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Um in kent and I'm moving over to psych in a couple of weeks, um but oh mg is what I really enjoy, so, I'm glad I'm being able to come and give you the talk for this. Um It's called an overview because o. N. G. Is a huge topic and you've got the next seven weeks to kind of go through more detail, we'll be talking about pregnancy complication and the miscarriages in a couple of weeks, are we doing another talk on that, So, this there's a lot of information in this, which will probably go through quite quickly, but you can have the slides. I think I believe it's being recorded and there'll be lots of other talks to go through it in a lot more depth, um but this is a very quick overview of kind of everything you'll need for your Oscar stations and a little bit more before we start anyone got any questions or anything specific that they'd like to go over. No okay, feel free to put anything and I can't see the chat, but feel free to put something in the chair and then hopefully somebody will shout at me that there's something there um as we go along, that's fine, I don't mind answering questions as we go um So we'll start with me just go through basically the same things twice, so the history red flags, you need to look out for and some kind of common stations once we've gone through, go any and knobs about those things, we'll look at some common common follow up questions that you often get in all skis, The communication skills you'll need to do well in these information giving and then a quick practice station at the end, so a gynie history. So obviously all of the histories have their same template structure. Your introduction, your one line are describing exactly what's happened, so you're presenting complaint, so 30 year old female presenting with severe dysmenorrhea. It's just one line you're presenting complaint. The history is the longest part that you're going to be doing um the history of presenting complaint, so starting really in depth about exactly what has happened. Um Socrates is taught for pain, but really I still use it now for absolutely everything because it's a great template to work around to get all of the information you need for pretty much any presenting complaint, um but like I'll talk about later in the communication skills, part don't feel stuck to it, let the patient guide you in terms of what your next question will be or how you respond instead of having a checklist in your head. Um Past medical history important, especially asking about things that are relevant um So asking generally, do you have any medical conditions is really important same with allergies and medications, but also asking specifically have you ever been diagnosed with endometriosis, fibroids that kind of thing for these stations. Medication analogies, important social family history very important um And then I see ideas, concerns, and expectations, which I imagine you're all familiar with if you're from georgia's. It's very it comes up a lot in our communication skills, teaching, and in the off skis um and it's really important in gynie and obs histories. Because often it can be with china. Some people patient's can feel really embarrassed. It's not something they're used to talking about it, it isn't embarrassing, it's something that we talk about we talk to. As you know medical students and doctors all the time, um but some people find it difficult to discuss intimate things with somebody they don't know um So, Isis and your communication skills can be really important, so then gynie specific um we'll go through them in more depth in a minute, so the last menstrual period, their typical cycle pain um having sex, the kind of um like sexual health, their sexual health history. If they're on contraception, um they're smears if they're 25 over that's when they start having the smears. Previous pregnancy is including things like miscarriages and terminations, and the possibility right now of them being pregnant and the kind of dis, discharge and spotting especially after intercourse. So this is why they're important the last menstrual period will give you really important information about their cycle regularity and the possibility of them being pregnant or possibility of them being menopausal now the typical cycle. You're mainly looking for things like irregular periods, heavy periods, really painful periods. Because if you ask somebody what your typical cycle is, I think most people would know it's typically about this many days, I bleed for this many days. It's it's heavy or it's not heavy and it's pain, it's painful or it's not, um but those are the kind of questions you want to pointedly ask if they're not willing to open up about it immediately. Um so Pcos, endometriosis fibroids, all of these can cause majority of the gynie presenting complaint. Which is why it's important to kind of re drill down into exactly what's been going on. Pain during intercourse is important. Um We're not going through a sexual health history in this talk, It's useful to go and have a look through it in your own time though um because it does come up in georgia stations, um but for a gynie specific station, just asking about pain during intercourse is kind of enough for the sexual history, unless something more comes of it, so it can either be deep or it can be superficial and then different things cause the deep and different things called a superficial like endometriosis, etcetera, so the cervical smears women over 25 over will be invited and it doesn't stop until age of 64 it will be every five years. It used to be three and recently it's been changed every five years and the smear the sample that is taken is tested for HPV. If it's positive then it is sent off for cytology, but if it's not positive doesn't get sent off cytology. The person returns to routine screening every five years um Usually patient's will know if they've had this done and what the results were um. It can also come up in these stations that you ask them what was your last smear like and they said oh I haven't had it. I'm you know, I'm anxious about having it and the station could turn into a bit more of a communication skills station about exploring why they don't want to have it, explaining why it's important information giving that kind of thing previous pregnancies and we'll go through g. N. P. A bit Later, recurrent miscarriages can point you to things like anti phospholipids syndrome important to make sure you clarify exactly what they mean by pregnancy because some people think a baby that so they've gone through an entire pregnancy. They've given birth and they have a healthy baby at the end, but obviously you can have miscarriages terminations. Stillbirths. There's lots of different things you need to be very clear about with the patient um discharge and spotting. We'll talk about in more detail in a bit, um but post menopausal bleeding is one that comes up quite often and is the biggest red flag for endometrial cancer. Um It's really important that one does come up a lot in written exams and in our skis, um so make sure it's one of the top differentials. If you come to that kind of station discharge can be lots of different things like bacterial vaginosis, s, t. I s, and we'll come to a bit more information that in a second um lots of additional questions with this. Um you always want to do a systems review anyway, so to look at fevers, feeling generally unwell, pretty much screening for every single system in the body, um So fevers especially can pointing towards pelvic inflammatory disease, especially if they're feeling really kind of fatigued, generally unwell, and getting fevers on and off fatigue in itself can cause. Can be you can start thinking of anemia. If they have really heavy periods, um it's quite common for hB two drop quite low, so fatigue and looking pale and just feeling not great, can often point you to that and also you've got your constitutional symptoms about malignancy, so fatigue, weight loss, night sweats, all of those things, urinary symptoms like