Common Gynaecology Conditions



Join two experienced ST three registrars in an informative on-demand teaching session, where they delve into the diagnosis and management of common gynaecological conditions. Covering issues such as ectopic pregnancy, gestational trophoblastic disease, hyperemesis, miscarriages, and ovarian hyperstimulation syndrome, the session consists of case-based brainstorming to stimulate a comprehensive understanding. Enhance your expertise in recognizing common presentations and strategizing day to-day management in regular clinical practice. This session is an engaging combination of theoretical knowledge and practical application, making it an ideal learning opportunity for medical professionals looking to expand their skillset in gynaecology.
Generated by MedBot


Come join us to learn more about obstetrics and gynaecology! In this talk, we will cover high-yield knowledge for the UKMLA, focusing on gynaecological conditions and presentations. Along with the knowledge you will gain from the session, you will also receive a lecture recording and a certificate for your medical portfolio.

Learning objectives

1. Identify the common types of gynecological conditions along with their symptoms, such as ectopic pregnancy, gestational trophoblastic disease, hyperemesis, miscarriages, and ovarian hyperstimulation syndrome. 2. Apply appropriate methods to diagnose common gynecological conditions using patient history, clinical signs, and lab tests. 3. Interpret critical lab test results, such as Beta HCG levels, WBC count, and ultrasound reports, for accurate diagnosis. 4. Understand the differential diagnosis related to symptoms presented in gynecological conditions and how these can differentiate between ovarian torsion, tubo-ovarian abscess, appendicitis, and bowel disruption among others. 5. Create effective management strategies for gynecological conditions, including outpatient management, laparoscopy or determining when an urgent surgery is necessary.
Generated by MedBot

Related content

Similar communities

View all

Similar events and on demand videos


Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yeah, hi, everyone. Thank you very much for joining our beam a lecture today. Um It's our final p er part of the OBS and G series and the second part of gynecological conditions. Um So without further ado I'll pass on to you um our two doctors here who are hosting the lecture. Hi, everyone. Uh This is uh doctor. I'm currently working as an ST three registrar at University Hospital. So, um and you, we have a colleague as well. Oh, hi. I am Sonia. No, I'm also ST three registerr working along with the doctor at uh in uh so today we both gonna talk a few things about the common gynecological conditions and um how to deal with the day to day activities of how to manage and diagnose such conditions. Yeah. So I can't see how many participants we have. So, can we start now or should we wait for something? Uh Yes. Yeah, I think you can start. Yeah. So today's talk outline is going to be a case based brainstorm sessions on uh common gynecological conditions like um opic pregnancy, uh gestational trophoblastic disease, hyperemesis, miscarriages and ovarian hyperstimulation syndrome and a short few questions based on these case scenarios. So, uh the key objectives of today's presentations are um to recognize common presentations and to diagnose and manage on day to day basis in your regular clinical practice. So, before we start, how interested are you in gynecological topics? Uh So whom do we have there? Can I have their names? Sonia, please? Any participants? Oh, we've only got a couple so far. So it might be worth moving on. Yeah. Sure. So, yeah, the first question, um, we have got a 15 year old girl, Vanessa, uh, she recently, uh, diagnosed to be her pregnancy test positive and she's complaining of vaginal bleeding and uh lower abdominal pain. So, what further information would you like to know in the history? So whenever a 15 year old girl comes with a positive pregnancy test, uh we have to know, we have to ask her a few questions that like how is she in pain and how much she's bleeding is the bleeding associated with any clots? And we need to ask her sexual history, any past medical history, past surgical history or is she on any taking any medication like drugs or something like that? These, these are the normal clerking, um, basics which you need to know coming to the history. Uh, she, she has been sexually active for the past year and she was shocked to know that her pregnancy test has been. Can you remember your life? Yeah, I'm I'm moving my slides. Can you see that? No. Oh. yes. Yeah, we can see your slides move. Yeah. Ok. Uh, are you able to see now? History? Yeah. Yeah. Yeah, we were able to see you. That's fine. Yeah. Uh, so, uh, this girl, uh, wea, she has been sexually active for the past one year and today morning, uh, she's complaining of, uh, pain in her right leg foa. And she also noticed, uh, vaginal spotting. She firstly thought that it was, uh, just her normal period, but, uh, the pain keeps on increasing and she thought that's not like a period pain and it's something different. And she's worried about that and she denied having any pelvic inflammatory disease. And she's complaining of dull lower abdominal pain and fell sick this morning and her appetite has been reduced for the past two days. So, what examination would you like to perform on this patient? So, the first thing we'll do is the vitals, we have to take, uh, vital signs like pulse rate, BP, respiratory and temperature. Uh, in order to see if she vitals and then we'll quickly do a abdominal examination to see what's the si size of the uterus, the height of the uterus. And to see if she has got any abdominal guarding or rigidity. And then we, uh, ask her verbal consent. And, uh, with the chaperone, we will do a prospective examination to see how much she's bleeding. And what's the quantity of the bleeding and the site of the bleeding? Is it from the cervix? Is it from the vagina? And then uh we'll quickly do a bimanual examination with the left hand on the top of her abdomen and the right hand in her vagina to see the size of the uterus and uh to see any cervical motion tenderness, which is one of the critical part of our diagnosis. Uh The first case, the dia diagnosis of her first case. So here are the results of the examination, her vitals have been stable now. And on her para adominal examination, we found that uh there's a positive tenderness in the right iliac foa, but there is uh no rebound and no guarding rigidity and on per speculum examination, uh we found that uh there's a slight brown discharge and her cervical os has been closed. And on bimanual examination, her uterus is a non tender and there was no cervical excitation, no adnexal masses have been felt. And um there was just a small tenderness on the right side. So what would be the differential diagnosis in her case, any one of the participants can answer fine. Um So firstly, starting with our and gynecology, one thing it could be ovarian torsion sometimes like the small is a, a bit smaller and uh if the stalk is a bit longer, sometimes it can tor it, it can uh rotate by itself that is called ovarian torsion And uh even in this case, as a patient can present with uh severe vomiting pain and uh sometimes bleeding as well. Sometimes it can be an ovarian cyst accident such as rupture. And it can also be a tubo ovarian abscess, especially pelvic inflammatory disease sly. And it can also be ectopic pregnancy in this case because her urine pregnancy test is positive and um the other symptoms, uh other systems are appendicitis and it can be a bowel perforation, ischemia, obstruction or mild rotation of the bowel. These are the differential diagnosis. When uh a patient comes with