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3rd year medicine > repro 3 > Flashcards

repro 3 Flashcards

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1
Q

triad of PET?

A

Hypertension

Proteinuria

Oedema

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2
Q

chronic HTN vs PET?

A

PET after 20 weeks gestation

HTN <20 weeks gestation

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3
Q

eclampsia?

A

Eclampsia is when seizures occur as a result of pre-eclampsia

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4
Q

high risk factors vs moderate risk factors PET?

A

High risk factors PET

  • Pre-existing hypertension
  • Previous hypertension in pregnancy
  • Existing autoimmune conditions e.g. SLE
  • Diabetes
  • CKD

Moderate risk factors PET

  • >40 y/o
  • BMI >35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • FHx of pre-eclampsia

Women are offered aspirin from 12 weeks until birth if they have one high risk factor or more than one moderate risk factor

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5
Q

symptoms pre-eclampsia?

A

Headache

Visual disturbance/blurriness

Nausea + vomiting

Upper abdominal or epigastric pain (this is due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

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6
Q

Dx PET?

A

Systolic BP >140mmHg

Diastolic BP >90mmHg

Plus any of:

  • Proteinuria ≥1+ on dipstick
  • Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, or haemolytic anaemia)
  • Placental dysfunction (e.g. FGR or abnormal doppler studies)
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7
Q

Tx gestational hypertension without proteinuria?

A

Aim for BP <135/85mmHg

Admission for women with BP >160/110mmHg

Urine dipstick testing at least weekly

Monitoring of blood tests weekly (FBC, liver enzymes and renal profile)

Monitoring foetal growth by serial growth scans

PlGF testing on one occasion

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8
Q

Tx PET?

A

Labetolol = 1st line

Nifedipine is 2nd line (1st line in asthma)

Methyldopa 3rd line (needs to be stopped within 2 days of birth)

IV hydralazine used in critical care in severe pre-eclampsia or eclampsia

IV MgSO4 given during seizures, labour and in the 24 hours after labour to prevent seizures

Fluid restriction used during labour in severe pre-eclampsia or eclampsia to avoid fluid overload

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9
Q

Tx PET after birth of baby?

A

Enalapril (1st line)

Nifedipine or amlodipine (1st line in black African or Caribbean patients)

Labetolol (3rd line)

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10
Q

Tx eclampsia?

A

Seizures associated with pre-eclampsia

Tx = IV MgSO4

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11
Q

HELLP syndrome?

A

Complication of pre-eclampsia and eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
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12
Q

where does breast lie?

A

sits anterior to pectoralis major

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13
Q

secretory tissue of breast made up of?

A

Secretory tissue of breast made up of 15-25 lobes

Each lobe consists of tubulo-acinar gland which drains via a series of ducts leading to the nipple

Adjacent to secretory lobules is dense fibrous tissue which is surrounded by adipose tissue

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14
Q
A

….

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15
Q

basic functional secretory unit of breast?

A

TDLU - terminal duct lobular unit

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16
Q

drainage of secretions from breast?

A

In non-lactating breast, TDLUs lead into intralobular collecting duct → lactiferous duct → nipple

(expanded duct region near nipple = lactiferous sinus)

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17
Q

which cells line acini in lobule?

A

cuboidal/columnar = secretory epithelium

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18
Q

lactiferous duct lined by?

A

as lactiferous ducts approach surface they become lined by stratified squamous epithelium

Deeper they are lined by stratified cuboidal epithelium

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19
Q

changes in breast during menstrual cycle?

A

Luteal phase

  • epithelial cells increase in height
  • Lamina of ducts become enlarged
  • Small amounts of secretions appear in ducts
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20
Q

changes to breast in pregnancy?

A

First trimester - elongation and branching of smaller ducts

  • Also proliferation of epithelial cells, glands + myoepithelial cells

Second trimester - glandular tissue continues to develop

  • Secretory alveoli differentiate
  • Plasma cells and lymphocytes infiltrate tissue

Third trimester

  • Secretory alveoli continue to mature with development of extensive rER

(these changes are accompanied by reduction in amount of connective + adipose tissue)

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21
Q

which hormones stimulate proliferation of breast secretory tissue in pregnancy?

A

oestrogen + progesterone

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22
Q

composition of human milk

A

88% water

1.5% protein (lactalbumin and casein)

7% carbohydrate (lactose)

3.5% lipid

Small quantities of ions, vitamins + IgA

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23
Q

mechanisms of milk secretion?

A

2 mechanisms!

Lipid droplets = apocrine secretion

  • Droplets secreted carrying small amount of cytoplasm with it

Proteins = merocrine secretion (also called exocytosis)

  • Proteins in milk made in rER
  • Secreted via vesicles which merge with apical membrane to release only their contents into duct system
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24
Q

changes to breast after menopause?

