Quesmed wrong answers

Question 1

What is vasa praevia?

Answer 1

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.

Question 2

What are the RFs for vasa praevia?

Answer 2

The aetiology of vasa praevia remains unclear, but it has been associated with multiple gestations, in vitro fertilization, and velamentous cord insertion.

Question 3

What is the classic triad of vasa praevia?

Answer 3

Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)

Question 4

How is vasa praevia diagnosed and managed?

Answer 4

Investigations
Diagnosis of vasa praevia is usually made with transabdominal or transvaginal ultrasonography. Most cases can now be diagnosed antenatally, a significant improvement from prior times when the condition was usually only diagnosed post-delivery following a foetal death due to haemorrhage.

Management
The primary management strategy for vasa praevia is an elective caesarean section prior to the rupture of membranes, typically arranged for 35-36 weeks gestation. However, if the mother goes into labour or her membranes rupture, an emergency caesarean section should be carried out immediately to prevent foetal death.

Question 5

What are the risk factors for breast cancer?

Answer 5

1. Increased hormone exposure
   - Early menarche or late menopause
   - Nulliparity or late first pregnancy
   - Oral contraceptives or Hormonal Replacement Therapy
2. Susceptibility gene mutations
   - Most commonly BRCA mutations (BRCA1/BRCA2)
3. Advancing age
4. Caucasian ethnicity
5. Obesity and lack of physical activity
6. Alcohol and tobacco use
7. History of breast cancer
8. Previous radiotherapy treatment

Question 6

What are the types of breast cancer?

Answer 6

1. Invasive ductal carcinoma (IDC): This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.
2. Invasive lobular carcinoma (ILC): This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.
3. Ductal carcinoma in situ (DCIS): This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.
4. Lobular carcinoma in situ (LCIS): This is not a cancer but an area of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later.
5. Inflammatory breast cancer (IBC): This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.
6. Triple-negative breast cancer (TNBC): This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.
7. HER2-positive breast cancer: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.

Question 7

What are the signs and symptoms of breast cancer?

Answer 7

• Unexplained breast mass in patients aged 30 and above, with or without pain
• In those aged 50 and older, nipple discharge, retraction or other concerning symptoms
• Skin changes suggestive of breast cancer
• Unexplained axillary mass in those aged 30 and above

Question 8

What are the possible differentials for an unexplained breast mass?

Answer 8

• 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.

Question 9

What is the process of breast cancer screening in the UK

Answer 9

In the United Kingdom, the NHS Breast Screening Programme provides free breast screening services for all women registered with a GP. The programme invites women between the ages of 50 and 70 for breast screening every three years, with the first invitation to screening usually sent to women before they turn 53.

This screening process involves a mammogram, which is an X-ray of the breasts that can help detect breast cancers early, often before they can be felt. The aim of breast cancer screening is to find cancer at an early stage when treatment is most effective.

In 2018, the age range for screening was extended as part of a trial, and some women were invited for screening from the age of 47 up to the age of 73. Women over 70 can still ask for a screening every three years.

Question 10

How is a suspected breast carcinoma investigated?

Answer 10

Triple assessment is used to investigate suspected breast carcinoma:
1. Clinical examination: of the breast and surrounding lymph nodes
2. Radiological examination: typically a mammogram, can also involve breast ultrasound and MRI
3. Biopsy: often a core needle biopsy or fine needle aspirate (FNA)

Staging involves the TNM system considering the size of the tumour (T), the spread to the lymph nodes (N), and the presence of metastases (M).

Question 11

What are the management options for breast cancers?

Answer 11

The management strategy for breast carcinoma can vary based on several factors including the subtype of carcinoma, stage, hormonal receptor status, and the patient’s overall health and preferences.

1. Surgical management: Wide local excision (WLE) or mastectomy, with sentinel node biopsies for invasive cancers and possible axillary node clearance for positive nodes. Breast reconstruction can be done concurrently or later.
2. Radiotherapy: Adjuvant radiotherapy is commonly offered following WLE to reduce recurrence. It may also be given to patients with higher stage cancers post-mastectomy.
3. Chemotherapy: Suggested for hormone receptor-negative and HER2 over-expressing patients. Neoadjuvant chemotherapy may be given to downstage tumours before surgery.
4. Biological Therapy: Trastuzumab (Herceptin) / Pertuzumab may be given to HER2 positive patients, either as neoadjuvant therapy to downstage the tumour or as part of the overall treatment regimen.
5. Hormonal Therapy: Anastrozole (aromatase inhibitor) for postmenopausal or Tamoxifen (oestrogen receptor antagonist) for premenopausal patients with oestrogen receptor-positive breast cancer.
6. Bisphosphonates: May be used for reducing occurrence in node-positive cancers.

(Also Neratinib, a tyrosine kinase inhibitor indicated in patients with HER-2-positive breast cancers)

Question 12

What are the possible side effects of medications used to treat breast cancer?

Answer 12

Treatment for breast cancer often involves medication, including chemotherapy, hormone therapy, and targeted drug therapy. Each of these can have different side effects.

1. Chemotherapy drugs are powerful medications that aim to destroy rapidly dividing cells, such as cancer cells. However, they can also affect healthy cells, leading to a range of side effects, including fatigue, hair loss, easy bruising and bleeding, infection, anemia, nausea and vomiting, appetite changes, and problems with concentration or memory.
2. Hormone therapy drugs, such as tamoxifen and aromatase inhibitors, are used to treat hormone receptor-positive breast cancers. Common side effects include hot flashes, vaginal dryness or discharge, menstrual changes, fatigue, mood changes, and osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.
3. Targeted drug therapies, such as trastuzumab (Herceptin), pertuzumab (Perjeta), and ado-trastuzumab emtansine (Kadcyla), are designed to interfere with specific proteins or processes that contribute to cancer growth. Side effects can vary but often include diarrhea, liver problems, heart problems, mouth sores, and high blood pressure.

Question 13

What is a lactational breast abscess?

Answer 13

A lactational breast abscess refers to an accumulation of pus within an area of the breast tissue, often as a complication of infectious mastitis. It commonly occurs in lactating women.

Question 14

What is the cause of lactational breast abscess?

