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Summary

In this comprehensive on-demand teaching session, the lecturers guide viewers through a deep dive into preeclampsia and associated complications, using the U.K. MLA curriculum as a foundation. They carefully break down complex ideas and medical jargon into digestible concepts and practical applications, interspersing the session with Q&A-style interactions for better understanding. Several scenarios and instance-based medical questions are presented, with definitions and answers thoroughly discussed and explained. This session would be valuable for medical professionals preparing for their finals or anyone interested in learning more about preeclampsia and its impact on maternal and fetal health.

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Description

Join us for "Conquer Finals! Obstetrics and Gynaecology." This valuable class, led by our tutors, Dr Victoria Leigh (FY2) and Dr Kashmira Jeeva (FY2), will focus on key O&G presentations and conditions for finals & MLA. It is a must-attend event for all medical students aiming for success in their finals.

Learning objectives

  1. Understand the specific terminologies involved in diagnosing hypertensive disorders in pregnancy such as chronic hypertension, gestational hypertension, and preeclampsia.
  2. Comprehend the etiology and possible complications of preeclampsia from a cellular level and its impact on both the mother and the fetus.
  3. Identify the clinical symptoms associated with preeclampsia and understand the criteria for diagnosis, particularly in relation to blood pressure readings and proteinuria.
  4. Gain awareness of the management strategies for preeclampsia, including which antihypertensive medications are first-line choices, as well as the indications and benefits of aspirin prophylaxis.
  5. Understand the different presentations of antepartum hemorrhage, specifically placental abruption and placenta previa, and be able to identify risk factors for each.
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Computer generated transcript

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

Welcome to our next um another session this week where we're gonna cover S and G um by Vicky and myself. Um So this is our, if you guys are new here is our weekly session where we do online sessions on med all um covering specialties for finals. Um And we broadly base it on the UK MLA curriculum. So um next slide, so we've put up the curriculum as always. So it's a lot to cover. Um So we're gonna show you guys what we're gonna cover for this session as those are the key ones. So as you can see just by that alone, that's quite a bit to cover. So we'll just give it a start so that we, we save a bit of time. Ok. Um So the first question so you guys can have a little bit of a read. I'm just gonna put the pole up. We'll give you guys a minute to s um go through, let's put the pole. Mm I don't think I see any response to here. Oh Yeah, I do now. So most of you have gone for b um so basically a 37 year old woman she is 16 weeks. Um gestation, no past medical history but has f or headaches. Her BP is 148 76 and her dipstick shows plus one protein urea. And um, so most of you have gone for B which um we'll go through the terminologies in a bit. But the correct answer for this question is chronic hypertension. And that's because um she's 16 weeks gestation. So when we go through the terminologies, it's above 20 weeks. Um That's when it's classified as preeclampsia. And um can we go to the next slide? So, um I've put it down like this cause I think it's easier to visualize and understand each of the words. So if it's less than 20 weeks, it's preexisting hypertension. And if it's beyond 20 weeks, then it's pregnancy induced hypertension or gestational hypertension. And if it's above 20 weeks gestation and protein urea, then it's preeclampsia. The reason why the patient earlier wasn't preeclampsia was because it was just plus one protein U urea. Um Usually you need two and above and as well as it is less than 20 weeks gestation. So that's not um it doesn't fit the definition of preeclampsia. Um Gestational hypertension can also be defined based on the BP readings if it's increased from booking. So it'll be a systolic of above a 30 or diastolic, above 50 next slide, the next one. So we'll cover preeclampsia for now. So, um it's always important to divide things based on high risk and moderate risk or modifier, nonmodifiable when it comes to risk factors. So, for preeclampsia, it's easier if you divide it based on high and moderate because that kind of um, gives you a clear cut um, understanding on whether you need aspirin or not. So, for high risk factors, it'd be um if they've had a previous um, episode of pregnancy induced hypertension or preeclampsia or they've got diabetes or a preexisting chronic condition like autoimmune disease or C KD. Um And then the list of moderate risk factors are as follows. Next slide. So, um I think for preeclampsia, it's very important to understand why it happens cause it's kind, it kind of leads to other conditions which we will, which I will touch on a little bit. Um So think of the placenta as a giant vessel. I like to think of it that way because it's just very vascular. So you've got your, so when the embryo is at its very initial stages, you've got the blastosis and around the blastosis are the trophoblast cells and these trophoblast cells basically are the building blocks of the placenta. Um And if they don't form properly, so that means they don't attach to the uterine lining and form the placenta properly. The spiral arteries that then get formed and get um attached to the uterine lining, they don't form properly as well and they become really fragile. Um And a result of that the placenta then becomes really um becomes really poorly perfused. So that causes um an increased, that cons cause causes the spiral arteries of vasoconstrict. And basically, it triggers an inflammatory response because there's lack of blood flow to the placenta. And that also causes the release of cytokines. And that's why you get the raise BP and the end organ damage, which is uh affecting the liver and the kidneys. Um Does anyone have any questions with that? Cause that's quite a bit of a those are quite long and to properly visualize it. I think the image on the bottom, right is pretty good at that. So think of it like in a normal pregnancy, it has look at the um where the vessel is attached to the placenta. It's pretty broad. So that's how it should be. So it's a pretty big vessel, but in preeclampsia it's narrow and you can see the spiraling is pretty fragile and it looks like it's really small. So that triggers um that's the reason why um they eventually get raised BP because there's increased resistance throughout the vessel. Next slide. So, complications of preeclampsia, you've got maternal and fetal, I'm sure you guys know of eclampsia and um the Hellp syndrome, which we will touch a bit more later, but it's got organ damage and um D IC. So D IC basically, pregnancy is a hypercoaguable state. So I um when you're pregnant, you're at risk for D IC anyways, but having preeclampsia kind of increases your risk or predisposes you to develop D IC. Um fetal complications, you get intrauterine growth, retardation, preterm delivery abruption and hypoxia essentially next slide. So, cicer features are as follows. And um so you've got edema because of the state of reduced oncotic pressure because you're peeing out all the protein. Um definition wise is about 300 mg over 24 hours and more than 30 mg miller of PCR. And I think ACR is above 8 mg miller. And what I meant by PCR is the protein crashing ratio and ACR is the albumin creatinine ratio. So a different trust use either albumin or PCR um protein creatinine ratio and if it's severe, it's above um systolic of 160 diastolic of 110. And it's with