1
Q
What is the first milk produced?
A
colostrum
2
Q
WHO/UN advises for women to breast feed exclusively for 6 months for optimal lifetime benefits. What are the advantages, to the BABY, of this?
A
- reduced incidence of GI, resp and middle ear infection
- decreased risk of childhood diabetes, asthma and eczema
- reduced risk of lactose intolerance
- improved intellectual and motor development
- decreased risk of obesity in later life
- possible reduced autoimmune diseases
- 27% reduced risk of sudden infant death syndrome
3
Q
Why is breast feeding beneficial to the mother?
A
PROMOTES: - recovery from childbirth - return to 'normal' body weight - promotes period of infertility REDUCES risk of premenopausal breast cancer POSSIBLY: - reduces risk of ovarian cancer - improves bone mineralisation
4
Q
What is the role of prolactin in lactational amenorrhoea?
A
- suppresses hypothalamic release of GnRH and therefore pituitary FSH and LH
- prevents follicular growth, ovulation and menstruation
5
Q
Describe the development of the breast, from birth to after parturition.
A
- at birth breast consists of lactiferous ducts w/out any alveoli
- at puberty, under the influence of oestrogen, ducts proliferate and masses of alveoli form at ends of branches
- each cycle involves proliferative changes in alveoli and may be some secretory activity
- during pregnancy, due to oestrogen, progesterone and prolactin, glandular portion of breast undergoes hypertrophy replacing adipose tissue
- from wk 16, breast is fully developed for lactation but is awaiting activation
- atfer parturition breast produces colostrum before mature milk production begins
6
Q
What happens to the alveoli during pregnancy?
A
- prior to pregnancy few alveoli exist
- in early pregnancy alveoli grow
- in mid-pregnancy, alveoli enlarge and acquire lumen
- during lactation, alveoli dilate
- after weaning, gland regresses
7
Q
What do alveoli empty via?
A
Lactiferous ducts that are dilated to form lactiferous sinuses which open on the surface of the tissue
8
Q
What are (i) secretory alveoli/acini (ii) contractile myo-epithelial cells surrounding stimulated by?
A
(i) prolactin
(ii) oxytocin
9
Q
What is lactation initiated by? Explain the points when prolactin is increased, and then decreased.
A
Initiated by precipitous drop in oestrogen and progesterone after delivery
- prolactin surges each time mother nurses baby due to nerve impulses from nipples to hypothalamus
- when not nursing, hypothalamus produces prolactin inhibitory hormone
- lactation inhibits FSH and LH and thus lactation interferes with repro function
10
Q
How is lactation inhibited during pregnancy?
A
- prolactin controls/promotes milk production
- prolactin is secreted during pregnancy but its action is inhibited by high progesterone and oestrogen levels in hPL
- these steroid levels fall after parturition and milk production begins
11
Q
What is the role of prolactin in the sucking reflex?
A
- suckling stimulus inhibits hypothalamic release of dopamine (PIF) and prolactin released in proportion to the strength and duration of the suckling
12
Q
What is the role of oxytocin in the milk ejection reflex?
A
- suckling stimulated neurones in hypothalamus to synthesise oxytocin which is carried to the posterior pituitary
- release of oxytocin into blood stream acts on myo-epithelial cells in alveoli, causing ‘let down’ of milk
- conditioned reflex: let down in response to cry of baby, oxytocin release inhibited by catecholamines and stress can inhibit this reflex
13
Q
When does the coordination of suckling develop? What is the correct way for baby to suckle? Why is it important?
A
- between 32 to 35 eek gestation
- correct attachment important to suckle effectively to avoid engorgement/blocked ducts for mum and ensure sufficient intake for baby
14
Q
What happens to (i) synthesised milk fat (ii) milk protein?
A
(i) moves through cell surface membrane. Enclosed droplet pinched off into duct lumen
(ii) passes through Golgi apparatus and released by endocytosis
15
Q
What is the difference between colostrum and mature milk?
A
- colostrum has greater amounts of immunoglobulins (IgG, IgA) and a no. growth factors, conferring passive immunity
- relatively low protein and fat compared to other mammals means that human babies don’t grow as fast
16
Q
What is the composition of mature milk?
A
- main energy source = fat
- lactose = main carb, it promotes growth of lactobacillus bifidus and provides galactose for myelin formation
- proteins casein and lactalbumin
- fat soluble vitamins A, D, E, K
- water soluble vitamins B6, B12, C, folate, niacin, riboflavin, thiamine
- gut is initially sterile and first feeds will contain acute dose of antigens and bacteria
17
Q
What does benign breast disease consist of?
