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Right. Hello, good evening everybody. And thank you very much for joining on time. So, uh today we're going to be doing a talk on Gynie emergencies and it will be starting very shortly. Um And what we'll do first is I'll just give a little bit of an introduction and then we will get started. Okay. All right. Uh First and foremost, can someone just say in the chat whether or not you can see my screen? Yes, perfect. Thank you very much. Okay. So my name is Anamika Banerjee. I'm a foundation year one doctor working in the University Hospital, Lester and I graduated from Imperial and the current academic lead of Bima or the British Indian Medicine Association. And I'll be co hosting this effect today. Uh So just a short introduction first and then I'll be handing over to our speaker. Uh So just a little introduction as to what Bima are and who we are and what we do in case you're not familiar. Um So Bima stands for the British Indian Medical Association and it's essentially a large national Nonskilled uh sorry nonprofit Laskin Organization which is created or, and by medical students and professionals aiming to try an increase educational support, training support, as well as networking support for both not only medics but healthcare professionals across the country. And in addition to providing tutorials, we are also organising conference which is due to take place in shortly in April. Uh So do keep on top of our emails and social media posts to be able to join that conference event, which will be very exciting. And of course, we have lots of networking opportunities and research opportunities as well. And so of course, if you want to know more and you can always follow us on our social media accounts, you can email be men and we have a beemer website as well. Um Best such biting Vezina and then you can find us there and just a few housekeeping rules as we do for any teams meeting. So just for you guys to be aware, this meeting will be recorded and for monitoring and also share ing purposes after the talk, you can access the talk for revision purposes. But during the talk, if we can request you all to please keep your cameras and microphones muted. And if of course, there are any interactive options or Q and A sessions, the speaker will direct you when you can mute for that. And you can also use the chapter if you're unable to mute. And of course, as we are with any online meeting, please remain polite and respectful to each other. And during the meeting and towards the end of the meeting, I'll also be releasing a feedback form which will be found through the medal platform for which after filling that out, you'll be able to get a certificate of attendance. So without further a do, I'm going to stop my screen shirt and hand over to our speaker. Good evening everybody. Um Can you hear me? Yes, I hope. Yes, we can hear you and see. All right, let's see. So, well, what I'm going to talk about that uh emergency gynecology that I've been told uh is a, is a, a lot of patience you can see as an emergency gynecology. And uh so I would probably try to concentrate on some of the common things and uh and we probably will be discussing the way it presents and relevant investigation and more sort of both in practical life. What he'll be doing as a foundation year one and also at the same time, which may be living for your example, Pacific combination of both. Try to get, let me see, I can get the soon slides. Can you see? No. Can you see me now? It's light. Yes, we can see you can, you can. Okay. Good. All right. Okay. So as an ecology uh introduced me that I'm working as a gynecology consultant in Leicester. And uh so, so the main thing is that our topics is gynecological emergency. Now, when you own emergency duty and uh my experience is that the most of the patient's coming with few headings to the heading. Sell like this that pain, bleeding, trauma, injury, rape, violence. And if you think of the emergency gone gynecology, then probably emergency contraception as well, it can be uh there. So, but the thing is that my plan will be do more consented on pain and bleeding. That's the main thing. And then some of the things I'll just touch on with trauma injury and the rape and balance emergency contraception. Probably you don't have to deal with that. So I'm not going to talk about that. So let's talk about this at case scenario. So you're on emergency duty as a foundation ear doctor. And you were a lady who is 27 years old power. One, she's got one child presents to gynecology assessment unit or gynecology emergency ward. Each hospital has sorry uh Miss Tiffany get your um screens just stop share ng um one second, let me see if we can support you. Is it visible now? Yes, we can hear and see, you know. Thank you. Sorry. Shall I go back? Yes, please. Ok. Right. So yes, the most of the sorry, there's some technical problem. I think that uh yeah, we we were now back to the or talk discussion. So the most of the gynecology emergency problems, I put it on these few headings and then they come with the pain, bleeding, trauma, injuries, rape violence and emergency contraception. So the plan will be to talk about the common thing is the pain, the bleeding. And I'm probably going to touch on trauma injuries and just get some idea about rape and domestic violence. So which probably may not to deal with on regular basis. But it's better to our of the situation, emergency contraception. We're not going to talk today is very rare, you'll get them. And uh so I will consultant first few to the areas. So this is the case scenario. Say 27 years old power lady has got one child vaginal birth presented to Gynecology Assessment Unit or gynecology, um emergency ward with the pelvic pain, dark drug brown vaginal discharge for last 3 to 4 days and heart pain is not getting better on paracetamol. And she's concerned trying to contact a GP did not get any answers. She just talked into any department. And from that to Ghani Assessment Board, see what the foundation your doctor on duty. Just think about the case scenario. The history got. What are the four important gynecological conditions you should think of and what are the information and investigation will help to diagnose and manage this scenario? Okay. So you've got some responses from the chat. So people are suggesting uh thinking about cancer, endometriosis, ectopic uh the cysts also ovarian cancer, ovarian cysts. Hmm. Right. OK. So we think of the common things like that how ages 27 probably the over in cancer, not maybe the right, you know, age group, but the rest of the thing, it could be probably right. So let's let's get some more information. So, so the nursing staff did some observation. They came back, okay. Had policies. 