43
What are the symptoms of Fibrocystic change (FCC)?
- Most asymptomatic
| - Some present with nodularity & pain
44
What is the risk of cancer with Proliferative Breast disease?
- Without atypia entails 2 fold increase risk of carcinoma over 5-15yrs
- Lesions with atypia involve even greater relative risk (5 fold)
45
What is the chain of events of breast carcinogenesis?
Normal epithelium --> Proliferative disease without atypia --> Atypical hyperplasia --> DCIS --> Invasive breast cancer
46
How can you distinguish a breast cyst from solid masses?
Ultrasonography & fine needle aspiration (FNA) cytology (highly accurate)
47
What is Gynaecomastia?
- Hyperplasia of male breast stromal & ductal tissue
| - Caused by relative increase in oestrogen to androgen ratio
48
What can be the cause of Gynaecomastia in the young & elderly population?
- Young: cannabis, anabolic steroids, anti-ulcer drugs, antidepressants
- Old: cardiovascular & prostate drugs
49
What are physiological & pathological causes for gynaecomastia?
- Physiological: spontaneously in neonates, pubertal & senesence
- Pathological: undiagnosed hyperpolactinaemia, liver failure, alcohol excess, obesity & malignancy (tests & lung)
50
What are the 4 different types of benign breast tumours?
1. Fibroadenoma
2. Duct papilloma
3. Adenoma
4. Connective tissue tumours
51
Describe Breast Fibroadenomas?
- Breast lobules & composed of fibrous & epithelial tissue
- Well circumscribed & highly mobile
- Difficult to differentiate from Phyllodes tumours
52
Describe Phyllodes tumours?
- Sarcomas which rapidly enlarge & have variable degrees of malignant potential
- Larger than fibroadenomas & tend to occur in older age group
53
Describe how fat necrosis presents?
- Soft, indistinct lump than develops a few weeks after traumatic incident (older women with fatty breasts)
- Core biopsy taken
54
What factors can increase & decrease the risk of breast cancer?
- INCREASES risk: alcohol, contraceptive pill, X radiation, body fat, adult heigh, HRT, smoking, digoxin
- DECREASES risk: breastfeeding, body fatness, physical activity
55
What are the 2 forms of non-invasive precursors of breast cancer?
1. Ductal carcinoma in situ: often unilateral, localised within epithelial layer
2. Lobular carcinoma in situ: often bilateral, can be multifocal, malignant proliferation in lobules with no invasion of BM
56
Describe the 3 types of Invasive carcinoma's?
1. Most are of "no special type" 70-90%
2. Infiltrating lobular carcinoma (10%) may be multifocal
3. Some special types, less common
57
What is Paget's disease of the nipple?
- Leads to erosion of nipple than resembles eczema
| - Associated with underlying in situ or invasive carcinoma
58
What are the 4 different ways breast cancer can spread?
1. Direct
2. Lymphatics
3. Blood stream
4. Transcoelomic
59
What are the different prognostic factors for breast cancer?
- Tumour type
- Tumour grade (A)
- Tumour stage (size, node metastasis (B), other metastases)
- Oestrogen receptor (C)
- HER-2 amplification
60
What are the different screening strategies for breast cancer?
- Breast self examination
- Clinical breast examination
- Mammography
- Ultrasonography
- Magnetic resonance imaging (MRI)
61
What is the NHS Breast screening programme?
- Invited all women 50-70yrs for screening every 3 yrs
- Around 4/100 called back for further tests
- Finds cancer in ~8/1000 women
62
What chance of survival for 5yrs does women diagnosed with breast cancer at earliest stage have?
9 in 10 chance (90%)
63
What do NICE recommend for women that have a gene mutation known to increase risk of breast cancer (family history)?
Yearly MRI scans from age 20 for women with TP53 mutation, age 30 for women with BRCA1 or BRCA2 mutation
64
What scenarios would you refer urgently for suspected breast cancer?