Answer 14

The most common causative organism of lactational breast abscesses is Staphylococcus aureus, which enters the breast tissue via a crack in the nipple skin or through a milk duct. The accumulation of milk, called milk stasis, and trauma to the nipple skin from incorrect latch or pump use can contribute to the infection and subsequent abscess formation.

Question 15

What are the clinical features of a lactational breast abscess?

Answer 15

Individuals with a lactational breast abscess may exhibit:
- Fever or rigors
- Malaise
- Pain over an area of the breast
- Erythema over the affected breast area
- Possible presence of a fluctuant mass, which may not always be palpable
- History of recent or ongoing mastitis

Question 16

What are the differentials for a lactational breast abscess?

Answer 16

The differential diagnoses for a lactational breast abscess include:
1. Mastitis without abscess: Characterised by inflammation and infection of the breast tissue, often with flu-like symptoms but without the presence of a fluctuant mass.
2. Engorgement: Overfilling of the breasts with milk, causing discomfort, tightness, and sometimes fever. However, engorgement lacks the localized erythema and fluctuant mass typical of an abscess.
3. Mammary duct ectasia: This condition involves inflammation and blockage of milk ducts, but it usually lacks the systemic symptoms like fever seen in abscess formation.
4. Inflammatory breast cancer: Presents with rapidly progressive erythema, edema, and warmth over the breast, often mistaken for an infection. However, it is not typically associated with a palpable mass.

Question 17

How is a diagnosis of lactational breast cancer confirmed?

Answer 17

The diagnosis of a lactational breast abscess may be confirmed with:
- Breast ultrasound: To visualise the abscess and guide the procedure for drainage
- Diagnostic needle aspiration: For both diagnostic and therapeutic purposes, i.e., to culture the causative organism and evacuate the abscess

Question 18

How is a lactational breast abscess managed?

Answer 18

The primary strategies for managing a lactational breast abscess include:
- Incision and drainage or needle aspiration (with or without ultrasound guidance)
- Antibiotic therapy: Oral or intravenous antibiotics, according to local protocols, targeted towards the most common causative organisms

Question 19

What is an amniotic fluid embolism?

Answer 19

An amniotic fluid embolism (AFE) is a life-threatening condition that occurs when amniotic fluid, or other debris enters the maternal circulation.

Question 20

What are the causes of amniotic fluid embolism?

Answer 20

It is hypothesized that during labour or shortly after, amniotic fluid can enter the maternal circulation and form an embolism. This fluid may then block the circulation much like a blood clot, particularly in the lung, leading to symptoms that resemble those of a pulmonary embolism. The fluid also triggers an inflammatory response within the mother’s immune system, which can result in disseminated intravascular coagulation.

Question 21

What are the signs and symptoms of an amniotic fluid embolism?

Answer 21

• High respiratory rate
• Tachycardia
• Hypotension
• Hypoxia
• Disseminated intravascular coagulopathy

Question 22

What are the main differentials for amniotic fluid embolism?

Answer 22

• Septic shock: Fever, increased heart rate, confusion
• Anaphylactic shock: Rash, swelling, shortness of breath, low blood pressure
• Pulmonary embolism: Chest pain, shortness of breath, irregular heartbeat
• Hypovolaemic shock (e.g. due to placental abruption): Rapid heartbeat, cold and sweaty skin, irregular heart rhythm

Question 23

How is amniotic fluid embolism managed?

Answer 23

1. Immediate transfer to an intensive care unit
2. Continuous foetal monitoring if the embolism has occurred before delivery
3. Provision of oxygen and fluid resuscitation
4. Correction of any coagulopathy, including administration of fresh frozen plasma for prolonged PT, cryoprecipitate for low fibrinogen, and platelet transfusion for low platelets

Question 24

What causes puerperal mastitis?

Answer 24

Puerperal mastitis is often caused by blocked milk ducts or bacteria entering the breast tissue, often through a cracked or sore nipple. Staphylococcus aureus is the most common bacterial pathogen implicated in infectious cases.

Question 25

What are the signs and symptoms of mastitis?

Answer 25

- Localised symptoms: Painful, tender, red, and hot breast. - Systemic symptoms: Fever, rigors, myalgia, fatigue, nausea, and headache. - Other clinical features: The condition is typically unilateral and typically presents one week postpartum. - Potential complications: In some cases, a breast abscess may develop, which presents as a fluctuant, tender mass with overlying erythema.

Question 26

How is mastitis diagnosed?

Answer 26

1. Clinical evaluation: Puerperal mastitis is primarily diagnosed based on clinical symptoms and breast examination. 2. Ultrasonography: This may be used in cases where an abscess is suspected. 3. Cultures: If an abscess is present and drained, or if symptoms persist despite antibiotic therapy, cultures should be obtained.

Question 27

How is mastitis managed?

Answer 27

- Analgesia: Over-the-counter pain relievers and anti-inflammatories can help manage pain and inflammation. - Continued breastfeeding or pumping: To promote milk flow and prevent stasis. - Antibiotic therapy: Typically started empirically, with Staphylococcus aureus coverage. The choice of antibiotic may be guided by culture results if available. - Surgical drainage: This may be required in severe cases where a breast abscess has developed.

Question 28

What are the foetal complications of maternal diabetes?

Answer 28

- Macrosomia, or an unusually large birthweight (>4kg), due to excess maternal blood glucose crossing the placenta and inducing increased neonatal insulin production. Macrosomia can increase the risk of shoulder dystocia, birth injuries, and emergency caesarean section. - Pre-term delivery, which may result in respiratory distress syndrome. - Hypoglycaemia in the baby shortly after birth due to sustained high foetal insulin levels after delivery. Severe hypoglycaemic episodes may lead to seizures in the baby. - Increased risk of the baby developing type 2 diabetes later in life.

Question 29

What are the types of vulval cancer?

Answer 29

A variety of skin cancers can affect the vulva, with the most common being squamous cell carcinomas. Other types can include basal cell carcinomas and melanomas. The exact cause of vulval cancer is unknown, but risk factors include increasing age, exposure to the human papillomavirus (HPV), and conditions that cause chronic inflammation of the vulva.

Question 30

What are the features of vulval cancer? Which other conditions can present with similar features?