A

Secretory cells in TDLU degenerate leaving only ducts

In connective tissue, fewer fibroblasts and reduced collagen and elastic fibres

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25
blood supply/drainage to breast
26
lymph drainage of breast
27
diagnostic Ix breast lump?
Needle core biopsy Vacuum assisted (large volume) biopsy Skin biopsy Incisional biopsy of mass
28
therapeutic approaches breast cancer?
Vacuum assisted excision Excisional biopsy of mass Resection of cancer * Wide local excision * Mastectomy
29
needle core biopsy results?
B1 - unsatisfactory/normal (doesn’t rule out malignancy?) B2 - benign B3 - atypia, probably benign B4 - suspicious of malignancy B5 - malignant * B5a - CIS * B5b - invasive
30
which cell types line ducts + lobules?
Myoepithelial cells - **CONTRACTILE** * Assist in milk ejection + provide structural support to lobules Epithelial cells * Produce milk both lie on **basement membrane**
31
benign breast tumours?
Phyllodes tumour Intraductal papilloma
32
Ax gynaecomastia male?
exogenous/endogenous hormones Cannabis Prescription drugs Liver disease (metabolises oestrogen)
33
fibrocystic change affects? risk factors? Symptoms? Macroscopic features? Miscroscopic features? Tx?
very common in women age 20-50 RF = early menarche or late menopause symptoms = smooth discrete lumps, sudden pain, cyclical pain, or asymptomatic macroscopic = usualy small + multiple microscopic = apocrine metaplasia (change of ductal depithelium to apocrine) Tx = exclude malignancy * reassure (most resolve after menopause) * excise if necessary
34
hamartoma?
**Circumscribed** lesion composed of cell types normal to breast but in excess
35
fibroadenoma? risk factors? clinical features? histological features?
Common - peak incidence in 30s RF = commoner in african women Clinical features * Usually solitary * Painless, firm, mobile, discrete * “Breast mouse” because of how mobile they are * Solid on USS **biphasic tumour** = epithelium + stroma
36
Tx fibroadenoma?
Reassure Excise if patient wishes
37
sclerosing lesions breast? malignant?
Sclerosing adenosis and radial scar benign but may mimic carcinoma! - esp **radial scar**
38
sclerosing adenosis s/s?
often asymptoamtic but can present with pain, tenderness, lumpiness/thickening
39
radial scar features?
\<10mm stellate shape central puckering radiating fibrosis
40
Dx radial scar?
requires **vacuum biopsy** as can mimic + become carcinoma
41
fat necrosis Ax? features? Tx?
local trauma (seat belt injury) + Warfarin ## Footnote features = foamy macrophages + fibrosis Tx = exclude malignancy + reassure
42
duct ectasia? clinical features? risk factors? Tx?
affects subareolar ducts clinical features * pain * acute episodic inflammatory changes * bloody or purulent discharge * nipple retraction **associated wih smoking!!** Tx = treat acute infections, exclude malignancy, **stop smoking**, excise ducts
43
Ax acute mastitis/abscess? Tx?
Ax = 2 main causes * duct ectasia (mixed organisms + anaerobes) * lacation (staph aureus) Tx = antibiotics, percutaneous drainage if abscess * treat underlying cause i.e. **remove ectasia**
44
phyllodes tumour affects? features? Tx?
Age 40-50 features * Slow-growing unilateral mass * Biphasic tumour - unlike fibroadenoma, dominated by **stromal** overgrowth * leaf-like structure Tx = prone to local recurrence if not adequetely excised
45
intraductal papilloma s/s? Tx?
Nipple discharge +/- blood large lump near nipple + smaller lumps further from nipple Treatment * Benign can be excised without margins * However, atypia or CIS needs completely excised with margins
46
malignant tumours breast?
Malignant phyllodes tumour Angiosarcoma - post radiotherapy (iatrogenic) Lymphoma Metastatic tumours * Carcinoma: lung, ovarian, clear cell of kidney * Melanoma * Soft tissue tumours - leiomyosarcoma * You can get primary leiomyosarcoma of the breast, **precursor is phyllodes**
47
breast carcinoma refers to?
Specifically talking about epithelial cells * Glandular epithelium of TDLU It is an adenocarcinoma but usually just referred to as breast carcinoma
48
precursor lesions breast carcinoma?
Ductal * Epithelial hyperplasia * Columnar cell change +/- atypia * Atypical ductal hyperplasia * Ductal carcinoma in situ Lobular * Lobular in situ neoplasia * Atypical lobular hyperplasia * Lobular carcinoma in situ
49
in situ carcinoma?
**Confined within basement membrane** Malignant but non-invasive **Precursors of invasive carcinoma** Classification * Lobular * Ductal
50
lobular in situ carcinoma types? features? Tx?