a proteinuria of five, more than 500 mg in over 24 hours. And they've got the other features suggestive of endocrine damage. Um and it's a war. It's a warning sign of impending um eclampsia if they've now become uh if they've got altered mental status, hyperreflexia and they've got clonus because now it's affecting the upper motor neuron. So it's um an impending eclampsia next slide. So, just to summarize how we define preeclampsia, BP above 1 40 91 of this. So it's normally proteinuria that we say because usually proteinura is the first thing to present, then you get the an organ damage um and the placental dysfunction. So what I've told you earlier, it's PCR above 30 ACR above eight. So, um signs of organ dysfunction would be affecting the kidneys. So the creatinine would be elevated. Um LFT S will be elevated. So they've got altered mental status. So they will have neuro signs um and they will have hemolysis and um thrombocytopenia and with placental dysfunction, you probably will have um abnormal Doppler and you also will have fetal growth restriction and the CTG S will probably be abnormal as well and slide. So, for a high-risk patient, um so that's based on the risk factors you went through earlier. Um they usually will be followed up quite extensively in like a consultant like clinic. And um anyone that's high risk would be started on aspirin, uh 75 mg from 12 weeks until delivery. And normally they would also, you know, advocate for lifestyle changes to help with reducing the BP. Um But if any pregnant woman comes in with a BP, 1 61 10, that's an immediate admission um because they need to be monitored and they probably need IV antihypertensives to um bring down the BP. Um And also, if you've got two or more of the moderate risk factors, that's also um an indication to start aspirin 75 mg. Uh next slide. So for management wise, it's normally labetalol, that's first line. But if they're asthmatic, then it's Nifedipine then you've got other drugs like medopa, um the enhydria and um the pneumonic that I've used all throughout med school is um hypertensive mom's need love cause I think that's easy to remember the whole thing. But obviously, the definitive management for preeclampsia and to prevent eclampsia is for delivery of the baby as well as the placenta. Next slide. So um ex eclampsia is essentially a complication of preeclampsia where they develop seizures. Um This is pretty straightforward because the treatment and to prevent it is the same which is max self infusion or Boers. Um Normally patients who um have got preeclampsia when they're admitted for planning surgery. Anyway, they're given magnesium sulfate and then um and it's, it's very important to remember. Um anyone that's got um preeclampsia or they're very high risk to develop eclamptic seizures, you should continue the magnesium sulfate 24 hours after delivery um or last the last seizure. Um That's because about 40% of recorded eclamptic seizures happened actually after delivery. I'm not too sure exactly the me mechanism why, but it's just been reported that 40% of uh eclamptic seizures um happen after delivery. That's one thing to remember with um giving magnesium sulfate is that can cause respiratory depression and you treat that with calcium gluconate. Um And anyone with eclampsia you need, you should fluid restrict them. Um And that's because they're at high risk of developing fluid overload as well as um renal failure as well. Next slide. So we're gonna go into the next question. Um So it's a 26 year old woman who presents um with moderate vagina bleeding and abdo pain. She's 34 weeks pregnant. First pregnancy. She smokes one cigarette a day. She's had a cervical cone biopsy in the past. She um has preeclampsia and is taking medication for it and her fundal height is 31 cholic presentation in 3/5 engaged. So it's um asking, given the f diagnosis, what features are from a history is a risk factor. So I'll start the pole and I'll give you guys a minute to answer. Ok. So I've kind of got a mixed bag and it's a split between B and E. Um oh, it's more b now. Ok. Um So I see why you've most like most of you have gone for B um previous history of cervical cone biopsy. Um But this patient, so basically she's got pain and PV, bleeding. So when you've got pain and PV bleeding, um that's alluding towards an abruption, we'll go through the antipas hemorrhage properly. But basically, this is asking risk factors for placental abruption having um a survive previous surv cone biopsy. That's more of a risk for um ruptured membranes or premature rupture of membranes. Um that doesn't really affect the um placenta, it more, it's more below it. Um So we'll go through why abruption, but the answer is preeclampsia and that's to do with the, um, spiral arteries that I've explained earlier. So let's go to antepartum hemorrhage. So, there are differentials for antepartum hemorrhage. But the most, um, common ones, they're, first of all, they're quite rare in general, but the common ones from the rare bucket is placenta, previa and abruption. Um Basa Praevia basically means you've got, um, you've got vessels that are low lying and they're kind of around the cervical os. So, um, they are at risk of getting rupture um during the pregnancy anyway, because of the location of the vessels. So you try and ruptures, you try and rupture. Um, bloody show is basically when you've got, um, when throughout the pregnancy, they kind of form a mucous plug from all the discharge and the fluid and that gets dislodged and when it gets dislodged, it kind of takes a line, the lining of the uterus as well. So it kind of looks like they're bleeding, but it's mostly mucus. So, um we won't really cover that cause that's just a presentation that's it really affect the maternal. So, next slide. So, basically def the definition for antepartum hemorrhage is bleeding after 24 weeks. Um And then like I said, we're gonna cover previa and abruption. So, previa just always remember as painless PV bleed and then abruption is painful. Um And with previa, the bleeding, most of the time will stop on its own or um it takes quite a bit of a time to stop, but with abruption, it just keeps bleeding. Um And with abruption, they will not necessarily have a bleed, they most likely will come with abdominal pain because you can have a concealed bleed because the bleed can still be um within the um place sorry, within the um uterine lining. And another thing with the uterus, it kind of feels like a peritinic um abdomen where it's tense and it's, the description is woody, but I don't really know, I've never seen it personally as woody, so I don't know what that means, but textbook wise, it says it's woody. Um and normally you would not be able to hear fetal sounds and um placental abruption. Um but you can hear fetal heart sounds in pre next light. So covering pre first. So essentially, it's low lying placenta and you can see in the diagram below it kind of has different stages depending on where exactly the placenta lies. And if it's covering the sub os, um and usually this is picked up um during uh during the antenatal followups. Um there's some risk factors for it. So, um multiparity and you've got twin pregnancy um previous C section. So if that, if it's been picked up at the 20 week scan, that they've got a low lying placenta that will be monitored every um usually it's every two weeks um and that gets um and at 34 weeks, depending on the um stage of the previa that changes the management. So if it's grade one and two, which means it's not um occluding the sebical Os, you just keep monitoring it every two weeks. But if it's grade three and four, you plan for an elective C section from um weeks, 37 onwards. But if they come in with, if they've got placenta previa and they've come in with um bleeding, they would need admission and it, all the, the treatment management depends on how much they're bleeding. If it's a