A
- a heterogeneous group of lesions including developmental abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms
18
Q
When in a womens life is it most common to acquire benign breast disease?
A
- increases in frequency towards menopause, then decreases
19
Q
How is benign breast disease diagnosed?
A
with use of mammography, US, MRI and extensive use of needle biopsies
20
Q
For BENIGN breast lumps, describe the (i) shape (ii) alignment (iii) margins (iv) lateral shadowing?
A
(i) oval/ellipsoid
(ii) wider than deep; alligned parallel to tissue planes
(iii) smooth/thin
(iv) present
21
Q
For MALIGNANT breast lumps, describe the (i) shape (ii) alignment (iii) margins (iv) lateral shadowing?
A
(i) variable
(ii) deeper than wide
(iii) irregular or spiculated
(iv) absent
22
Q
What is fibrocystic change (FCC)?
A
An exaggerates physiologic response
- nonproliferative change which induces gross and microscopic cysts, apocrine metaplasia, mild epithelial hyperplasia, adenosis and an increase in fibrous stroma
23
Q
Who does FCC affect? What symptoms do women tend to have?
A
- over one third of women 20-50 years old, then declines after menopause
- most are asymptomatic but some present with nodularity and pain
24
Q
Does FCC increase your risk of breast cancer? Explain/
A
- doesn’t increase risk of getting breast cancer but it can make it more difficult to identify potentially cancerous lumps during breast examination & on mammograms
25
What is the difference for proliferative disease (i) without atypia (ii) with atypia?
(i) entails a 2 fold increased risk of developing carcinoma over 5-15 yrs and classified simply as proliferative breast disease
(ii) even greater relative risk (5 fold). Such patients require close clinical monitoring
26
What are the stages of breast carcinogenesis?
- Normal epithelium
- Proliferative disease without atypia
- Atypical hyperplasia
- DCIS (ductal carcinoma in situ)
- Invasive breast cancer
27
How is benign breast disease diagnosed?
- cysts can't reliably be distinguished from solid masses by clinical exam or mammography, so in these cases ultrasonography and FNA cytology are used
28
What are the causes of gynaecomastia? What does it involve in older and younger pts?
- usually caused by a relative increase in oestrogen to androgen ratio in circulation or breast tissue
- most common cause is secondary to drugs
- in older pts it involves CV & prostate drugs, and in younger pts, cannabis, anabolic steroids, anti-ulcer drugs and antidepressants
29
What are other pathological causes of gynaecomastia?
- undiagnosed hyperprolactinaemia
- liver failure
- alcohol excess
- obesity
- malignancy (testes and lung)
30
What are the 4 types of benign breast tumours?
1. fibroadenoma
2. duct papilloma
3. adenoma
4. connective tissue tumours
31
What are fibroadenomas? What do they look like? What are they composed of? What is the difficulty of them?
BENIGN
- arise from breast lobules and are composed of fibrous and epithelial tissue
- well circumscribed and highly mobile, because of the encapsulation and pliability of young breast tissue
- clinically fibroadenomas are difficult to differentiate from Phyllodes tumours, which is a distinct pathology
32
What is the difference between fibroadenomas (benign) and Phyllodes (malignant) tumours?
- phyllodes are sarcomas which rapidly enlarge and have variable degrees of malignant potential
- phyllodes are larger than fibroadenomas and tend to occur in an older age group (15-20 yrs later)
- fibroadenomas appear well-defined, smooth, oval-shaped lump, distinctly mobile and easily identified on US
- young pts (less than 25) with clearly benign clinical and imaging findings are usually spared a core biopsy but in older pts we must rule out occult malignancy/Phyllodes tumour
33
What does fat necrosis present like? What can be an issue with imaging?
- presents as a soft, indistinct lump that develops a few weeks after a traumatic incident, and often in older women with fatty breasts
- on imaging, some are difficult to distinguish from breast cancer and a core biopsy is often indicated
34
What is the commonest cause of death in women aged 33-35?
breast carcinoma
35
What are the main types of invasive carcinoma?
- most are of 'No special type' 75-90%
| - infiltrating lobular carinoma 10% may be multifocal
36
What does Paget's disease of the nipple (i) lead to (ii) associated with?