such complications. You need to that. Uh, you need to investigate based on this coming to the next question. So we have done triple swabs while we are doing a post speculum examination. And what other investigations would you like to do on this patient? We can do a full blood count to see her hemoglobin because she's complaining of heavy bleeding. We need to know what her hemoglobin status is. And we also need to do a blood grouping and typing and group and say if possible because if we need to take her to a theater, we need to have a group and save ready. And the most important thing is we need to do a beta head C level, uh to know what beta head CG uh level she is is not present. And then we need to follow up based on that. The last thing is a transvaginal ultrasound scan. This is a gold standard investigations for the early pregnancy scan. So we need to do that as well to see if the pregnancy is intrauterine or maybe an opic pregnancy. We don't know until we do a pelvic ultrasound scan. So come into the ultrasound report. Uh it was an empty uterus and there were no adnexal masses as well. There is a small amount of free fluid and we have got her blood test results as well. The hemoglobin level is 13 WBC count is 12,000. Serum beta head C level is 516. What do you think the results mean? Usually if it's we find the uterus um embryo implanted in the uterus, but here we have got an empty uterus but the serum beta head seizure level has been raised. So, what do you think the results mean anyone of you can answer this, please? Fine. So her uh we have done a repeat blood test after 48 hours and her WBC count have been 11,000 and her beta HCG levels have doubled from 560 to 800. It's nearly doubled in 48 hours. So, what do you think is the cause of this race? Could it be an atopic pregnancy? Could be a pregnancy of unknown location. Could it be a miscarriage? Yeah, because the beta HCG levels have been nearly doubled. It could be either an ectopic pregnancy or failing pregnancy or a pregnancy which is, uh, slowly going to miscarry itself or very uncommonly, it could be a viable intra pregnancy as well because especially in an intra pregnancy, we expected a beta CG level, raise minimum of 66% in 48 hours. But here it's just less than 50%. So most probably we will take this case into either an active pregnancy or a failing pregnancy. What do you think the subsequent management of the procedure can be? No. So usually in such cases like uh our patient when she's not complaining of much pain and uh she's, her vitals have been stable. So most probably what we'll do is we'll do um an outpatient management and we'll ask her to follow up with the beta results. But if we have any concern of the patient, like um if her blood results have been abnormal and her um vitals have been unstable and she's collapsing, then we may need to uh do a uh urgent investigations like um laparoscopy or uh we need to do a urgent surgery and we need to prepare her for the theater. So, coming to the first thing, uh what is ectopic pregnancy? Usually fertilized dome gets implanted into the uterus, which is the usual case in normal pregnancy. But unfortunately, in this ectopic pregnancy, the fertilized dome gets implanted outside the uterus. Anywhere in the abdominal cavity. It can, the most common site of pregnancy would be to, it can be either the is site, pill area, infundibular or maybe interstitial area of the fallopian tube. Very rare cases. It can be in either in the abdomen, in the peritoneal cavity anywhere here or it can be in the cervix as well. Sometimes it can be even on the cesarean section scar, coming to the symptoms and signs of ectopic pregnancy. Most commonly, the patient presents with a MR period. Her, she says that her uh was positive and she's complaining of pelvic abdominal pain. She may even come with uh vaginal bleeding with the which is associated with clots. She may even have breast tenderness, which is again a physiological uh sign and of pregnancy. Sometimes uh she may have gastrointestinal symptoms, urinary urgency because of uh a lot of blood accumulated in the uterus. It may press on the bladder. That could be one of the reason why she might be having the urinary symptoms as well. And very rarely, she can have dizziness, fainting and syncope, which is a predictive of rupture atopic pregnancy. And she has got a lot of hemoperitoneum. That means she has lost a lot of blood. That's the reason she is in uh fainting and syncope area. What are the signs effect of your pregnancy? So, uh on uh conjunctival lower conjunctiva, you can see paler, which is a sign of uh that she has lost a lot of blood. Sometimes you may have rebound tenderness on uh or peritoneal signs while doing parad uh examination which is a sign that a lot of blood have been accumulated in the peritoneal cavity. And uh that can irritate the peritoneal cavity. And sometimes on bimanual examination, as I've already told you guys, it can be, uh you can also feel that uh the patient is experiencing cervical motion, tenderness. It can be abdominal distension, enlarged uterus, and uh the vitals will be very unstable because she has got a lot of uh lost, a lot of blood. You may, you may experience, I mean, you can um get tachycardia and hypotension. Sometimes the patient may collapse as well. So how do you diagnose this atopic pregnancy. Transvaginal ultrasound scan is the best way to diagnose atopic pregnancy. It can uh help uh to identify the location of the pregnancy. Is if it's an intrauterine or is it an extrauterine or anywhere or the abdominal cavity where you'll find an empty uterus, sometimes you can also feel a collection of fluid in the uterine cavity, which is described as a pseudosac. So what is the susac? This is some inhomogeneous mass. Uh We just uh or some blood clots which gets accumulated in the uterine cavity because of the abortion or uh ruptured uh atopic pregnancy. Some, some of the fluid or some of the blood can get accumulated in the uterus. Usually in, if the gestational sac is implanted in the uterus, we find two concentric echogenic rings in the endometrium that is called double residual sign So in activ pregnancy, we find an empty gestational sac, which is in the tube. So that is called either tubal ring or bal sign on ultrasound scan. So if you can see this ultrasound scan picture, this is like a bagel or a donut sign. If you can see this is like a donut. And um there is nothing in between. Uh there's an empty gestational sac and uh there's a lot of vascular around when you do a, a color Doppler, uh which suggests it's a tubal ring or a ring of fire sign, which is significant of atopic pregnancy. When you see this on an ultrasound picture, you can directly tell that it, this is an opic pregnancy. If you can see this ultrasound scan, uh This is the uterus and uh this is the ovary, how you can see, find the or find it as an ovary is uh there are a lot of follicles around and uh this is the fallopian tube, this is the left fallopian tube. And if you can see this, the small round part, this is the yolk sac. And uh the there's a fetal pole which is an o shaped one and there's a lot of vascularity around this, which suggests that it's a viable tubal ectopic pregnancy. I mean it's still viable because of a lot of blood supply and coming to the laparoscopic view affect pregnancy. This is the uterus. And uh if you can see here, there are left normal Adex the tube and ovary. This the white part is the ovary and this is the fallopian tube. And if you can see on the right side, the fallopian tube have been um enlarged because of the tubal pregnancy. And uh it's ruptured. You can see a lot of blood in the peritoneal cavity in the pouch of Douglas as well. And the blood is literally extending into the mesosalpinx and the extraperitoneal space. This is a classic feature of