massive hemorrhage, you'll just put a major obstetric hemorrhage, call out and you'll follow a trust protocol. If they're unstable, then it's emergency c sections. A cat one. But if, um, if they're, and also if they're close to um 37 weeks, then that's also a cat one section. Otherwise, um, if they're pretty stable, you would monitor and you would try to get them for 37 weeks if you can. But again, if they're unstable and they're bleeding a lot, it's imme immediately a cat one section next slide. So, um now we're gonna cover the next topic which is placental abruption. So basically, it's when the placenta separates from the uterine wall. Um and it results in bleeding. So you can have a concealed and a revealed. It basically depends on whether the placenta is, whether the bleeding is in between or um it's outside of the placenta. Um And you can have it, it can happen acute or chronic and acute is usually due to trauma. So like them being in like a motor vehicle accident or something. Um And chronic is when the spiral arteries um have developed abnormally. And as we covered earlier, preeclampsia is a condition where the spiral arteries are abnormal and they are quite fragile. So, preeclampsia, um plus, so having preeclampsia actually is a in so increases your risk to get abruption because your spiral arteries are already abnormal. So, one of the most important um risk factors for abruption is if they've got preeclampsia. Um and then the rest of it, as you can see, it's cocaine, multiparity, trauma, older maternal age. And if they use alcohol, if they consume alcohol during pregnancy and use cigarettes next side. So, normally diagnosis is clinical and um you can do a transabdominal ultrasound if you wanna, if you can't pick up the hemorrhage and usually, and if it's um behind the placenta. So a concealed hemorrhage, um you do an at assessment like every um every acute con um presentation and this is quite important to check the research status because this is a sensitizing event cause they're bleeding. Um And if there is negative, we need to give anti D um injections. So you need to monitor the fetus. If the fetal is in fetus is under stress, it's a emergency c section. If it's below 36 weeks and the fetus is fine, you can monitor and you can give steroids to um promote lung maturation. Um And, but if it's above um 36 weeks and the fetus is still doing fine, um They can either opt for um a section or deliver vaginally. Um And unfortunately, if it's a dead fetus, they, you still have to deliver it vagi vaginally or they can do section um for it anyway, slide. So um like preeclampsia earlier, think of it as maternal and fetal complications. So, maternal will be shock cause you're losing a lot of blood D IC like I mentioned earlier. So, um PPH renal failure um that's because of hypovolemia and it's quite, it impacts um the moms pretty badly in terms of the psychological um side and fetal complications. You've got IU R prematurity, hypoxia and death next side. So we're going to the third question. Um So it's a 28 year old Gravida two para one who complains of bleeding following delivery, she's unwell and needs immediate treatment. And you've spotted that it's likely PPH. So the question is which of the following defines a major primary? Um PPH. So, so yeah, most of you have gone for C Yeah, so most of you have gone for AC which is the right answer. So um we'll go to the next slide. So, but yeah, so basically, it's primary. Um PPH. So that normally happens within 24 hours and it's the question says major. So it has to be above 1000. So we'll go to the next slide to cover, um to figure out what it means by um major and primary, next slide. So primary occurs within 24 hours of delivery, secondary if is, if it's um 24 hours to 12 weeks after delivery and um, if it's major, it's above 1000 mils. Um, otherwise, um, a blood loss of 500 mils is the cutoff for it. So I always like to think of the causes for PPH as the forties makes it really simple. So, tone, which is um uterine tone, um that if the uterine, if the uterus is not contracted properly. So normally in the normal, um after after delivery, the they'll give Oxytocin to get the uterus contracted, but sometimes it just doesn't work well enough and the uterus acts like when it's contracted, it acts almost like a tourniquet to keep all the blood in it. Um But when it doesn't, when it's not contracted properly, that's when you get a lot of blood loss because you nothing is stopping it from not bleeding. So that's the first one and the second one is retained placental fragments. Again, that affects the way um the uterus gets contracted and third one would be trauma. So any surgical incision, a bisect toy, any tissue damage anywhere in the around the uterus can cause PPH. And for thrombin, that's pretty self-explanatory. If you've got any bleeding slash clotting disorders, or if you've got any vascular issues, like preeclampsia that can also cause PPH. Um there's some risk factors that I've listed earlier. So, um mater age above 40 having a high BM I, um and if the uterus has been distended, so that means a prolonged pregnancy. Um and if they've got any preexisting, placental problems like abruption, uh or previous, that can also increase the risk of having PPH as well as prolonged labor. Next slide. So, uh management for PPH, a lot of trust have uh most trust have their own protocol and it's you just follow your trust protocol. But um in general, the gist of it is you do at assessment to make sure they're stable. Um You do bloods and you would just, you would administer agents to get the um uterus contracted if that's the cause. So for PPH, the most important thing is to figure out the cause, that's why we've got the forties. So if it's um uterine um A and A you do bimanual compression as you can see in figure A. Um And if, if, if um you figured out that that's the definite reason why they're in PPH, then you can do something called an intra, you try and balloon tamponade, which is in figure B basically to keep it open. Um And then you can give um Pharmacologic management like Oxytocin ergometrine or Carboprost. Carboprost is a Prostaglandin and all of them. Um They, they can keep the um uterus contracted um If other surgical uh interventions that you can do is a bin suture, um or um ligation of the uterine arteries or internal iliac arteries. A bin suture is basically one of the, the ways of suturing the uterus to stop it from bleeding. Um But just if you've done all of that and they're still bleeding heavily, then unfortunately, the only thing that can stop it is hy hysterectomy next slide. So, um knowing all of that, we've now got preventative man uh measures uh which is why we've got the active management of third stage of labor, which is why everyone gets um oxytocin that is to prevent it. And, and in C section, they also get Oxytocin because you can still get PPH um even though you don't deliver vaginally and one way you can um that I'm sure most of you have done um an obstetrics rotation, you would have seen them do controlled core traction. That's basically when you pull the placenta in one direction and you apply um an opposite force towards the uterus that basically that maneuver has been shown to reduce um the amount of blood that gets expelled versus just pulling the placenta out. Next slide. So, um next question, um a 30 year old woman attends GP following a positive home pregnancy test. This is her third pregnancy. Her first was an ectopic uh surgically managed and that was four years ago and she had a medical termination two years ago. Question is having which of the following medical condition is an increased risk factor for ectopic pregnancy. So let's put the pull up now. Yeah, most of you have gone for B do you, is anyone put on the chart? Why? It's B? No? OK. So basically, there are a couple of reasons why it's b um basically, when you've got endometriosis, you basically