urgency, frequency, dysuria. There's a huge link between the urinary system and the guy in the system. So making sure you go through. Kind of all of this is important especially in older patient's because prolapse is often a cause of lots of urinary symptoms um and you'll tend to to refer these patient's to a uro gynecology clinic um rather than them being dealt with gynecology specifically, um bowel symptoms, so change in bowel habits can pointing towards malignancy, but pain when opening bowels can pointing more towards endometriosis because of the deposits that you can get around. Weight loss and abdominal distension cause ovarian cysts and ovarian tumor's. They often you often don't know about them until they're very very big and it's very very late because abdominal dispense distention and discomfort can be pretty much the only sign until it's really far gone um. And women and well people generally often just think they put on a bit of weight, which is not true. It's actually this huge cyst um or a huge tumor, so if somebody comes in and just says oh you know I feel like my tummy's got a bit bigger, I've got it's a little bit uncomfortable, don't dismiss it it really often is dismissed. When you know, doctors are busy and patient's don't think much of it and then it goes unseen for a really long time so if somebody comes in and they say you know big abdomen quite uncomfortable um This is it's very new hasn't happened before. Um then make sure you're screening them for this especially with the very malignancies, you can also get ascites red flags, So pain is always a red flag, but specifically sudden onset severe pain can lead you towards things like an ectopic pregnancy, ruptured ovarian cysts, ovarian torsion, chronic severe pain, endometriosis is the biggest player here. Chronic pain and endometriosis could be really bad pelvic inflammatory disease. Adenomyosis. All of those kind of things. Postcoital bleeding in younger women is typically due to electro peon, um kind of, when the transitional zone, kind of pushes itself out and then you get bleeding from those really kind of tender cells after sex. Usually, it can be pretty much any point it can be after using a tampon or something like that um but that's a really common cause of it, but it can also be malignancies. It can also be sci, there's lots of different reasons uh like we said any of the constitutional symptoms, weight loss, fatigue, night sweats, anything that might point you towards malignancy into menstrual bleeding. It can be as simple as contraception. A lot of contraception will either stop your periods, are kind of, give you a like a irregular periods or some kind of spotting, um but it can also be things like fibroids, malignancy, ovulation can cause that miscarriages as well, So there's loads of different things that cause most of these presented complaints post menopausal bleeding like I said earlier endometrial cancer is the big one that they like you to know, but vaginal atrophy can also do it pretty much all of the cancers, uterine cervical, vaginal, they can pretty much all cause it um abnormal discharge with volvo skin changes and itching should always point you towards doing an s. T. I. Screen and painful sex. Again, we talked about it, endometriosis, public inflammatory disease, s. T. I. S. If it's deep, if it's kind of more of a superficial pain, it can be to do with vaginismus so kind of really tight um feelings When you end up so superficial, let me go back to it with vaginismus. Um I've lost it, so deep is more to do with things like endometriosis and s. T. I. S. And superficial is more to do with tightening of the muscles, which makes it really painful that again it's more to do with sexual health and maybe a euro gynecologic um so with the gynie stations, it's very rare I don't think I ever had a station at George's, where I was asked to present at the end. I know when we practice and do all sorts of all these things you often get, we often practice presenting but really the only time I actually had to present something was in my final year, which was when I had to pretend to call a Mezrich and ask for help, but other than that never really had to present something, but if you are asked to present something or you just want to kind of go over with the examiner, s far as a system that pretty much everybody uses the situation, background assessment, and recommendation, so for example the situation, 24 year old female with heavy periods and fatigue, which is likely anemia from heavy bleeding caused by known fibroid, so you kind of want to give it a title. Because if you just start saying a 24 year woman has come in with really bad bleeding. She's not been feeling well. She's been really really tired and fatigued and really tired um that doesn't tell the person on the other end of the phone or who you're talking to what's actually happening, so try and give it a title um and make it really clear right at the beginning, what you think is happening and what is happening and then background you can kind of go into a little bit more detail. You also want to put in here like the past medical history or anything that's relevant in their medication or family history. So in this case, six month history of heavy and prolonged period she's known to have to uterine fibroids. She's become tired and more pale than usual over the last couple of weeks. Your assessment is going to be your investigation, so your examination your blood tests or any special tests, so in this case pale and lethargic abdomen is nontender, but you can feel the masses um and an h. B. Is 65 then your recommendation is when you are saying what you have done or what you would like to do and in real life what you would like the team you're referring to to do so. In this case, her low hb, we'll send off a cross match and we'll give her a unit of blood maybe more than one unit of blood um. And if you're on the phone to the guy, any team say please can you come and review her because I'm concerned that the fibroids are causing severe bleeding and they may need surgical management, so you're asking them exactly what you want cause. If you just say, can you see her please, they might say no because they're busy and you don't have a clear indication for why or they might ask lots more questions, so it's be very clear with what you're asking them to do. Um So in this case, you may need to refer to the guy, any team for the management, e. G, something like uterine artery embolization um. At the end, give your top differentials ideally three in the order of probability slash the order of severity. Um Your investigations remember where you are you'll be told if you're in a gp in the clinic or in a hospital, if you are in a gp surgery and somebody really really unwell, your first thing that you're going to say that you're gonna send them into hospital um because you can't manage that in the community and structure it as examination, blood's imaging and any special tests that you might do management, you tend to go from conservative to medical to surgical, so you're not jumping straight in with let's cut it out. Um you're going to start with things like healthy diet, analgesia and then move on to medications like contraceptive and in the case of endometriosis usually kind of last line, but really only definitive thing is laproscopy plus minus removal of adhesions and deposit cinnamon endometriosis in fibroids, uterine artery embolization, or you could do a hysterectomy or a myomectomy. There's lots of different things but make sure you don't just jump to the very specialist, very invasive things because remember you're not that specialist and they're not really expecting you to have the amount of information that a specialist would have they just want to know that you're safe, you can safely identify when things have gone wrong and you know what to do with it and who to send it to um So these are probably the most common gynie stations, so menor, asia, dysmenorrhea, heavy painful periods, pv bleeding, so abnormal, pv bleeding, abnormal discharge, and amenorrhea. There's