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Good evening everybody. Um Thank you so much for joining us. I can see the numbers are rising and rising as we just pass 730 this evening. Um Thank you so much for joining us. Um Welcome to this middle primary care network session. Um I'm delighted that I'm joined by Professor David Chill and I will introduce him in just a moment's time. I just want to take one moment to quickly share with you um on the screen now. Um And I will pop a link in the chat as well um to the MD All app um on the Med All app. You can now complete your feedback forms and get your certificates. Um and it is just growing and growing um As med all is growing and growing, so be really grateful if you can get on there and then you can get notifications for our upcoming events in the primary care network as well. So tonight, as I said, um we're delighted to be joined by Professor David Chill. He is um we were speaking before the session and he is recently retired. I say six years is still recently retired professor in reproductive Medicine and Medical Education at the University of Bristol. As you know, tonight, we are talking about antenatal care and we'll spend around 45 to 55 minutes with the presentation and then we will fill the question and answer session at the end. So please do be interactive, fill out um questions in the chat and I will make sure that they're put into the Q and A and we will get through as many of them as we can at the end. Um Medal, we do run free primary care events every week and it means you're the first to hear if you're on the app to get the notifications, get the slides and the on-demand content as well. So without any further ado, I'm going to hand over to Professor Cahill and let him share his slides and begin tonight's presentation. Thanks very much, Tim. And uh here we go. Excellent. So I'd like to welcome you all. Um Thank you very much Tim for that introduction. Um What uh Tim didn't say is that uh I was born six miles from where he's working. Um I um and uh we're both Irish men, uh which is a good thing. Um I've been asked by um med a to speak this evening about um Antenatal care. They gave me a brief to discuss several important issues and aspects. Um And so I'm going to do that um and try to cover all of those, but I think one of the things that I would say is, is hugely important as you are looking after women who are pregnant is the words that are on this very first slide. So I think that if you, if you want to do a good job looking after pregnant women and this applies to most aspects of medicine truthfully. But it's critically important. I think that you listen to the women as they speak to you and express what they're feeling to you and you don't just listen with your two ears, you listen with your ears and your eyes and your fingers and your senses as it were and be aware of all the subtle of what they are saying to you and read into what they're saying and try to voice for them what their concerns are because they may not be able to express them as well as you can. And then when you find out what their concerns are, be responsive to those. So if they tell you that they're anxious because they haven't felt their baby move, what they're really saying is, I'm afraid my baby is dead. Can you reassure me that it's not? And, and if the terrible thing happens that it is, then can you tell me how we're going to get ourselves out of the situation? So I think, you know, in terms of principles, uh if you did only those things and followed only those rules, you'd be a pretty good doctor looking after women who are pregnant. So um the brief I was given was to speak very much about the system as it exists in um the British Isles and particularly in the United Kingdom. I guess. So, uh in the United Kingdom, there are uh four countries. Uh but midwifery, midwifery and antenatal care are run fairly similar lily across the board. So in this country, if you are pregnant, um and you want to get into the system of antenatal care, how do you, how do you go about that? So one way to do that would be to get on your phone, get on your ipad or get on your laptop or whatever and open uh a referral form from your local health care provider. Um Trying to ensure that you get on the one to the hospital that you want to be referred to and they are fairly distinctive in that regard. It's very easy to ensure that you're going to the right place. So you can refer yourself using that. There's a and we're going to go through that form in just a moment. You can be referred by a GP uh from their clinic. You can be referred by a midwife, um uh or another healthcare professional like um a physiotherapist or occupational therapist, somebody who might come across you in whatever setting, but you can also be referred by other people. So for instance, if you're a girl who's 15 and find yourselves pregnant. You can be referred by the school nurse. If you're a person who's homeless, you can be referred from community centers if you're a person in this country. And there are many of them. If you're a person in this country who's a refugee from another country, you can be referred from the refugee hospital that you're staying in if you're forced enough to be in one. So there's lots of ways into it. The forms look like this. They're fairly straightforward, they're not complex. So they ask you to put your name and a an email address which the vast majority of people are going to have a phone number, um your date of birth and then uh for things like do, do you have any medical problems wrong with you? So, so for the vast majority of people, 80 plus percent, probably the answer will be no, but they may do. Uh is this your first pregnancy? Are you diabetic? Do you smoke? Um Do you want to get a message from us about finishing off your referral? And do you want to get notifications about your care and all of that you will submit and then you will click next and it will take you uh to the submission button and we'll send that in and it will finish. And within a week or two, you'd expect to hear generally from a midwife belonging to a particular GP practice. It's particularly important to recognize in antenatal care. And this um these rules apply