- >30yr & have unexplained breast lump with/without pain
- >30yr with unexplained lump in axilla with skin changes that suggest breast cancer
- >50yr with any of the following in 1 nipple only: discharge/retraction/other
65
When would you consider non-urgent referral for suspected breast cancer?
Under 30yrs with unexplained breast lump with/without pain
66
What is the commonest cervical cancer?
Invasive tumour of epithelial origin with squamous differentiation
67
What is the main aetiological factor of cervical squamous neoplasia?
Human papillomavirus
68
What are the 2 immune modulations of cervical squamous neoplasia?
1. Smoking
| 2. HIV infection
69
How is the pre-invasive phase of cervical squamous neoplasia detectable?
Cervical cytology
70
What is the grading system (Bethesda Classification) for pre-invasive cervical squamous neoplasia?
- "Low grade squamous intraepithelial neoplasia" LSIL versus "high grade" HSIL
- Cervical intraepithelial neoplasia (CIN) grades 1 to 3 (2 & 3 correspond to HSIL)
71
Describe how common Human papillomavirus is & what it causes?
- Most common STI, 70-80% sexually active women affected in lifetime
- 80% cases HPV produces transient infection & cleared from body within 2yrs without clinical consequence
72
Describe what happens when Human Papillomavirus (HPV) is left untreated?
- Virus may incorporate DNA into host cell's genome
- Production of viral oncoprotein can go unchecked & host's genes that suppress tumours inactivated
- Damaged DNA replicated without being checked & repaired
- Malignantly transformed cells proliferate uncontrollably
73
When is HPV cleared?
93% by 3yrs
74
What is the female transformation zone?
- Most common site for cervical cancer=
Squamo-columnar junction
- It goes through a lot of change through life (menstruation)
- Get neoplastic changes, high proportion will resolve without any intervention
75
What are precursors of invasive cancer?
Squamous intraepithelial lesions
76
What are the different ways of cervical screening & intervention?
- Cytology/Pap test: spatula, cytobrush, glass slide, liquid based
- HPV detection
- Visual inspection with acetic acid/iodine
- Vaccination
- Colposcopy & biopsy
- Local excision
- Cryotherapy
77
What does LEEP & LLETZ stand for?
- LEEP= Loop Electrosurgical Excision procedure
| - LLETZ= Large Loop Excision of the Transformation Zone
78
What are the 2 types o invasive cervical cancers?
1. 70-75% squamous cell carcinomas
| 2. Minority are adenocarcinomas: precursor lesion cervical glandular intraepithelial neoplasia (CGIN)
79
What are the classical symptoms of invasive cervical cancer?
- Post coital bleeding
| - Many asymptomatic in early stages
80
What is the mean age at which women develop Squamous intraepithelial lesions (SIL/CIN)?
25-30yrs
81
How often does LSIL (CIN1) progress to HSIL (CIN2&3)?
6% & less than 1% become invasive cancer
82
What % of HSIL (CIN2&3) progress to invasive carcinoma if untreated?
10-20%
83
What are the average ages of patents with stage 0 (HSIL), stage 1A, stage IV squamous cell carcinoma of cervix?
- Stage 0 (HSIL): 35-40yrs
- Stage IA: 43yrs
- Stage IV: 57yrs
84
What is the % of 5yr survival for the different stages of squamous cell carcinoma of the cervix?
- Stage I: 90%
- Stage II: 75%
- Stage III: 35%
- Stage IV: 10%
85
How common are congenital uterine abnormalities?
- ~5% of women
- Lower rate in general population
- Higher in infertile
- Highest in women with recurrent pregnancy losses (10%)
86
What are most Müllerian malformations associated with?
- Abnormalities of the renal & axial skeletal systems
- Function of ovaries
- Age-appropriate external genitalia
87
What 2 procedures can detect uterine malformations?