Answer 30

- A lump, which may be associated with lymphadenopathy - Itching or discomfort in the vulval area - A non-healing ulcer - Vulval pain - Changes in the skin of the vulva, such as thickening or changes in color - Bleeding or discharge not related to the menstrual cycle 1. Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort. 2. Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva. 3. Bartholin's cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.

Question 31

How is vulval cancer diagnosed and managed?

Answer 31

Investigations The initial investigation of suspected vulval cancer includes a thorough examination of the vulva. If there is a suspect lesion, a biopsy is performed to confirm the diagnosis. Additional tests, such as imaging studies or blood tests, may be performed to assess the extent of the disease and to aid in staging. Management The primary treatment for vulval cancer is surgery. This can range from a radical or wide local excision in simple cases, to a radical vulvectomy for multi-focal disease. Reconstructive surgery may be performed to maintain the structure of the vulva. In cases of advanced vulval cancer, radiotherapy, with or without chemotherapy, is now being used as an adjunct to surgery.

Question 32

What is PID?

Answer 32

Pelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.

Question 33

What are the common causes for PID?

Answer 33

1. Chlamydia Trachomatis (14-35%) 2. Neisseria gonorrhoea (2-3%) While Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.

Question 34

What are the signs and symptoms of PID?

Answer 34

- Bilateral abdominal pain - Vaginal discharge - Post-coital bleeding - Adnexal tenderness - Cervical motion tenderness upon bi-manual examination - Fever Approximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome.

Question 35

How is PID investigated and managed?

Answer 35

- Pelvic examination - Pregnancy test - Swabs for gonorrhoea and chlamydia - Blood tests - Transvaginal ultrasound Management Treatment of PID typically takes place in the outpatient setting and involves a combination of antibiotics, such as: - Ceftriaxone (given intramuscularly) + doxycycline + metronidazole - Ofloxacin + metronidazole Analgesia may also be required, and the patient is generally reviewed after 4 weeks. It is noteworthy that empirical treatment for PID is often initiated in sexually active young women presenting with bilateral lower abdominal pain and adnexal tenderness due to the substantial number of women with PID that remain undiagnosed.

Question 36

What are the potential complications with PID?

Answer 36

- Chronic pelvic pain (in around 40% of cases) - Infertility (approximately 15%) - Ectopic pregnancy (about 1%) - Fitz-Hugh-Curtis Syndrome Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.

Question 37

What is the definition of secondary amenorrhoea?

Answer 37

Secondary amenorrhoea is a common condition affecting approximately 4-5% of women of reproductive age. It is most frequently observed in women aged 20-39 years.

Question 38

What are the causes of secondary amenorrhoea?

Answer 38

- Pregnancy (most common cause) - Breastfeeding - Menopause - Intrauterine adhesions leading to outflow tract obstruction (Asherman's syndrome) - Polycystic ovary syndrome (PCOS) - Drug-induced amenorrhoea (e.g. contraceptive use) - Physical stress, excess exercise, and weight loss - Pituitary gland pathology, such as Sheehan syndrome or hyperprolactinaemia - Hypothyroidism or hyperthyroidism

Question 39

What is Asherman's syndrome?

Answer 39

Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea. In this case, the cyclical abdominal pain may be a sign that menstruation is occurring. Ultrasound examination is not particularly sensitive for making the diagnosis so an HSG or hysteroscopy might be needed for confirmation

Question 40

What are the 3 types of ovarian cancer?

Answer 40

1. Epithelial ovarian tumours - Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries - Epithelial tumours are partially cystic, and the cysts can contain fluid - The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm - Around 90% of ovarian cancers are epithelial ovarian tumours. - Germ cell tumours features 2. Originate from the germ cells in the embryonic gonad - These tumours typically grow rapidly and spread predominantly via the lymphatic route - Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer - Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG). 3. Sex cord stromal tumours - Originate from connective tissue - They are rare, making up less than 5% of all ovarian tumours. They are malignant tumours, but are much less aggressive than epithelial tumours - Additionally, ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a ""signet ring"" sub-type of tumour, typically gastrointestinal in origin, which has metastasised to the ovary.

Question 41

What are the signs and symptoms of ovarian cancer?

Answer 41

The clinical features of ovarian cancer typically present late in the disease progression and include: - Abdominal discomfort - Bloating - Early satiety - Urinary frequency or change in bowel habits In later stages, the disease may cause: - Ascites (due to vascular growth factors increasing vessel permeability) - Pelvic, back and abdominal pain - Palpable abdominal or pelvic mass

Question 42

What are the investigations for ovarian cancer?

Answer 42

- Blood test for CA-125 - Pelvic and abdominal ultrasound scan These results can be used to calculate the Risk of Malignancy Index (RMI), which stratifies the likelihood of cancer. Further investigations can include: - CT scans for staging - AFP and beta-hCG tests for younger women who may have germ cell cancers - Laparotomy for tissue biopsy

Question 43

How is ovarian cancer staged?

Answer 43

Stage I (limited to the ovaries): - Stage IA: limited to one ovary, the capsule is intact - Stage IB: limited to both ovaries, capsules intact. - Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings. Stage II involving one or both ovaries with pelvic extension and/or implants: - Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings - Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings - Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings. Stage III involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis: - Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour) - Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm - Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis. Stage IV ovarian cancer is tumour involving one or both ovaries with distant metastasis.

Question 44

How is ovarian cancer managed?

Answer 44

Surgery If early disease surgery can include removal of the uterus, ovaries, Fallopian tubes and infracolic omentectomy In advanced disease debulking surgery can be performed. Chemotherapy: Adjuvant chemotherapy in combination with surgery Intraperitoneal chemotherapy may be performed at the time of operation Biological therapies are being trialled.

Question 45

How is placenta praevia managed?

Answer 45

1. Bleeding with unknown placental position: - ABC approach, resuscitation and stabilisation - If stable, perform urgent transvaginal ultrasound - If the bleeding is not controlled, immediate caesarean section required 2. Bleeding with known placenta praevia: - ABC approach, resuscitation and stabilisation. If stabilisation is not achieved, send for emergency caesarean Section. - Corticosteroids should be considered if between 24-34 weeks gestation and there is risk of preterm labour 3. In labour: caesarean section 4. Placenta praevia with no bleeding and not in labour: - Monitor with ultrasound scans - Give advice about pelvic rest (no penetrative sexual intercourse) and advise to go to hospital if there is significant vaginal bleeding 5. At term: - If there is any degree of placental overlap at 35 weeks, aim for an elective caesarean section at 37-38 weeks gestation. Urgent C-section if she goes in to labour (due to risk of significant bleeding) - When the placental edge is greater than 20mm from the internal cervical os, women can be offered a trial of labour (if no bleeding and with careful intrapartum monitoring). If significant haemorrhage or foetal distress develops during trialled vaginal delivery, immediately take to theatre for caesarean section.