ruptured tubectomy pregnancy. So how do you manage atopic pregnancy? So, if you find like Vanessa who is asymptomatic and just complaining of mild to minimal pain, uh We first uh ask her, how is her pain if she complains of no pain? And um then we'll do a beta head seg levels. If her serum beta head sei level is uh less than 1500 international unit per liter. And then we'll do a transvaginal ultrasound scan, then we find if her gestational sac is less than 3.5 centimeters, we will try to do a medical management of mis uh atopic pregnancy, which is mostly methotrexate. But if she has got uh her serum C level between 1500 to 5000 and if she has got mild pain and her adnexal mass, that is gestational sac on transvaginal ultrasound scan being less than 3.5 centimeters, we can offer her either methotrexate or a laparoscopy, either a medical management or a surgical management, but it uh purely depends upon patients preferences and desires. Then if you, if the patient comes in uh severe pain and uh you notice uh serum beta had level of more than 5000 international unit per liter. And on ultrasound scan, her uh fetal heart rate is present and adnexal mass is more than 3.5 centimeters. We definitely have to consider the surgical management of uh miscarriage because the patient is not hemo unstable and uh even the free fluid in the transvaginal ultrasound scan denotes that um she had an rupture ectopic pregnancy and she may slowly collapse. So what do you do at this point of time? We will crossmatch her blood and then we'll take her to the to, to the theater, we will uh consent her, we'll take a written consent uh to either remove her complete fallopian tube, which is salpingectomy. Uh And you will also tell her that there can be very few recurrences with the salpingectomy compared to Salpingostomy. And uh if the saling uh and the next procedure is Salpingostomy, it is done only when the other fallopian tube is either damaged because of the previous opic pregnancy or if the other fallopian tube uh is either damaged because of the pelvic inflammatory disease. Uh sa with additions or uh some other things, then we may resort to Salpingostomy in order to save uh the fallopian tube rather than completely cutting it. So, what do you do in Salpingostomy. So in Salpingostomy, we will suck out the ectopic pregnancy and then try to resuture the fallopian tube to make it uh normalize and uh to make it um essential uh to get the next pregnancy. And then we will do a weekly follow up of serum beta head CG levels until it is negative. So if uh in one week, if it's 400 then the next week, if it's uh 250 or something or uh less than 100 then the serum beta head seizure level is dropping. So, and the patient is uh and that's a very good sign. The serum beta head seizure level is dropping by more than 15%. But if the serum beta head seizure level is not dropping by 15%. And if the patient is still asymptomatic, then we can still try medical management of methotrexate. But if the patient is having pain and if the patient's uh vitals have been very unstable, then you may have to resort to laparoscopic cell inject me again. So coming to the medical management of active pregnancy. So following administration of methotrexate, we will uh do serum beta HCG levels on day four and day seven of uh methotrexate injection and compare both the levels. So if the beta head CG levels have been dropping by more than 15% from day four to day seven, then we will do a weekly serum beta CG levels until the beta head seizure level is less than 25 international unit para. But if the beta levels have not been dropping by, uh, more than 15% then it's not a very good sign. So we need to do either a repeat methotrexate. If the patient prefers to only try methotrexate and she doesn't want any surgery, we may try repeat methotrexate or if she says that no IV with this methotrexate, I really want to do a surgery, then we can resort to surgery as well. Uh So this is all about atypic pregnancy. And um there are uh some, as I have already told you, there are a few unusual sides of atypic pregnancy. If you can see here, this is the empty uterine cavity. And uh there you can see the barrel shaped cervix. It's literally like a wine barrel which you see in uh Pirates of Caribbean movie. So this is like a barrel shaped cervix. Here, you can see empty gestational sac here, this is a cervic like tropic pregnancy. And uh if you can see here, this enlarged part is the uterus and this is the bladder and in the lower uterine segment, you can see a gestational sac implanted exactly in the lower uterine segment between the uterus and the bladder, which is two office X and scar pregnancy because we usually give a curvilinear incision in the lower uterine segment. That's the reason why it's getting implanted in the lower uterine segment. So, what is a prognostic modality of is that it's usually a transvaginal arts scan where you find an empty uterine cavity. And sometimes the gestational sac is uh uh located at the anteriorly at the level of the internal loss. As I have already told you, that's the way that's where we do a cesarean scar. And then it can also uh you can also find the thin or absent myometry between the gestational sac and the bladder and the gestational sac is literally pushing the bladder. And that is why you have seen the ultrasound scan, that the gestational sac pushing the bladder because it's it is growing in size. So what is the management of psychotropic even here, you can uh give the patient options like uh she can try for a medical management by using systemic methotrexate or she may even resort to a surgical management. We can do an ultrasound guided intralesional sac methotrexate and thus, we can terminate the pregnancy. Fine. Um This is all about atypic and here we have got another case scenario. Uh Do I have any voluntaries for this case, please? Ok. Fine. Uh So this woman, she is a 24 year old uh primary gravida. She's complaining of irregular heavy vaginal bleeding for the past few days. She's also complaining of worsening of nausea, vomiting, headache and dizziness for the past few weeks. Her last menstrual period started six weeks ago and on examination for abdominally, you found that her uterus is enlarged to 10 week size. And the on her vaginal examination, you notice that the blood is oozing out of the cervic loss. Her beta HCG is positive and her vital signs uh on her vital signs, you found that she's tachycardic. This is her ultrasound scan of the uterus. You can see snow storm appearance. I have given you a clue. So what is the probable diagnosis of this condition? Anyone? Yeah, this is a molar pregnancy because if you can see here, um thi this is a snowstorm appearance of the uterus. And uh um her urine pregnancy test is she's complaining of worsening of nausea and vomiting. All are significantly pointing out to the molar pregnancy. So what is gestational trophoblastic? Usually there are few cells, the fetal cells sometime. Uh usually they develop the trophoblastic cells develop into placenta but unfortunately, sometimes in this gestational trophoblastic disorders, the trophoblastic cells have an aberrant fertilization and they proliferate very rapidly to cause this gestational trophoblastic disease. These are of again, two types. One is benign and the other one is malignant. The benign conditions are called a molar pregnancy or high mole. Whereas in malignancy, they can be severe. Uh other things, uh I mean many other things like uh invasive mole, choriocarcinoma side prophylactic tissue disorder or or uh epitheloid trophoblastic tumor. We'll um speak about it after that. So, what are the mechanisms of molar pregnancy? Here, we have two types. One is a partial mole and the other one is a complete mole in a partial mole. Two sperms gets attached to the old one and then results