86 BP, normal temperature, normal's as normal human grouping done. 12.6. Watch Celcom 10 platelets, 2 to 6 crp 18, just a borderline. So what else do you need any further investigation or any further information will be helpful to know in this case? All right, let's see what next coming up. We've got a few options here. We've got pregnancy test. Yep. Correct. We did a pregnancy test. She said that her period was seven weeks ago. We didn't get the history of menstrual period. So that would be informative. But again, then we don't trust that. So pregnancy is done it, which is positive, nitrate, negative liquids it positive. So what else do you think that you should be thinking about in this situation or the next thing? And what you'll be thinking? What are the possibilities you got uti mhm and request for urine culture. Okay. There's a female coming in one second. Uh urine analysis again, right? Ok. So she has got a positive pregnancy test. We know that well, she has got pregnancy a positive test night. It is negative leukocyte is high, positive. So the thing is that in pregnancy, the discharge, sometimes we do get like a side can be high. So maybe infection, maybe not, we don't know. So she has got a positive pregnancy test, some pain discomfort or some discharge. So either with the examination for general or we should go for an ultrasound scan, right? So she, this lady had an ultrasound scan and which confirmed she has got an intrauterine pregnancy about 6 to 7 weeks. Now, if you look at the scan picture, let me go through it. It'll be interesting. So that's a whole new tris as a fondness of nutritious and that's the cervix. So the cervix external loss and if you see that's a nice thin area, white line. So that is a indo cervical canal coming up and that is the endo metro cavity. So this is the just ish inal sac and this is another ring there that is the yolk sac and there's a fiddle fall. She is about 6 to 7 expectant. So yes, she has been an ongoing pregnancy and we're happy that nothing to worry about. So, so, so this is one of the things. Now, let's talk with accurate pain. How the patient's come with the pain. I mean, order the causes could be the pain, the causes of accurate pain in gynecological emergency is him a peritoneum that is either the bleeding inside the pelvic cavity or in the abdominal bleeding. It could be disturbed, pregnancy, infection can cause equipment, vascular complications or visceral distinction means any stretching of the ovaries or any Dorsch in all these things will come later. No, the acute pain, we continue the hemo peritoneum that bleeding inside the peritoneal cavity. What the cause is the communist is ruptured ectopic pregnancy, ruptured corpus luteum or follicle assist, ruptured endometriosis cysts can also can cause the bleeding and pain and discomfort, retrograde menstruation, which is not very common, but sometimes usually they come with that pain. During demonstration, the blood go, can go through the tubes and can edit it inside the pelvic cavity. They can have pain and discomfort, perforation of the uterus. Somebody might have some outside any uh procedures done, whether it's a histoscope or determination of pregnancy and then came back within 24 hours time, pain and discomfort because publishers that operation, which is not recognized. And when he's coming to that disturbed pregnancy situation, no obvious interp original bleeding. So that could be that there is no bleeding but pain can be there because of the district pregnancy which could be active, pick where that tube can get stretched but no obvious bleeding can cause a tubal crime that can cause a pain which is early activity. Pregnancy can uh present with or the miscarriage, interpreting and bleeding. But the uterus is not trying to cramp to expel the miscarriage tissues out. So those are the causes of pain just to get some basic idea. I mean, what will be thinking and what we'll be looking for according to the history in investigation. The pain also could be due to infection that could be accurate, pelvic implemented disease chew over an abscess. When the infection is much more severe, they can have the taxes in the tube and ovaries. But the synapses can come with the pain and discomfort. The valuable region. There's also presentation on gynecology ward is an emergency. Heart is genital is usually that goes to that uh the virus in clinic, but we still can get on and off. Sometimes occasionally that scenario, not just doing it our off and also accurate all varieties. Now, when it's coming to the vascular and visceral situation, the pain, the torsion, a pad naxi to our ovaries can get sorted and can cause the pain and discomfort. Hemorrhage, inter cyst like a corpus luteum hemorrhages very common will call the hemorrhage is not a massive massive bleeding, but some amount of bleeding can stretch and can cause a lot of pain and discomfort. Both like the testes and over the capsule is called rigid to see any stretching, they cannot expand and can cause quite accurate pain, fibroid degeneration, which sometimes more sort of Afro Caribbean women. Commonly that one, you had a large fiber nutritious and known fibroid coming the