loads of information within this so we'll go through I think quite quickly and then you'll get other talks that go through in more detail, um but does anyone have any causes of heavy painful periods. They tend to come together heavy and painful but causes of either endometriosis. Yep endometriosis is a big one. There's loads of different things. Um Endometriosis is definitely one of the most common cause. I would say and I think it's becoming a lot more people are coming a lot more aware of endometriosis over the last couple of years of being diagnosed a lot more because I think patient's are a lot more informed about what is normal in a period and what isn't um because I don't know at least me growing up. I was just told periods should be painful and they should be heavy and then you kind of leave it at that and people don't ever really think actually that's not quite right, um but now people are talking about it a little bit more openly and realizing well that my period doesn't look it, doesn't feel like that you're like it's it's much longer, it's much heavier, it's much more painful and then they think um medical attention earlier, but having said that it still takes a long time to be diagnosed with endometriosis, and I think it's probably because you go to the g. P. And you say your periods are painful. If you have a g. P, who's busy, they might just say well, that's normal periods as opposed to hurt, and then it can take a lot of different gps a lot of different specialists to end up actually getting a diagnosis and your management. Um We'll talk more about demetrius in the second pelvic inflammatory disease can also cause this, the same as fibroids. There's loads of other things that can cause that this is not an exhaustive list, but these are the ones that are common in oskin's um So endometriosis lots of different symptoms but typically heavy painful periods associated with abdominal pain, not necessarily crampy abdominal pain. It can just be any kind of abdominal pain, which can include pain during intercourse and pain on urination and also pain when opening about, so the endometrial tissue tissue grows outside of the uterus and it can literally go anywhere. Typically, it will go to local areas like the fallopian tubes and the bowel um so that can cause pain. It can cause fertility problems. It can cause a fixed retroverted uterus because of the adhesions um which you are likely to pick up on your examination and in your written exams, it's like a um a very quick diagnosis. When they say that to you, they always pretty much will always mean this, um but the deposits can like I said literally go anywhere. I think they can also go like as high as the chest um So you can get a myriad of symptoms with this that can seem unconnected and like unconnected, but actually it's all because of the same thing, the only real definitive way to diagnose it is to look at it so to do a laparoscopy and actually go and see the adhesions and the deposits themselves management really realize around managing the pain um that can be done with analgesia, but often it's really not enough because it is one of the most incredibly painful conditions. People really suffer with it um hormones, so contraceptives can be really useful like the combined pill, the implants, and the eye us to regulate the cycle, is what we're really trying to do um or you can use gonadotropin releasing hormone analog is like I think the Zoladex, um but those look that's quite a severe option. It's it's not a very nice medication so trying to manage it with other things is very important um and then we're moving on to surgery, so we've got the conservative, the medical, and then the surgical um the deposits can be removed. The adhesions can be removed, but they often go back and the surgery itself, any surgery that you do in the abdomen is a risk factor for causing further adhesions. So some women opt to have it removed and some women opt to just leave it as it is because they don't want to make it any worse um But on laparoscopy, this is what you are likely to see, so you've got your uterus and your fallopian tubes and your large intestine. There you can see the right ovary, not quite the left, um and all of these little black red marks those are deposits of endometriosis, So in this case, it's not quite so it's it's not so extensive It kind of looks like it's just within the pelvis, um but what you can often get is these little black spots getting bigger and being everywhere um So that's endometriosis pelvic inflammatory disease is when it's typically caused by an untreated st, i like chlamydia or gonorrhea so if you go a long time without it being treated, it can kind of spread and cause information in your entire pelvic area, presents with pain in lots of different areas, abdominal pain, pain you're in sex, dysuria, dysmenorrhea pretty much any type of abdominal pain. It can be caused by this. You put you're also likely to get the abnormal discharge and you can also get spotting because of this, untreated sci, because of the infection, can diagnose it with the laparoscopy, but a positive s. T. I. Swab associated with severe pain is enough to support a diagnosis and management of this. Um Antibiotics and pain management are the main ways of treating it, as well as contact tracing is important, which can be done anonymously via the gp. Um It's that's a whole other talk about the confidentiality and tracing contact tracing with them, especially sexually transmitted infections, but it can be done anonymously. Um fibroids They again are a cause of really painful really heavy periods and sub fertility especially if they're kind of subserosal or sub mucosal when you can see in the picture there kind of really in the way um So management is either about removing the fibroids or just managing the symptoms. If we kind of go for our conservative medical surgery, the conservative is just about analgesia if it, if it's causing severe pain um and you can give certain medicate medications for um the blood loss like tranexamic acid for the blood loss. You can also use an eye us to reduce the amount of blood loss, but obviously if you've got really bad, sub mucosal podunk yah lated fibroids would be very difficult if not dangerous to put in an eye us. Um So it really depends, case by case about what the fibroids look like where they are how big they are um and said typically work for pain relief, um although it's not great to be on those long term because if your stomach you might want you might end up getting ulcers um being on and says long term is not good, so typically will end up adding something else some kind of hormonal therapy like the compound. The combined pill, oral and injected progesterone can also be really helpful, but the definitive management of these is around the reduction so reducing the size of them or just getting rid of them completely. Now, a hysterectomy is removal of absolutely everything so you would not be left with the uterus. Uh Once you've had a hysterectomy and that's a very radical way of managing fibroids. Know if you're if the patient is, has had all their children and they're very happy with you know their what they their reproductive life and then they're done with they're making their family. Then a hysterectomy might be the right way to go for them um and they might be perfectly happy to do that, but in a younger patient, it's unlikely that they will want to deal with their fibroids by having the uterus removed, so there are other options. Myomectomy just means removing the fibroid, which can be tricky, it can cause a lot of bleeding. It can cause a lot of scarring. It can end up meaning that you need a hysterectomy during that surgery because it's just leading too much. It's not working. Uterine artery embolization is literally that you embolize the artery that is supplying that fibroid, which then should shrink the size of that fibroid. There's lots of complications with that, but that tends to be the least invasive option as well as endometrial ablation at minutes. Um Lots of information there, it's all the