(i) erosion of the nipples that resembles eczema
| (ii) with underlying in situ OR invasive carcinoma
37
What are the 4 ways that breast cancer can spread?
1. direct
2. lymphatics
3. blood stream
4. transcoelomic
38
What factors have led to steady improvements in the long-term survival rates for breast cancer? (HINT: there's 4)
Better diagnosis, improved treatments, screening programmes and public awareness
39
What are the screening strategies for breast cancer?
1. breast self exam
2. clinical breast exam
3. mammography
4. ultrasonography
5. MRI
- risk factor based vs universal
- age
- does it change the outcome?
40
Describe the NHS screening programme.
- invites all women 50-70 yrs for screening every 3 yrs
| - the earlier breast cancers are diagnosed, the easier to treat.
41
What does NICE recommend for women who have a change in gene (mutation) known to increase the risk of breast cancer?
Yearly MRI scans from:
- age 20 for women with a TP53 mutation
- age 30 for women with a BRCA1 or BRCA2 mutation
42
When are urgent referrals for suspected breast cancer done?
1. aged 30 and over and have an unexplained breast lump with or w/out pain
2. aged 30 or over with an unexplained lump in the axilla with skin changes that suggest breast cancer
3. Aged 50 or over with any one of the following symptoms in one nipple only: discharge/retraction/other changes of concern
43
What is the commonest cervical cancer? What is its main aetiological factor?
- An invasive tumour of epithelial origin with squamous differentiation
- HPV = main aetiological factor
44
How is the pre-invasive phase of cervical squamous neoplasia detected? What is the grading systems for pre-invasive disease?
- detected by cervical cytology
GRADING SYSTEM:
Bethesda classification
- low grade squamous intraepithelial neoplasia LSIL vs high grade HSIL
- cervical intraepithelial neoplasia (CIN) grades 1-3 (2+3 correspond to HSIL)
45
80% of cases HPV produces a transient infection and cleared from body w/in 2 years w/out any clinical consequences. What can happen, if HPV infection persists?
- the virus may incorporate its DNA into the host cell's genome
- once incorporated, the production of viral oncoproteins can go on unchecked and the host's gene that suppress tumours (p53 and pRb) can be inactivated
- damaged DNA is replicated w/out being checked and repaired, and malignantly transformed cells proliferate uncontrollably
46
Screening and intervention strategies q?
- cytology (spatula, cytobrush, glass slide, liquid based)
- HPV detection
- Visual inspection with acetic acid/iodine
- vaccination!
- colposcopy and biopsy
- local excision ('large loop excision')
- cryotherapy
47
What are most types of invasive cervical cancer? What are the classical symptoms?
- most (70-75%) are squamous cell carcinomas and a minority are adenocarcinomas (precursor lesion cervical glandular intraepithelial neoplasia CGIN)
- symptoms = post coital bleeding but many asymptomatic in early stages
48
What is the mean age that women develop SIL (CIN)? (squamous intraepithelial lesions, cervical intraepithelial neoplasia)
25 - 30 years
49
What are the various outcomes of SIL?
- 70% SIL (CIN 1) regress
- 6% progress to HSIL (CIN 2 +3)
- less than 1% become invasive cancer
50
What are the 2 forms of non-invasive precursors for breast cancer?
1. ductal carcinoma in situ (DCIS)
- often unilateral
2. lobular carcinoma in situ (LCIS)
- often bilateral, can be multifocal
51
How do you check if breast cancer has spread?
sentineal node biopsy
52
What are the prognostic factors for breast cancer?
- tumour type
- tumour grade (A)
- tumour stage = tumour size, node metastasis (B) or other metastases
- oestrogen receptor (C)
- HER-2 amplification
53
What are you looking for upon breast clinical examination in suspected breast cancer? (HINT: there's 6)
- lump
- pulled in nipple
- dimpling
- dripping
- redness/rash
- skin changes
54
Where does cervical cancer occur?
Transformation zone
| - where lining of womb meets lining of vagina
55
WHat is the average age of women with (I) stage 0 HSIL tumour (ii) stage IA (iii) stage IV?
(i) 35-40 years
(ii) 43 years
(iii) 57 years
56
When/where is the best predictor of survival of cervical cancer?
the anatomic stage
57
What is the 5 year survival of squamous cell carcinoma of the cervix in (i) stage I (ii) stage II (iii) stage III (iv) stage IV?
(i) 90%
(ii) 75%
(iii) 35%
(iv) 10%
58
What is gender based violence?