pain and that pain can be very selective pinpoint particular area of the fibroid over in hyper stimulation. Also IV a pregnancy, they can come with the pain and discomfort, but there's over in hyper stimulation syndrome that's also coming with as well, they can have the pain. And if it's non gynecological cause, we think about still they can present. It was the bowel related to the appendix, appendicitis, diverticular disease or I B S can count as well. And then if you think of the urinary track societies, your arthritis, I don't not calculate and also accurate retention of urine can cause pain. Also don't forget about that muscular skeletal, that's quite common. Sometimes we do see we do investigation and nobody actually bothered to examine the patient. And if you examined them, she was working somewhere, heavy lifting has done something and very pinpoint pain in the musculoskeletal region. Maybe that people typical ligaments or sacroiliac joint and you can touch it. The pen is there. So it's very important that you do all the investigation but trying to take them in the patient to find out worries a pen that will help. Now, the bleeding, we also talked about the bleeding that bleeding could be pregnancy collected or non pregnancy related bleeding as well. Does the second presentation we come as an emergency gynecology when they're pregnant could be the miscarriage, which is probably common because incidents of miscarriages pretty high out of five pregnancy, roughly one miscarriage you were expecting is almost 20% and then ectopic pregnancy and molar pregnancy. So, so communism discourage the neck to bit pregnancy after about 1 to 1.5% molar pregnancy, much more rare. Only one in 1000 in this country. Now, if you're coming to the non pregnant bleeding, the communist single with a dysfunctional uterine bleeding and then it could be the noon fiber of the polyp in the material and cervical cancer, which is not very common area. And most of them, the material cancer. More elderly people, you still can get them as an emergency. We just recently had one lady, she was nearly 79 years old. They thought that hemorrhoids causing bleeding. But eventually on investigation, she's got a cervical cancer. Yes, it can get it like that. So in the tower of the situation, let's talk about this case. This is 34 years old parents trip was to lady she prisons with the irregular vaginal bidding and pelvic pain. More on the back for last two weeks. She has been using registration only pill P O P for contraception. She says she might have missed pills about the pregnancy test three weeks ago which was negative. She's in a new relationship for last six months. Her BP balls temperature says all known. So let's go through Diggins. He's 34 para three irregular vaginal bleeding, pelvic pen pen more on the back the last two weeks wasn't pill. She thought she might have missed it. But pregnancy test was negative three weeks ago and she's a new relationship follow six months. So you might have thought, what are the possibilities by this time? Now. So we've just got some things coming through in the chat, I think. Yeah. Okay. So we've got pregnancy test, full blood count, trans vaginal infections can good. So, yes, again, union nineties negative pregnancy is positive hemoglobin. 112 white cell count. 11, black lives normal CRP 12. Do you have any concern about white cell count? 11? Here. Anybody has got any concern. Well, that's quite normal in pregnancy, white cell count. He can get slightly raised. So I only worry too much about that one side. Um But S E G 2143. So what do you think you feel better on mute as well? Or common democrat? Okay. So we've got some comments for ectopic. Okay, good. So this is a scan result. Sorry. Do you want me to unm ute myself for you? Okay, but we can hear you. That's fine. OK, fine. So, so that's okay. So this this is the ultrasound scan, this a trans vaginal ultrasound scan. So that's the cervix again and that's the fondness of the uterus service doing like that. Um This is the cervical canal and that's the endometrial canal or cavity that's more appropriate to say the cavity of the uterus. So this is a thickness but there is no obvious act there. And this black area on the scan does a freed the ultrasound scan. The fluid is coming with more black and the more solid the tissues are, uh, they're much more dense, they're more white. So there's no obvious interest in pregnancy and got some fluid in the pelvic cavity. So it's probably quite obvious what it is. Height activity, pregnancy, we're suspecting. So she went for laparoscope. So she had a right tube elective it pregnancy. And there's a tube, there's a swelling, there's active it, pregnancy there and there's a clot inside and the clot was more in the back of the uterus because she has been bleeding from the tube is not ruptured. You can see that, but he's having the table miscarriage at the stretch of the tube and also the collection of the clot back of the uterus in the porch of Douglas. That's why she was getting irritation behind the uterus, causing her back pain. So that's quite interesting history that, well, not that always, it will be the pain on the right side, the left side of the word that you are sometimes they can come when the chronic collection of the blood in the pelvic cavity, the back pain as well. Okay. All right. So, yes. So that's the way it works. That pregnancy get start more on the ethnic region that is the thinnest part and then cannot grow further and it can rupture or it can constrict and cause the bleeding and the pain. Now let's go back to that bleeding plus minus pain in early pregnancy. When you combine both together, maybe pain may be bleeding on may be bleeding like that. So this is an early pregnancy situation. So, first thing we remember, yes, we need to exclude the ectopic pregnancy. Once you know that it's not active it pregnancy, then you got to sit tight and got a time to think about. So the commonest things that