management of fibroids can be quite complicated, which will be discussed again another um another talk, so, pV bleeding by which I mean abnormal PV bleeding um Any causes that you know of that, obviously just a period would be TV bleeding, but it may mean more inter Menschel pV bleeding, s. T. I. S, yeah, s. T. I. Has been my only sort of infection really um I guess you can probably split it up into pre and post menopausal courses um And this is very generalised you can get the pre ones in postmenopausal as well. Cervical ectropion is a really common cause of bleeding, especially in younger people and especially in people on the contraceptive pill. Um It's more likely more likely to get this and it's typically postcoital bleeding. It's not very much, it's kind of a few spots on some paper on the toilet paper when they wiped or something like that miscarriages, more of an ob thing that we'll talk about in a second, but can be pelvic inflammatory disease, malignancies, can also cause that and you can have malignancy pre or post menopausal, but like I said earlier post menopausal. They love this at georgia, and I think most medical schools, they love this post menopausal bleeding about endometrial cancer, so if you get a 70 odd woman who's come in with spotting or PV bleeding and it's been more than 12 months, which is likely to be a 70 since her last period. This is the main thing that you want to rule out malignancy. In general is the main thing you want to rule out, but endometrium is the most common so abnormal discharge, then so some discharge is normal and many people young people especially won't know that. Um again it's kind of like periods. People might not know that their periods are abnormal because they don't talk about it. They don't see much about it, they haven't been educated um and it's the same with this. People don't really tend to talk about their discharge among friends just on an average day, so some people might think that what they are having is normal and it's not or it isn't normal and it is um the main thing that you're going to get in Medical school of skis and written exams about this is s. T. I. S. So stds that have an abnormal discharge pretty much. All of them, gonorrhea and chlamydia can both have kind of a yellow, smelly, thick, discharge, trichomonas, it's yellow and frothy discharge with itching and irritation and when you look at the cervix, it could be called a strawberry cervix, lots of little red dots um You can also have bacterial vaginosis, which is not an s. T. I, um but as another one that comes up quite frequently, so you get thick kind of white gray discharge and they often describe it smelling fishy um So those are kind of your key words that you're looking for when you're looking for discharge and if you're taking a history and they have this. The things you want to ask about volume so how much difficult, always because people in their minds have different, if they say a lot that means different things to different people, um but give it a go volume, color, consistency, and smell um and again this is something that people might be quite embarrassed to talk about um even though we talk about it a lot. As you know, medical students and doctors, other people are not used to talking about it, so approach it sensitively. Signposts make them feel comfortable before you start asking the difficult questions um amenorrhea, a big one, so it means not having periods essentially a menorrhea. What kind of causes do you know well. The most common cause maybe it's a big topic yes menopause is definitely a big cause of amenorrhea, Probably, I would say the most common natural course of amenorrhea. Um There's two different types, there's primary and secondary to primary is when you've never had a period at all, um So no menstrual periods by 15 with girls that have secondary sexual characteristics, or people that have secondary sexual characteristics and 13 in those without secondary though is cessation of menstrual periods, So you they have had periods before, but now they've had a period of 3 to 6 months where they haven't had any which is in in women or people who have had periods regularly before 6 to 12 months. If they have always had irregular periods, If they haven't had a period for 6 to 12 months, then you're starting to talk about secondary amenorrhea, primary. I won't spend too long on this because we'll go through it again later and we need to get through the obstetric stuff as well, but endocrine stuff is typically what will cause this um So knowing your HBA access is really important um and also things like stress, weight loss, the overuse of exercise, and things like that can also delay having a period, secondary amenorrhea. Again, it can really typically be because of um endocrine problems, cushing's can do it, so the HBA access you really do need um and you can get there's, we won't go into it now but primary uh very insufficiency can be caused by genetic things like Turner syndrome um which can also cause this, it can cause primary and it can cause secondary, but PCOS is probably one of the most common reasons for secondary amenorrhea um and it's associated with features of excess androgens so hair, acne virilization um and PCOS is another common thing that really comes up a lot um so it presents with irregular periods, can have those androgen excess symptoms may also experience some weight gain to diagnose it. You need two of the three so irregular periods, high testosterone levels and an ultrasound showing multiple follicles in the ovaries, so they are not cysts, so calling it polycystic ovarian syndrome was a little bit mean of the people who named it because they are not cysts. What you will see in the ovary are under are just follicles that never um ovulated, so they just kind of sat there ovulation didn't happen but they matured, so you just get lots and lots of these little follicles within the ovary. Management tends to be more again conservative, medical, surgical, um lifestyle changes including diet and exercise. Because um it can cause weight gain and reducing, reducing your weight will reduce the amount of testosterone that you have in your body um and also it's very highly linked to insulin resistance. So often people get put on that form of PCOS, but diet and exercise and lifestyle changes can also help with that bit. Medications contraceptives tend to be the first line and they can be beneficial like the combined pill because it can start to induce regular or regular bleeds, not regular periods but regular bleeds and start to get things back on track, okay, so that was gynie sorry, I apologize it was very very quick, um but you'll get more information on it in another session, so any questions on gynie, before we go to a stay tricks. There'll be a chance at the end to have a chat about it all as well, so we have our skeleton structure of a history, which you will always stick to and you always need to ask all of those things, but then you in these specialty ones you need to make sure you're adding in these specifics, so obstetrics, it's very similar to guy that you want to know things like last menstrual period, whether they've had their smears and what the um and what the outcomes of those were their sexual history there contraceptive history. You do want to know all of that, but you also want to know this their current gestation. If they've had their appointments, they're booking appointments, their anatomy scans, etcetera, their blood tests, but some remembering that people from low socioeconomic backgrounds or those being abused or those you know with low access to things may not be able to get to their appointments. I think in Oscar stations and just in general life. If somebody says to you oh, I haven't been going to my appointments, it's easy to judge them and say well how do you expect us to look after you. If you don't turn up, but there's so many different reasons why that might happen and especially at george's, they love the communication skills session um stations, So you might think you're taking a guide you're an