- Hysterosalpingogram
| - MRI image
88
What are ~90% of vulvar cancers?
Squamous cell carcinomas, typically develop at edges of labia majora/minora or in vagina
89
Since vulvar squamous cell cancers are slow growing, what do they usually develop from?
"Precancerous", pre-invasive areas called vulvar intraepithelial neoplasia (VIN)
90
Describe the 2 subtypes of squamous cell vulvar cancer?
1. Common in young women: HPV
| 2. Common in older women: vulvar dystrophy, including lichen sclerosus
91
Describe the vulval non-neoplastic epithelial disorder: Squamous hyperplasia?
- Hyperkeratosis
- Irregular thickening of ridges
- Some neoplastic potential
92
Describe the vulval non-neoplastic epithelial disorder: Lichen Sclerosus?
- Hyperkeratosis
- Flattening of ridges
- Oedema in connective tissue with chronic inflammation
- Some neoplastic potential
- Sometimes white patches "leukoplakia"
93
What is vulval dystrophy: Lichen Sclerosus treated with?
Potent topical corticosteroids
94
What are the 2 chief constituents of endometrium which links the uterine corpus?
1. Endometrial glands
| 2. Endometrial stroma
95
Describe the inactive prepubertal & postmenopausal endometrium?
- Cuboidal to low columnar epithelium
| - Do NOT exhibit any proliferative/ secretory changes that are hormone dependent
96
Describe the 2 clinico-pathological endometrial adenocarcinoma types?
1. ENDOMETRIOID: related to unopposed oestrogen, atypical hyperplasia, polycystic ovary syndrome
2. NON-ENDOMETRIOID: affects elderly postmenopausal, p53 often mutated
97
Describe the 4 different stages of Endometrial Adenocarcinoma?
I: confined to uterine body
II: involvement of cervix
III: involvement of ovaries/tubes or extension beyond serosa
IV: spread to other organs
98
Describe Endometrial cancer?
- Presents with post-menopausal bleeding
- Women in 50s, 60s, 70s
- Incidence increasing, probs due to increased population age, obesity & HRT
99
Describe 2 other Endometrial Tumours?
1. Endometrial stromal sarcoma
| 2. Malignant mixed Müllerian tumour: epithelial & stromal elements, poor prognosis
100
What is Endometriosis?
Endometrial glands & stroma outside the uterine body
101
What 3 things can Endometriosis cause?
1. Pelvic inflammation
2. Infertility
3. Pain
102
What are the different possible sites of Endometriosis?
- Ovary ("chocolate" cyst)
- Pouch of Douglas
- Peritoneal surfaces, including uterus
- Cervix, vulva, vagina
- Bladder, bowel etc
103
What is Adenomyosis & what does it cause?
- Endometrial glands & stroma within the myometrium
- Causes menorrhagia/ dysmenorrhoea
- Benign
104
Describe the 2 Smooth muscle tumours that can occur in the myometrium?
1. Leiomyoma (fibroid): very common, benign smooth muscle tumour, degeneration, menorrhagia, infertility
2. Leiomyosarcoma
105
What are the 3 difference types/locations of Leiomyomas of the uterus?
1. Intramural
2. Submucosal (pedunculate)
3. Subserosal (compressing bladder or rectum)
106
What does UAE stand for?
Uterine Artery Embolisation
107
What 5 elements of the ovary can ovarian cysts arise from?
1. Mesothelial
2. Epithelial
3. Follicular
4. Luteal
5. Endometriotic
108
When would small cystic ovarian structures be considered abnormal?
- Pre-pubertal
- Post-menopausal
- Pregnant
- Mean diameter >3cm
109
How do women with polycystic ovary syndrome initially present?
- Hyperandrogenism symptoms (hirsutism, acne, alopecia)
- Menstrual disturbance
- Infertility
- Obesity
110
What are the possible long term associations of polycystic ovary syndrome?