2 types * Atypical lobular hyperplasia (\<50% of lobule involved) * Lobular carcinoma in situ (\>50% lobule involved) features: * multifocal and bilateral * Incidence **decreases** after menopause * **Not palpable, not visible grossly** * May calcify - mammography Tx = ????? excision not possible because multifocal and bilateral - so mastectomy??? since true precursor for carcinoma
51
ductal carcinoma in situ (DCIS) features?
15-20% of breast malignancies are DCIS Arise in TDLU Single duct malignant epithelial cells confined within basement membrane **May involve nipple skin (Paget’s)**
52
Paget's disease of nipple? S/s?
High grade DCIS extending along ducts to reach epidermis of nipple Still **in situ carcinoma**!!!! s/s = itchy, sore, discoloured, ulcerated
53
DCIS risk? Tx?
75% progress to carcinoma Tx * surgery * radiotherapy (don't use chemo)
54
microinvasive carcinoma?
Rare DCIS (high grade) with invasion \<1mm Treat as DCIS rather than carcinoma in terms of management
55
risk factors breast cancer? protective factors?
* risk increases with age * COCP, HRT * early menarche, late menopause * nulliparous * precursor lesions * BMI, alcohol, smoking * genetics * 1st degree relative doubles risk * BRCA1, BRCA2, TP53, PTEN exercise + NSAIDs lower risk
56
mortality of breast cancer?
57
commonest type of breast carcinoma?
ductal carcinoma
58
breast carcinoma grading?
Objective assessment of * Tubular differentiation (1-3) * Nuclear pleomorphism (1-3) * Mitotic activity (1-3) So total scores * 3, 4 or 5 = grade 1 * 6 or 7 = grade 2 * 8 or 9 = grade 3
59
hormone receptors breast cancer? Tx?
80% oestrogen receptor (ER) positive * anti-oestrogen therapy * oophrectomy * tamoxifen * aromatase inhibitors (letrozole) * GnRH antagonists (goserelin) Progesterone receptor HER2 * Tx = **trastuzumab** (herceptin)
60
tumour staging breast cancer
61
presentation breast cancer?
50% asymptomatic 50% symptomatic: * dimpled skin * visible lump * nipple change e.g. inversion * bloody discharge * texture change (peu d'orange) * colour change
62
process breast clinic?
examination + mammogram + USS
63
treatment breast cancer?
Local (surgery, radiotherapy) General (chemo, hormonal therapies, targeted therapies) * Small tumours = lumpectomy * Large tumours = mastectomy
64
systemic Tx breast cancer?
Chemo * Adjuvant * Neo-adjuvant Hormonal therapy * Non-invasive (SERMs, AIs, GnRH) * Invasive (oophorectomy) Targeted therapies * Trastuzumab (herceptin)
65
nipple discharge that isn't blood or yellow?
physiological
66
mammogram vs USS for breast lumps?
Mammogram only useful \>40 age USS before that
67
if size of lump fluctuates with mensrual cycle?
likely to be benign
68
eczema of the nipple?
paget’s disease
69
tomosynthesis?
3D mammography
70
imaging modality of choice for women with **palpable mass**?
USS
71
disadvantages USS?
low sensitivity DCIS (mammogram has high sensitivity)
72
uses of MRI in breast disease?
lobular cancer Paget's disease of nipple
73
commonest cause of breast lump age \<30? 30-50? \>50?
\<30 = fibroadenoma 30-50 = cyst \>50 = cancer
74
Best imaging modality to assess breast masses? then?
USS then do mammorgaphy if US findings suspicious or age \>40
75
cyst
76
cancer - irregular, taller than it is wide (fibroadenomas wider than they are tall)
77
staging of advanced or recurrent breast cancer?
CT chest, abdomen, pelvis to look for metastasis (not required in local operable breast cancer)
78
worrying nipple discharge? Ax?
unilateral single duct is worrying Ax * Invasive cancer * DCIS * Duct ectasia * Papilloma
79
breast asbcess/infection seen in?
Tend to see in 2 groups of patients * Breast feeding * Duct ectasia - smokers
80
types of breast surgery for cancer?
breast conservation (just as effective) mastectomy
81
procedure breast conservation?
clear margins \>1mm PLUS breast radiotherapy
82
axillary metastasis staging? axillary treatment options? complications?
USS axilla + core biopsy axillary Tx = axillary clearance + radiotherapy comps = axillary node clearance can result in lymphoedema
83
neoadjuvant endocrine therapy?
pre or peri-menopausal (menstruation in last year) * tamoxifen 20mg daily for 12 months + goserelin implant * letrozole 2.5mg daily for 12 months + goserelin implant post-menopausal * letrozole 2.5mg daily for 12 months
84
side effects aromatase inhibitors?
joint pain fatigue weight gain loss of libido mood swings
85
mammogram + biopsy
86
Dx? next step? Tx? sentinel node biopsy indicated?
Dx = suggestive of DCIS **vacuum biopsy** Tx = surgery + radiotherapy (no chemo) no its DCIS so in-situ i.e. cant metastasise
87
Dx? next steps? Tx?
Dx = cancer or radial scar next steps = core biopsy (no need for vacuum as localised mass) Tx = WLE
88
Tx = neoadjuvant chemo - **trastuzumab** then WLE + axillary node clearance
89

3rd year medicine (13 decks)

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