pretty much no matter where you're living, you may have to adapt them to think about uh how they apply to you wherever you're living. But there are particular at risk groups um in pregnant women. So women who misuse substances. So uh that includes people who take heroin, who take marijuana, uh who take other like crack cocaine and whatever these particular, these women because of their addiction. Uh and the use of these drugs are a particular risk in their pregnancy. People who have come to the country that you're living in recently. Um either as um economic migrants or as um refugee migrants or asylum seekers. So even economic migrants are going to be at more risk because if you imagine that you come to live in the south of England and you come from Scotland, for example, that might sound like, well, they all speak the same language and whatever. But of course, the woman in the south of England whose parents live 500 miles away will have nobody to talk to, will have nobody to get comfort from will have nobody to look after their Children if they need child care to go to the hospital or whatever. So they are in quite a big risk. And in England, women who have difficulty reading or speaking English are at particularly high risk. Um And we'll see just how much uh in a few minutes young women, particularly those aged under the age of 20 are at risk uh because they are inexperienced in life and they may have become pregnant unwillingly and women who experience domestic abuse. So maybe their first or second or further pregnancy. But women who experience domestic abuse, all of these types of women are all at risk in pregnancy, of becoming more ill of becoming having health problems themselves and particularly having health problems in the baby. So the baby is more at risk because of all these situations. Now, this is a picture of which I imagine most of you are familiar with er if we were in a live audience and I could ask you all the questions. You should be able to tell me that this is the Taj Mahal. It was built in the 16 100s by uh one of the uh rulers in India, the Shah Jahan. And he built it this, he built this beautiful building because one of his wives, mum Taj Mahal died in childbirth in her 14th pregnancy. So this is a striking mausoleum to a woman who died in pregnancy. Uh And um I think that's quite, it's a beautiful building but it's a shocking thing that that was to happen in England. Women die from pregnancy a lot. Um And this diagram, I'll just take some time to go through it to ensure that you can see what it's talking about. But this diagram looks at maternal mortality by cause in the last uh time when records were done for this between 2019 and 2021. So this records all the causes which women died during that three years. Not surprisingly, the highest number of deaths came from COVID. And if you look at the colorings on these bars, the dark purple reflects an indirect cause. In other words, they were pregnant but died from something else. And the hatched bars which look a bit insignificant are direct causes. So the condition that they had caused them to die. So, cardiac disease uh was involving the deaths of a lot of women. Um co uh less than COVID but still quite a lot thromboembolism and thrombosis was involved in the same number as cardiac disease. But all the deaths from thromboembolism were caused by being pregnant. It was their pregnancy that made them be killed because of it or die because of it. And then as you run down your eyes through it, uh psychiatric causes and sepsis are uh a large cause of deaths due to direct uh effects from the pregnancy, bleeding and hemorrhage. And you can think of things like uh ectopic pregnancies, uh miscarriage, antepartum, hemorrhage from placenta, praevia from abruption, uh early pregnancy, deaths from uh unwanted pregnancies, uh preeclampsia, a condition exclusively of of pregnancy in women, amniotic fluid embolism by definition, a, a condition exclusively uh in pregnancy. But these were all the causes of death in women. So, diseases certainly are going to cause women to die. So it's important to see what the illnesses are and to be aware of those. So if you're thinking about women in your, in your care, you should therefore be focusing on these illnesses and think about, for instance, psychiatric causes and these will usually be suicides caused by a psychotic illness or um a would be called a neurotic illness. But things like depression, anxiety and so on when people are led to uh to kill themselves. So, as well as causes by illness, we can look at cause by ethnicity. And these ethnicity diagrams are clearly for England, but they apply right through the British Isles throughout Europe, pretty much um throughout North America and to a greater or lesser extent throughout the rest of the world depending on what the populations are. So the big huge differences in this diagram are that women who come from a white ethnic background have the least chance of dying from pregnancy when they're pregnant. Women from a black African Afro Carribbean uh Caribbean background have the greatest chance of dying from pregnancy. You might look at that and think that's, that's terrible and it is that there should be that difference. There are and there are reasons behind it. Uh Some of them relate to the fact that women in that Black Afro Carribbean and Caribbean background have got a much greater distrust of doctors who they see as being still sadly dominating bullies who don't listen to them. And they would feel there's no point in going to see a doctor in the hospital because the doctors are um ignorant pigs. Those, those are words, I've made up patients haven't said those words. But, but I have seen doctors behave like that. Let me tell you, I have seen my colleagues behave uh terribly against women who are pregnant of whatever color you can see. But between the extremes of the white ethnicity and the black ethnicity that there are some other groupings, the green is for people from the Asian subcontinent, uh India Bangladesh and Pakistan. Mhm They have a lower level of mortality. Their mortality rates are often complicated by or implicated worse because of language problems. So many of them will be first generation women