obstetric history and it turns out to be a sexual abuse history or something like that and you need to approach it with a very different kind of way of thinking, they're recent status. They probably will know this especially if they've had previous pregnancies um and then rigidity, so your number of pregnancies and parity is a number of birth with the gestational age of more than 24 weeks, even if stillborn, we'll go through this and do a kind of a practice in a minute um and you always want or socrates, specifically looking at bleeding, pain, nausea, vomiting, any discharge or headaches, visual disturbances, edema, itching, jaundiced as well, can come up a lot in obstetrics histories, chest pain, shortness of breath, fatigue, fever. All of these things doing your review of systems and looking for your red flags, so in this case ending the stations again you're gonna give your top differentials ideally three in your order probability slash severity, remember where you are with your investigations um Often in obstetrics, what you can do if they're in their first trimester. You can refer them to the early pregnancy unit, the ep you um and it would it make sure that really good in asking is if you know that that exists and that's what you're referring them to instead of just the hospital um and make sure that you stick to kind of your level. Your you know you're a medical student, you're not a consultant in the specialty and they don't expect you to know what a consultant in that specialty would know or a reg, or an s. H. O. They expect you to know medical student or f, one level of knowledge um. So when you are talking through your management, you are not going to be the one who goes and does surgery on them or does the laparoscopy, so what you need to say is that you will refer them to the gynecology surgeons for this, so say what you know and then say who would do it because it isn't going to be you. So make sure that you always talk about the referrals and involving a senior and it's really good to summarize with the patient Before you actually end the station, you may not get time, but summarizing throughout and at the end helps you um and I'm sure you've probably done this in your practice before it helps you because you might end up realizing oh I forgot that question and it's completely fine to just add that question on. At the end. As long as it doesn't affect the flow of your conversation with the patient, you won't lose marks for adding something on at the end. Um It's always better to add it on than to think oh I forgot that, but I don't want to start talking after I finish, so I'll leave it always add it um and you can amend what you say at any point um okay, so comma noski, stations with obstetrics a lot of them end up being information giving, so information giving about things like multiple pregnancies, gestational diabetes, um what they're like the need for inducing in certain in different um pathologies so that comes up a lot of the history of abuse, domestic abuse, sexual abuse that can come up a lot as well. But when we're talking about specific pathologies for oh engine of stay tricks, these are kind of the ones that come to mind so pv bleeding in pregnancy. What would you start thinking if you heard that miscarriage yeah, exactly so it depends on the gestation, um so early gestation, it's more likely be caused by something like a miscarriage and I know I keep harping on about it, but michael ectropion as well make sure you go and have a look at this after. So I collect tropia because it's something that a lot of people. I think don't know about, but it's a very common cause of PV bleeding that is innocent um later in the later gestation, ruling out things like visa previa, placenta previa, placental abruption, which is tends to be painful where the others are not things like infection as well. So this is where ensuring you've got a really thorough obstetric history is really important um and tailoring it to the presenting complaint. Um abdominal pain. Um There's lots of different things. Again, there's so much in ob synjardy, they are both huge specialties in themselves um and five weeks and p year is not enough um to learn all of it. Um so contractions it that is as simple as it can be. They can just be contractions and in late gestation completely normal. It's just um the beginning of labor, but it can signify problems if it occurs too early, so placental abruption is probably the main one that I would learn if I were you um severe abdominal pain, often with quite heavy PV bleeding and they tend to describe the abdomen or the uterus as being woody so quite hard when you push on it. Um In early pregnancy, abdominal pain can also point towards miscarriage, but don't forget that people who are pregnant can also get other things like appendicitis. This tends to come up a lot. They try to trick you it's not fair, um but it is important to remember that it doesn't have to be an obstetric cause of abdominal pain, so always in your differentials say or include something like appendicitis. If they've got right iliac fossa pain, let's say a little bit more about placental abruption, so it's when the placenta pulls away from the uterine lining, which will often cause a lot of bleeding and the bleeding can either be, can either come out and you end up getting p. V. Bleeding or it can kind of get stuck behind where the placenta is and this is kind of a little bit more dangerous because they have pain, but you don't see any bleeding and so it can often be kind of overlooked but actually they're bleeding into the uterus sick and we're in significant amounts which you won't see until it gets really bad, um so it can cause sudden severe pain with PD bleeding and on examination, you'll get this hardwood the uterus as a junior. You're not going to put a speculum in and have a look because you might make it worse pretty much all of the severe bleeding in pregnancy. You're not going to touch um you're going to immediately refer this patient to a senior and a specialist and then you do what you can so you're not going to do any examinations down below, but what you can do is you can do their bloods. You can do an abdominal examination As long as you're kind of soft with it, so you can send off the blood if severe bleeding, they may need a transfusion It depends, um but the most important thing is to refer this patient quickly and appropriately to the right people and identify that it is an emergency to the mother and to the baby. One thing that you can do is an ultra abdominal ultrasound to check on the baby or you could just get a Doppler to have a look at the heart beat um and an important thing to mention is to keep the nil by mouth because they may need to go to theater. They may need to deliver the baby now, they're likely to need to deliver the baby now because of the bleeding. It's very unlikely to stop on its own um so keeping the nil by mouth until the specialist is seen, in which it won't hopefully wouldn't be long in this case, it's emergency would also be important um okay, and headache. So really this is a pre eclampsia station pretty much always and it does come up um preeclampsia. Something you need to have a really solid hold of uh ensure that you get a full socrates history of the headache, but you know you won't really get much else apart from they put a really bad headache, but the systems review is where you're going to get the majority of your information, so visual disturbances, swollen ankles, fatigue, urinary symptoms. Things like that pregnant people should have had very regular BP monitoring during their pregnancy and previous pregnancies. They may or may not know what it was that they probably won't know the numbers. They probably will know if it's been high or low or normal. Um They may already be taking the beetle all if they've got really high BP so systolic over 100 and 40 or uh diastolic over 90 then they probably will already have been started on anti anti hypertensives, so ask them after their medication, ask them what's happened in their prenatal appointments and