miscarriage when you talk about the certain miscarriage, which is a common thing and then means threatened, miscarriage means when the pregnancy is still horrible and good, good potential, it will it can continue. It depends on how far we are in the gestational age, more and more advanced, far in the pregnancy, more chance to to contain the pregnancy, then inevitable or incomplete miscarriage. Inevitable means the pregnancy can see on the scan, the pregnancy sac in the cavity of the uterus and may be fatal. Heart is there maybe not. Usually we call the treated artist that it was inevitable going to be miscarriage. The cervix is open so that pregnancy going to come out. So it's inevitable incomplete when most of the sac is out, some tissues still inside that we call that in complete miscarriage conflict, miscarriage. When the pregnancy tissues and the sac everything came out, uterus is almost empty. Now, complex miscarriage, you only can diagnose not buy one scan, complete miscarriage and incomplete miscarriage. There should be scanned beforehand where they can compare that there is a pregnancy. Now we cannot see it other ways one scan, there is no pregnancy, he cannot see the complete miscarriage because there's nothing to compare. So in that case, you need to be careful. Are you missing anything usually recommend with the follow up to see what's happening and the next coming to the missed or delayed miscarriage or write it over. That means the one is that you can see the sac, you can see the fetus and then there's no fatal heart and bleeding hasn't started yet. So that's the MS miscarriage or delayed miscarriage. And miss miscarriages, a very old terminology when needs to miss the miscarriage, but with the scan and all these things, so you don't miss them anymore. So he say that probably is a delayed miscarriage and the blanket over one where there's no fetus as an embryonic pregnancy circles there and then coming to the molar pregnancy and maybe bleeding in pregnancy due to the cervical ectropion. Usually they come in the history of sexual intercourse and then bleeding started. You can check there's some cervical ectropion is there or maybe some small, small polyp sitting down there, okay. But we need to rule out all other things. In the meantime, before you say that, now there are few criteria according to NYS guideline, how to diagnose miscarriage or viable pregnancy. So it is important to remember this for your exam and also for regular daily practice before you can say something to the patient, see the crown rum left, that's the FRITO uh the length on trans vaginal ultrasound scan less than seven millimeter and we cannot see the viability. Then we need to either say the repeat the scan in a week's time. If we get that from rum length, fatal length, seven millimeters and more and then no fatal heart, either we need another somebody to scan to confirm it or offer them risk in any week's time. So the same a millimeter just to remember then if there's no fatal pole, then just a schimmel sack. The measure just occasional said diameter, less than 25 no fetal pole risk. And again, more than 25 then again, the same scenario like seven millimeter, no fetal pole of our second opinion or risk. And again, so just to remember the seven millimeter, if there's a fetal pole plus minus, it depends on where we are. And in 25 millimeter, if there's no federal poll, then the Justice Inal Sac. So if you see the fatal pole, then you don't measure the just ish inal sac as simple as that. Some sonographer, they're still doing it, which is not correct. It's only confusing the people. Any questions at this stage? Okay. Let's move on. Now, the table ActiVit pregnancy. I'm just going to give you some brief idea how to manage. You don't have to probably remember details as a foundation here. One as a medical student just need, need to have some idea what are the options you have got because in exam, we're not expecting you to know. So details like that because we'll be working the function here. One and there's much more uh level of decision making in it to just our off anyway. So there's three ways until we can uh manage the ectopic pregnancy. One is the expected management, medical management, and the surgical management. So when did you expected management? That is wait and see. So when there is no fatal heart and then the diameter of the active it pregnancy means the whole swelling in the tube less than 35 millimeters and that's better scg less than 1000 or at least 1000. Then we can decide clinically stable, no bleeding into the peritoneal cavity. And patient is happy to come back to for a follow up. If you don't trust the patient, they're not going to come back, they might disappear. Then it is difficult to allow them to go for expecting management. That's for any, any, any treatment. Probably if you're worried and concerned and patient is not very uh compliance, then you have to be careful and we're expecting Vita C G to fall 15%. They're two therefore and day seven, if that's the situation, then you can carry on debating every week basis until it is negative. Next, coming to the medical management, which is the methotrexate, we're using it and the doses average 50 mg per square meter body surface. We do calculation, it varies from person to person. So there's no fixed dose, but the doses calculated like a 50 mg per square meter. So again, the medical management clinically stable, no obvious pain, no active bleeding, no viable pregnancy, and then ectopic pregnancy less than 35 millimeters. Almost the same like this expected management, only the bigger cities like you won't hire. There are some situation where we can offer them methotrexate even more than 1500 B to C G. But that's a clinical scenario. There's a risk of surgical and all these things. You don't need to think about that at the present moment. So follow up again, then it was having methotrexate day one therefore, and day seven, if we're happy with that week, following