Question 46

What are the stages of placenta praevia?

Answer 46

Stage 1: In stage I the placenta reaches the lower segment but does not reach the internal os. This can be treated conservatively, and a vaginal delivery can be attempted with stage I placenta praevia. Stage 2: Stage II refers to marginal previa: placental tissue reaches the margin of the internal cervical os but does not cover it. Treatment is dependent on the stage and effect on birth. The later stages of placenta praevia require a planned caesarean section to prevent maternal and foetal risks. Stage 3: Stage III is diagnosed when the placenta covers the internal os prior to dilation but not when the cervical os is dilated. Stage 4: Stage IV is the category where the placenta completely covers the internal os.

Question 47

When is Anastrozole used and what are the side effects?

Answer 47

Anastrozole is an aromatase enzyme inhibitor, which blocks the conversion of androgens to oestrogens. It is predominantly used as adjuvant therapy post surgery in the management of post-menopausal women with oestrogen receptor positive breast cancer. Anastrozole's side effects include arthralgia, menopausal symptoms, hypercholesterolemia, osteoporosis, and rarely Henoch–Schönlein purpura, a form of vasculitis, which the patient is presenting with.

Question 48

What criteria is used to diagnose PCOS?

Answer 48

Upon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met: 1. Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm) 2. Oligo-/anovulation 3. Clinical or biochemical features of hyperandrogenism

Question 49

What test is carried out to check whether a woman has ovulated?

Answer 49

The serum progesterone blood test should be carried out 7 days before the end of the cycle, at the peak luteal level.

Question 50

What is fat necrosis of the breast?

Answer 50

Fat necrosis refers to a non-malignant condition in which there is death of adipose tissue (fat cells) within the breast, typically leading to the formation of a lump. It is more frequently observed in patients with obesity and postmenopausal women. Trauma is often associated.

Question 51

What are the signs and symptoms of fat necrosis of the breast?

Answer 51

The presentation of fat necrosis can vary, but typically includes: - A firm or hard, irregular lump in the breast - Overlying skin may show signs of inflammation, such as redness and warmth, or bruising It's worth noting that these signs and symptoms can mimic those of breast cancer, making differentiation on clinical grounds alone challenging.

Question 52

How is fat necrosis of the breast investigated?

Answer 52

1. Clinical examination 2. Imaging: Mammography and/or ultrasound 3. Tissue sampling: Fine needle aspiration cytology (FNAC) or core biopsy

Question 53

How is fat necrosis of the breast managed?

Answer 53

Management of fat necrosis is primarily conservative, as intervention is usually not required. Patients should be reassured about the benign nature of the condition. Regular follow-up may be necessary to monitor any changes in the lump's characteristics or size. In case of persistent or enlarging lumps, or if there is diagnostic uncertainty, surgical excision may be considered.

Question 54

What are the features of atrophic vaginitis?

Answer 54

- Thinning of the vaginal mucosa - Loss of pubic hair - Narrowed introitus - Loss of vaginal rugae (folds) - Vaginal dryness and itching - Dyspareunia - Post-coital bleeding - Vaginal discharge from inflammation - Urinary symptoms such as dysuria and recurrent UTI

Question 55

How is atrophic vaginitis managed?

Answer 55

1. Hormonal treatment: - Systemic hormone-replacement therapy (oral or transdermal) - Topical oestrogen preparations 2. Non-hormonal treatments: - Lubricants, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia - Moisturisers, which should be used regularly

Question 56

What is Paget's disease of the breast?

Answer 56

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.

Question 57

What are the clinical features of Paget's disease of the nipple?

Answer 57

Common clinical features of Paget's disease of the nipple include: - 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)

Question 58

How is Paget's disease of the nipple investigated?

Answer 58

To diagnose Paget's disease of the nipple, the following investigations are typically carried out: - 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

Question 59

How is Paget's disease of the nipple managed?

Answer 59

Management of Paget's disease of the nipple primarily involves surgical intervention and is guided by the presence and extent of underlying breast cancer. Approaches can include: 1. Simple mastectomy: Removal of the entire breast, including the nipple and areola 2. Modified radical mastectomy: Removal of the entire breast along with some of the axillary (underarm) lymph nodes 3. 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.

Question 60

What is the aetiology of postpartum depression?

Answer 60

1. Biological Factors: Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones, may contribute to PPD. Additionally, alterations in melatonin and cortisol rhythms, immune-inflammatory processes, and genetic predispositions are considered contributory. 2. Psychological Factors: A history of mood or anxiety disorders, previous episodes of postpartum depression, and certain personality traits such as neuroticism are associated with increased risk. Additionally, psychological stress from the transition to parenthood, and unrealistic expectations of motherhood may also contribute. 3. Social Factors: Lack of social support, relationship issues, life stressors, and low socioeconomic status can increase the risk of developing PPD.

Question 61

What are the features of postpartum depression?

Answer 61

- Persistent lowering of mood and reduced enjoyment or interest in activities. - Lowering of energy levels. - Biological symptoms of depression like poor appetite and disturbed sleep patterns. It's important to distinguish between sleep that is disrupted due to the infant's sleep cycle and sleep disruption stemming from other causes. - Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.

Question 62

How is postpartum depression assessed and investigated?

Answer 62

1. The Edinburgh Postnatal Depression Scale (EPDS) is a widely accepted screening tool that consists of 10 questions and takes around five minutes to complete. It evaluates the intensity of depressive symptoms over the past seven days. 2. A detailed psychiatric history is essential to understand past episodes of depression or other mental health disorders, previous treatment regimens, and the family history of psychiatric conditions. 3. A complete physical examination and relevant laboratory investigations may be necessary to rule out other potential causes of depressive symptoms, such as hypothyroidism or anemia, especially if the patient presents with atypical symptoms or does not respond to standard treatment.