who come from the Indian Subcontinent, whose English is poor and we saw earlier that being from another country and having poor English is a high risk issue. Interestingly, people who are Chinese um have almost the same risks as people who are white. They have a different um demographic um than people from the Afro Caribbean group. They tend to come to England as uh um this is these are broad generational statements, generalizations and so you may think what I'm saying is racist or whatever, but it's, it's based on facts. So people who come from Hong Kong and Malaysia and China itself will tend to be generally more wealthy, more educated and more prepared to engage with the health services when they come here. And, and that does mean that they get, they get access to and get to be able to avail of better health care. There's a mixed group who come from all sorts of backgrounds and they have a higher mortality rate than uh white people do. Um And they, we've only started to look at the populations of Chinese and that mixed group since 2013. So we don't have much data on it, but they, they seem to fall into those groups. So we've looked at disease diseases that c cause cause maternal death. We've looked at ethnicity that causes maternal death. And the final thing to think about in this regard is socioeconomic deprivation. Um And this diagram looks at the rates of socioeconomic deprivation uh by putting people into five different classes of population depending on whether they are professionals, um whether they are plumbers, whether they are teachers, whether they're unemployed and whatever. And again, somewhat like the last like related ethnicity. You can see that socioeconomic groupings which are the least deprived. In this case, the blue diagram, these women are the least likely to have a maternal death. The women who are the most deprived, the gray and the uppermost lines in this diagram are the ones most likely to have a maternal death. And there is some degree of overlap between being white and being least deprived and being Chinese and being least deprived and whatever. So they, they are, they're not, these are not mutually exclusive things. So I would say what kills mothers. So diseases clearly and we can work against diseases. Ethnicity and we can work to try to make sure that ethnicity is not such a barrier to access to health care. Poverty however, is something that is, I would hesitate to say much more difficult to tackle because poverty um uh is generational. Uh it's geographical. So if, if you're not listened to this from England or Scotland or Wales, you, you wouldn't probably know the people who live in and around the south east of Lo, of England, around London are generally speaking, the least deprived. The most wealthy people in the country people who live in Wales are have in the past certainly been some of the most deprived people who live as you go up country uh from London up to uh Birmingham York, Manchester, Newcastle. You get much higher levels of socioeconomic deprivation. Uh in some cities in Scotland like Glasgow, there are vast tracts of poverty across the city. Uh true also in Edinburgh, although better hidden. Um but you it's much harder to deal with poverty than it is with e ethnicity and diseases. Actually. Now this is a, this is an ideal plan for antenatal care. It comes from some government website and it talks about how women who are in their first pregnancy who are nulliparous should have 10 routine antenatal appointments and women who had a baby before should have seven. So this is a perfect situation. We all know life is not perfect. We all know that life consists of errors and mistakes, things going wrong, telephones, not working letters, not being delivered or whatever, but this is the perfect situation. So a woman who's in her first pregnancy should have a booking appointment to see a doctor or a midwife. According to this, between five and six weeks of pregnancy, the challenge is that some women don't even know they're pregnant and who they're 15 or 16 weeks or pregnant. But by then, they should have had their booking appointment. They should have had their 12 week scan. They should have had a visit at 16 weeks to see the midwife and another one at 20 weeks to have a further scan to look at um structural abnormalities in the baby. Generally speaking, a healthy woman who's had a baby before uh doesn't require uh much more than that. A woman who's had no Children before will require some further visits, uh 25 weeks and 31 and 40. Uh in addition to all the others, and ideally, they should all be seen at her around 41 weeks to plan a delivery by induction of labor probably uh for women who haven't yet given birth. And ideally, women should not go over the gestational age of 42 weeks because we know that fecal or neonatal mortality increases a lot every day. You go beyond 4 to 2 weeks. Um And as you pass beyond that time, that becomes a real challenge. The difficulty of course is that if you don't have a booking appointment in the early weeks of pregnancy, in the first trimester weeks, 5678, you won't have accurate dates perhaps. So the woman will say to you my last period was the first of August. So she should be due on the seventh of May. But actually her last period might have been on the first of September, but she didn't spot it or it was very light or whatever. And therefore, you don't know when it comes to 42 weeks, how pregnant she actually is and therefore how much strain or stress you should put her on trying to get her delivered before she goes over 42 weeks. This is some of the aspects. This is some of the things that the errors that go wrong when people don't recognize the need for early visits to antenatal care. So the key messages from the report that looks at maternal deaths every three years are included in this. They talk about all the illnesses. So in that three year period, 240 women died during or up to six weeks after pregnancy, 33 of them died from COVID. Um and then as you go down for, there were 33 from COVID, 33 from cardiac disease, 33 from blood clots, all of which practically are treatable. 25 10% of the deaths were from mental health conditions. 