- violence which is directed against a woman because she is a woman, or violence that affects women disproportionately.
- includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty.
59
What is domestic abuse?
- occurs w/in a current/previous intimate relationship and can be physical, sexual or emotional and includes controlling and coercive behaviours
- most victims women but men can also experience DA and it occurs in same sex relationships
60
What are the other terms used to describe domestic abuse?
- domestic violence
- intimate partner violence
- spouse abuse
- battering
- wife beating
61
What % of female and make homicide victims are murdered by current or ex-partners?
```
Female = 50%
Male = 12%
```
62
What is the lifetime prevalence rates (%) of DA for women?
25%
63
What is the link between DA and pregnancy?
- 1/3 of all women who experience DA are assaulted for 1st time whilst pregnant
- women at highest risk of homicide whilst pregnant/post-partum
- 14% of maternal deaths occurred in those who disclosed DA
64
When did rape within marriage become illegal?
1989
65
What % of (i) women (ii) men in UK who admitted to non-consensual sexual experiences as adults?
(i) 17% women
| (ii) 3% men
66
What % of reported rapes result in conviction?
6% (4% in scotland)
67
What does stalking and harassment mean?
- intentional behavioural, involving more than one incident, which causes fear, upset or annoyance to the victim.
Such as: unwanted phone calls and texts, unwanted gifts, "cyber" stalking, threatening emails, letters or calls to family and friends, surveillance, damage to property
68
What are 4 examples of harmful traditional practices?
1. Female genital mutilation
2. "Honour" based violence
3. Forced marriage
4. Dowry related abuse
69
What are the types of commercial sexual exploitation?
1. prostitution
2. trafficking
3. pornography
4. lap-dancing, pole-dancing, stripping
5. saunas, brothels, massage parlours
70
Who are typically the abusers in childhood sexual abuse (CSA)?
Men are abusers in 90% cases
71
How many (i) women (ii) men have experiences CSA? (state figures as ratios)
(i) 1:4
| (ii) 1:5
72
What are the impacts of GBV on (i) physical health (ii) mental health (iii) reproductive health?
(i) injuries, disability, impaired ability
(ii) PTSD, anxiety, phobias, depression, addictions
(iii) STIs, infertility, miscarriage, pregnancy complications, poor birth outcomes
73
What are the various public health approaches to eliminate GBV? (HINT: there's 4)
1. Educational programmes to address entrenched societal attitudes and beliefs which reinforce gender inequality
2. National campaigns to raise awareness of GBV and promote social services
3. National campaigns to encourage non-abusing men to challenge sexist behaviours and attitudes which reinforce gender equality
4. Ensure health services are responsive to those affected by all forms of GBV and offer appropriate care and support
74
Principles of good practice?
1. safety of children and women is paramount
2. treat ppl with respect and dignity at all times, listen and avoid being judgemental
3. only ask a woman about abuse and she is alone, the only exceptions being a professional interpreter
4. document findings accurately and fully
5. recognise skills and contributions of other agencies
6. keep yourself and your colleagues safe
75
What are Mullerian malformations frequently associated with?
- abnormalities of renal and axial skeletal systems, and they are often first encountered when the patients are initially examined for associated conditions
76
What are most mullerian duct anomalies associated with? When are these abnormalities recognised? Why is this the case?
- most associated with functioning ovaries and age appropriate genitalia
- often recognised after onset of puberty
- after onset of puberty young women present to gynaecologist with menstrual disorders
- late presentations include infertility and obstetric complications
77
What type of carcinoma are the majority of vulvar cancers? Where do they tend to develop?
Squamous cell carcinomas
| - which typically develop at edges of labia majora/minora or in vagina
78
What are vulvar squamous cell cancers like? What are the 2 subtypes? Describe.
- usually slow growing and develop from 'precancerous' pre-invasive areas called vulvar intraepithelial neoplasia (VIN)
2 TYPES:
- one more common in younger women and associated with HPV
- other in older women, not associated with HPV, but instead with chronic vulvar skin changes (vulvar dystrophy) including lichen sclerosis
79
Describe (i) squamous hyperplasia (ii) licken sclerosa of the vulva.
(i) hyperkeratosis, irregular thickening of ridges, some neoplastic potential
(ii) hyperkeratosis, flattening of ridges, oedema in connective tissue with chronic inflammation, some neoplastic potential
80
What does Lichen Sclerosis of the vulva look like? What makes it worse? How is it treated?