Question 63

How is postpartum depression managed?

Answer 63

- First-line treatments typically involve self-help strategies and psychological therapies such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). - Pharmacological treatments, such as antidepressants, are considered in cases of high severity or distinct risks. - In severe cases, admission to a mother and baby inpatient mental health unit might also be necessary.

Question 64

What is premature ovarian insufficiency?

Answer 64

Premature ovarian insufficiency (POI) is a medical condition characterized by the onset of menopause in a woman aged below 40 years. The term ""premature"" is used to highlight the early onset of menopause compared to the normal age range. The aetiology of POI can be idiopathic or iatrogenic. Iatrogenic causes include invasive procedures or treatments such as ovarian surgery, radiotherapy, or chemotherapy that directly impact the ovaries.

Question 65

What are the features of premature ovarian insufficiency?

Answer 65

1. Vasomotor symptoms: hot flushes, night sweats 2. Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia 3. Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration

Question 66

What are the differentials for premature ovarian insufficiency?

Answer 66

1. Hypothyroidism: fatigue, weight gain, cold intolerance, depression, hair loss 2. Hyperprolactinemia: irregular menstrual cycles, infertility, breast milk production not related to childbirth or nursing 3. Polycystic Ovary Syndrome (PCOS): irregular periods, hirsutism, obesity, infertility

Question 67

How is premature ovarian failure diagnosed and managed?

Answer 67

The primary investigation for POI is to test for raised FSH levels, indicative of menopause. These levels should be repeated at least once more to confirm the diagnosis and ensure the first result was not anomalous. Management The primary management strategy for women with POI is to offer hormone replacement therapy (HRT) until at least the age of normal menopause, unless the risks of HRT treatment outweigh the benefits. Additionally, psychological support should be provided due to the potential mental health impacts of early menopause.

Question 68

What is the mechanism of action of tamoxifen?

Answer 68

Tamoxifen is used in patients who have oestrogen receptor positive breast cancer who are pre or peri-menopausal. This selective oestrogen receptor modulator will inhibit the oestrogen receptors on the breast cancer thus reducing the growth drive from oestrogen. Tamoxifen is not used in patients who are post-menopausal because it is actually a partial agonist for oestrogen so for post-menopausal women it increases the risk of endometrial cancer. Tamoxifen increases the risk of thrombosis and endometrial cancer

Question 69

What is the mechanism of action of anastrozole?

Answer 69

This aromatase inhibitor is used in post-menopausal patents with breast cancer that oestrogen receptor positive. This helps reduce the levels of oestrogen in post-menopausal women, who make the majority of their oestrogen via aromatisation

Question 70

What is cord prolapse?

Answer 70

Cord prolapse refers to a situation during labour when the umbilical cord exits the cervix ahead of the infant. This position poses an acute risk to the umbilical blood supply to the infant and demands immediate delivery.

Question 71

What are the risk factors for cord prolapse?

Answer 71

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

Question 72

What are the signs of cord prolapse?

Answer 72

The primary symptom of cord prolapse includes a sudden change in the fetal heart rate pattern, particularly variable or prolonged decelerations. Other signs and symptoms can include: - Feeling of the cord in the vagina or visible cord after rupture of membranes - Abnormal fetal heart rate detected on cardiotocography

Question 73

How is cord prolapse managed?

Answer 73

When cord prolapse is diagnosed, swift action is vital to prevent fetal hypoxia and death. Management strategies include: - Immediate delivery of the fetus, preferably via instrumental delivery or caesarean section if the cervix is not fully dilated - The use of ""knees-chest"" position to prevent further prolapse - Filling the bladder with 500ml warmed saline to aid in preventing further prolapse - Avoidance of exposure and handling of the cord, reducing cord into the vagina - Use of tocolytics, such as terbutaline, to stop uterine contractions

Question 74

What are the acceptable values for symphysis fundal height from 24 weeks of pregnancy?

Answer 74

From 24 weeks of pregnancy, the SFH is equal to gestational weeks with the accuracy and precision of ± 2 cm. For example, if a patient's SFH is 30 cm, her gestational weeks should be in range of 28–32 weeks of pregnancy.

Question 75

What is the definition of Postpartum haemorrhage and what is the aetiology?

Answer 75

Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery. Aetiology The aetiology of postpartum haemorrhage (PPH) can be remembered using the mnemonic of the 4 'T's: 1. Tone: The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery. 2. Trauma: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries. 3. Tissue: Retained placental or foetal tissue can cause continued bleeding. 4. Thrombin: Coagulopathies can lead to continued bleeding due to a failure of clotting.

Question 76

What are the risk factors for PPH?

Answer 76

Risk factors for postpartum haemorrhage (PPH) include: - 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

Question 77

How is postpartum haemorrhage assessed and managed?

Answer 77

Investigations for PPH include blood tests for Group/Save and Crossmatch, and consideration of fresh frozen plasma if clotting abnormalities are present. In cases of secondary PPH, ultrasound looking for retained products and endocervical/high vaginal swabs looking for infection are recommended. Management Initial management of PPH involves: 1. Resuscitation with an ABCDE approach 2. Consideration of activation of a major haemorrhage protocol 3. Laying the woman flat 4. Inserting two large bore cannulas 5. Providing oxygen 6. Considering fresh frozen plasma if clotting abnormalities are present Further management strategies may include: - Mechanical methods such as rubbing the uterus and catheterisation - Medical treatments including oxytocin, syntocinon, ergometrine, carboprost, misoprostol, and tranexamic acid - Surgical treatments such as intrauterine balloon tamponade, B-lynch suture around the uterus, uterine artery ligation, or hysterectomy For secondary PPH, management depends on the cause and can include surgical evacuation for retained products of conception or antibiotics for infection.

Question 78

What are the steps for minor PPH due to uterine atony after the woman has been stabilised?

Answer 78

1. Uterine massage 2. Bimanual compression (fist inside uterus and pressure outside uterus) 3. Oxytocin 4. Ergometrine (though CI in Hx of HTN)

Question 79

How is gestational hypertension and pre-existing hypertension differentiated?

Answer 79

gestational hypertension occurs after 20 weeks.

Question 80

Which blood pressure is considered hypertensive in pregnancy? When is treatment recommended?