got um a an additional uterine lining kind of placed and, and so bas uh not quite. So, basically, when you've got endometriosis, you've got endometrial tissue outside of um the endometrial, the uterine lining. So that's another, that's like basically another area where um a pregnancy can get implanted there. And also because when you've got endometrial scar. So if you've got previous fibroids or um endometriosis, you tend to have lots of scarring and adhesions around that area. And that makes it a better, that makes it like a good area for um the embryo to implant because it's like an artificial area. It's not like the surface of any other surface. So it's like more of a grippy surface if that, if it's like if that makes sense, like it's more of a grippy area. And um but for endometriosis specifically, it's because you've got um an, you've got basically got an endometrial lining, an additional endometrial lining that's not part of the uterine lining. So it's in another area where um it can implant. Does that make sense? So we're gonna cover ectopic pregnancy next slide. So we all know what ectopic pregnancy is. It's when a Novum implants outside of the uterine cavity. Um So the table below shows the risk factors for developing it. So as you can see, not just fibroids, as I mentioned, you, um pelvic P ID as well as because you've got adhesions and scar tissue and that makes a favor favorable environment for an to implant. Um And so in the clinic of yes, clinical features um are, if they've got pelvic pain or lower abdo pain, you can, you might get PV bleeding, bec um you might not because most of the time with ectopic pregnancies, intraabdominal bleed, um not so much PV bleeding. Usually if it's PV, bleeding, it's because it's traveling down, if it's like fallopian tube or ovaries that it's come traveling down from. Um Does anyone know why you get um shoulder tip pain and what's like that as sign off? Nice. Yeah, exactly. So um basically, it's irritation of the diaphragm and that's a sign that there is retroperitoneal bleed. Um And it's C 345. That's the reas that's the um dermatomes and that corresponds with the um shoulder tip as well. So nice one. That's good. Um And so, and the diagram on the bottom, right, basically shows the um most common areas by topics. So, number one being fallopia, number two, being ovaries and three, being abdomen. Let's go to the next slide. So appreciate it's a very busy slide. But basically the, it's anyone with a positive um, urine beta H CG. Um you do a transvaginal ultrasound or a, a transabdominal ultrasound. Usually it's transvaginal ultrasound and the management depends on a few things. So, one, it depends on the size. If it's above 35 millimeters, it's surgical management already. If they've got a heartbeat, that's surgical management. If they've got pain and they're in a lot of pain. Again, that is surgical management. And if the H CG is above 5000, that's surgical. So I think, I think of it as just remember what is definitely surgical and it makes it so much easier to remember the um management for expected versus medical. It depends on um if the, if there's an H CG level and it also depends on how if they're in pain or if they're asymptomatic and also um ex expecting, sorry, medical versus surgical management, it's also dependent if they can come back for a followup. So if they can't come back for a followup, most of the time, they would prefer surgical management because you can just get it done. But if you know that they can come for a follow up, then they would either do medical management. Um And that will be with methotrexate. So there are some disadvantages slash contraindications for methotrexate. So if they've got myelo suppression or they've got um renal dysfunction, it's not an absolute contraindication. But um you would probably need to discuss with hematology to see if you can actually give methotrexate. There are alternatives to methotrexate like I think Letrozole, but that's not commonly used. So a lot of times if they've got um minor dys myelosuppression, renal dysfunction or hepatitis, um most of the time they'll do surgical management even though they can have medi they are, you know, the criteria fits medical management just because it's safer to do. So. Um and methotrexate is usually it can be unsuccessful. So that's also another reason why um surgical management is preferred next slide. But for example, purposes, remember it as the table. Um So what happens if the transvaginal ultrasound or the transabdominal ultrasound is inconclusive but they've got a positive beta HCG. So that's labeled by definition, pregnancy of unknown location. There are three things that could be the most like the reasons, the reasoning for it. So it could be a very early intrauterine pregnancy. You just can't see it yet, it could be a miscarriage or it could be an ectopic pregnancy. So if the um levels is above 1000 500 there's no inter intrauterine pregnancy that is ectopic until proven otherwise. And they will need to get a diagnostic lap. If the level is less than 1000 500 you'd repeat the levels in about 48 hours. If the pregnancy is viable, you would normally see the HG level double um in two days time. And if it's a miscarriage. It would um come down to half. So that's kind of how you figure out where exactly it is next slide. So, um the last one that I'm gonna cover is Court Prolapse. I thought of covering Court prolapse. So it came out in my ays uh and I think that this is not covered very well in medical school curriculum, I think, and uh when I did not got any rotation, at least I didn't really get to see this much. Um So I thought it would be an important one to cover is this part of your curriculum next slide. So it's basically when the umbilical cord comes through the down through the cervix and it's below beyond the presenting part of the fetus. Um it may or may not happen with ruptured membranes, you can have uh membranes that are intact and still have um a prolapse. Um And that's normally it's called uh an occult or a hidden prolapse. So, as you can see in the image on the um left side, uh the cord is basically being compressed. So that's not, not, that's not entirely prolapsed yet. That is like uh you would say it is called compression. Um And then the second image, you can basically see the cord is around the fetal head and it's coming towards the cervical os. And then the third one you can see is literally gone through the cervical os. And that's a complete cord prolapse. So, um there's a few risks with that. So with cord compression, you're essentially pressing down the vessels and that can, that just drops blood flow and that can cause fetal hypoxia. And you would see that in the CTG S where they would have fetal bradycardia and have decelerations. And then um the danger with cord prolapse as well is not just the um disruption to the blood flow, it's the cord is now outside. So the temperature of um outside in like the vaginal area is considerably warmer than intrauterine. So that causes the vessels to vasoconstrict and that further worsens the um hypoxia as well because of the reduced blood flow with vasoconstriction. Next slide. So risk factors for um cord prolapse. So breech presentation um that's normally seen with like foot length presentation. So if they've got like their foot is at the presenting part, um cause there's more space. So the cord can actually just slip through unstabilized. That basically means the light is not fixed. So they go from like cephalic to breech or transverse. Again, that just means that there's more room for the cord to move. Um and rupture membrane sometimes by rupturing it, you're kind of moving the cord as well unknowingly, um polyhydramnios kind of the same reasoning as unstabilized because there's more think of it as like more fluid. So there's more area for the cord to kind of play around and that can come down. Um And premature