- Type 2 diabetes
- Dyslipidaemia
- Hypertension
- Cardiovascular disease
- Endometrial carcinoma
111
Why is the combined oral contraceptive pill prescribed to women with Polycystic ovary syndrome (PCOS)?
- Contraception
- Protection against development of endometrial hyperplasia & cancer
- Suppress excessive androgen secretion to control acne & hirsutism
112
What is the alternative for the combined oral contraceptive pill in the treatment of Polycystic ovary syndrome?
Mirena intrauterine system (IUS)
113
Why do women with PCOS have a 64% risk of endometrial hyperplasia or adenocarcinoma?
Unopposed actions of oestrogen in absence of progesterone that is normal released after ovulation
114
What is the risk of PCOS women developing endometrial cancer?
Threefold increased risk
115
What should be considered in the absence of withdrawal bleeds or in presence of abnormal uterine bleeding?
Transvaginal ultrasound
116
When would you consider an endometrial biopsy &/or hysteroscopy?
- Thickened endometrium in amenorrhoeic/oligomenorrhoeic
| - Endometrial polyp
117
What are the 5 classifications for ovarian neoplasms?
1. Epithelial
2. Germ cell
3. Sex-cord/stromal
4. Metastatic
5. Miscellaneous
118
Describe the ovarian cancer symptoms?
- Insidious onset means 75% patients present with advanced disease
- Bloating, indigestion
- Increasing abdominal distension
- Chronic abdominal, pelvic/ back pain, urinary frequency/urgency, constipation, leg swelling, DVT/PE
- Abnormal vaginal bleeding
- Pleural effusion, ascites, weight loss, fatigue
119
What can happen less commonly when there is sudden torsion, rupture or infection of the ovarian tumour in early disease?
Present with acute abdominal or pelvic pain leading to early diagnosis
120
What are the 3 different types of Epithelial ovarian tumours?
1. Mucinous cystadenoma
2. Borderline serous tumour
3. Serous adenocarcinoma
121
What is the management of Ovarian Cancer?
- Total abdominal hysterectomy (TAH) & bilateral salpingo- oophorectomy (BSO), infracolic omentectomy, pelvic & para- aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings, sampling of ascites
- Chemotherapy given to all patients >stage Ic
122
How is the Ovarian Cancers response to treatment monitored?
CA-125 levels, which decrease if treatment is effective & increase if there is a relapse
123
What is emerging as a new potential treatment for Ovarian Cancer?
Biological immunotherapy, specific monoclonal antibodies
124
Describe the 2 germ cell tumours?
1. DYSGERMINOMA: undifferentiated, young women, counterpart of male seminoma
2. TERATOMA: elements from all 3 embryonic germ cell layers, mature cystic teratoma common (Dermoid cyst), immature teratoma rare, monodermal (struma ovarii- thyroid tissue)
125
What are the 2 different types of Extraembryonic germ cell tumours?
1. Yolk sac tumour: young, produces alpha fetoprotein, highly malignant but treatable
2. Choriocarcinoma: usually seen as part of teratoma, different from gestational choriocarcinoma
126
Describe the 3 different sex cord/ stromal tumours?
1. Fibroma/Thecoma: benign, may produce oestrogen
2. Granulosa cell tumour: potentially malignant, associated with oestrogenic manifestations
3. Sertoli-Leydig cell tumours: rare, may produce androgens
127
What are the 4 commonest metastatic tumours?
1. Stomach
2. Colon
3. Breast
4. Pancreas
128
What are the 5 abnormal pregnancy gestational trophoblastic diseases?
1. Hydatidiform mole (complete/partial)
2. Invasive mole
3. Choriocarcinoma
4. Placental-site trophoblastic tumour
5. Epithelial trophoblastic tumour
129
Describe how a complete hydatidiform mole develops?
- When either 1 or 2 sperm cells fertilize an egg cell that contains no nucleus or DNA
- All genetic material comes from fathers sperm cell
- No foetal tissue
130
Describe how a partial hydatidiform mole develops?