Answer 80

>140/90 is hypertensive Treatment with labetalol is recommended when 150/100. Alternatives include methydopa (Alpha-2 agonist) and nifedipine (CCB) Regularly monitor BP and urinalysis

Question 81

What are fibroadenomas?

Answer 81

Fibroadenomas are benign tumours that consist of a mixture of fibrous and epithelial tissue. They originate from the lobules, the milk-producing glands in the breast. Fibroadenomas are most commonly seen in young women, with the highest incidence occurring in the early 20s. They are particularly common during periods of reproductive hormonal change such as puberty, pregnancy, and perimenopause. The exact cause of fibroadenomas is unclear. However, they seem to be influenced by reproductive hormones, as they often enlarge during pregnancy and shrink after menopause.

Question 82

What are the clinical features of fibroadenomas?

Answer 82

Patients with fibroadenomas typically present with the following: - A firm, non-tender breast mass - The mass is rounded and has smooth edges - The mass is highly mobile upon palpation, often referred to as having a "rubbery" consistency - The mass typically does not grow beyond 3cm in diameter

Question 83

How are fibroadenomas investigated and managed?

Answer 83

While fibroadenomas are benign, patients usually undergo a triple assessment to exclude more serious pathology. This includes: 1. Clinical examination 2. Imaging (usually ultrasound and/or mammogram) 3. Needle biopsy (fine needle aspiration or core biopsy) Management Management of fibroadenomas can vary depending on the size, number, patient age, and symptoms: 1. Conservative management: Many fibroadenomas do not require treatment and will regress naturally after menopause. 2. Surgical excision: This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment.

Question 84

Which is the HPV vaccine and which types of HPV does it protect against?

Answer 84

Gardasil is the vaccination used and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58

Question 85

What are the risk factors for VTE and when should postnatal thromboprophylaxis be given?

Answer 85

Risk factors: - Previous VTE - Thrombophilia - Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions) - Age >35 - BMI >30 - Parity >3 - Smoking - Multiple pregnancy - Pre-eclampsia - Caesarean section - Prolonged labour - Operative delivery - Preterm birth - Stillbirth - Postpartum haemorrhage >1000mL - Other surgical procedure carried out - Immobility - Systemic infection Those with four or more risk factors are usually recommended 6 weeks of postnatal thromboprophylaxis.

Question 86

What is Bowen's disease?

Answer 86

A form of skin cancer which presents typically as a red, scaly patch on the skin

Question 87

What are the signs and symptoms of HELLP syndrome?

Answer 87

Headache Nausea and/or vomiting Epigastric pain Right upper quadrant abdominal pain due to liver distension Blurred vision Peripheral edema

Question 88

What are the maternal and foetal complications of HELLP syndrome?

Answer 88

Maternal complications include: Organ failure Placental abruption Disseminated intravascular coagulopathy (DIC). Foetal complications include: Intrauterine growth restriction Preterm delivery Neonatal hypoxia

Question 89

How is HELLP syndrome investigated and managed?

Answer 89

Investigations for HELLP syndrome may include: 1. Full blood count to assess for low platelet count and evidence of hemolysis 2. Liver function tests to assess for elevated liver enzymes 3. Coagulation studies to evaluate for disseminated intravascular coagulation 4. Ultrasound scans to assess for liver abnormalities and placental abruption Management The definitive treatment for HELLP syndrome is usually the delivery of the baby. In some cases, mothers may also require blood transfusions to manage anemia and thrombocytopenia or steroids to accelerate lung maturation in the fetus prior to delivery. After delivery, supportive care and close monitoring are essential.

Question 90

What is oligohydramnios and what are the causes?

Answer 90

Oligohydramnios is defined as the presence of a lower than normal volume of amniotic fluid within the uterus. Aetiology The causes of oligohydramnios are numerous and include: 1. Uteroplacental insufficiency: This can lead to intrauterine growth restriction and is often due to maternal conditions such as hypertension, pre-eclampsia, maternal smoking and placental abruption. 2. 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. 3. Premature rupture of membranes 4. Post-term gestation 5. Chromosomal anomalies 6. Maternal use of certain drugs including prostaglandin inhibitors and ACE-inhibitors.

Question 91

What are the complications of oligohydramnios?

Answer 91

The complications of oligohydramnios are largely due to the reduced ""space"" surrounding the fetus and the subsequent lack of amniotic fluid for fetal lung growth and development. These can include: 1. Due to fetal compression: clubbed feet, facial deformity, congenital hip dysplasia. 2. Due to lack of amniotic fluid: pulmonary hypoplasia in the fetus. The combination of these features is commonly referred to as Potter syndrome.

Question 92

How is oligohydramnios investigated and managed?

Answer 92

The diagnosis of oligohydramnios is usually made via ultrasound, which shows a reduced amniotic fluid index (AFI) or single deepest pocket (SDP). Additional investigations may be required to determine the underlying cause, such as maternal blood tests or fetal karyotyping. Management The management of oligohydramnios largely depends on the underlying cause, the gestational age, and the presence of fetal distress. Options may include: 1. Maternal rehydration: This may help to increase the amniotic fluid volume in mild cases of oligohydramnios. 2. Amnioinfusion: This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid. 3. 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. In all cases, close monitoring of the mother and fetus is required.

Question 93

How is congenital rubella syndrome acquired?

Answer 93

Congenital Rubella Syndrome (CRS) occurs when a woman contracts rubella during her pregnancy, affecting the developing fetus. The risk of developing CRS is greatest in the first trimester. This serious condition is now rare due to the success of the MMR (measles, mumps, rubella) vaccine. CRS is caused by maternal infection with rubella virus during pregnancy, particularly in the first trimester. The virus can cross the placenta and affect the developing fetus leading to a range of congenital abnormalities.

Question 94

What are the features of congenital rubella syndrome?

Answer 94

Newborns with CRS commonly present with: 1. Sensorineural deafness 2. Cataracts or retinopathy 3. Congenital heart disease Other symptoms include: - Organ dysfunction - Microcephaly - Micrognathia - Haematological abnormalities - Low birth weight - Developmental delay and learning disability in later life - A characteristic petechial rash described as a “blueberry muffin” rash.

Question 95

What are some differentials for congenital rubella syndrome?