of the satisfactory fall of the better city, then carry on doing that. If there's no satisfactory fall, then either we repeat that another methotrexate after four days of poor follow bit ecg or we think about if they're getting pain or bleeding, we go for the surgical option when you do the surgical method, laparoscopic procedures, either self injecting myself in good to me when the bit messages more than 5000, definitely active pick pregnancy, much more bigger or it is a small but fatal heart. Is there live active pregnancy or their hemodynamically unstable that would be bleeding going on as well or they're not suitable for expected management or medical management because they're not a complex with that follow up. Now, management is very easy. If the hemodynamically unstable, they go straight win theater most of the time we manage the laparoscopically. But there are some situation where the mammogram is too low. Uh patient is very, very unstable, then probably quick option will be laparotomy, open surgery and self inject um it to remove the tube soon and stop the bleeding. Otherwise laproscopic self ingo ostomy or self inject A me, it depends on the situation and circumstances. If she already lost 12, before then we try to set the tube. In that case, self IgG ostomy is open the to remove the pregnancy and said that to be possible if they're races negative, definitely they need entity and also depends on the situations. It'll be cereal bit STD. We offered them mainly when you do the self invest to me because you're not sure that whether all the pregnancy tissues, trophoblastic issues, we managed to get them out or sometimes if they bled a lot, we do find some few truffle justice tissues can dropped in the pelvic cavity or the sac can be dropped there. And we think that we remove the hole to with a clot, but that actually the sac actually adopting the politic cavity. So that's why we, we sometimes we do that. It depends on that was a situation like to make sure the bigger cities falling contraception advice. Just to mention, we used to say that, well, we cannot use, this cannot use that. But nowadays, we say that any contraception better than no contraception, they can have any contraception they want. And the important parties having another scan in early pregnancy because there were 10 times hard that it's almost 10% chance of having active pick pregnancy in future. So they need a early pregnancy scan to make sure pregnancies in the right place. So this is that self induced to me, we make an opening here and then we remove that pregnancy tissues from there and this is active it pregnancy and then we remove the tube called self inject a me, the whole tube came out. So these are not picture just to get some idea at different ways. That's how the activity pregnancy can be. Say that most of the activity pregnancy almost 91st and they're in the tube. So starting from ethnic ampullary or fimbria, if their funeral, most of the time, they can actually have a tubal abortion quicker. Uh sometimes you can milk them out rather than doing any uh doing the whole cheap if they're not bleeding, then over an ectopic pregnancy pretty rare. Same with that cervical cesarean scar pregnancy, usually cesarean sections currently there from the internal loss level. And then the pregnancy can get stuck in the scar and can bulge outside. And this is the interstitial pregnancy that is the part of the tube, which is within the intramural part. And pregnancy can be there or it could be here because the cornel as well. So the continual or interstitial almost the same, the miscarriage. I think this is another one you need to know very, just in brief idea, this is very common things. You'll find that bleeding and miscarriage, whether you do are the pregnancy unit or an emergency is common findings, you deal with them. So expected management is very safe up to nine weeks. Said if they're not breathing very heavily, allow them to just carry on naturally. Usually if they're not passing any tissues within two weeks time, then we need to think about any some active management. Then the medical management nowadays, we provide the miSOPROStol uh and in miscarriage, we don't. Now according to nice, we don't have to give them if a pissed um uh which is the anti registration preparation, not an type registrations, basically progest region uh receptor modulator. So 800 micrograms or 600 micrograms. One does visional sublingual or buckle. Ideally, they should have them in place for at least half an hour, allow them to dissolve. And then if they're baccala sublingual under the tongue or side of the cheek allowed them to dissolve for 30 minutes and then sold after that, if the swallow, Torrey doesn't work that way. The same with the visional tablet, we said they will stay on the bed for at least half an hour. Allow them to dissolve and absorb surgical evacuation, manual vacuum aspiration under local anesthetic just on the ward or that one of the scan room can be done and then electric vacuum suction evacuation, which is a traditional suction evacuation can be done under germ anesthetic. It depends on patient's choice or some sedation as well. Usually the our legislation can be done with the local anesthetic on the ward in the air and the molar pregnancy can be partial or complete mole. We offered them the surgical. We don't go for the medical treatment. And then the follow up in checking Cross Sheffield and Dundee, they're the three centers, regional center depends on which area they are. Pelvic informative disease. Okay. Uh Time wise we're okay. Probably any, any questions of heart. Yes, we're fine for time. If you have any questions, feel free to unusual message in the chat. I think let's do the high premises, hi premises is another another uh the very common one you will be facing on your uh emergency duty quite often. And that's what I thought they just briefly mentioned that one. So here, the main important thing is that, that try to have a scan