use as a risk factor cause uh you, they're already premature. So the cord tends to be lower anyway. Um And the consequence of um cord collapse is like I explained earlier, it the most it causes fetal hypoxia and that's very dangerous. And you would see that as decelerations on the CTG and um the fetal, the heart rate will essentially be bradycardic and that's a sign of fetal distress next slide. So this is an obstetric emergency. You would so imme immediately call for help. Um So what would normally happen is you would either try to elevate the presenting part. Um I don't know if you can see it in. Oh, the, we've lost um Vicky. Hold on. Uh Right. All right. Oh Vicky's back. So sorry, I don't know what happened there. Um Let me go back to that slide. Ap thanks. Sorry guys. We'll just get back to that, right. So, thanks Vicky. So, um as I was saying, you try to elevate the presenting part, basically try to relieve the pressure from the cord being compressed. Um or you fill the um bladder with 500 mils of normal saline and usually like, usually use a catheter, I think you can see in the image on the top, right? Um And you give it, wanna give it warm water cause you don't wanna, you don't wanna worsen the vasoconstriction and you try to get the mom into the position as you can see in those images. So it's left lateral position with head down and a pillow placed under the hip or the knee to the chest that basically allows the cord to kind of like hang on its own without it being compressed. And then you can give terbutaline to again prevent um uterus from contracting as much so that you relieve the pressure from the cord. And this would be an emergency c section. Um However, there's a, a few caveats to this if they're fully dilated and uh but like they're literally about to deliver vaginally. Um You can continue that and use instruments to help with the delivery. Um But if they're premature, you, you kind of will try to delay it as possible so that, you know, you can get the um fetus to grow further. But if again, if it's high risk, then you'd kind of need to discuss with the um mom to whether you need to do, whether it's safe enough to do C section or we can, I mean, it's safe enough to wait or uh it needs an emergency C section essentially. Next slide. I think that should be it for mine. Yeah, I think that's, yeah, some obstetrics. Lovely. So we move on to, let's say hi, Ron and Vicky. I'll be covering the gy side of things. Um So I tried to cover topics that I think are most relevant for the finals. I appreciate that. Um Obs and Gynae in some unis, I don't know if it's every uni but at leeds, um, it definitely was mostly covered in fourth year. Um, so some of the stuff I'm hoping is not in too much detail, but looking at what the UK MLA want you to know, there's still quite a lot of like in depth stuff that they would like you to be aware of in terms of OBS and Gyn wise. Um, so, you know, maybe your med school finals or the UK M UK MLA side of things will definitely cover the um obs and Gyn side of things. Um But yeah, apologies if it's in a bit of detail, like I said, just try to cover the most relevant things. So moving on to our first question of the Gyne side of things. So let me just read this out for you first. So we've got a 26 year old female presents with a four day history of yellow vaginal discharge and itchy itchiness. No significant past medical history, no regular medications, no allergies on speculum. You see this the reason why I haven't given you much details. Co hopefully this is a bit of a spot diagnosis. So what is the first line management for this patient? So just read through those options there and I'm just gonna put a pull up here we go. So give it a go. Ok, we got some answers coming in. Perfect. Ok. So say most people went for B which is the correct answer. Well done those of you. Um So just to go through the other options then, um so the first option A is actually would be a second line therapy. Um Azithromycin is used in the treatment of chlamydia. Uh fluconazole would be a use for, you know, candida infections and iron ceftrixone would be used in the management of er, gonorrhea. Ok. So that's why it's b and then let's go into a bit more detail. So just before I go into um oh, sorry, and the diagnosis would be trichomonas, apologies. So that's the reason for putting that speculum image down. So we go back, it's because it's sort of what we call a strawberry cervix. Um And in finals, we or sorry, fourth, the fourth year exam, which had covered a lot of and guy and we definitely did get like image questions slightly blurrier than this to be honest. Um but it is possible that they might give you a picture instead of like giving you lots of history. Um So I think it's good to be aware of these sort of like spot diagnoses type questions. So now you've seen it. So this is what we call a a strawberry cervix in addition to all the um symptoms here you would think, right? This is trichomonas probably could have given you maybe more of a history of like, you know, sexual partners and that sort of thing. But hopefully with the image that would have given you enough information there to make that diagnosis. Um So, and just before I go into trichomonas specifically, um I think it's good just to have uh an understanding of different causes of vaginal discharge. And so, II have this a copy of this from my notes. Um So basically, just think about it is this infective is this non infective. So non infective ones, a a classic one is like cervical er ectopy ectopy, sorry. Um So if they have a history of C OCP use, er recent C OCP use young female, you maybe think more along that, that side side of things infective. Um Just think, you know, is it non S ti or S TI and just think of the common um factors that are gonna make you decide one way or the other. I've got a few more spot diagnoses questions coming up where I just want you just to put it in the chart. So we'll go through how you differentiate those. Um But yeah, so going into trichomonas specifically cos it actually was mentioned as a specific point on the er curriculum. So what is it? So it's a sexually transmitted infection caused by trichomonas, vaginalis. It can be asymptomatic, but in females, you would be looking for sort of vaginal discharge, frothy yellow color is how they describe it. A strawberry cervix on the speculum. So lots of like sort of pink dots, basically looks like a strawberry, apparently, um itchiness um may be present with pain when passing urine. Um in males, it can present with similar symptoms as well. Um But as this ob gyne will be focusing on the sort of female presentation side of things. Um in terms of diagnosing it, um it's not part of routine um sexual health screening, but you can diagnose it in several different ways. And if they present with the symptoms, you would obviously try and um diagnose whether that could be a possibility. So, microscopy and that can be done on wet mount microscopy. You can do point of care testing. Uh You can then do nap on it as well, which is probably the the best way of doing it and then you can also um culture it as well, but that's not really done as much now. Um And in terms of treatment like we said before, so first line would be metroNIDAZOLE 400 to 500 mg twice daily. Um And important point, alcohol should be avoided during treatment. Um Individuals with trichomonas should go undergo a sort of form sexual health screen contact, tracing needs to be undertaken and all forms of intercourse needs to be avoided until all parties are test and treated and a test of cure is not routinely required. Ok. So going into just a bit um a few more differentials that you could have. Um So I've just got three quick questions. I haven't put a poll for these. So just put them in the chart, you should hopefully get these just by looking at what I've given you. So uh first one is 23 female, three day history