Answer 95

Differential diagnosis for CRS may include other TORCH infections such as: 1. Toxoplasmosis: Presents with chorioretinitis, hydrocephalus, and intracranial calcifications. 2. Other (Syphilis, Varicella-Zoster, Parvovirus B19): Symptoms vary, but may include rash, fever, and various congenital abnormalities. 3. Cytomegalovirus (CMV): Presents with microcephaly, periventricular calcifications, and sensorineural hearing loss. 4. Herpes Simplex Virus (HSV): Presents with vesicular lesions, encephalitis, and eye disease.

Question 96

How is congenital rubella syndrome diagnosed and managed?

Answer 96

Diagnosis of CRS involves serology tests to confirm rubella infection. Other investigations may include audiology tests for hearing impairment, ophthalmology review for eye abnormalities, and echocardiography for congenital heart defects. Management Management of CRS is primarily supportive and symptomatic. Early intervention services may be beneficial for affected infants. Regular follow-up is important to monitor progress and manage any long-term complications.

Question 97

What are the 4 types of miscarriage?

Answer 97

1. Threatened miscarriage This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the ""threat"" of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine. 2. Inevitable miscarriage There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine. 3. Complete miscarriage There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding. 4. Missed miscarriage The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.

Question 98

How is miscarriage managed?

Answer 98

Miscarriage often cannot be prevented or stopped. Management therefore revolves around ensuring complete removal of foetal material. 1. Expectant management = allowing the products of conception to naturally expel 2. Medical management with e.g. misoprostol 3. Surgical management e.g. dilatation and curettage If the woman is rhesus negative they may require anti-D prophylaxis.

Question 99

What are the 8 types of benign breast disease?

Answer 99

Benign breast diseases are a variety of non-cancerous conditions that cause breast symptoms such as lumps, pain, and nipple discharge. 1. Fibroadenomas arise from the breast lobule stroma. Highly mobile, encapsulated breast masses. 2. Breast cysts occur due to the overgrowth of glandular and connective tissue, leading to blocked breast ducts and subsequent fluid accumulation. Lump potentially with distension. 3. Mastitis is typically caused by bacterial infections, often related to breaks in the skin around the nipple. Breast redness, mastalgia, malaise and fever 4. Intraductal papilloma is a benign tumour of the breast ducts. Bloody discharge from the nipple without a palpable mass. 5. Radial scar is a benign sclerosing breast lesion. Presents on mammogram as a stellate pattern of central scarring surrounded by proliferating glandular tissue 6. Fat necrosis is a response to adipose tissue damage. Painless breast mass, skin thickening or radiographic changes on mammography 7. Fibrocystic breast disease is due to an exaggerated hormonal response causing inflammation, fibrosis, cyst formation, or adenosis. Breast lumps, pain and tenderness 8. Mammary duct ectasia is due to inflammation and dilation of the large breast ducts. Palpable peri-areolar breast mass, thick nipple discharge and potential mammographic similarities to cancer.

Question 100

What are the features of vulval cancer?

Answer 100

- A lump, which may be associated with lymphadenopathy - Itching or discomfort in the vulval area - A non-healing ulcer - Vulval pain - Changes in the skin of the vulva, such as thickening or changes in color - Bleeding or discharge not related to the menstrual cycle

Question 101

What are the effects of Lithium use during pregnancy?

Answer 101

The primary signs and symptoms associated with lithium exposure in utero include: 1. Congenital anomalies, particularly Ebstein's anomaly 2. Increased risk of miscarriage 3. Neurodevelopmental impairments in the offspring

Question 102

What are some risk factors for uterine fibroids?

Answer 102

Oestrogen and progesterone, the hormones that stimulate the development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more oestrogen and progesterone receptors than normal uterine muscle cells. Risk factors: - Afro-carribean - Early menarche - Obesity - Nulliparity - Increased age until menopause (peak incidence at 40 years)

Question 103

How are uterine fibroids managed depending on size?

Answer 103

<3cm and no uterine distortion = Non surgical: - NSAIDS - Anti-fibrinolytics eg tranexamic acid - COCP - Mirena Symptomatic due to mass effect = Surgical management: - Myomectomy - Ablation - Uterine artery embolisation - Hysterectomy

Question 104

Who is offered screening for gestational diabetes?

Answer 104

Happens at 24-28 weeks - BMI above 30kg/m2. - Previous macrosomic baby (weighing 4.5kg or above). - Previous gestational diabetes. - First degree relative with diabetes. - Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)

Question 105

What are the features that point to shoulder dystocia?

Answer 105

- Difficult delivery of the foetal face or chin - Retraction of the foetal head (turtle-neck sign) - Failure of restitution - Failure of descent of the foetal shoulders following delivery of the head

Question 106

How is shoulder dystocia managed?

Answer 106

Once shoulder dystocia has been recognised, management is as follows: 1. Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required - Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction 2. McRoberts manoeuvre - Hyperflexion and abduction of the mother's legs tightly to the abdomen - This may be accompanied with applied suprapubic pressure - Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released. 3. All fours position 4. Internal rotational manoeuvres: - Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back. - Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest *Note that episiotomy will not relieve shoulder dystocia as it is a bony obstruction, but may be indicated to allow space for internal rotational manoeuvres. 5. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament) 6. Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section Following the delivery of a baby after shoulder dystocia: - The mother should be examined and monitored for postpartum haemorrhage, severe perineal tears and other genital tract trauma. - The baby should be examined by a neonatologist for injury including brachial plexus injury, hypoxic brain damage, humeral or clavicular fractures

Question 107

How does lobular carcinoma in situ and invasive lobular carcinoma look on biopsy?

Answer 107

A lobular carcinoma in situ would most likely reveal an abnormal proliferation of small, round, lobular cells arranged in a uniform pattern. There would be no infiltration of the basement membrane. An invasive lobular carcinoma would most likely reveal an abnormal proliferation of lobular cells which are small and round and arranged in a uniform pattern. They would also infiltrate the basement membrane.

Question 108

How does ductal carcinoma in situ and invasive ductal carcinoma look on biopsy?

Answer 108

A ductal carcinoma in situ would most likely reveal irregularly distributed cells which form no obvious pattern, with atypically larger nuclei. The atypical cells exist within the milk ducts of the breast, and the basement membrane is not breached. Invasive would be if the basement membrane had been breached.