in triploidy or tetraploidy zygote, either it can be 69 X xx or 69 X xy. Whereas in a complete mole, one sperm gets attached to an empty wor results in 46 xx or sometimes one sperm gets attached to um normal, resulting in 46 xy. So how do you differentiate a complete mole and a partial mole in a complete mole? Usually you can see a fe uh a fetal tissue is usually absent. But whereas in a partial mole, fetal tissue is usually present. And that is why the partial mole is uh very difficult to diagnose with uh I mean, differentiate between a miscarriage and a partial mole. And in a complete mole, you usually have a lot of vous capillaries, lot of trophoblastic hyperplasia and um significant chorionic swelling. And that is the reason why it has got a lot of uh uh uh a a bit higher malignant potential compared to a partial mole in a partial mole. All these will be very focal and mild and that is why the malignant potential have been very less in cases of a partial mole. So, what are the signs and symptoms of hemo pregnancy? Bleeding is one of the most common symptom. Usually, a patient presents to the Gyne assessment unit with the passage of grape like vesicles, which is a typical symptom of a molar pregnancy, especially in the cases of complete mole. Patients will have a first trimester with preeclampsia, hyperthyroidism, hyperemesis. And uh on abdominal examination, you can even see increased uterine size because of the grape like vesicles get got accumulated in the uterus. And on ultrasound scan, you can find fecal uterine cysts. So here I have got a question. Can anyone tell me what is the reason why hyperthyroidism and hyper co exist in molar pregnancy, please anyone? Ok. Uh So the thing is uh because of the, there is a molecular mimicry between a beta HCG level and the TSH receptor. And that is why a lot of, I mean in a molar pregnancy, the serum beta HCG levels are significantly increased and the beta head C levels cross reacts with the TSH receptors. And that's uh that's the reason why there is a hyperthyroidism and hyper coexisting in cases of molar pregnancy and in cases of partial mole, as I have already told you that it's very difficult to diagnose I missed or incomplete abortion because we still have fetal tissues present in a partial mole. So what is the diagnosis? Clinical lesions with the uh passage, passage of tissue and even the beta se levels, significantly increased of more than one lac international unit per liter and there is an enlarged uterus and vaginal bleeding. What is the diagnostic investigation of choice? Ultrasound is always the best choice uh of uh diagnosing a hirate hormon. We will see no storm appearance as I have already shown you in the other picture. And then we'll do beta se levels for a follow up following up of the beta head seizure levels in cases of molar pregnancy. But the definite diagnosis is always a histological examination where in cases of a molar pregnancy that is complete mole, we have no tissue fetal tissue and there is excessive trophoblastic proliferation. But in some cases, it's very difficult to diagnose a partial mole and a complete mole. So that is where the immunohistochemistry staining that is P 57 staining comes into play. The PF is PP 57 staining is positive in cases of a partial molar pregnancy but it is negative in cases of a complete molar pregnancy. So how do you manage molar pregnancy? That is ultrasound, guided suction evacuation. But in some cases, especially in cases of a partial molar pregnancy, uh the fetal head is already formed and it's very difficult to get the fetal head out with a small suction tubing. So at that time, we will do a suction curettage with the forceps or with the uterine curettage and take out the baby fetal tissue and everything. But uh we should always remember, especially in cases of Rh negative pregnancy, we need to give anti prophylaxis before we come doing an suction curettage. I mean, uh soon after doing suction curettage to prevent sensitization of uh fetal antibodies to the mother. So, this is ultrasound scan. Here, you can see a lot of um vesicular tissue, which is again a stone stro appearance and this is the baby's fetal head and these are the baby parts. So there is a coexisting of both the fetal parts as well as the um vesicular form. So what do you call this? This is a partial molar pregnancy coming to the third place. So here he gravida, she's uh presenting to the emergency department with hemos hemoptysis. And she's also complaining of increased cough and shortness of breath for the past eight weeks. Upon asking for the history, she told that she had a spontaneous abortion six months back and then she's complaining of irregular and heavy period for from four months. And on examination, you found that her uterus is enlarged to 12 week in size, her serum beta head CG is significantly elevated. Her hemoglobin is low. She you noticed that she is anemic and on chest X ray, you noticed because of the shortness of breath, you have done the chest X ray as well. You are a very brilliant um junior doctor and then no chest X ray, you have noticed two lung infiltrations. So what is the probable diagnosis here? So, because uh she's having hemoptysis, she has got lung infiltrations most commonly, it will be a choriocarcinoma. Lung infiltrations is usually when there are metastasis of the cancer, right. So, that is why she, it's a choriocarcinoma. So how do you manage gestational trophoblastic neoplasia? As I have already told you, gestational trophoblastic diseases are either benign or malignant. And that I uh this is these are the types of uh uh malignant type of gestational trophoblastic diseases, which can be predicted by a modified fal scoring system uh based on different characteristics like age. If uh the patient's age is more than 40 years, she scores higher. And if her previous pregnancy is uh is a term pregnancy, then she scores higher as well. But if the interpregnancy interval, if it's more than one year, she scores higher, if her pretreatment had seizure level, if it's more than one lack, she scores higher. If her largest tumor size, if it's more than five centimeters, again, she scores higher and the site of metastasis, if it's involving some complex organs like brain liver, she scores higher. And if her metastasis have been on uh different sides of more than eight, again, she scores higher. If she has got uh previous two or more drugs failed chemotherapy. Again, she scores higher. Based on the scoring system. We categorize women at low risk or high risk. Uh with the course of six or less, no one is treated as a low risk. And then we'll give a systemic intramuscular methotrexate that is a single agent one. And then alternatively, we'll give you Folinic acid in order not to drop her hemoglobin levels. Much further because uh methotrexate is an immunosuppressant drug. And then uh we'll follow up her for the six days and in this course of seven or higher, we have to give a chemotherapy that is intravenous multiagent chemotherapy. With IAC arrangement, IMA is etoposide methotrexate, Dactinomycin, cyclophosphamide and Vincristin. So how do you follow up such cases? The treatment is continued in all these uh high risk cases until the seg level has returned to normal. But we have to continue for further six weeks because we need, we don't want any recurrence of the gestational trophoblastic neoplasia in such cases. And there are, there are the, these are the cases who have higher risk of recurrence. So how do you follow up molar pregnancy in cases of a complete molar pregnancy? If the HCG levels have been reverted back to normal within the 1st 56 days of the pregnancy event, then we will follow up with for six months from the date of suctional curettage. But if the head seizure levels have not been reverted back to normal within the 1st 56 