- 2 sperm fertilize a normal egg
- Tumours contain some foetal tissue, but often mixed in with trophoblastic tissue
- Viable foetus is NOT being formed
131
Describe how an invasive hydatidiform mole develops?
- Grown into muscle layer of uterus
- From either complete or partial moles, complete moles become invasive more often
- Develop in less than 1/5 women who have had complete mole removed
132
What increases the risk of developing an invasive mole?
- Long time (>4months) between LMP & treatment
- Uterus become very large
- >40yr
- Gestational trophoblastic disease in the past
133
Why do women with hydatidiform mole usually have higher than normal hCG compared with women with normal pregnancy?
Hormone produced by trophoblastic tissue & there is an excessive amount of trophoblastic tissue with hydatidiform mole= more hCG
134
Describe Choriocaricnoma?
- Malignant form of gestational trophoblastic disease (GTD)
- 1/2 start off as molar pregnancies
- 1/4 develop from miscarriages, intentional abortion or tubal pregnancy
- 1/4 develop after normal pregnancy & delivery
135
What can ectopic pregnancies cause?
- Ruptures
- Fatal intra-abdominal haemorrhage
- Amenorrhoea
- Acute hypotension
- Acute abdominal pain
136
What is the % of adult female homicide due to?
50% murdered by current or ex-partner
137
What is the lifetime prevalence rates of domestic abuse for women?
~25% (Home Office 2015)
138
How many women who experience domestic abuse are assaulted for the 1st time during pregnancy?
1/3
139
When are women at highest risk of domestic abuse?
Pregnant or post-partum
140
What % of maternal deaths are due to domestic abuse?
14%
141
How many women have been victims of rape?
1 in 20
142
When did rape within marriage become illegal in Scotland?
1989
143
What is stalking & harassment defined as according to Scottish Executive 2000?
Intentional behaviour, involving more than 1 incident, which causes fear, upset or annoyance to the victim
144
What are 4 examples of harmful traditional practices to women?
1. Female Genital Mutilation (FGM)
2. "Honour" based violence
3. Forced marriage
4. Dowry related abuse
145
What % of men are the abusers in childhood sexual abuse (CSA)?
90%
146
How many women and men have experienced childhood sexual abuse (CSA)?
- 1:4 women
| - 1:5 men
147
What are the principles of good practice regarding domestic abuse patients?
- Respect & dignity
- Only ask women about abuse if she is ALONE, exception being a professional interpreter
- Document findings
148
What is the perinatal period?
Commences at 22 weeks (154 days) of gestation & ends 7 days after birth
149
What is the neonatal period?
First 28 days of life
150
What is the postnatal period?
First 6 weeks after birth
151
When can vertical transmission occur?
- Across placenta (intrauterine)
- During birth
- Direct contact with maternal body fluids
- Prolonged rupture of membranes
- After birth
152
Describe the Rubella Virus in the foetus & baby?
- Primary maternal rubella infection in 1st trimester
- High risk of congenital rubella syndrome (60%)
- IgM persists for 1st 3 months of life
153
What are the initial signs of rubella viral infection in babies?
- Hepatitis-associated jaundice
- Haemolysis
- Thrombocytopaenia
154
What can happen to the foetus & baby if infected with Rubella?
- Microcephalus, cataract, deafness, heart defects
- Low birth weight
- Termination of pregnancy in some cases
155
What is the vaccine for Rubella?
MMR vaccine (measles, mumps, rubella)
156
Describe the pre-natal screening programs for Rubella?
- From 1 April 2016, pregnant women in England no longer offered screening as Rubella infection in UK is eliminated by WHO
- Screening doesn't give any protection
- Test can offer false reassurance
- Stopping anteantal screening is unlikely to result in increased rates of congenital rubella
157
What does Varicella Zoster Virus (VZV) cause?