10% were from sepsis. And then it goes down a lot more from that 2% were from cancer. That's, that's shocking. And most of those cancers are going to be probably in the reproductive tract and probably in the cervix. And so that have cervical cancer. Uh I worked in Dublin in one hospital in one year where the throughput the number of deliveries was about 7000 women a year. And in that year, we saw two women who presented with antenatal antepartum hemorrhage and they both had cervical cancers. And that was a real eye opener to me. Look at the smaller writing over here. So it shows you that the the rates for maternal deaths are 10 per 100,000 for women who are white, almost 20 for women who are Asian. So still higher than whites, but almost 40 for women who are black. That's, that's a shocking figure. And if you live in an economic area that's privileged, you have a less than less than 10 of the women who get pregnant in that area in in 100,000 will have a maternal death. Whereas if you live in a deprived area, almost 20 women in 100,000 will die from being pregnant. That's all very sad news, isn't it? And depressing maybe. But, but these are the facts that we have to deal with and we have to then think about what can we as doctors do to try to fix that? So there's a lot of words on the screen. Um, and I apologize for that, but they are very important. And if you're seeing a woman for antenatal care, these are some of the things you need to be aware of and we're gonna deal with many of these as we go along through in the next hour or so. Um II, I'm aware that um, from the point of view of uh, the guys in the background who are listening in and organizing all this, uh, forgive me if I run over a bit. Uh II don't have anywhere else to go, so I'm happy to continue. But, um, I'm aware of my time slipping. So you want to know a little bit about their past medical history. Have they been previously healthy? And well, no major illnesses, no operations, no asthma, no diabetes, all those kind of things you want to know about their current medications. If they are on anything, um uh particularly you're going to be focusing on things as it says, further down this page gestational diabetes or diabetes itself and think about things like, um, insulin and the need for it to be increased thyroid disease and the need for thyroxine to be increased and all those things which change in pregnancy. Think about allergies. You don't want to give someone who's pregnant a drug that they're allergic to because it will kill them and kill the baby. You want to think about their gynecological history, particularly, you want to think about when their last period was and calculate from that when their expected date, expected date of delivery is I would urge you not to use an obstetric wal because they are inaccurate and give a false sense of when the woman's date is. So I would rather that you use the figures uh of, you know, if I, if my last period was on the first of March 2024 then I'm going to be having my baby. Uh So at seven days on the eighth of and then uh subtract three months. So it'll be on the eighth of December 2024. Rather than using an obstetric wheel. You want to know what contraception they were on beforehand because it may well be that they missed a pill. And therefore their pregnancy might have started quite a bit before they realized they were pregnant and you want to know about their cervical smear history. So in this country, if they're over the age of 25 they should have had cervical smears or uh screening for HPV, you want to know about that and where they are with that and have they had any uh problems with it? Have they had any treatment for it because that might affect all their cervix. Is there could be things like past obstetric history, family history of diseases, which they might be more likely to have past history with risk factors. Like, have they had in a previous pregnancy? Have they had preeclampsia? Because if they have, they're more likely to have it again. Have they had diabetes? Because if they have, they're more likely to have it again. Have they had a thromboembolism? You know, and have they had a small for gestational age baby? Because all those things are more likely to occur. What's their mental health status? Are they? Well, how would, you know, if they're, well, uh, will come to, um, a screening tool you can use for that later in the talk. I want to know about their social history. Do they smoke? Do they drink alcohol? Do they take other substances? Um, smoking particularly affects fetal size, affects placental function. Um, and if they are smoking, you should get them to try to engage with smoking cessation services. It's true that it's unlikely to work, but it's still worth doing because it may help them to reduce their, uh chances of having a small baby. They may think that's a good thing, of course, which makes it a little more difficult to argue against, think about diet, uh ensure that they're getting enough protein, good quality protein. So women who are vegan particularly need to be much more careful about their dietary intake in pregnancy because they're not going to be getting as many first class proteins as they would do if they were eating meat. Histories of domestic violence are important because it may have an impact on the pregnancy, measuring their height and weight and body mass index, BP, proteinuria, all those things, screening for the mother and for the baby, we'll come to those in a minute and then information on uh support during pregnancy, on breastfeeding and teaching how to do it uh benefits that they might be eligible to from the government if they're pregnant and classes to help them to cope with the challenges of being pregnant, of having a baby, of looking after the baby and then you record all that in their notes and then you give them back their notes to empower them. So there are a number of key things that are involved in routine antenatal care. So booking is really important. We've just been through the key things to talk about in booking that will take a long time. I think that will probably take 45 minutes to an hour on average for each woman. And if things are much more complicated, it will take longer. So you need to be prepared for that. And your midwife, if