days of the event, then we will follow up from the six months and uh uh from the uh normalization of the head seizure levels. So this is for complete molar pregnancy. How do you follow up with a partial molar pregnancy? Here, we will do, we'll take two blood samples of one head c uh um four weeks apart. And then if the two head CG levels have been negative or if it's uh normal, then we will conclude it because in partial molar pregnancy, the chances of recurrence and uh the chances of growing them to neoplasia is very, very less as I've already mentioned prior. So uh whenever woman, uh the women who have not received any chemotherapy in cases of e molar pregnancy, they need not have any further follow ups with head CG in their subsequent pregnancy. So, coming to the next question. So we have go to primary care done. She's spontaneous pregnancy. Uh she's complaining of constant vomiting and nausea for the past three days, unable to tolerate any oral intake. Her medical history is uh insignificant for any other and any medical problems on examination. We noticed that she is looking very ill, uh dehydrated, sunken eyes, dry mouth, uh BP shows hypotension, tachycardia, tender epigastrium, 6% of weight loss compared to her prepregnancy weight. And on investigating further, we noticed that her full blood count renal function, test, liver function tests, everything have been in normal limits and we have done a urine pregnancy, uh urine dipstick as well. We noticed that she has got three plus ketones, no muscles and no heart disease. So what could be the most likely diagnosis and called the differential diagnosis? Anyone can answer, please. Ok. Um so because she has got uh she's in early pregnancy which is less than 16 weeks most probably. And she's complaining of constant vomiting. Most commonly, it will be a hypertensive gravidarum. That is the most common. Uh the this is how the patient presents in cases of hypertensive gravity because she has literally lost more than 5% of her weight loss compared to the prepregnancy weight. But there are other differential diagnosis. We need to rule out them as well. Sometimes it can be a urinary tract infections if you notice any urinary dipstick of nitrates or it can be pyonephritis as well. Sometimes it can also be gastrointestinal symptoms. Uh conditions like uh cholecystitis or hepatitis, pancreatitis, appendicitis or it can also be a metabolic conditions like um diabetic ketoacidosis, gastroenteritis, peptic ulcers. These are the differential diagnosis of my case. So how, what all we need to ask the patient in this history. First, we need to assess her mental status, how she's doing. And uh then we have to ask her if she is able to tolerate any fluids or food or something and how this hyper gravity room is affecting her day to day a daily activities. And then we will assess her weight loss. We have to take her prepregnancy, weight loss and then we have to take her present present pregnancy, weight loss and we have to see how much she reduced her weight. Then we need to ask her abdomina. Uh did she have any abdominal pain? Is she having any urinary symptoms? Like uh frequency dysuria, burning, maturation? Any urgency in urination so that we can treat urinary tract infection along with the hyper graft. And also we need to ask if she has got any infection history or is she on any drugs like recreational drugs like uh morphine or something? And then we need to, how do we examine such cases? Uh While we take vitals, usually in cases of dehydration, we see uh the patient's heart rate is increasing tachycardia and they may even have low BP because the intravascular space, extravascular space is already reduced. And that is the reason why she might having uh hypotension and she may even try to get g gra, I mean gasping. She may, she may even uh uh have gasping that is called tachypnea, increased respiratory rate. And then we need to assess the signs of dehydration. Like um we need to assess her face, sunken eyes, dry lips, dry mouth. And she'll really have either she may have very reduced urinary output or she may have no urinary output because she's not drinking anything and whatever she drinks, she's, it's coming out. And uh we need to assess her uh weight loss as well. If it's uh more than 5% of prepregnancy weight, we need to assist her neurological examination as well because uh she is literally puking everything her Vitamin B deficiency uh is also present and that is why uh we will have one encephalopathy where she presents as confused uh patient and uh with nystagmus in her eyes and it acid gait. So how do you investigate such patients? First thing you can do is urine analysis. You can do a urine analysis to see if she has got any nitrates and treat urinary tract infections. And uh this Green talk guideline um have been recently modified where ketonuria uh is not a indication for dehydration and it has got no significance in the management of nausea and vomiting in pregnancy that uh you have to keep in mind. And um then we need to do a midstream urine specimen using these, that is your urea and electrolytes. Uh full blood count, we need to assess if she has got any infection by doing CRP and uh see her anemia and do her blood glucose levels to exclude any diabetes or diabetic ketoacidosis and definitely do an ultrasound scan to see if the baby is still viable or it could be an ectopic pregnancy as well as we have already discussed. Uh We need to see if it's an intrauterine or either ectopic pregnancy or is it a molar pregnancy because of her hyperemesis? And uh we need to do a thyroid function test if the patient is already hypothyroid or hyperthyroid or if she is taking any levothyroxine medication. Uh we need to do liver function tests to exclude any hepatitis, any cholecystitis. And uh we need to do amylas to exclude any pancreatitis. So, how do we score this hyper grab we have a unique preg pregnancy, unique quantification of M SIS score. This is called the P score. So how do I ask these patients uh the following questions? So we will go to the patient. We'll ask her if she's feeling nausea or uh if is she vomiting for the past 24 hours or is she having any itching or any dry heaves in the past 24 hours? If uh all these are present in less than one hour, then she scores very less. But if she's having all these for more than six hours, then she scores higher. The uh the mild scoring is six, but uh the severe scoring is 13 to 15. Uh This algorithm I have taken from green guideline of uh nausea and vomiting in pregnancy. So we'll first do an initial assessment of the patient uh like uh see her face is she dehydrated. Uh we uh see her weight loss and stuff and then we'll do a quick P score and then uh we'll see from based on the P score if her P score is 3 to 12 and if she has got no complications, then we can still manage her in the community. Uh We can either give an antiemetic medications. We have to ensure that she drinks a lot of fluids and uh a lot of water. And uh we can also give her laxative if she needs them. And we can also give pump inhibitors like omeprazole or lansoprazole. If she has got any epigastric tenderness or uh epigastric irritation and uh we have to reassess in 1 to 3 days. If she's improving, then we can still manage her in community. But if she's not improving and, and she's still not tolerating oral fluids, then we may even add any second or third class of antiemetic drugs. But or we can take her on in, in patient management. And the next one is if the peak score is more than 13, if the score is higher and she has got no complications and uh she's still having difficulty uh to tolerate oral intake. And all these community measures have failed. Uh all these 1st and 2nd anti ins have failed, then we may have to refer her for ambulatory day care management where we give IV fluids