Chicken pox (shingles)
158
What can primary maternal VZV infection in 1st 20 weeks of gestation do to the baby?
- May cause congenital varicella syndrome
| - Eye defects, hypoplastic limb, microcephalus
159
What can VZV infection around delivery do to the baby?
- May cause neonatal varicella syndrome
| - Rash, pneumonitis
160
What is the treatment & prevention methods for VZV?
- Aciclovir (IV) high dose
- VZV immunoglobulin (within 7-10 day of exposure)
- Live Vaccine (Varivax, Varilrix)
161
What can Maternal Parvovirus B19 during 1st 20 weeks of gestation do to the baby?
- Foetal anaemia, hydrops in <10% (monitor for ascites)
| - Slapped cheek syndrome ("fifth disease")
162
How can you diagnose Parvovirus B19 in foetus?
- Amniocentesis
- Chorionic villus sampling
- Cordocentesis (decreasing use)
163
Describe Cytomegalovirus (CMV) in pregnancy & neonates?
- Herpes family
| - Maternal infection = either primary or reactivation
164
What can Cytomegalovirus do to the foetus?
- Deafness
| - Retardation
165
How do you diagnose Cytomegalovirus (CMV)?
- NAAT on amniotic fluid
| - NAAT on neonatal blood/urine within 3 weeks of birth
166
Describe Listeria Monocytogenes in pregnancy & neonates?
- Listeriosis
- Often unapparent in maternal infection
- Transplacental transmission
- Isolation of infected mother & baby
- Prevention is key!
167
What can infection of Listeria Monocytogenes in early pregnancy cause?
Foetal death
168
What can infection of Listeria Monocytogenes in later pregnancy cause?
Associated with premature birth
169
What can exposure of Listeria Monocytogenes in intrapartum cause?
- Meningitis
| - Bacteraemia
170
What are the possible complications with foetal infection of Listeria Monocytogenes?
- Bacteraemia
- Hepatosplenomegaly
- Meningoencephaly
- Thrombocytopaenia
- Pneumonitis
171
Describe Toxoplasma gondii infection?
- Incidence varies globally (common in France due to raw meet)
- Definitive host: cats
- Faecal contamination
- Infected, under-cooked meat, infected fruit & veg
172
What is the chance of transplacental transmission if the mother is infected with Toxoplasma gondii during pregnancy?
1:3 chance
173
What can happen to the foetus if infected with Toxoplasma gondii in the 1st & 2nd trimester?
- Stillborn
- Death soon after birth
- Cerebral calcification
- Cerebral palsy
- Epilepsy
- Chorioretinitis
174
How do you confirm maternal Toxoplasma gondii infection?
Presence of IgM antibodies
175
How do you treat Toxoplasma gondii infection?
Spiramycin
176
What is the % risk of vertical transmission in absence of treatment of HIV?
25-30%
| greatest risk with advanced maternal disease/high viral load
177
How do you reduce the risk of HIV mother to foetus transmission?
- HIV testing
- Counselling
- Antiretroviral medication
- Delivery be caesarean section prior to onset of labour
- Discouraging breastfeeding
178
What does infection of Treponema pallidum (Syphilis) do to babies?
- Rare due to pre-natal screening
| - Fever, rash, condylomata, mucosal fissures
179
How do you treat Treponema pallidum (Syphilis) infection in neonates?
Benzylpenicillin
180
What can Staphylococcus aureus infection cause in neonates?
- Scalded skin syndrome
| - S. aureus toxin
181
Describe how Zika Virus is spread?
- Bite of infected Aedes species mosquito
- Male to sexual partner
- During pregnancy
182
What can Zika Virus cause?
Fever, rash, joint pain, conjunctivitis
183
What can infection of the Zika Virus do in pregnancy?
- Severe congenital brain effects ie. microcephaly, Guullain-Barré syndrome
184
Since there is no vaccine or treatment, how can you prevent spread of Zika Virus?