- sometimes white patches 'leukoplakia'
- causes pruritis
- excoriation makes things worse
- treat with potent corticosteroids
81
What are the 2 clinico-pathological types of endometrial adenocarcinoma? Give a brief description of each.
1. ENDOMETROID
- related to unopposed oestrogen
- associated with atypical hyperplasia and/or PCOS
2. NON-ENDOMETROID
- not associated with unopposed oestrogen
- affects elderly post-menopausal women
- p53 often mutated
82
What are the 4 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 organas
83
Who does endometrial cancer tend to affect? What are risk factors?
- women in 50s, 60s, 70s and rare in those under 40
| - obesity and use of HRT
84
What are 2 other types of endometrial tumours? Describe briefly.
1. Endometrial stromal sarcoma
- tumour arising from endometrial stroma
2. Malignant mixed Mullerian tumour
- mixed tumour wuth malignant epithlial and stromal elements. poor prognosis
85
What can endometriosis cause? Where are the common sites that it occurs?
CAUSE: pelvic inflammation, infertility, pain
SITES: ovary, pouch of douglas, peritoneal surfaces (including uterus), cervix, vulva, vagina, bladder, bowel etc.
86
What is adenomyosis? What does it cause?
Abnormality of myometrium where endometrial glands & stroma w/in myometrium
- benign disease of uterus due to presence of ectopic endometrial glands and stroma, deep w/in myometrium with adjacent reactive myometrial hyperplasia.
- can be diffuse, or focal (adenomyoma)
- causes menorrhagia/dysmenorrhoea
87
What are 2 types of myometrium smooth muscle tumours?
1. Leiomyoma (fibroid)
- v. common, associated with menorrhagia, infertility
- benign smooth muscle tumour which is a v. common cause of uterine enlargement and may undergo degeneration
2. Leiomyosarcoma
88
What are the types of leiomyomas of the uterus?
1. intramural
2. submucosal - pedunculated one appearing in form of endometrial polyp
3. subserosal - one compressing bladder and the other the rectum
89
Ovarian cysts can arise from what parts of the ovary? (5 places)
1. mesothelial
2. epithelial
3. follicular
4. luteal
5. endometriotic
90
What is PCOS? What will women initially present with? What are long term associations?
- heterogenous condition whose pathophysiology appears to be multifactorial and polygenic
- initially present with symptoms of hyperandrogenism (hirsutpism, acne, alopecia), menstrual disturbance, infertility or obesity
- long term: type 2 DM, dyslipidaemia, HT, CVD, endometrial carcinoma
91
Why is the combined contraceptive pill given to women with PCOS? What is an alternative to the combined pill?
- for contraception, or protection against development of endometrial hyperplasia and cancer, and to suppress excessive androgen secretion to control acne and hirtuism
- Mirena intrauterine system (IUS)
92
What are those with PCOS at risk of? Why is this?
Endometrial hyperplasia or adenocarcinoma
| - due to unopposed actions of oestrogen in absence of progesterone that is normally released after ovulation
93
Describe ovarian neoplasms. What is their classification?
```
Solid vs Cystic
Benign vs Malignant
- epithelial
- germ cell
- sex-cord/stromal
- metastatic
- miscellaneous
```
94
Describe epithelial ovarian tumours.
Benign
Borderline - cytological abnormalities, no stromal invasion
Malignant - stromal invasion
95
What are the symptoms of ovarian cancer?
- Non specific GI symptoms = bloating or indigestion (often misdiagnosed as IBS)
- gradually increasing abdominal distension (misdiagnosed as 'middle-aged spread')
- increasing tumour size results in pressure effects causing chronic abdo, pelvic or back pain, urinary frequency/urgency, constipation/altered bowel habit/bowel obstruction, leg swelling, DVT/PE
- abnormal vaginal bleeding
- symptoms of metastatic = pleural effusion, ascites, weight loss and fatigue
96
How is ovarian cancer managed?
- surgical management generally choice of treatment: exploratory laparotomy for tumour debulking and formal surgical staging
- comprises TAH (total abdo histerectomy) and BSO (bilateral salpingo-oophorectomy), infracolic omentectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings, sample of ascites
- radiotherapy not really used as tumours usually radioresistant
- biological immunotherapy emerging as potential new treatment (specific monoclonal antibodies)
- advanced metastatic cancer requires individualised palliative treatment
97
What are the 2 types of ovarian germ cell tumour?