to the patient like Hartman's solution and crystalloids along with the potassium chloride because her uh urine electrolytes have fallen down and we may even have to give parenteral um um IV anti medication as well because she is not tolerating any oral medication. The next one is if she has got any red flag symptoms like uh complications of uh urinary tract infections, or she might be having diabetic ketoacidosis or diabetes mellitus or any metabolic conditions, then we may definitely need to admit her because uh she has got a significant weight loss of more than 5% body weight. And um she's not tolerating anything orally, then we need to do an inpatient management of this patient. So what are the recommended anti medications which we have to pre gravid and which is safe in pregnancy. So, the first line medications are always cyclo which is an antihistaminic medication. And the next ones are prochlorperazin, promethazin, chlorpromazin, which are D2 receptor anti uh uh antagonists. And then the second line medications are uh prokinetic drugs like uh metoclopramide, domperidone and uh five ht two receptor um blockers like onset. And then the third line, the last resort would be steroids. Uh We'll first start with hydrocortisone and once the patient starts improving clinically, that means she's tolerating orally and she feels ok, then we can slowly convert to predniSONE. Sometimes some patients, they uh they don't want this pregnancy because of the seizure hyper gravity and they wanted to go for a termination of pregnancy. Uh But then we need to assess her uh mental health status. And then uh we have to see if uh that is what she needs and uh that is what makes her hypertensive better. Then we need to terminate the pregnancy as well. That is in very rare cases. So this is all about uh hyper gray and uh for your further reading. Um I have taken all these from uh nice guidelines of opic pregnancy and the Green talk guidelines of uh gestational trophoblastic disease and uh nausea and vomiting in pregnancy and the to article of Cesarean scar if you have any doubts. Can you uh you can please ask me now? Thank you so much. Now, uh I think one of my friends, Sonia can uh speak about the next topics. Ok. So now let's move to case number five. So this, ok, I can't see the full sentence. No, Sonia. Yeah. Yeah. Oh, yeah. So this is a 31 year old female who was brought in by ambulance to A&E with vaginal bleeding. She was stable in her observations except for a mild tachycardia with a heart rate of 90 beats per manage. And her urine pregnancy test was positive. Actually, she was waiting for a dating scan in a few days time and on examination, she has a soft and nontender abdomen. Bimanual examination showed an enlarged soft nontender, uterus adnexa was nontender and free. So any thoughts around this case? So what are your top differentials? No, next slide, please. So there are a lot of conditions can uh present in this way. So we can categorize this as either pregnancy related or non pregnancy related. So it could be a bleeding in a viable pregnancy, what we can call it as either it could be an ation pregnancy or a subchorionic hematoma that is a hematoma developing inside the gestational sac and it could be drug and miscarriage. Inevitable miscarriage, mis miscarriage, incomplete or complete miscarriage or even a mis miscarriage or even a molar pregnancy. Non pregnancy related conditions are like infections of the vagina and the cervix or cervical abnormalities like ectropion, polyp, malignancy and trauma. So, there are instances where cervical cancers have been uh first diagnosed uh when a uh pregnant lady presents with vaginal bleeding. Next slide, please. So how can we differentiate all this condition when a lady presents with a bleeding p uh in the presence of a pregnancy, urine pregnancy test, pa. So by taking a proper history and doing a g uh abdominal and speculum examination. So the speculum examination is a very important symbol in this uh examination, which will help us to differentiate all these condition. So now let's see, how can we do that. So you have done a speculum and you can see the cervical uh o appears to be open, then it could be inevitable miscarriage or incomplete miscarriage. If you're seeing some products passing through the s, then uh it could be incomplete miscarriage. In addition to that, if you are able to uh find any evidence of uh features of sepsis, then try to rule out septic miscarriage. Ok. And inevitable miscarriage means it's inevitable. So at any point, she she will start passing the product of conception. In next scenario, the cervical osis closed, then it could be threatened miscarriage or it could be a mis miscarriage or a complete miscarriage. No, this condition, the pregnancy test will be positive except in complete miscarriage that naturally you can expect a negative pregnancy test. However, in some situation where the complete miscarriage has happened recently, then the pregnancy test will be positive. Next slide, please. Bye. You're coming to the uh confirmation of a mis miscarriage by doing an ultrasound scan. So by doing one ultrasound scan, we cannot guarantee 100% in an accurate way. We can't diagnose uh mis mis miscarriage as there is a small chance that the diagnosis may be incorrect. Maybe we can miss uh intrauterine pregnancy, especially if it is done in very early gestational ages. So basically, we are doing uh two types of measurements, crown length or CRL and mean gestation, sac diameter or MSD. So let's see, we how can we decide on which measurement we need to use previous slide. So first what we are doing, we are looking into the fetal heartbeat. Ok. We can see the fetal heartbeat, then it is viable pregnancy. If we are not able to see the fetal heartbeat, then, but we can see the fetal pole, then we will go for cr but if there is only sac, you can't see any fetal pole, then we will go for mean sac diameter. Now, what are the criteria to confirm mis mis miscarriage next slide. So, as I told you before, we are going ahead with the CRL with the new visible fetal heartbeat and the measurement is less than seven or means diameter with no fetal pole and the measurement is less than 25. Then we will request for another scan in seven days time with a transvaginal scan. If it is transabdominal, then we will uh rescan in a 14 days time. If CRL is more than seven or sac diameter is more than 25 then either we can ask for a second opinion or we can go for a rescan in seven days with a transvaginal and uh in 14 days time with a transabdominal scan. Yes, Ringo has uh suggested molar pregnancy as to one of the differential diagnosis. Uh You're absolutely right, Ringo, you're coming to the management. So first threatened miscarriage. So considering the progesterone deficiency as one of the predisposing factor for threatened miscarriage, we can offer vaginal micronized progesterone, 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan. And if, if they have preceded with the vaginal bleeding and have previously had a miscarriage. So basically, a lady is proceeding with the vaginal bleeding and she has a history of a previous miscarriage. And we have done the scan and we have confirmed that it is an intrauterine pregnancy. We excluded ectopic, then we can start progesterone. So once the fetal heart is confirmed, then continue the progesterone until 16, completed weeks of pregnancy. And if the bleeding gets worse or passes beyond 14 days, then we need to review her in case if the bleeding stops, then we can advise her to continue with the routine antenatal care. Next side please. So next to one mis miscarriage. So there are three options open to the women. Expectant management, medical and surgical management. So the expectant means we are waiting for a period of 7 to 14 days and the lady can expect to have