- Barrier contraception
| - Avoid mosquito bites
185
Describe the relationship between maternal & newborns microbiota?
- Newborns gut microbiota can affect its own immune system
| - Mothers microbiome shapes immune system of offspring
186
How does Cervical cancer spread?
Direct extension or through lymphatic vessel & only rarely by hematogenous route
187
What can local extension of squamous cell carcinoma of the cervix into surrounding tissues (parametrium) cause?
Ureteral compression & cause clinical complications of hydroureter, hydronephrosis & renal failure
188
What can happen when squamous cell carcinoma of the cervix spreads to the bladder & rectum (Stage IVA)?
Fistula formation
189
Why are bilateral nipple changes/discharge NOT a red flag under the NICE referral criteria for suspected cancer?
Breast cancer is usually unilateral & evidence suggests bilateral symptoms do not reach 3% positive predictive value threshold for cancer used by NICE as a cut-off for urgent referral
190
What would you find on examination of a patient with endometriosis?
- May be normal
- Tenderness
- Uterus retroverted or less mobile than expected
191
What is the gold standard diagnostic test for endometriosis?
Laparoscopy
192
What tests are used to diagnose Wilms tumour in a child?
Ultrasonography & sonograms show a smooth, well-defined mass of renal origin with uniform echogenicity
193
What does bilateral discharge from both breasts usually indicate?
- Systemic cause:
- Physiological (lactational)
- Endocrine (prolactinoma, hypothyroidism)
- Iatrogenic (medications)
194
What does unilateral discharge from breast usually indicate?
- Local cause:
- Ductal papilloma
- Breast cyst
- Ductal carcinoma
195
What is the prevalence of Wilms tumour/nephroblastoma?
Most common solid renal mass & abdominal malignancy of childhood, prevalence of 1 case per 10,000 population
196
What are 4 important factors in development of bonding & attachment between the mother & her baby?
1. 22 weeks baby responding to sound esp mother
2. In womb baby has preference for mothers voice & native language
3. At birth auditory pathways developed in womb enable baby to match mother's voice to face
4. Neural pathways laid down antenatally for smell to enable baby to identify the smell of mother's breast milk
197
What effect does maternal stress & anxiety have on the baby?
- Small head circumference
- Earlier gestational age
- Lower birth weight
- Language delay
- Conduct disorder
- Autism
- Physical abnormalities ie. cleft palate
198
What effect does the mother taking alcohol & drugs have on the baby?
- Foetal alcohol syndrome
- Growth impairment
- Abnormal facial features
- Problems with learning attention, memory, problem solving, speech & hearing
199
What effect does a mothers eating disorders have on the baby?
Closure of neural tube
200
What effect does domestic abuse during pregnancy have on the baby?
- Starts 3rd trimester
- Stress (cortisol) restricts blood flow to fetal brain
- Child more anxious
- Symptoms of ADHD
201
Describe a newborns nervous system/brain?
- Full term baby born with 100 billion brain cells
- Making 11 million connections per second
- Only pathways used repeatedly are laid down, those not die away
- More highly evolved organisms have less hard-wired nervous systems at brith
- Pathways laid down early are resistant to change
202
How does positive experiences & a good upbringing influence the future of a baby?
- From early infancy, they naturally reach out to create bonds & they develop best when caring adults respond in warm, stimulating ways.
- Secure attachment with those close to them leads to development of empathy, trust & well-being
203
How does negative experiences & a bad upbringing influence the future of a baby?
Impoverished, neglectful or abusive environments can result in child who doesn't develop empathy, or learn how to regulate their emotions or develop social skills & this can lead to increased risk of mental health problems, relationship difficulties, antisocial behaviour & aggression
204
What are 5 myths about the human brain & fetal development?