1. DYSGERMINOMA
- undifferentiated tumour
- young women
- counterpart of male seminoma
2. TERATOMA
- contains elements from all 3 embryonic germ cell layers
- mature cystic teratoma common (Dermoid Cyst)
- immature teratoma rare
- monodermal (commonest = struma oavrii, thyroid tissue)
3. EXTRAEMBRYONIC
- yolk sac tumour: in young, produces alpha fetoprotein, highly malignant but treatable
- choriocarcinoma: pure variety rare, normally seen as part of teratoma, different from gestational carcinoma
98
What are the types of ovarian sex cord/stromal tumours?
1. FIBROMA/THECOMA
- benign, may produce oestrogen, causing uterine bleeding
2. GRANULOSA CELL TUMOUR
- all potentially malignant and may be associated with oestrogenic maniefestations
3. SERTOLI-LEYDIG CELL TUMOURS
- rare, may produce androgens
99
Where do metastatic ovarian tumours tend to come from?
Commonest = stomach, colon, breast, pancreas
100
What are the names of types of gestational trophoblastic disease? (HINT: there's 5)
- hydatidiform mole
- invasive mole
- choriocarcinoma
- placental-site trophoblastic tumour
- epitheloid trophoblastic tumour
101
What ages of pregnant women have a higher risk of developing a molar pregnancy?
- under 16
| - over 45
102
What is a (i) complete hydatidiform mole (ii) partial hydatidiform mole?
(i) often develops when either 1 or 2 sperm cells fertilise an egg cell which contains no nucleus or DNA. All genetic tissue comes from fathers sperm cells so there's no foetal tissue
(ii) when 2 sperm fertilise a normal egg. These tumours contain some foetal tissue but this is often mixed in with trophoblastic tissue. Important to know that a viable foetus NOT being formed
103
What is an invasive hydatidiform mole?
- has grown into the muscle layer of uterus
| - can develop from either complete or partial moles, but complete moles become invasive much more often than partial
104
What increases a womens risk of developing an invasive hydatidiform mole?
- theres more than 4 months between LMP and treatment
- uterus become v large
- women over 40
- has had gestational trophoblastic disease in past
105
What is the relationship between hCG and hydatidiform moles? Explain this relationship.
- have higher than average levels of hCG compared with that of a normal pregnancy
- hCG is produced by trophoblastic tissue - the hormone detected in a standard pregnancy test.
- high levels occur because excessive amount of trophoblastic tissue with a hydatidiform mole
106
What is choriocarcinoma?
Maligant form of GTD
| - more likely than other types of GTD to grow fast and spread to organs away from uterus
107
What are non-gestational choriocarcinomas? Where are they found? What can they develop into? How are mixed germ cell tumours formed?
- choriocarcinomas not related to pregnancy
- found in areas other than uterus and can occur in both men and women
- may develop in testicles, ovary, chest or abdomen. In these cases it's usually mixed with other types of cancer, forming a mixed germ cell tumour
108
Compare gestational and non-gestational choriocarcinoma.
non-gestational can be less responsive to chemo and may have a less favourable prognosis
109
What can ectopic pregnancies cause?
Often ruptures which causes catastrophic intra-abdominal haemorrhage
110
When would you consider ectopic pregnancy as a diagnosis
- any female of any reproductive age with amenorrhoea and acute hypertension or an acute abdomen
111
What is the treatment for ectopic pregnancy?
Methotrexate or surgical resection
112
Define (i) congenital (ii) perinatal period (iii) neonatal period (iv) postnatal.
(i) condition present at birth (inherited or caused by the environment)
(ii) commences at 22wks of gestation and ends 7 days after birth
(iii) first 28 days of life
(iv) first 6 weeks after birth
113
Describe various examples of vertical transmission. (HINT: there's 5 examples)
1. across placenta (intrauterine)
2. during birth
3. direct contact with maternal body fluids
4. prolonged rupture of membranes
5. after birth (from mother or other contacts)
114
What does maternal rubella cause in the child? When is the infection passed to the child? What are the initial signs of congenital rubella?
Causes low birth weight (failure to attain developmental milestones), microcephalus, cataract, deafness, heart deafness
- infection in 1st trimester with high risk of congenital rubella syndrome
- first signs = hepatitis-associated jaundice, haemolysis, thrombocytopaenia
115
Is there pre-natal screening for rubella? Describe.