a bleeding and it usually it will settle within two week period. And so that we will review her in a week time. And uh a scan is recommended if uh the woman did not start any bleeding or pain, which means that expectant management failed in her case, or if she uh presents with a persist, persisting bleeding even uh at two weeks, then it is incomplete miscarriage. So we need to rule out by doing a scan. Next option is medical management. So we will start with a single uh dose of 2 200 mg mifepristone. Then 48 hours later, 800 mcg miSOPROStol will be given in different groups. Then we will review her uh in 48 hours time and then we will discuss uh we will assess her and discuss the options. Some uh she may not respond to medical management and there is no bleeding, no pain. Then uh it's uh considered as a failed medical management. In another situation, she may present with a heavy bleeding. Ok. So it is incomplete miscarriage in those type of situation. Uh We can uh discuss further option, either repeating medical or going for a surgical surgical means we can uh do the surgical management, either under local anesthesia by doing a manual vacuum aspirator or under general anesthesia, which is called EVAC. And then we will discharge her on the same day and we will review her with the histology. So we will discuss all these options. We will explain all the pros and cons with the V and we will uh guide her and help her in making a decision. Now, next one inevitable, as I told uh before, at any point, she can miscarry. So it's basically an expectant management. We will give all the support to her and uh enough analgesics will be provided incomplete, so we can go for a medical or surgical management. So here we will start with the miSOPROStol and uh mione not required surgical uh the same either um manual vacuum aspirator or reac complete means. Ok. Uh One point uh here because we need to confirm that this is a complete miscarriage. Next slide. No, there are some contraindications for expectant management. So we can't agree with the woman if uh she opts to expectant management. So what are the indications in case if the woman is at increased risk of hemorrhage? For example, if she is in the late first trimester, because in that case, we can expect heavy bleeding. So it's not a safe option. And also if she has a previous adverse or traumatic experiences associated with the pregnancy like uh stillbirth, miscarriage or antepartum hemorrhage in those type of women, it's not a good idea to wait for two weeks time and then it can adversely affect her mental health condition. So in that case, it could be a better option either going for a medical or surgical. And if the woman is at increased risk from effect of the hemorrhage, for example, if she is having some coagulopathies or is unable to have a blood transfusion. And also in this case, also, she's uh expectant management is not going to be safe because expectant management, we never know at what point uh she will bleed and until what period she will bleed, how will be the severity of the bleeding comparing to yes, ok. In the uh women who are at high risk of bleeding with a background history of the coagulopathy, if we are able to control the bleeding in a uh control the management in a by doing a surgical, even that will be a more safer option. And if there is evidence of infection, it's not a good idea to wait for another 14 days to further care. So all women will be provided with uh an information leaflet as you know, it's a sensitive information. So it need a lot of time and we need to uh ensure the privacy and we need to give her enough time to uh accept uh the information, to accept the bad news and then to think about that and to take a decision and also uh uh ensure them that waiting for a repeating scan has no detrimental effect on the outcome of the pregnancy. Always give them a 24 hour contact telephone number so that they can uh seek a medical help help whenever they need. And all for all women receiving medical management, uh enough pain relief and antiemetics. Next slide, how can we follow up before that? A few points about anti D or an immunoglobulin prophylaxis at a dose of 250 international unit or 50 mcg. To all research negative women who have a surgical procedure to manage miscarriage. However, it is not indicated in case of medical miscarriage, medical management threat and miscarriage or complete miscarriage. Next slide. So now coming to the follow up, we will advise all women uh to have a urine pregnancy test, get done in three weeks time and we are expecting a negative pregnancy test. And if the uh pregnancy test turn to be positive, we uh we will advise them to report to the hospital because in that case, we need to rule out retained product molar pregnancy and even ectopic pregnancy. Some uh the pregnancy test will be negative but still they will be complaining of her bleeding. In this situation. We need to review the patient and we need to uh further investigate her. No. So now this is one scenario, a 28 year old woman presents to the early pregnancy unit with two days history of heavy vaginal bleeding and abdominal cramps. Now, the bleeding and the pain settled. Actually, she missed her period two days back and uh she started her bleeding on the expected day of her period. So initially she thought it's her normal period. Observations are stable abdominal examination, soft, non tender abdomen, speculum shows smile bleeding with a nose, uh closed ose pregnancy test was positive. So, what are the differentials? How will you confirm your diagnosis? Any thoughts? One of you can type a message either Ringu or Gia. No. So it could be a complete miscarriage or it could be an intrauterine early pregnancy because we are seeing for the lady first time. So we can't uh confirm that it is going to be a complete miscarriage. So how can we differentiate? It would be a better idea to request for a 48 hour B type CT. Now, next case, uh it is, this is a 31 year old female presents to the Gynecology assessment unit referred by her GP with a five day history of lower abdominal pain, nausea and bloating. She has been trying to conceive for 2 2.5 years. She underwent fertility treatment in Morocco and she was treated with gonadotropin injections for ovarian stimulation. She started symptoms a few days after taking an HCG trigger injection, which was administered one week back. Coming to the observation, she was tachycardic and tachy with normal oxygen saturation and BP. She was able to lie flat and speak a full sentence without any difficulty. And her HCG test was supposed to be. So, what are your differentials? I know that it is a straightforward case of an ovarian hyperstimulation syndrome. However, we need to rule out ovarian torsion, ovarian cyst rupture, uh previous slightly suppose uh if the baby presents with the uh pyrexia, in that case, we need to rule out pelvic infection, pelvic, a appendicitis and in all ways rule out ectopic pregnancy. Next slide. So, better facility. So basically, the pathophysiology is that the ovaries are hyper reacting, hyper responding to the fertility drugs, then they will start releasing some inflammatory mediators like uh um um vegf and some cytokines that will cause uh some local and systemic effect, including increased permeability, vascular permeability and a prothrombotic effect. So, when there is increased vascular permeability, there will be uh uh fluid loss into the third space. So basically third space accumulation of the fluid resulting more commonly ascitis, less commonly pleural and pericardial effusions. So this is the basic pathophysiology. No incidence. My is common, 33% moderate or severe is 1% that is one in 100% 1 in 100 women. So the risk is higher in women with the Polycystic ovaries and under 3830 year old and who had a previous history