of green vaginal discharge and dysuria on microscopy. See the following. Firstly, what is the diagnosis? And then how would you manage this? If you were listening in my previous explanation, you should probably know this. So any takers, I'm pretty sure this actual image even came up in my, in my final exam, which obviously, I know it will be different to your guys', but any takers at all, chlamydia fair enough, but uh any other answers. No, no unfor uh anyone else wanna give it a go? It's OK. No worries. I know it's, it can be quite niche stuff if you've not looked at it in a while. Um And I appreciate that. So um this is actually gonorrhea. So it's got the classic gram negative intracellular diplococci and you can see that by the sort of shape like little 22 little buddy things there. So when you, well, now you've seen this, if you see it again in your exam, gonorrhea instantly and like I was saying before, the first line of treatment for gonorrhea would be a single dose of im ceftrixone. All right. Now you've seen it. Uh moving on to question B so a 34 female presents with vaginal discharge reports. Funny smell down below. No itchiness. Uh the ph you've tested it is six and you see the following on a wet melt. So, like with the previous one, what is the diagnosis? What is the management in this case again? Just put it in the chart. Have not made a pause for this one. Perfect well done Adele. So, yes, it is um, bacterial vaginosis and you can probably get a lot just from the history itself. Um So yeah, it's usually sort of offensive, apparently fishy smelling vaginal discharge without um any soreness or irritation. And the PH will be over 4.5 if you test it. Um So you can see, so you know, they may give you an image as well. So on the wet mount here, you can basically see um clue cells. Um So now you've seen them as well that will help you with the with diagnosis if this does come up uh in an exam. So ways you can also diagnose it is. So if you remember the A S or criteria. So, one of which is seeing clear cells on a wet mount microscopy, like I said, a thin white yellow homogenous discharge, vagina fluid ph of over 4.5 release of fish odor when potassium hydroxide is added. So sometimes there is the with test. So presence of three or more of this criteria is sufficient to make a diagnosis of BB. So you may not even need to actually visualize it um on, on the Wet mount microscopy and the treatment of choice is a short course of oral metroNIDAZOLE. Um And you can also use a Clindamycin pessary. Um If metroNIDAZOLE is not suitable, then last one of the spot diagnoses. So this one hasn't got an image, but hopefully you get enough information from the history. So a 24 year old female presents with vaginal discharge, itching of the vulva and vagina. She's been in a relationship with the same male partner for the past five years. No history of S ti infections on examination, non offensive white lumpy discharge visible and the PH H is 3.5. So a what is the diagnosis? How does she manage this and would management change if she was pregnant? Any ideas? Perfect again. Well done Adele and sorry, I did see uh fatima before you, you responded correctly. Well done as well. Yeah, well done fatima as well. You've both all responded correctly there. Um So yeah, it's er vulvovaginal candidiasis. And the description there is basically of a sort of non offensive white lumpy because I'm running a lot of foods tonight. Cottage cheese discharge that might be associated with the vulval itching and soreness and the PH will be less than 4.5 in this case. Um So you would use oral fluconazole to manage this in the first line. Um However, a bit of a clue with that last question there. Yes. Well done again. Uh fatima, you've got that right. So just remember in pregnancy, um you wouldn't use oral fluconazole. You would use topical um clotrimazole. So or yeah, so topical antifungal cream instead you wouldn't use the oral fluconazole. Ok. Hold on. So, moving on. Ok. So now next question. So 70 old female presents with urinary incontinence when laughing or coughing. She's had three vaginal deliveries in the past bloods are normal. Uh no sort of signs of infection there, urine death is negative, no significance of past medical history on vaginal examination. You see um you know, sorry, uh u urine leakage when coughing and you also see a vaginal prolapse. So what would be the most appropriate next step? And I will pop the pole in the chart? Ok. Excellent. Well done. I think most of you have answered a which is the correct answer. Well done. So, what I was trying to get at with that history is that it's um basically a stress incontinence and all of the other answers there are not unreasonable. It's just in this case because the history is very heavily geared towards the sort of stress incontinence. And that that actually would be one of the first things um you would suggest um in this case. So just to go through the other answers though, so oxybutynin would actually be used in sort of urge incontinence rather than stress incontinence. And we'll go through the differences of why you would think that um, versus stress. Um, urodynamic testing can be useful. Um, if you're unsure of the type of incontinence, but in this case, um, fairly obvious from the history, I would say, um, but definitely could be considered, um, the whole post suspension surgery again, an option. But it would be sort of after you've tried all these different other options. And I think you'd need sort of Gyne opinion. Absolutely. You would need Gyne opinion before even considering that. So just way, way down the line and then um e bladder retraining exercises. Um So that is more to do also with managing urge incontinence rather than stress incontinence. So it is just the best option there. So this moves on to urinary incontinence. So there's lots of different types of urinary incontinence and the main two that I think we need to sort of differentiate between our urge and stress. You can also get a, a combination of the two, hopefully in the exams, they should make it fairly obvious as well. Um But just to be aware, there are also lots and lots of other types. So you can get overflow as well as from the bladder cannot empty, normally sort of likely due to neurological condition or can be continuous as well. So it's persistent urinary leakage and that can be due to sort of fistulas. Um and things like that. But I would say just mainly focus on the urge and the stress uh incontinence. Ok. And if you actually, if you want further reading on this, um Geeky Metics has a really, really good page on sort of general sort of lower urinary tract symptoms in females. So it covers everything, not just sort of incontinent side of things. So if you want some extra reading, um but yeah, moving on to stress incontinence. So it's defined as the involuntary leakage of urine during increased of abdominal pressure. And this is due to an incompetent incompetent sphincter, I'll show you an image in just a second. Um and it can be associated with prolapse as well, hence why it was in the history. Um So clinical features are you get urinary leakage on um coughing, sneezing exercise and on examination, you may uh feel a prolapse and on examination. Again, if you ask the woman to cough with a semi full bladder, that may also demonstrate the incontinence and then in terms of urge incontinence. So it basically is the sensation of urgently needing to pass urine and then that results in the sort of involuntary leakage. And so this is due to detrusor muscle instability or hyperreflexia leading to involuntary detrusor contraction. Again, I will show you in a measure in just a second. Um but this can be idiopathic. So no particular cause or there can be, it can be secondary to neurological issues. Sort of described, there can be caused by local irritation due to infection or bladder stones. It's always important to do urine