she's seeing women needs to be prepared for that, uh you need to talk to them about screening and what's available, you need to plan for review of them during the pregnancy and give them some idea about when and why you want to see them. You need to plan delivery, uh, because you might, if they've had a previous Cesarean section, you will need to decide around 37 or 38 weeks, whether you're going to allow them to try labor again, depending on a number of other factors, other risks that are going on. There's a youtube video which is about screening uh in the UK, which is on your handout, which I've sent to Tim. Er and you will get that in your on the app. I suspect I'm not going to show it now because it will save time. So I'm going to go and talk now specifically about screening and fetal screening and maternal screening. So why do we do screening on the fetus? Mostly we want to uh exclude the baby having a fetal abnormality. The most obvious ones of these are Down Syndrome, which is Trisomy 21 and Edwards and Patos which are Trisomy 13 and 18. Those are much more rare than Down Syndrome. There are other things you want to screen for because of the importance of picking them up. So renal agenesis, the absence of kidneys, which you can see uh at certainly at 20 weeks. So the absence of kid kidneys is a fatal condition. The baby cannot and will not survive beyond 24 to 48 hours of birth. Because once they are separated from the placenta, they have no means of excreting, uh, their, their products, uh, and they will die from all of that hydrocephaly, uh can be seen certainly. Uh, 20 weeks. Um, so that's a swelling, uh in the ventricles of the brain that's repairable. And therefore it's worth picking you up and you can put shunts into the brain to drain the fluid off duodenal atresia. So, the absence of the er, the duodenum, the lower part of the gut below the stomach uh is also repairable, but outcomes are not as good as they would be with hydrocephaly twin to twin to twin transfusion is a condition which is rare because it only affects identical op psychotic twins. It doesn't affect non identical dizygotic twins. And as a condition, uh it's, it's caused by a shunting of blood supply from one twin to the other. And the effect of that is usually to cause uh anemia. Uh and uh hypoxia in the twin that's giving the blood and uh thromboembolisms and blood clots in the one who's receiving the blood, it's repairable because you can, on ultrasound, you can see uh where the shunt where the shunts are. And using um laparoscopic techniques, you can go into the abdominal cavity into the uterine cavity and you can layers of the blood vessels that are causing that something to happen. Heart defects are worth picking up because they may well be amenable to surgery after uh delivery, if you know that they're there and the baby can be delivered in a suitable hospital. But if you find them, uh and there's nowhere for the baby to go, then in a sense, almost, it's almost worse finding them because you know, the baby's going to die from the point of view of screening the mother. Uh This is obviously important because you want to prevent conditions that are going to affect the mother's health and may kill her, which will also affect the baby's health. So there's a list of things here, the um which you're able to read. Uh and we're going to deal with these from the bottom up. So we're going to look at hypertension and preeclampsia and I don't have small for gestational age on this list, but we will look at that as well. So, um and as well as those specific conditions, you want to screen for these broad things. So you want to look at women whose body mass index is more than 30 which means that they are obese and therefore at risk of several other problems in pregnancy. Some whose baby was whose last baby was macrosomic weighing more than 4.5 kg or 10 lbs. Somebody who's previously had diabetes in pregnancy or who has a family history uh with a first degree relative, meaning sister, brother, father, mother with diabetes or an origin, a family origin with a high prevalence of diabetes, particularly from the South Asian Peninsula, from India, Pakistan, or Bangladesh, from Black Caribbean population and from these countries in the Middle East, Saudi Arabia, the Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon and Egypt. All those uh populations tend to have a higher prevalence of diabetes than uh African populations than a other Asian populations and European populations. So, with regards to um looking at uh some of these, we can divide women into having a high risk or a moderate risk depending on uh their conditions. And this specifically is looking at the risks of uh blood clotting disorders. So, if somebody has had hypertension in a previous pregnancy or have themselves got chronic disease in their kidneys and autoimmune condition, diabetes, hypertension or previously had some placental abnormality, which gave rise to a small baby, then you will consider that they are at more risk of a disorder in this pregnancy. And you might consider putting them on aspirin. If they have one or more of these high risk factors, lower risk factors are things like first pregnancy being 40 or older. It being more than 10 years since the last pregnancy being again, obese a family history of preeclampsia or having a multiple pregnancy. And in those situations, you might consider giving aspirin, perhaps she's got two or more of those risk factors. Whereas if a woman has one or more of the high risk factors, you'll definitely put her on aspirin because you get a better outcome. So for small, for gestational age, here are some things you can look out for at booking and then during the pregnancy to help you screen out for uh women who are more likely to have a baby whose baby will be small. So at booking, if she's older and older than 35 and that's a real challenge because in England now the average age of first birth is 33 when I were a lad and doing, uh, obstetrics as a student. The average age of first birth in the city that I was working on was something like 21 or 22. But as women have started having their babies older, then they become, they much more easily fall into these risk factors. If they've