they will usually be able to tell you so preeclampsia. Typically, it's due to incomplete remodeling of the spiral arteries within the placenta. This is something that will be talked about in another at another point in more detail, but that is kind of the typical cause of it. Um The clinical features you can get like I said hypertension is really the first sign that you'll see just on routine examination in somebody more than 20 weeks of more than 20 weeks gestation, under 20 weeks. It's just hypertension, over 20 weeks. We're starting to look at pre eclampsia when you have the other things associated with it, so like I said systolic BP of more of 100 and 40 or diastolic of more than 90 on two separate occasions, it can be the same clinic um session, so you do it once the beginning and what's in the end. I think it needs to be a certain amount of time in between them. Um It's something that you should get on top of really quickly and realistically if patient's have preeclampsia, conservative measures are not going to do anything and starting with medication is a good idea. Labetalol is the first line um There's other ones that are there for people who are asthmatic or allergic beta blockers, but labetalol is the one that you should know protein. Urea is another big cause. Another clinical feature That's important you will need to have the majority of these be able to diagnose preeclampsia, headaches, and disturb vision is a later sign because it's starting to tell you that this hypertension is causing end organ damage, peripheral peripheral adema as well. They'll usually say oh my ankles are really puffy, but again they might not know that this is abnormal. A lot of people do get swollen and puffy during pregnancy and they might just think oh that's normal you know I just have a headache and I've got a bit of swollen legs and that's normal for pregnancy, but actually in some cases it's not and it's important to make sure that there that people know that because of the complications are, really can be quite severe, so help syndrome is him pollicis, elevated liver enzymes, low platelets. Again, you're going to need to refer that to a specialist immediately if you see it eclampsia is when it progresses and then you start getting seizures. Um There's all sorts of other complications like AKI because of the severe hypertension, the protein area that strain it puts on the kidneys, d. I. C, so low platelets can cause bleeding, respiratory distress syndrome. There's so many things that it can cause. Um we will talk about it in another talk that we do later in much more detail than this, um but these are the main things to know for your oscal stations, specifically so management for this. One you need to monitor for end organ dysfunction and pretty much all of the tests in the world will be needed for this, but mostly full blood count using these lfts. Um The risk of a clot is much higher. It is always high in pregnancy, but this makes it much worse, so typically that would be management the low molecular weight heparin like enoxaparin data parent um anti hypertensive, like I said labetalol is the first line delivery is the only definitive management, so if it gets really really bad, cannot be controlled with medication or they start showing signs of eclampsia and having seizures. Delivery is the only way um postnatal monitoring is really important because they are still at risk of seizures up until I think 24 hours post delivery um so it's really important to monitor them and to monitor their BP and to continue to monitor their BP until they're at least a month postnatal um because it can lag, and it can keep going and you may need to continue the antihypertensives or you can stop them or reduce the dose important in this case to communicate well with the gp. If you're the hospital doctor making sure you say to the gp, they've gone home on these anti hypertensive, but they need to have their BP monitored in three days, five days, seven days, whatever it is that your consultant wants and then the reducing of the dose if possible, also making sure that you educate the parents about breastfeeding certain medications. You'll need to look into it specifically and give them information about that. So with ABSA Trick stations, Even if uh and going stations pretty much all the stations, they will usually get, give you a follow up question. Typically, they just say what are your differential, what's your differential diagnosis, What's your what investigations would you do what's your management and the aim of this is just to see that you're safe not that you know everything about everything you know having the knowledge. There is important, but if you start saying that you're going to give the prescribe all these medications and you're going to do all these surgeries, you're not going to do those yourself and it would be unsafe for you to attempt to do that so making sure that you refer to the right people involve a senior and recognize the level that you are at is really important um because knowing all the information is great and just saying it to the examiner, sure they know that you know what you're doing, but in real life that is not what would happen um and like if you don't know that's fine, you're very unlikely to fail the station. If you aren't completely sure as long as your history was really good. If you did a really good history communicated with the patient well, you are likely to pass. It might not be a fantastic past. If you didn't know about the management and the diagnosis, but it's very unlikely that you'll fail. If you worked well with the patient, so admitting that you don't know is fine as long as you do something about it, so just saying to examiner, all, I don't know you may as well, you probably would fail, but same examiner, I'm very junior, I'm not sure um what I'm going to do is. I'm gonna go and speak to my senior. I'm going to present the patient using an S bar format and then we're going to refer them to a specialist to come and see them as soon as possible to the um diagnosis and management of this um pathology, and then I will follow up later so as long as you can kind of give them your plan. Even if you're not sure of the specific plan, you should be okay and just just admit to not knowing. There are certain points where everybody isn't sure and that's absolutely fine as long as you do something about it um and they often will ask at the end of these things about medications, so I've had it quite a lot where they ask about analgesia and I've had you know what analgesia would you start with and it's important to know that ladder starting with things like paracetamol, moving up into ibuprofen and then up and up and up cocoa to more morphine, etcetera. Usually what they'll I've had a couple of times as they said okay you'll have you'll give paracetamol and I said yeah probably and they said what dose would you give and I thought it was a trick question um. And I got a bit confused um but the reason they asked usually it's 1 g q. D. S. But if somebody is less than 50 kg in weight, they have liver abnormal liver function test, then you would likely reduce that to 500 mg q. D. S. Or less. Um so typically what you could say is the majority of people would be fine with 1 g of paracetamol q. D. S. P. O. R. I. V, um but it would it would need to be weight based other than that contraceptives as well because you can often get a station that's just a contraception station kind of like an information given communication skills session um station sorry, um where you're talking to the patient at all the different options of what they might want and then they ask you at the end of the either the patient or the examiner, what do you think is the best one if the patient's asking you that you can't make that decision for them. Not really it's not a medical decision, it's their decision it's about what side effects, they're willing to put up with whether they think they could take a pill every day or if they're bad with injections or good with injections, it's completely up to them, um but if