dip and just check that you're not missing something there. Um But yeah, clinical features would be urgency frequency and nocturia. So, just to go through what those mean. So nocturia, obviously, you having to wake up during the night to pass urine urgency. A sudden sort of compelling desire to pass urine and it's, you just can't defer that and er, frequency obviously is increased need to pass urine. So, um there can be certain trigger factors like hearing, running water, cold w er, weather, and on average, it's sort of larger volumes of leakage compared to stress incontinence. And yeah, here is an image. So yeah, you can see the where the detrusor muscle is and where the sort of sphincters are as well. So just to help you visualize um where the pathology comes from. Um OK. And in terms of how to assess it. So a lot of it is gonna involve hi history taking. Um so important things to ask about sort of fluid intake, type of fluid caffeine and alcohol are sort of common triggers. Um And then just try and rule out obviously, your red flags, it is really difficult to always have everything that could possibly be going on in the back of your mind in an exam and they will try and hopefully make it fairly obvious, but just for your own practice, just remember any red flags as well like hematuria, bladder pain, recurrent urinary tract infections, constant leakage, all those sorts of things. And then you would probably as part of your assessment, need them to do a sort of bladder chart or diary for three days. So, um that will help give you a bit more information to make a diagnosis. And then you can also examine so digital assessment uh by manual vaginal examination, especially to look for any prolapse and then other examinations as well just to make sure you're not um missing anything else which could be causing the incontinence. Uh in terms of investigations, like I said, urine dipstick is very important. I know it's a bit of controversy in doing urine dipsticks uh in older people. Um I mean, this was from nice C KS and they didn't sort of particularly mention any age. Um But yeah, so you could do urine dipstick, even sort of an older person um if not urine culture as well based on symptoms as well and bloods as well. You could that could help you make that diagnosis, scan assessment. Um especially if you're worried about sort of avoiding dysfunction and neurodynamic studies as well can be considered. But like I said, it's not first line, you wanna do the conservative management first. Um And yeah, try and figure out the diagnosis first without, without using those studies um in terms of stress incontinence management. So lifestyle advice is always first line and that's also the same for urge incontinence. So things like reducing caffeine, not drinking excessive amount of fluids, you don't want them to stop drinking altogether. But, you know, just, you know, that could be a, a contributing factor, weight loss as well and then smoking cessation if appropriate. And then you will, um, and if, if the history is obvious enough and you feel happy that you can diagnose it, um, you would offer a trial of supervised pelvic muscle floor training and that's because that's where the sort of pathology is coming from. And if the above conservative treatments fail, uh they want further management, you can refer it to a specialty um or medication wise, you can use um DULoxetine. And the way actually, I remember this someone I remember it was like, I think it was um when I was at med school, they said you need like deluxe treatment when you're stressed. So, and you hope that stick in your brain as well. So that is also another treatment you can use. Um But like I said, second lines, you wouldn't, wouldn't start off with that and then urge incontinence, like with stress lifestyle first. But in this case, you're gonna offer a referral for bladder training. Um and that will be done in the community. And if the symptom sym symptoms persist even after six weeks, um then you can use anticholinergic drugs such as oxybutynin and the other one's mentioned there, but just be aware of sort of side effects as well. Um So it's like dry mouth constipation. And if all else fails, then you can um refer to specialist uro for a specialist urological assessment and they can consider all these other sorts of things, but again, not first line, er, and just to be aware. Um, so you get this when, if you look on my C KS guidelines, which I still use of uh as I'm practicing now, um, just be aware of any sort of red flags. Um Like I said, so age 45 with unexplained hematuria, visible hematuria that's present um or recurrent after successful treatment of UTI and then age over 60 with unexplained, non visible hematuria or dysuria. Um But yeah, you don't have to remember all of these is just, just to be aware of. Ok. And oh, when to refer again. So this is just um a bit further guidelines of when you wouldn't refer to a specialist. But again, don't worry, it's, it's a lot of information I'm aware. Ok. So question seven, let me pop this in the chart. Well, I'll read out first. So 40 year old female presents with a five month history of intermenstrual bleeding and post coital bleeding, swabs are negative for any S ti s urine dippers, negative. Um Pregnancy tests negative no abnormalities seen on the speculum examination, no masses felt on by manual examination. Um uses condoms for contraception is a has been a smoker for the past 10 years. Last smear test three years ago was normal. So no significant past medical history. What would be the most uh appropriate investigation? So let me put that in the chart. Question. Seven stop. Ok. Bit of a mix back here. Um I appreciate might be a bit confusing another few seconds. Ok. So I can see as, yeah, like a split back. So some people think a which I completely understand why we've got a few for B and then a few for D and E. So I feel that it should be D OK? And let's go through why. Um So the key thing here is with this history, there's basically no reason why she should have this intermenstrual bleeding. Um You know, so you, you would do all the things like look for any S ti S specifically chlamydia, you would do a urine dip, you would do pregnancy test and you would do all these examinations here. Um She is due for her next smear test, which is why I think probably a lot of you put a but a smear test is sort of part of the routine screening program. So it's not necessarily it obviously and it is part of the sort of um cervical cancer manage. Um you know, picking up early signs of cervical cancer. But if you are worried that someone is having abnormal vaginal bleeding and you cannot explain it, um then you need to, to figure out what, you know, is there a malignancy going on here basically. And then given her age and the presentation, the main thing you would want to do is a, is a colposcopy. Ok? Because we're worried here about, um, cervical cancer and there are other gynecological cancers as well. Obviously, to consider maybe a better answer could be refer to, you know, for specialty, but you would probably do this under a two week wait. Um And yeah, it's a bit of a tricky question there. So I understand why, why there was a bit of a split answers there. And like all these other answers are not completely out of the realm of possibility. It's just um you have to take in context with, with uh what the, the history that's given here. Um So yeah, some of these things would be done later on down the line. Yeah, let's go into a bit more detail. So, cervical cancer, so is the fourth most common female cancer worldwide and basically, it's all due to infection with HPV. Um So high risk ones are the 16 and 18 and they account for sort of most um cervical cancer cases, but there are other ones as well. Um So how it works is you get microtrauma to the sort of epithelial cells in the transformation zone and that basically allows HPV to enter, I