1. Can fix damage done early with love & affection later
2. How we develop is mostly determined by environment
3. How we develop is mostly determined by genetics
4. We aren’t affected by experiences we had as babies because we didn’t have language yet & we can’t remember things that young
205
What does early experiences of a baby determine?
Which parts of the brain grow & which parts do not
206
What is Containment?
- Notion of another person being able to hold onto these negative feelings, & then give them back detoxified & bearable
- This relies on the person having certain amount of self-knowledge & ability to know what is "mine" & what is "anothers"
207
What is Projective Identification?
- Step further in theory of Containment
- "You have this anger to
understand how I feel. Now I don’t have to feel so angry & I can criticise you for being angry"
208
What 4 things is a person good at to Contain others?
1. Receptive
2. Able to hold onto persons difficult feelings without being overwhelmed by them
3. Makes calm & thoughtful attempts to understand the problem
4. Can convey feeling that what the other person is feeling is tolerable, meaningful & manageable
209
Describe the containment of emotional experience?
- When a particular feeling is aroused, old neural networks automatically become activated to manage the arousal in the old way
- Process of having feelings recognised & acknowledged by another person can facilitate development of new ways & new pathways
210
What is Reciprocity according to (Hazel Douglas, 2002)?
- Sophisticated interactions between baby & adult when both are involved in the initiation, regulation & termination of the interaction
- Reciprocity applies to interaction in all relationships
211
How is Reciprocity important in development?
- Crucial to development of language
- Rhythm of sucking & stopping when feeding is the prototype for the development of turn taking
- If reciprocity has not developed well in an emotional way, language acquisition is likely to be impaired
212
What are the 7 steps to the Dance of Reciprocity?
1. Initiation
2. Orientation
3. State of attention
4. Acceleration
5. Peak of excitement
6. Deceleration
7. Withdrawal or turning away
213
What are the 4 strategies found by Brazelton that babies use to withdraw from too much or inappropriate stimulation?
1. Turning or shrinking from it
2. Rejecting it by pushing it away
3. Decreasing its power to disturb by withdrawing attention
4. Signalling behaviour, by crying, fussing, laughing, yawning
214
What is the "Lookaway"?
- Baby's attempts to self regulate as well as process information so immature nervous system is not overwhelmed
- Opportunity for brain to store interactions to memory or make new synapse connections
215
What is rupture & repair in a baby's interactions?
Getting out of step in the dance (RUPTURE) but adjusting to get back into step (REPAIR) = Normal
216
What does repeated rupture with repair lead to the development of?
- Hope, optimism, belief things get better, self esteem, self worth, trust in others
- Good quality relationships
217
What does repeated rupture without repair lead to the development of?
- Don’t develop self worth, self esteem or trust in others
| - Poor quality relationships
218
What is the definition of Ethology according to John Bowlby (1907-1990)?
Observable, external behaviours
219
What is the definition of Psychoanalysis according to John Bowlby (1907-1990)?
Internal unconscious processes
220
Why is maternal separation/loss dramatic to the baby?
Prevents the development of a biological need to bond
221
What is the "secure base" in the attachment system of a child?
- What the attachment figure represents for the child
- A secure base provides a safe haven to return to in case of danger or anxiety & a launch pad from which the child can explore
222
What is the paradox in the attachment system of a child?
“Attachment system” gets triggered & becomes evident at times of danger or when disrupted & is turned down when all goes well
223
What are the child contributions to mother-child interactions?
- Difficult temperament, lack of fit with caregivers
- Premature birth
- Medical conditions
- Hospitalisations, separations
- Failure to thrive
- Neurological impairments
224
What are the parents contributions to mother-child interactions?
- Parental mental health
(depression & anxiety)
- Parents’ own parenting experiences (abuse, neglect, attachment)
- Parents’ attributions/beliefs
225
What are the environments contributions to mother-child interactions?
- Poverty
- Violence: victim or witness
- Lack of social support
- Multiple caregivers
- High stress from marital conflict
- Lack of stimulation
MD3002
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