of o next slide, please. And multiple pregnancy. Now, let's see, what are the symptoms of how can the women present. She can present with abdominal bloating, abdominal discomfort or pain, uh need for analgesia, nausea, vomiting, breathlessness and inability to lie flat or talk in full sentence and reduced urine output or with the leg swelling. Vulval swelling and associated comorbidities like thrombosis. While taking history, ask for the time of onset of symptoms related to uh trigger and the medication used for the trigger. It could be HCG or GNR check and the number of follicles on final monitor, monitoring, scan number of eggs collected where embryos replaced. And how many? And uh is she a Polycystic Ovary Syndrome? Diagnosed patient examination as I told like uh uh since there is intravascular volume depletion, so there will be a hemoconcentration. So while doing her general examination, assess for dehydration, look for edema. It could be pedal vulval or sacral edema and record the vitals like a heart rate, respiratory rate, um BP, body weight, daily, body weight, checking to be done. And on an abdominal examination, try to find out asciis palpable mass peritonism and measure the girth uh daily and respiratory for pleural effusion rule out pneumonia or pulmonary edema. Next slide according to the investigation. So we will order full blood count hematocrit uh to uh check hemoconcentration, crp to a severity u where we can expect hyponatremia hyperkalemia and it is a a low oscular condition. So, osmolarity will be low. T you can expect elevated enzymes and reduced albumin coagulation profile. It's a prothrombotic state. So, expect elevated fibrinogen and reduced antithrombin. HCG and ultrasound scan where you can assess the size of the ovary, pelvic abdominal free fluid and consider Doppler if torsion suspected. And the other tests that may be indicated are ABG D dima ecg echo chest x-ray ctpa O BQ scan. Now coming to the classification, there are four categories of OS. So based on clinical bio uh biochemical and ultrasound features mild case. The women will present with abdominal bloating and a mild abdominal pain. And the ovary in size is usually less than eight centimeter. Moderate case, she will present with a moderate type of symptom like a moderate abdominal pain, nausea, vomiting and while doing ultrasound, the ovarian size will be around 8 to 12 centimeter and there is evidence of ascitis in ultrasound. In severe case, there will be clinical ascitis plus or minus hydrothorax and other uh biochemical abnormalities along with oliguria. So, hematocrit will be more than 0.4 more than not 0.45 hyponatremia, hyposmolality, hyperkalemia, hyponatremia and ovary in size more than 12. So in mild ovary, less than eight, moderate, 8 to 12, severe, more than 12 critical, there will be 10 societies or large hydrothorax, hematocrit more than uh not uh 55 white cell count, more than 25,000 and uh complications like oliguria, anuria, thromboembolism or a TS. Now, let's see how can ma how can we manage uh this condition? Two types of management, outpatient and inpatient. So, outpatient management is indicated in mild or moderate OS and in all selected uh and in selected cases with a severe Os. So we will provide a verbal and return information to the patient and we will uh advise her to avoid NCD and we will encourage her to drink to thirst rather than a set amount and maintain fluid input output chart. If the urine output less than 1 L per day or positive fluid balance of greater than 11 L per, she should pro uh she should uh uh come for medical review CV, which says we will uh provide thromboprophylaxis. Now, how, how can we follow these outpatient uh outpatient managed patients? So we will review them urgently if they develop symptoms or signs of worsening or otherwise, we will review them every 2 to 3 days. Baseline laboratory investigations uh should be repeated if the severity is thought to be worsening. Hematocrit is a single useful guide to uh useful investigation to guide the degree of the intravascular depletion. So, what are the symptoms of burning you? It's just where she need to come to the hospital if there is increasing abdominal distension and pain and there is shortness of breath and she there is tachycardia or hypotension and the urine output is reduced and the weight gain and increased abdominal girth and increasing hematocrit. It is greater than 0.45. So, what are the indications of uh of hospital admission or indications for inpatient management. When the uh when we are unable to achieve a satisfactory pain control or unable to maintain adequate fluid intake due to nausea or if there is signs of worsening despite outpatient intervention or unable to attend for regular outpatient follow up for all cases of critical need admission. So few words about fluid management. So fluid replacement by the oral route, guided by thirst. This is the most physiological approach to correct intravascular dehydration. So, persistent hemoconcentration, despite odium replacement with IV colloid may need invasive monitoring with anesthetic input. Diuretics should be avoided as they further deplete intravascular volume. But then I have a role in a multidisciplinary setting if oliguria persists despite adequate fluid replacement and drainage of fascitis. Now, let's see the indications of parasitosis if there is severe abdominal distension and abdominal pain, secondary to asciis, shortness of breath and respiratory compromise secondary to ascitis and increased intra abdominal pressure, oliguria despite adequate volume replacement, secondary to increased abdominal pressure, causing reduced renal perfusion. How can we do paracentesis? It can be uh done uh either under ultrasound guidance and it can be done either vaginally or abdominally IV therapy. Uh should be considered for women who have large so fluid removed by paracentesis, thrombosis management. So, for severe or critical os and those admitted with oas should receive low molecular weight. Uh Heparin prophylaxis, the duration. It should be individualized according to the risk factors and the outcome of the treatment for moderate or it just uh we will evaluate and we will uh identify the risk factors for thrombosis. And then we can either prescribe either an embolism or stockings or heparin thrombo embolism can happen at upper body sides or arterial system. And they can present with unusual neurological symptoms like dizziness, loss of vision or neck pain. Now, what are the indications of surgery if there is a coincident problem like adnexal or ovarian rupture or ectopic pregnancy? So now the pregnancy is complicated by OS may be at increased risk of preeclampsia and preterm delivery. Mm. Right for the reading of Green talk guideline for management of OSS. Thank you. Any question, any doubt. Uh This is a QR code code for the feedback form. Uh Please share your feedback form and get your ain certificate. Thank you so much guys. That's great. Thank you. Yeah. Are you right to just keep the QR code on the? I just love you. Um Yeah, fill that out and then I'm just going to copy the link into the chat as well just to make it easier for no good. Thank you. Yeah, that's great. And if you're all right to just hang around just for one minute, just uh in case there's any um Yeah, any questions. That would be great. Yeah. Yeah. Yeah. Sure. Thank you. Right. Stri Yep. So I've just posted a link, the form in the chat and the QR code is just gonna still be on. Um and any questions then feel free to either uh unmute yourself and answer or just put them in the chat. Yes, please. Ok. Yeah, so people are starting to leave now so um we can just give it another 2030 seconds. Um Yeah, if not. Yeah, that's great. Thank you very much for that lecture is really good. Thank you. Go. Thank you. So Sh Shelby. Um Yeah, I.