gotten pregnant from IVF and have just, even just one baby, they're more at risk of having a small baby and so on. Not a parity being very thin or being overweight, being smoker, not eating much fruit, preeclampsia in the past and so on. So if they've got a number of those risk factors, you'll then look at them again at 20 weeks and do a Doppler Doppler studies of their uterine artery at 24 weeks. If that's normal, you might do one more, uh, Doppler study at, um, 34 weeks and then if that's normal, you'll love to continue for the rest of the pregnancy, excuse me. But they, if they fall into higher risk categories and we've looked at these already. So these are on the left hand side. So, previous stillbirth, chronic hypertension antiphospholipid antibody syndrome. Um and so on, that makes them already at considerable risk. And you think you should put them on aspirin because of the risks for preeclampsia. If they've got this thing, which is a relatively recent protein that's been identified, which is called pregnancy associated plasma protein. A. So this should be present in fairly high levels. And if it's not, if it's less than 0.4 measures from the mean, then they're more likely to have a small baby, they're more likely to have a preterm birth and they're more likely to have preeclampsia and hypertension with proteinuria. In which case, you should certainly be putting them on aspirin because of the benefits of that. And you should be watching the baby carefully more carefully than normal by looking at its growth and monitoring its growth and looking at the blood supply of the umbilical artery and checking Doppler studies. And then if for instance, if the growth stops or if the Doppler studies begin to show arrested flow or reverse flow, then you need to think about delivering the baby and then there's a balance between if the baby is 28 weeks. Do you go ahead and deliver it? Recognizing it's going to have prematurity, you could give it steroids, you could give it surfactant when it's born and those things may help. But you're still going to give it lots of health problems because it's going to be small. If it happens at 36 weeks, you may be able to go ahead and induce her. Um, at 34 weeks, you probably will try to induce her and so on. And so these are discussion points rather than things to lecture on really venous thromboembolism. Remember, this is the third biggest killer of women. So a major risk factor is if they've had any episode of thromboembolism in the past, unless it was a one off thing and related to major surgery. So, if they had had an appendicectomy and had a blood clot after that, that would be ok. But if they had a blood clot four years ago for no reason, that's a high risk factor if they've had. Uh, so if they've had one with previous major surgery, it's not high risk, it's lower risk. But still you recognize it as being something and then thrombophilias medical comorbidities like hypertension, obesity, diabetes. I uh, yeah, any surgery of any nature in the past, even just an appendix which many people will have had done, uh, if they're obese, if they have low risk thrombophilia, if they're over 35 if they are immobile because they are overweight or they have mobility problems if they have had more than three Children in the past. And if in this pregnancy, they have a multiple pregnancy, all these are risk factors. If they're a smoker. So for the high risk group, the ones in red at the top, these are high risk and you would want to have them seen by doctors who are specialized in dealing with problems on maternal medicine. And they should be having prophylactic injections of low molecular weight heparin daily. The orange group who are at intermediate risk should again be referred to those doctors and depending on the number of risk factors, um you may, they may consider putting them on prophylaxis with heparin but maybe not in the lower risk group. If they have more than four risk factors, then yes, put them on heparin from when they book if they have less than three, think about doing it from 28 weeks onwards, but not before that because again, the risks of mobility and so on immobility become greater after 28 weeks. If they have less than two of those yellow ones, then you avoid them to stay mobilized. Don't get dehydrated. If they're taking a long plane flight, make sure they walk around a lot, drink a lot of water, go to the toilet, keep mobile. Now this this is an ultrasound study which looked at the value of ultrasound in trying to identify high risk fetuses in a low risk population. It was done in Belfast um about 10 years ago and um of no interest to anybody except me. One of the coauthors was the father of Jamie Dornan, the famous actor in all sorts of films. Um and the summary. So I'm not going to expect you to read all of that. The summary of this uh slide is that if you have an ultrasound scan at between 3032 weeks and 36 to 37 weeks, you may reduce the risk of a growth restricted infant. But the scan will lead people to make decisions which are going to be more interventive than you would have done if you hadn't done the scan. And also admissions to a neonatal unit because of prematurity or small for gestational age are not significantly altered, which I think really says that doing ultrasound in a low risk population of 2000 women at low risk is probably not worth doing. I think that's what that says. Now II pointed this point earlier about gaps in knowledge and there are lots of gaps in our knowledge which might be uh amenable to research by avid people involved in uh primary care like uh Phil mckay or Tim Tim Neal perhaps in the future. But questions like when is the most effective time for women to initially access antenatal care? Nobody knows how many times in pregnancy should a woman attend for antenatal care? Nobody knows. Um And so when we say to people, you should have 10 visits. But actually, all we're saying is I think you should have 10 visits. There is no evidence from you saying it Now, the last one here does sleeping on your back increase the chance of stillbirth or SG A, I'm going to stop for a moment and give you all a chance to put an answer to as yes or no in the chat. So if you sleep on your back, if the mother