to rule out multiple pregnancy or the molar pregnancy. Those are the things increase the bitter scg hormone levels and they can have more hyper massie's problem and sometimes the molar pregnancy, uh the eight C G one part, they behave like thyroid stimulating, they can have the thyroid hormones as well. So that can make them hyper thyrotoxic chrissy than uh hyperemesis as well. Even every tract infection can cause sickness, not ship vomiting in pregnancy. So those are the few things when they're coming with, we'll look for pelvic ultrasound scan to confirm single pregnancy, not molar pregnancy, check the urine sample and also the third function test. And that may be some of the issues like the social and psychological, mainly. Those are coming back again and again, a lot of the time if you take the history, probably they have got not enough support at home. So I've got a few kids or sometimes the in laws quite rough with them. So, so a few things here under innit explore as well. The main thing is that antiemetic and fluid and which could be started oral than I am or IV as needed. And then fluid is mainly the normal saline and Hartman solution. We avoid a destro's which can cause actually worse scenario with them. Uh Yeah, that's fine. If we're not careful with the vitamin B and B 12 injection, those are suffering from chronic hyper messi's, they can have their warnings encephalopathy. So most of the hospital now has got a protocol when they're coming in. The hyperemesis. See, but they got a three plus is of key tones and they need IV fluid. They should have one injection of vitamin B complex. We call it pain clinics to start with and if needed weekly basis, it depends on how bad they are. Once they start eating and drinking, then we don't need to worry about that one. The worst scenario they need the steroid hydrocortisone. I had to start with. Then you switch about the pregnancy salon, oral tablet and in that situation, sometimes we need to continue within 16 to 18 weeks or maybe longer in pregnancy. So that's in rough simple management of high premises. Sorry. We just got one question in the chat um discussing a case. Um I'm sorry, do you want to mute to ask your case if you'd like to? Okay. No worries. So I'll just read that the case and, and so saying that he's had a patient today, a 23 white caucasian, you know, is 20 weeks pregnant and began having morning sickness, vomiting from 16 weeks onwards and vomiting has been daily at least 4 to 5 per day. They ruled out appendicitis and Matthew sign was negative. Key turns were normal and I believe obvious is with us. Uh 4.9. Um, they've been, they've given them cyclizine, but in your opinion, what would you have done for management? So, so was the white cell count CLP uti all been ruled out and no other bowel gastritis or any other bowel problems just walking correspondence. One second. This is very unlikely. After the 16 weeks, somebody will develop high premises if she did not have anything before. Uh So nothing was done yet. She hasn't been to hospital and no bowel problems. Right. There was any history in early pregnancy, hyperemesis, first pregnancy, she had a paralysis but in this pregnancy, she's in almost 20 weeks. Now. Does she have any high premises in early pregnancy? Also, this is her best pregnancy of it and new previous history of hyperemesis ist then I think that this is not high premises hyperemesis, early pregnancy. She has got some other pathological conditions or psychological conditions going on. So that that needs to be yeah, investigated further. Okay, cool. You can continue. Thank you. So, pelvic inflammatory disease. So what does it mean is basically infection, not in the vagina, not in the cervix is more higher up starting from the endometrial cavity, uterus to use ovaries and from there to the political cavity. This is the most of the time is ascending infection from there and goes like that. So, so that we got the pelvic implemented disease and the communist thing is a sexual transmitted disease, but it's very rare. It could be some other bacteria's as well. So we've got lots of comments on in the vagina. Uh so they can cause as well. Uh So the common thing, the presentation of pelvic inflammatory disease is a bilateral lower abdominal pelvic pain, cervical motion, tenderness maybe may not be but usually at neck sultan nuns and our masses when you feel the masses, that means while it is quietly abscess formation, that's quite late. So investigation wise we take the swabs and nowadays, very easy. The patient's can have the self swabs. And the studies showed that endo endocervical swabs if we do it and the patient's doing the self swab that is sore from the vagina deep inside. Actually, the visional swabs is more accurate to pick it up. And that the swabs endo endocervical swabs done by the doctors. The most likely the reason behind the vaginal posterior fornix has got cells from endo cervical canal. And also sometimes you do get from irritable sales as well. It's a combination of both. Whereas if you take the swabs from specifically from the endocervix, it gets only the endo cervical sales. So that's why that nowadays they prefer the self swabs, even the genius in clinic, which is quite accurate, much more better. Uh We can do the white cell count CRP. All these things can help. But usually that when the white cell count CRP is quite raised there, probably actually having much more peritonitis feature as well. Irritable swap. Sometimes you have to take if they had the hysterectomy done because there's any interest in know cervix, but they have got to develop in tubes and ovaries left father diagnosis can be helpful with the art is um scan and also the city scan. The city's can quite helpful. Sometimes on this. A pelvic abscess. Do you know how much the bowel involvement there? So, diagnosis, most of the time, clinical diagnosis and his laparoscope used to call it. But nowadays, clinical diagnosis, patient's age, lifestyle scan, ct