Women in england no longer offered screening
- screening does not give any protection to unborn baby in current pregnancy
- test may offer false reassurance to women that aren't susceptible to rubella
116
When does primary maternal VZV infection occur? What does it cause?
1st 20 weeks of gestation
- may cause congenital varicella syndrome
- eye defects, hypoplastic limb, microcephalus
117
What can VZV infection around delivery cause?
- may cause neonatal varicella syndrome
| - rash, pneumonitis
118
How is VZV prevented and treated?
Aciclovir (IV) - high dose
VZV immunoglobulin
- to mother or neonate w/in 7-10 days of exposure, may prevent foetal/neonatal varicella syndrome
Live Vaccine - not part of routine child vaccination schedule - Varivax, Varilrix
119
When does parvovirus B16 cause maternal infection? What does it cause? How is it diagnosed?
During 1st 20 wks of infection
- foetal anaemia, slapped cheek syndrome
- diagnosis = amniocentesis, CVS (cordocentesis - decreasing use)
120
What can maternal CMV infection cause? How is it diagnosed?
May cause deafness, retardation in foetus
Diagnosis - NAAT on
- amniotic fluid
- neonatal blood/urine within 3 wks of birth
121
What can listeriosis result in if infects during (i) early pregnancy (ii) later pregnancy?
(i) foetal death
| (ii) associated with premature birth
122
What are the complications of foetal infection of listeriosis?
- bacteraemia
- hepatosplenomegaly
- meningoencephaly
- thrombocytopaenia, pneumonitis
123
How is listeriosis (i) diagnosed (ii) treated and managed?
(i) culture: blood, CSF, placental tissue, lochia
| (ii) takes specialist ID advice re: antibiotics
124
What is the chance of transplacental tranmission in someone infected with toxoplasmosis?
1 in 3 chance
125
What can occur if the foetus is infected with toxoplasmosis in 1st and 2nd trimester?
- stillborn
- death soon after birth
- cerebral calcification
- cerebral palsy
- epilepsy
- chorioretinitis
126
How is maternal toxoplasmosis (i) diagnosed (ii) treated?
(i) presence of IgM antibodies
| (ii) spiramycin
127
In the absence of an treatment, what is the risk of vertical transmission of HIV? What is done to try reduce the no. of vertical transmissions of HIV?
25 - 30 %
| - HIV testing, counselling, antiretroviral medication, delivery via C section prior to labour, discourage breast feeding
128
How common is syphilis in neonates? What does it cause ? What is it treated with?
Rare due to pre-natal screening
- fever, rash, condylomata, mucosal fissures
- benzylpenicillin
129
How is the zika virus spread? What symptoms does it cause?
Spread through bite of infected Aedes species mosquito
| - fever, rash, joint pain, conjunctivitis
130
How is zika virus transmitted? What can infection of zika during pregnancy result in?
From male to sexual partner(s)
| - severe congenital brain effects e.g. microcephaly, Guillain-Barre syndrome
131
What is the (i) treatment (ii) prevention of zika virus?
(i) no treatment OR vaccine (yet)
| (ii) barrier contraception, avoid mosquito bites
132
Scalded Skin Syndrome may
affect newborn babies.
Which pathogen is the most
likely cause of this condition?
staphylococcus aureus
133
Dormancy (latency) is a characteristic of the family of viruses to which cytomegalovirus (CMV) belongs to. What is this family of viruses?
Herpes viruses
134
The combined MMR vaccine is available in the UK for young children.
What do the letters MMR stand for?
measles, mumps, rubella
135
Conjunctivitis may be contracted by
newborns during delivery.
Which of the following pathogens is
the most likely cause of this?
neisseria gonnorhoeae
136
There are vaccines which can help prevent infection leading to a malignancy. A vaccine is available to girls of 12-13 years of age.
To which infectious agent is this vaccine aimed at?
Human papilloma virus
137
An endocervical swab may be used to provide
a laboratory sample for microbiology.
For which infectious
agents would this be an appropriate sample to
take in order to make an initial diagnosis?
chlamydia trachomatis
138
Genital warts may affect both males and females.
| Which virus is the most likely cause of this?
human papilloma virus
139
A patient presents with an intensely itchy vaginitis, dysuria, and a “creamy” discharge.
What is the treatment you should administer?
fluconazole
140
A Gram stain is a very useful lab diagnostic test.
For what type of micro-organisms would this test most likely give you information as to the best
course of anti-microbial treatment?
bacteria
141
“Typhoid Mary” was a chronic carrier of which bacterium?
salmonella typhi
142
Describe the various things which occur for the foetus before birth to enhance the mother child relationship?