sleeps on her back, is she more likely to have a stillbirth or a small baby? Yes or no. And I'm going to pause for a minute. And Tim, I don't know if you can hear me and if you could, but in and tell me what the general trend of answers is in that or if that's possible just to get some idea, I've actually just stuck a little pole in there. So, um folks, if you're able to, on the screen, hopefully you should be able to see the little pole. Yep. Fantastic. So we're getting some results in there. We'll give that 10 seconds or so. All right. Um We've hit 50 responses there pro Hill. We've got 62% saying no, 38% saying yes. OK, good. Well, thank you for answering. So, um the, the issues about um how many, how many times you should take care? There's no answer to that. All the women who received traditional care with more input, felt happier and people who received flexible care with less input, more unhappy. So sleep in your back. Uh Sleeping on your back says that if you do sleep on your back, you double the odds of a stillbirth and you treble. The odds of babies being born with small for gestational age. So I think 25% of you said yes. Is that right, Tim or I was the way, all the way around. But basically, if you sleep on your back, the chances of having a baby who's stillborn is doubled, the chance of having a baby who's gonna be small is troubled, which would suggest you shouldn't sleep on your back. Now, this is uh to do with screening for mental health disorders and it involves using the Edinburgh um perinatal depression score, which should be done at eight weeks and 25 weeks in a perfect world situation, which of course is a rare thing. But if you were to undergo that and take that scoring and give it back to your midwife or doctor, and then you had a high score that would suggest you're at risk of self harm or a low score. Uh Then there are some interventions that can happen in terms of a second lot of screening. And then perhaps if there's a real problem being seen by a psychiatrist or a member of uh what we call a mother and baby team. So uh a social worker or somebody else involved in that team would be an expert in that area. This uh and this is the source of reasons why people are likely to have a mental health disorder. You can see that they're, they vary a lot but things like physical illness. So, vomiting and nausea, physical symptoms are a big problem. Uh Poor social support, poor family support, financial problems, alcoholic husband, um being unmarried, these are, these are issues to do with deprivation, uh and so on and so forth. This is the depression scale. Uh It's 10 questions that you asked the woman to score on a naught to four. And if she gets all zeros, then she's fine. If she gets all fours, it suggests that she's quite depressed and needs to be seen by a professional. OK. So I've come to the end of what I wanted to say, we've covered a huge uh range of topics. Um And I want to stop there and then to return to uh to the studio as it were. Uh and to hear about any questions. Brilliant. Um pro thank you so much that was bent. Um Hopefully folks, we did get quite a few answers there for a little poll which is um yeah, well done. Thanks for doing that. I didn't warn you about it. No, not at all. No. Thank thank you to everybody for their engagement. One particular um interesting question I've just highlighted there. Um And while I'm, while we're getting to those folks, please do put um additional questions in the chat. A question about any studies on the impact of nicotine vapes on uteroplacental insufficiency. Obviously, we probably have a lot of data with regards to tobacco smoking. But um now vapes and disposable vapes have become a much more commonplace and the tax on them is going to rise and all those things. Um So the, the easy answer to him is no, there aren't because of course, though, the vapes have been around for five or six years. Um And I think that probably what, what will happen is there will be, there are probably some ongoing studies. Uh, if you were to go and look up the, um, the register of ongoing studies, you might find there were some, but we don't know yet, but I would suspect based on, uh, logic would be that vapes will have some negative effect on placental function, some negative effect on fatal size, but nothing like cigarette smoking because the amount of nicotine in them is, is much, much less. Um, the only thing that might f flip that would be that the amount of nicotine is less but people might be using them a lot more. Um, and they're cool, you know. Uh, so, and so pregnant women might use them and be seen to use them more than they would smoking. So, I mean, uh, nowadays it's rare to see somebody walking down the street smoking. Um, and therefore it's become certainly where I live, it's uncool but, but vaping is, is not. So I think that, um, I think we'll find that probably there are some negative effect but nothing like the effect of cigarette or other tobacco product smoking. Fantastic. Fantastic. Um Another interesting question in um what is your opinion on the safety of home birth? How, how long do you have Kiara Murphy? That's your question. It is. Um So uh I have a publishable opinion to give and I have an unpublishable opinion to give. Um And the publishable opinion would be that in particular settings and in particular uh geographical environments, home births are probably acceptable but are never safer than a hospital birth. So the geographical things would be that everybody talks about the Netherlands and the high proportion of home births that happens there and how safe they are. But the Netherlands is not Craig A and it's not Bristol and it's not London and the Netherlands, if you go, there is a small country um with a large number of hospitals and a very well developed emergency care system. Uh If you are having a heart attack in Bristol right now, you'll be lucky to get an ambulance at your door by it's, it's 830 here. You'll be looking to get an ambulance at your door by 11 o'clock. If you have a baby stuck in a pelvis with cord prolapse, your baby will be dead by 11 o'clock. Um So, uh you know, our, our health services are not geared to deal with the unpredictability of home deliveries. Uh You