scan, very helpful. It's very rare that we go for the laproscopy. Only. We keep the laproscopy. When we treated with the antibiotics, there is a politic abscess and the abscess not been resolved and then you go for it. So if the abscess is less than 5 to 6 centimeter, most of the time on IV antibiotics, we can control that infection. But if the abscess is more than 67 centimeter, the most likely it's not going to respond to IV antibiotics, they would need intervention surgically. So what do you do laparoscope during the abscess? Sometimes to put a drain in or to drain further washing out continent biotics, they respond better. Sometimes we end up with removing the tubes and ovaries as well or laparotomy. If there's a massive collection and massive additions that we cannot have the access to the laparoscope. So this is an area where, which is under the surface of the diaphragm, that's a liver. So anybody knows what is it call it. This is very commonly the gonorrhea infection and chlamydia infection. Commonly the gunnery. That's right, the violin string appearance, right? The treatment according the bash, the OK, free uh sun or safety oxygen, whichever way you say I am start dose 500 to 1 g and then followed by oral doxycycline, that metroNIDAZOLE combination for good 14 days. If we cannot have that first regime, then we can offer them Ofloxacin Ellen along with the Metronidazol, same of the B D. But this is the number one choice. And alternatively, he can have safe trucks and 500 mg followed by legitimizing 1 g weekly for two weeks as a third choice. So lots of women at the back to actually legitimize is getting very resistance uh not working well with the gonorrhea nowadays. So we don't use them quite often. So we switch back to here, number one or number two. But anyway, you need to get involved with the infectious disease and Jamie Recent clinic team as well, how to prevent it. Your condoms, you're safe sex. And now there's a query. Sometimes you get a patient who has got an IUD sited in the Children cavity. And then what do you do? Came with a P I D? Do you remove it straight way? There's a question. So what the best suggested that? Okay, if they're having unprotected sexual intercourse idea, you should remove them anyway, that if they've got a pelvic abscess is a very mild P I D, then probably don't have to. But now the pelvic abscess, you need to take it out. Otherwise it's not going to get better. It's unprotected intercourse in the preceding seven days. Give them hormonal emergency contraception and then remove it or if you can wait one or two days, start antibiotics, give them this and them. So take it out So those are a few things to know that, but it's a mild P I D. You don't have to take it out. So this is another presentation quite common. And gynecology Emergency Ward is about to run abscess. There's the one side of the vagina, there's another side of the vaginal wall is a bulging like this. That's a quite tourist region. So it is actually more apart to third and war one third, rough level that junction he can get a swelling like that. Anything going higher up is very, is not battling is it's available lapses. So common things that incision and drainage. If they're having recurrent, then you can do the multiple ization. Now there's the one more case, a 19 year old primary, well not primary. Actually, para zero women presented right earlier for the pain for the last seven days. You know, she's not sexually active. Her periods are quite irregular, about 5 to 6 weeks interval. Pen is intermittent and when it comes, she feels faint. These are observations, they're quite stable. The borderline 90. Yes or no. Him. A glob in white silken Crps happy. Just a borderline breast. What for the investigation you would like to do to know a little more about this history? Okay. Mm You have lots of information. Now it would learned a lot equally know better than me. Now think what are the investigations will be thinking about and what are the causes dating? There were what could be the cause? What are the causes? Yes. No, let's move on to the next slide, right. So, Shelly urine pregnancy test which is negative pelvic artisan scan, uterus normal size and limit your eight millimeter anti pasta thickness, which is within the normal range. Left ovary, normal looking right over five by four by 5.4 centimeter cyst tender pouch of Douglas, minimal straight. So what are the possible diagnosis? And what do you think we should be doing next? Definitely. She has got a cyst in the worrisome thing unless infection. God bless you. Damn, hemorrhage. So share the laparoscope industry shot. So we've got a few suggestions here and there's a very insist um Can we do your favor? Insist where have you got? Mhm Yeah. Yeah. Right. Good. So end of the day as a panel was not settling, she's very young girl. She got a cyst in the Ovary. We thought it's better to have a look, see what's going on. So I took her to theatre. Have a look at the laparoscope. So that's the round ligament. There's a round ligament. So that's sobering. That's a tube. Does it look like normal? So this is normal color of the tissues? That tube doesn't look normal, isn't it? So, they're both two and Ovary got sorted. She was having over in pedicle torsion along the tube. So we are induced it and waited color came back soon and then we opened Ovary. Removed, the cyst stepped over in the tube. So there's another case she was doing on and off pain, intermittent pain. So again, then on laproscopy, you can see that she was getting twisted there, but over is not yet. So it will probably come. You do if you would have waited longer. So silver in Dorsch in so usually common is one sided pelvic pain, not bilateral. That's bilateral pain. Usually common in the P I D pain could be intermittent in our little ocean it ocean and do torsion, torsion and detection that can cause an intermittent pain. And it's a constant pain, usually intermittent. Now it's getting more and more