it's with the pathology say PCOS and they ask you what kind of um contraceptive medication do you think is best if you've taken a thorough history from the patient and you know that they're not good at taking pills every day, um but they're okay with having an r us or an implant or an injection, then you can give that kind of information to them. Um communication skills going way back to basics open versus closed questions. Really important you want to start with those open questions and give them 30 seconds to a minute to just talk in osk ease. It's unlikely that that will happen because they are told the actors are told not to give you too much information without you specifically asking in real life, though it's important to give people that time to just tell you everything that they think is happening because if you just start immediately with what's happened, you're bleeding okay, how often you're bleeding how much are you bleeding, what does it look like then you kind of lose the patient agenda and you aren't following on from their cues, which is really important to do so let them speak freely for the first bit, um be flexible and let them guide you, so don't have this have the checklist in your head, yes, but don't just go through it da da da da da constantly. Make sure that you are led by them so if you would say, if you said to them okay, so do you have any bleeding and they said yeah I do have bleeding, but also I have a lot of pain with it, Don't then say okay, and what about your smears make sure you follow the route that they are going. Otherwise, it feel it seems quite robotic. It seems quite um but you're not listening to the patient you're likely to lose marks with it. Um The order of the questions is very rarely important You know as long as you get all the information, the order doesn't necessarily matter um So following what the patient is saying and how they are guiding you won't lose you marks. It will gain you marks because your communication skills are really good and like I said earlier, if you forget something you can always add it at the end as long as it doesn't affect your slow or you don't interrupt the patient or something to ask the question you won't lose marks as long as you remember it and you add it it's fine and make sure you're like I said before this can be embarrassing for some patient's and it can be really sensitive patient's and especially things like miscarriage and issues with pregnancy and maybe need a hysterectomy for fibroids when they still want children, etcetera can be really emotionally charged and you need to make sure that this person, actor, patient, whatever is comfortable before you start talking about these things because if you just go in introduce yourself and say how many miscarriages have you had. It's it's too much you need to sign post it you need to make them feel comfortable with you. First, if that's possible before you start asking these difficult questions and just say it like I know that some people find these questions. These things difficult to talk about, but that's what we're here to do. I've heard it all like this is what I'm here for I won't be judging you. It's not embarrassing you can talk as openly as you like and that often that gets people to just be like okay that's fine um bringing it up is not going to make it worse. Information giving um so many of the obs and going stations can be information giving um so it's important like especially the contraceptive one make sure you practice the contraceptive information giving station because it can come up really a lot, so remember to chunk and check the information so chunking is giving small manageable chunks of information as you go along, So say they've been diagnosed with uh well, let's say Pcos just start by saying what do you know about pcos without using the medical jargon, so saying polycystic ovarian syndrome. What do you know about it and if they say I no nothing they well, how much do you want to know which sounds like a silly question, but some people really just want to know what you're gonna do for them were like okay, so it's pcos, what are you gonna do some people want to know absolutely everything want to know what what that means what it is how you've diagnosed it what that means for them in the future, what that means for them now, so establishing the patient agenda is important, really important um and giving them those small manageable chunks and checking their understanding but not being too condescending as you do it because if you just say to them constantly, do you understand, do you understand it can come across as a bit on um a bit condescending, so you'll find your own style as you do information giving in real life, you're very unlikely to check understanding constantly as you go, um but in the oscars, they like you to see they like to see you doing that explain the diagnosis and the next steps very clearly without using medical jargon unless you have already explained what that means, so say you've used the word dysmenorrhea, but you've told them dysmenorrhea means painful periods, and if they seem to understand that phrase, you can then use it again, but don't start using jargon that they have never heard before. Use diagrams and visual aids, they're fantastic and give information leaflets office in a noski, you won't actually have them, but always make sure you say at the end, would you like an information leaflet about this and then we can bring you back for a follow up appointment to discuss it again If that's appropriate okay, so then we've got a quick practice station, so um 30 year old female presents to the early pregnancy unit at 14 weeks pregnant with Pv bleeding. Her g. P, sent her in, so try to make this as interactive as possible what would you want to do and what would you want to ask yeah what would you want to know about the bleeding, what would you want to know about the pregnancy in general or about the patient in general um just reading from the chat and someone said an acute versus a chronic pete, yeah, so the timing absolutely yeah, then yes, so we'll see sorry, go ahead. If there's any associated pain with the yeah yeah absolutely is there something else as well that someone was saying yeah, so there's two comments of this quantity of blood um and g. M. P. Yeah absolutely so all of those things definitely um So you speak to her and she said the bleeding started this morning. About two hours ago, she saw her gP as an emergency appointment. They sent her straight to the early pregnancy unit, which is where we are. It's fresh bright red blood, heavy heavier than her no period and she's passing clots and it's been almost constant since it started so a kind of slow steady stream with this bright red fresh blood with some clots and she's had some crampy abdominal pain associated with it, but other than that she's feeling okay, so what are you thinking for what else would you like to know paragraph to history yes, um I did accidentally click it, but yeah exactly, so she has had two full term pregnancies that resulted in live birth. She's got two children at home and two miscarriages and she is now pregnant at 14 weeks, so what would you say her g slash p, anyone brave enough to give it a go, So we said earlier G is number of pregnancies and parity is number of births for the gestational age of more than 24 weeks, even if stillborn, so what would hers be g five, p two. If you're counting the current one exactly so you've been pregnant five times including this pregnancy, so the G is 52 babies that were born alive, so her P is too, if she is, if this pregnancy is to end it a live birth. It be G five p three, um so when they're currently pregnant, the gravity is just one more but the parity doesn't have anything added to it, so with the first pregnancy, the G one p zero until the baby is more on examination, no systemic signs, but when you have a look um When you do a vaginal exam, you've got bright red blood and the cervix is open, so what are you thinking miscarriage, yeah and we I'm doing a talk like. I said about pregnancy