may want to ask a supplementary question here. I'd be interested to know what your views are you. Other people's views are. Yes, absolutely. Um, and I haven't, I haven't given you the unpublishable comment which is absolutely fair. Um, we tend to perhaps try and stray away from particular, um, cases but there is a more or a more general question here from San, um, a lady currently pregnant her second pregnancy, um, in her first trimester, it is an IVF pregnancy um and has a history of preeclampsia. When should aspirin be commenced in light of that history knowing that there is um a a past medical history of preeclampsia there. So um I think I covered that in the slides, but I would say she would need to be on aspirin from booking, from booking. Um would be my view. Perfect. Uh Clara has got back to you as there pro Cahill um said um thought that the birthplace study stated that it was safe for mothers if not first time mothers. Is that not a reliable study? Perhaps? Um I think that uh you know, first time mothers are an incredibly unpredictable beast and I don't mean that negatively, but there's no way of knowing and I suppose that um I think that uh the that if you're a if you've had two normal deliveries without complications, short labors, baby's weighing 6.5 or 7 lbs and you're expecting this baby to be 7 lbs. Um And you live, uh, and your husband's got a car, you know, all those kind of things. So, you know, if you live, uh, if you live 30 miles out of the city, um, no matter if your husband's got a helicopter, um II wouldn't advise it, but I think, you know, it is. So the, the, the answer to that question, you know, studies are, studies are always difficult to interpret because they deal with perfect situations. Um And I would think that if it was my wife and she was having her third baby and II can, when I look up the window here and look out the window, I can see the hospital over the road. Um It's about a half a mile away. I think I would have been happy uh for her to have had that baby at home. Um Although I actually wouldn't want to clean up the mess after myself. But um but that's neither here nor there. But I think that um that's a situation, you know, and every situation is going to be unique. And the problem is what I've come across Clara is that uh certainly in the town and the place that I worked with, we had a few, maybe less than five, but a few midwives who were phenomenally radical and they would have had women with preeclampsia and the previous section wanting to have a baby at home and they'd be supporting them. And that's madness. And I don't want to give this any more air time than it deserves because, but, you know, it really is an individual decision to be made based on the women's circumstances and all other things around it. That's a good question. Sure. No. Absolutely. And a debate that I imagine could easily go on for a long time. I think in the, in the interest of time we'll perhaps leave it there. But I want to extend a really massive thank you for coming along. I know personally, um some of my take home messages have definitely been um the significance of that variation that there is with socioeconomic depravity rates, race. And um in terms of antenatal outcomes, I think, I think the pr deprivation, deprivation. Um Again, your key message at the start there about listening to the people. I've just seen any rafferty who I remember, I remember her. Well, uh nice to hear from you on brilliant and we maybe squeeze question in there from any um regarding lupus in pregnancy. Is there any additional advice to give to the mother? Um Apart from linking in early with the rheumatology and obstetric teams, linking the teams together. So, I think um in uh so in my area also of trying to get people pregnant, um you know, with uh lupus and other anti cardio and antibody problems, uh it you, you need to work very carefully with them to make sure that the um that the timing is right that they're on the lowest dose possible of whatever, um, methotrexate or other noxious drugs that they're on is as low as it can be before they get pregnant and then manage them during pregnancy. I would refer them to my feet to my maternal medicine colleagues and I would imagine that they will be on a heparin for almost all of their pregnancies, almost all of the pregnancy. I recall a woman, um before s time. Uh but she was also a Bristol graduate and she'd had some uh problems and she'd had miscarriages because of phospholipid antibody syndrome. And in her first pregnancy, she got as far as 34 weeks and stopped her heparin and came in because there was no fetal movement. And for those of you who remember CTG, do you remember those things? You know where the line goes along the line in this baby's CTG was flat. So I was alive was non responsive and we delivered to the within two hours and that girl is now 25. Um But, you know, it's kind of, that was a scary one for sure, for sure. Um Absolutely brilliant. Um So in terms of feedback, folks, we always welcome your feedback, we're interested to hear on what you have learned from tonight as well as what you would like to learn in the future. I can see that already that has been emailed out to everyone who's attended. Um I'll also pop the link into the chat here. And additionally, reha just that QR code um to get in touch with us via the Med all app for our upcoming sessions in the primary care network. Um which on that will be the management of asthma, which is tomorrow night at 730 with doctor Steve Holmes and our next upcoming one on the 25th of April at 730 on personality disorder with Doctor Ma Capanna. Um I just want to say one massive thank you again to pro who is go ahead. So, um so two things for Emma Wood. Uh I've sent a copy of the slides to Tim and I don't know whether you've recorded this talk or not. The, the talk has been recorded. We will get all of that up on the Oh, yeah. Yes, I am still cycling. I'm doing a 40 Komet ride on Saturday just to keep you interested. Lovely to hear from you folks. Thank you all for joining us. It's great to have you here. We look forward to seeing you on our next middle primary care network event. Uh Have a great evening and thank you for coming this evening. Thanks, Tim.