- by 22wks baby responds to sounds, especially mothers
- in womb baby has preference for mothers voice and native language
- at birth auditory pathways developed in womb enable baby to match mother's voice with her face
- neural pathways laid down antenatally for smell to enable baby to identify smell of mother's breast milk
143
What may children be born with if there mothers have experienced stress?
- small head circumference
- earlier gestational age
- lower birth weight
- language delay
- conduct disorder
- autism
- physical abnormalities e.g. cleft palate
144
What can the following conditions of the maternal mother do to the child; (i) alcohol and drugs (ii) eating disorders (iii) domestic abuse?
(i) FAS - growth impairement, abnormal facial features, problems with learning, attention, memory, problem solving, speech and hearing
(ii) may affect closure of neural tube
(iii) usually starts 3rd trimester, stress (cortisol) restricts blood flow to foetal brain so child more anxious and ADHD
145
Describe the number of brain cells and connections in babies and their life cycle.
Full term baby born with 100 billion brain cells
- babies making 11 mil connections per second
- only those pathways used repeatedly are laid down - those not used die away
- process of evolution = more highly evolved organisms have less hard-wired nervous systems at birth
- pathways laid down early are resistant to change
146
Describe how babies early experiences determine their brain architecture.
- from early infancy they naturally reach out to create bonds, and they develop best when caring adults respond in warm, stimulating and caring ways, leading to the development of empathy, trust and well-being
- impoverished, neglectful or abuse environments can result in a child who doesn't develop empathy or learn to regulate emotions or develop social sills, can lead to increased risk of mental health probs, relationship difficulties, antisocial behaviour and aggression
147
What are some myths about the human brain? (HINT: there's 4)
1. we can fix any damage done early with love and 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 tiny babies because we didn't have language yet and we can't remember thing that young
148
What is containment?
The notion of another person being able to hold onto these feelings, and then give them back detoxified and bearable
- this relies on the person "doing the containing" having a certain amount of self-knowledge and the ability to know what is "mine" and what is "another's"
149
What 4 traits does a person who is good at containing others have?
1. receptive
2. able to hold on to another persons difficult feelings without being overwhelmed by them themselves
3. makes calm and thoughtful attempts to understand the problem
4. can convey a feeling that what the other person is feeling is tolerable and meaningful...and manageable
150
What is reciprocity?
The sophisticated interactions between baby and adult when both involved in the initiation, regulation and termination of the interaction, applies to interaction in all relationships
- crucial to development of language. the rhythm of sucking and stopping when feeding is the prototype for the development of turn taking
151
What is likely to have happened if reciprocity has not developed well in an emotional way?
language acquisition is likely to be impaired
152
What are the stages of the 'dance' or reciprocity?
```
initiation
orientation
site of attention
acceleration
peak of excitement
deceleration
withdrawal or turning away
```
153
What are the 4 strategies Brazelton identified which babies use to withdraw from too much stimulation/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. signaling behaviour, by crying, fussing, laughing, yawning
154
What is rupture and repair?
Getting out of step in the dance (RUPTURE) but adjusting to get back into step (REPAIR) = normal
155
What happens to the baby if they have (i) repeated rupture with repair (ii) repeated rupture without repair?
(i) develop hope, optimism, belief things get better, self esteem, self worth, trust in others... good quality relationships
(ii) don't develop self worth, self esteem or trust in others...?quality of relationships
156
What is a "secure base"? What is the paradox of the "attachment system"?
Secure base = the essence of what the attachment figure represents for the child. Secure base provides a safe haven to return to in case of danger/anxiety and a launch pad from which the child can explore
Paradox = the 'attachment system' gets triggered and evident at times of danger or when disrupted but turned down when all goes well
157
What are the various types of child contributions in early mother child interactions?
1. difficult temperament; lack of fit with caregivers
2. premature birth
3. medical conditions
4. hospitalisations, separations
5. failure to thrive
6. neurological impairments
158
What are the types of parent contributions in early mother child interactions ?
1. Parental mental health - perinatal depression and anxiety
2. Parents' own parenting experiences - abuse, neglect, attachment
3. parents' attributions/beliefs
159
What are the types of environmental contributions in early mother child interactions?
1. poverty
2. violence: victim or witness
3. lack of social support
4. multiple caregivers
5. high stress from marital conflict
6. lack of stimulation
MD3002
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