worse. That's typical history. It's a constant pain is, is probably getting late in getting across. Now, have you got a question here as to why the pain is intermittent in, in this type of snow? Yeah, because intermittent pain means that is a torsion and detection. What happened. The early stage of Torshin say it is the blood vein then get, get blocked partially quicker because they're soft wall and then artery is pumping has got a blood flow coming more right. Artery doesn't get blocked yet. And that's why that when it's getting slightly partial Torshin, so it get on and off pain coming up like that. And that's the typical history. It comes and goes, comes and goes, son scum is like, I feel faint. So that's, I mean, feel sick, faint during the acute pain and then I feel fine again. And when it's getting further torsion, then artery and then both get blocked, then start getting congested, get neck roast, then it'll accurate pain. And after that, that when it's completely neck roast and then pain will gradually subside and they get very high C I P and white cell count gradually get a little more toxic. So white cell and CRP, maybe raised but maybe not. It doesn't mean that always over interaction will have white cell count raised or CRP. Rest is more sort of clinical history. See on the scan, can you see any obvious list? Even there's a rare situation than normal looking ovary. Can abortion is more sort of tenderness, pain and clinical decision making. So you should have a low threshold for women within complex family and pain did over insist because if you wait late, we might lose ovary. Say diagnostic laproscopy, even if it's a negative still is what thinking that way in the pen is not settling and she's not getting better with, she needs some more pain relief, more than profitable, regular morphine or codeine or something more stronger and has got a cyst in the ovary. Local tenderness on scan, we should think about that way. And the most of the time onto onto sting in early stage, you may save the ovary or end up with necrotic debris when it's too late and end up the cell thing of rectory now just a quick, I mean, I mean, go through it because you're running out of time. Trauma injury can present as an emergency. Usually fall in a sharp blonde playing uh the valuable injury or can happen even after the intercourse, visional ultima, uh vaginal vault ear, mainly that uh quite in or elderly, the too extreme age group and they can have this type of volt here. The valuable hematoma can happen and foreign body in the vagina, that's quite common coming with more. You'll be getting them from your psychotic ward. So this is a valuable hematoma and this is a very convenient sometimes that can cause a torrential bleeding as well suddenly ruptured and there's a tear can happen playing on the cycle bike or fell over. So those are the things in a tower of but usually we manage with them. These are the conceptive. Sometimes they need to drain it here. This is a conservative management and this needs surgery. Oh, this is very small trinity and not bleeding. Now, rape and domestic violence. I'm just mentioning that one. So that can happen on the ward. You can get them the most of the rape and then domestic violence, you get the senior people involved and social team. And also if you said a any that any consultant to get involved in the police officer, also they get involved. But if you take a history like a pregnant patient or something like that, you get a history of domestic violence, then then probably it will be you need to know how to manage them to get a history, get a little more information, the social circumstances and then highlight that and then get the social work involved or talk to the senior people like that. So that's pretty important. So that scenario you might get on your exam as well. There's a lady who has a domestic violence fell over, she was pregnant now came with bleeding or miscarriage. So the two issues managing the lady, the problem, the pregnancy at the same time, waste of domestic violence. So you took out both part. So you need to balance not to put too much uh on the domestic violence get on with and the loser time you just mentioned that I'm not going to details here anymore. And uh I think that that's fine. That's probably just we just in the time, right? Question time. Anything else which you need to ask and discuss? Feel free to a new too. If you have any questions, please do ask. Ok, lovely. Um So we've got lots of thank you's coming in. So thank you very much, Doctor Banerjee for your lovely talk. It was really, really thorough and we learned a lot. Um If I don't, if you don't mind me asking, would you mind stopping your screen share? Just so I can share the feed back slide with your attendees. So don't stop shedding Yes, please. I'm just going to share the feedback slide. Thank you. Okay. Thank you all very much. Can you all see my slide? Okay. I take that and then yes, sorry, I can't see the chart at the minute. Uh Thank you. So this is secure code just for the feedback form. I've also posted it earlier in the chat, but I'm just going to repost now. Thank you again, very much, Doctor Energy for a very good talk. And thank you all for attending today. If I can, please request you all to complete the feedback form, it'll be by the Medal app. So it may ask you to create a new login if you don't already have one, but it's completely free to use. And it's a well known platform for academic events including us, but lots of others. And so, so please do you fill this out and if you do have any questions, feel free to email the Beamer team or on Facebook as well. And we have lots of the further events up and coming in the coming weeks as well. And we've had some previous events which hopefully you'll be able to access as well with the recordings. So, thank you very much. And if you do have any other feedback, you'd like to say, please let me know. Thank you all for attending. Thank you. Thank you.