complications and miscarriage at another point, I'm not going to go crazy in depth, but it is likely that she's having a miscarriage, but we talked earlier about other causes of bleeding, but this kind of heavy constant bleeding With the service being open, it's much more likely to be this and she has a past history of two other miscarriages and when you get to three miscarriages, you get referred for investigations as to why so you can have genetic testing and things like that to see exactly why and you can also have the products of conception. If you're able to collect them tested for genetic problems to see what happens um what would you say to her, then, so you finished your history. You finished your examination, you are quite confident that she's having a miscarriage, you would have you would refer her to the, you know the specialist, you'd involve your senior, but say that's all confirmed she's having a miscarriage, what would you say how would you approach that conversation like a kind of breaking bad news scenario, yeah so exactly and remembering that she's gone through this twice before, So she is quite likely to already understand a lot of the medical terms that you're going to use, so again it's really important to go through what do you already know how much do you want to know because she's likely to no more than the average birth about miscarriages because she's had two before to be sensitive and signpost um and give them time to be upset you, probably haven't done your um breaking bad news yet. Um. If you're in p year, but making sure you give them the space and the silence and the time to come to terms with this is really important, silence is not the enemy in our skis. I know that you only have a limited amount of time but giving them the time that they need to think and not constantly bombarded with questions and information is really important um remember to chunk and check, so give this information give that information really small chunks so to say to her okay, so what do you think has happened, so you can start with the ice as well. What do you think has happened and she is probably likely to think I'm having another miscarriage because she's had them before this is likely to be very similar and then you can go from there. You say, yeah I think that is what's happening, I'm really sorry that this is happening to you and then kind of go through the specifics like I said earlier diagram as visual aids, you may not need it in somebody who's you know has had this happen to them before, focus on the management because this is likely what she is really going to be concerned about what are you going to do now is it a complete miscarriage or are you going to need to refer me to somebody to have the products removed. Information leaflets are important, but it's unlikely she'll be going home. She will you will need to involve a senior very quickly and refer to a step tricks in this case, you're already in the early pregnancy unit, so you can probably just grab somebody from the room next door to come and speak to them and sort it out um. And like I said at this is her third miscarriage. She will be referred for further investigations, which is important to tell her because after you've had this many miscarriages, even one or two you'll you'll probably start thinking why, um and then curry the current guidelines, although there's campaigns trying to change this at. It's three, after three you get sent for a very in depth testing if that's what you want and again ending the statement ending the station top three diagnosis in this case you could have miscarriage, ectropion, infection, something like that investigations. This is a very quick one to diagnose because as soon as you do an examination and you see blood you could even see the products of conception coming out and an open cervix is pretty much diagnostic then and that but make sure you cover everything when you're talking about your investigation, so a full examination you can do blood because they may may may be anemic. If this bleeding has been going on for a long time, or if it's been really heavy speculum to look at the cervix. Trans vaginal ultrasound can be useful if the cervix is still closed, um or an abdominal ultrasound as well, you could take a swab if you're worried about infection and it is not severe bleeding, you could take a swab and send that off management depends on the type of miscarriage, which we will go through in a couple of weeks, when we talk about miscarriages and pregnancy complications specifically, um but in this case, ensure you refer to the obstetrics team and keep the patient informed about what's going on because it's a very emotional thing, especially if they need to go and have products removed um in theater, then it's quite it can be quite traumatizing and it is very emotional. You need to make sure they're informed because if somebody comes up to them and says okay, we're going to theater now and they didn't even know that that was a possibility it makes it all a lot worse. Um They can have analgesia. It's important to give that to them, but other than that keep them nil by mouth in case they do need to go to theater, so keep the nil by mouth or very small sips of water, clear fluids until the specialist has seen them and says they do or they don't need to go to theaters. If they need to go under general anesthesia, we may have to wait longer if they've been eating other stations to be aware of. your ogoni is up, so incontinence prolapse is that kind of thing information giving about contraception definitely definitely practice that really important the smears information giving and actually doing it sometimes it can come up um the models that we have you and you can actually do it um So practice that in the s. D. L. Room, abuse does come up. They do like to sometimes disguise stations as one thing and then they end up being a communication skills session about sexual abuse, domestic abuse that kind of thing Information giving comes up like, I said earlier about gestational diabetes. The research status, hyperemesis, cola stasis twins, triplets, There's so many different things. The Royal College of obstetricians has really good patient information leaflets that explain all of it in a lot of detail, so I go that's what I used when I was going through p and f year or skis to prepare for the o. N. G. One's about information giving because it tells you very clearly at 37 weeks weeks, you'll need to be induced after labor, This is what will happen um and if you use those leaflets, their in patient friendly language, So then you won't be naturally going towards jargon. If that's not what you've learned um and yeah I think that's pretty much everything so these are all the resources. I will send it to you, so you can have them all anyway, but geeky medics probably the one that I use the most with these things because they go through red flags and stuff really well um but yeah, so I think we went a little bit over the our um has anyone got any questions, no okay, um so what I will do is. I'll go back to the beginning slides. I put my email on it. I'm happy to be contacted not just about o. N. G, stuff for this talk, but if you have any worries about f one or applying um or literally anything Medical school work related, I don't mind you sending me an email um and I'm happy to kind of help you through stuff and talk you through things because I know a lot of the um f year application stuff is really confusing and you often don't actually get given much information before it happens, So happy to be contacted. If you want anything to do with that, thank you so much my line for the talk today, it was really beneficial and I'm sure everyone here um would agree. Um Thank you so much and no problem. I'll be sending out feedback form for everyone to fill it out for Madeleine's talk and also I was gonna say we'd email her email, but it's already on the screen for you all, yeah, it's there if you like it, thank you so much, no problem are there any questions, no cool okay. I'll stop sharing then cool.