Question 109

What is uterine inversion and how is it diagnosed?

Answer 109

Uterine inversion is a severe obstetric complication in which the fundus of the uterus collapses downwards, passing through the uterine cavity and the cervix, essentially turning the uterus inside out. The risk factors associated with uterine inversion include prolonged labour, rapid and forceful delivery, and fundal placental implantation. The exact cause of uterine inversion is not entirely understood, but it is believed to be associated with excessive traction applied to the umbilical cord before placental separation. Other contributing factors may include relaxed or atonic uterus, short umbilical cord, or previous uterine inversion. The primary symptom is a large post-partum haemorrhage. Investigations The diagnosis of uterine inversion is primarily clinical, based on the characteristic presentation. However, ultrasound imaging can be useful in confirming the diagnosis and ruling out other causes of post-partum haemorrhage.

Question 110

How is uterine inversion managed?

Answer 110

The management of uterine inversion focuses on maternal resuscitation and repositioning of the uterus. The primary methods include: - Johnson manoeuvre: This involves using the hand to push the fundus back into the abdomen. - Hydrostatic methods: This method involves filling the vagina with fluid to inflate the uterus back to the normal position. - Laparotomy: This surgical procedure is usually considered when conservative options fail.

Question 111

Why does PCOS increase the risk of endometrial cancer?

Answer 111

In PCOS increased levels of androgens in the ovaries leads to anovulation. As a result, the corpus luteum does not develop and hence progesterone is not produced. Progesterone mediates the shedding of the endometrial lining each month and its absence increases the risk of endometrial hyperplasia. This, in turn, is a risk factor for endometrial cancer

Question 112

What is fibrocystic disease of the breast?

Answer 112

Fibrocystic breast disease is a benign condition characterised by the presence of fibrous tissues and cysts in the breasts. This condition is not considered a disease but rather a variation of normal breast tissue. Fibrocystic disease is the most common benign breast condition. The condition predominantly affects the 20-50 year old age group. Fibrocystic breast disease is the result of the cumulative effect of cyclical hormones. The primary hormones involved are oestrogen and progesterone, among others, leading to changes in the breast tissue, including the formation of multiple small cysts and proliferative changes.

Question 113

What are the features of fibrocystic disease of the breast?

Answer 113

- Bilateral “lumpy” breasts, most commonly in the upper outer quadrant. - Breast pain. - Symptoms that worsen with the menstrual cycle, typically peaking 1 week before menstruation.

Question 114

How is fibrocystic breast disease investigated and managed?

Answer 114

Investigations for fibrocystic breast disease often start with a clinical breast examination. Other investigations may include: 1. Mammogram: Useful for identifying any abnormalities in the breast tissue. 2. Ultrasound: May be used to distinguish between solid masses and fluid-filled cysts. 3. Biopsy: May be required to exclude malignant changes if there is a suspicious finding on imaging or physical examination. Management Management of fibrocystic breast disease is primarily supportive and includes: - Encouraging the use of a soft but well-fitting bra for comfort. - Providing appropriate analgesia for pain relief. - Most cases resolve after menopause, and reassurance can be provided about this natural course.

Question 115

How should PROM be investigated?

Answer 115

Investigations for PROM should focus on assessing signs of infection and foetal distress, including: 1. Monitoring maternal temperature 2. Assessing foetal movements 3. Monitoring foetal heart rate 4. Observing vaginal discharge

Question 116

How should PROM at term be managed?

Answer 116

- 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.

Question 117

What are some potential complications of PROM at term?

Answer 117

PROM at term can lead to several complications, including: - Chorioamnionitis due to ascending infection - Preterm birth and the associated complications such as respiratory distress syndrome, necrotising enterocolitis, and foetal death - Developmental problems such as pulmonary hypoplasia, facial and limb deformities due to compression in the uterus, and cord prolapse due to low levels of amniotic fluid.

Question 118

What is the PAM1 test?

Answer 118

Placental-alpha-microglobulin-1 (PAM1) test PAM1 test is performed during speculum examination to detect the premature rupture of membrane in women with no established labour. A positive test will be indicated with the presence of two red lines.

Question 119

What is a malignant Phyllodes tumour?

Answer 119

A malignant phyllodes tumour is a type of breast cancer of fibroepithelial origin. It is composed of both epithelial and interlobular stromal components, and it is most frequently observed in women in their 40s or 50s. It is established that these tumours predominantly affect pre-menopausal women, with peak incidence in the fifth decade of life. The exact aetiology of malignant phyllodes tumours remains unclear. They do not appear to be strongly linked with typical breast cancer risk factors, such as family history or hormonal influences. Some genetic mutations have been suggested, but further research is needed in this area.

Question 120

What are the features of a malignant Phyllodes tumour?

Answer 120

- Usually presents as a rapidly enlarging, smooth, hard, palpable breast mass, sometimes visible as a smooth bulge under the breast skin - In advanced stages, an ulcer may form on the breast - Despite their potential for rapid and aggressive growth, malignant phyllodes tumours rarely metastasise.

Question 121

What is an Actim-PROM test?

Answer 121

An Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood. Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes.

Question 122

What is a serious well-documented side effect of Trastuzumab?

Answer 122

Cardiotoxicity resulting in heart failure - SOBOE -Peripheral oedema - Ascites - Paroxysmal nocturnal dyspnoea

Question 123

What is the BRCA2 gene and what are the risks associated?

Answer 123

The BRCA2 gene is a tumour suppressor gene and repairs double-stranded DNA. Mutations in the BRCA2 gene increase the risk of prostate, pancreatic, gastric and breast cancer. In females, there is also an increased risk of developing ovarian cancer.

Question 124

What are the criteria for genetic testing for BRCA genes?

Answer 124

The criteria for referral include: * one first-degree relative < 40 with breast cancer * one first-degree male relative with breast cancer * one first-degree relative with bilateral breast cancer * a first- and second-degree relative with breast or ovarian cancer * three first- or second-degree relatives with breast cancer

Question 125

What is the most effective method of preventing GBS infection?

Answer 125

Antibiotics, commonly penicillin, are administered intravenously during labour and delivery if risk factors for GBS infection are present.