will go and show you your a diagram in just a second. Um And this basically HPV can inhibit tumor suppressors and that results in uncontrolled uh cellular proliferation. Um and then accumulations of these mutations can result in premalignant abnormalities. So, we would call that uh cervical intraepithelial neoplasia. And that can obviously then progress to carcinomas. But luckily because of the screening program, these are picked up um quite uh they're picked up quite early on. So, um yeah, this, that's the reason for the um the screening program. Um OK. And then yes, here's a bit of an image to just put that into context there. Um So yeah, the transformation zone that I was talking about is just pictured there. And then this basically just is a picture of what I just explained there. So that's how sort of HPV enters and at that sort of second image that you can see most people actually get rid of HPV by themselves and um it doesn't progress into anything else more worrying. Um But yeah, un unfortunately, if it does progress, it doesn't get picked up early enough, then it can progress into cancer. Um So risk factors. Um So greatest risk factor is HPV infection. It's a bit mean, I probably maybe should have said that in the, um, in the history, maybe she picked up HPV sort of in those years, er, after her last Cervical Smith, um and that spread through skin to skin contact most commonly during sexual intercourse. But other factors to just consider, uh you know, smoking if you're not attending your cervical screening. Um high parity, oral contraceptive use, coinfection with other sexually transmitted infections. HIV, in particular, because that just suppresses your immune system. So it just allows that in uh HPV to sort of replicate further and then obviously in your previous cancers, um as well and when to suspect. So this again is taken from IC KS. So you basically suspect a diagnosis of cervical cancer. If a woman presents with any of the followings, this is persistent unexplained, abnormal vaginal bleeding, inter menstrual bleeding and or post cord bleeding, which is not secondary to infection or other causes, which is what that history was trying to get at. Um same again with vaginal discharge and that can be associated with pelvic pain, postmenopausal bleeding, not taking H RT. Um basically anything post menopausal bleeding, you just have to be on very high alert. In this case, it was a younger female. Um So that's why I wrote everything else about considering infection and all those sorts of things first. But yeah, definitely any postmenopausal bleeding just sends alarm bells. So you just need to rule out worst case scenario. Um And then if there is an abnormal appearance of the cervix, probably be quite difficult for you to see early stages. But you know, if people aren't attending their cervical screening and things get missed, then you may see on examination as well. So what to do next. Um Luckily most cases are diagnosed through the cervical screening program. Um However, you know, if that's not the case, then clinical examination, uh bedside investigations there. So your cervical swab s ti screening urine, different culture, pregnancy test, and you're gonna arrange an urgent referral for Colposcopy or gyne oncology for an urgent assessment. So that's why it sort of bypasses that um the cervical smear side of things. So that's, that's more to do with the screening program. Um Yeah, that just goes into a bit more detail about why you would do that and then colposcopy. So, and then if the diagnosis of cervical cancer is confirmed, then you, you do further investigations there. Um Yes. Oh, double sl apologies. Ok. So, um this image here just basically describes what happens in uh c in. So that's the sort of pre er cancer stages there. And yeah, so you just visually can see how it can progress and you manage. Um, you manage it differently if it, if it's caught at this stage here. So maybe in the first stage you wouldn't maybe routinely offer treatment in can one. But in can two or three, you would consider sort of excision or ablation to remove the tissue before it develops into cancer. And this is really advanced stuff. So don't worry, you don't need to say it's just, just for your own interests as well. So different. Um, if it then does progress, you can um, stage it according to sort of the Figo system and then it would be, you know, things like surgical management and then if it's spread past uh you know, metastatic disease, then you would, you know, consider chemotherapy all sorts of things like that. So just for your information, this is an overview of how you would manage it if it was past the um c in stage uh differential. So it's just gonna depend on the history. But yeah, always just consider infection, cervical ectropion, polyps, fibroids, pregnancy related bleeding and in postmenopausal populations to exclude endometrial carcinoma. So that's why she was a bit younger. You'd be thinking more cervical cancer rather than endometrial. OK. Moving on to question eight. So we've got a 28 year old female who presents with repeat cervical screening and it shows that she is positive for high risk HPV 12 months ago. She was also positive for high risk HPV. But her cytology was normal. So what is the next most appropriate investigation here? And I will the pole up any ideas, give you a few more seconds, any other responses? See at the moment, we're split, basically testing your knowledge on the cervical screening pathway. OK, a decent amount of reply. Now, so again, split between A BD and E. So the correct answer is actually B um So you would need to do cytology again, basically to figure out is there any high risk um appearance basically um based on the, on the HPV results. So the reason why HPV is tested first is because like I said, it's the main risk factor for cervical cancer. So if you don't have HPV, then you're extremely unlikely to, to get uh cervical cancer. Um But um in this case, yeah, so she is positive for high risk HPV. Um So all of these other answers here basically are all reasonable. But the question here says, what is the most appropriate next investigation? Um So let me show you a pathway just so that makes a bit more sense. So in her case, so she tested um high risk HPV test was positive. So that's her first test, but her cytology was negative. So it was normal. So she was rescreened again in 12 months. She again tests for high risk HPV positive if you can just follow the little um the diagram basically. Um So then you would now need to do cytology to then figure out what we do next. OK. So it's just AAA test of your knowledge of this. Um I think it's fairly examinable. Um So yeah, worth just knowing about again, it's, you don't need to know the ins and outs, but just maybe the first two stages, at least just have it in your head. Um So remember always test for the high risk HPV first because that's the main risk factor with cervical cancer. And then we're gonna look at the cytology next to decide, do they need a colposcopy or can they just be uh rescreened again. Um But yeah, most people do tend to clear the high risk HPV within the sort of 12 months, which is um why we have this system in place. And then just for your interest, you don't ii don't think you really need to know the details of what happens after. Uh but basically, if you have to do a colposcopy, um then you just figure out whether there's any sort of findings from that colposcopy and that will lead you to sort of different, uh, options there, which you saw as the other answer options. But in her case, we hadn't even done the cytology yet. So we couldn't think about those other options yet. It was first cytology first. So, just have a look at the time. But I'd say this one is the one just to remember. Ok. All right. Uh, and, yeah, just a little bit more information about the cervical screening program. So it's offered to all women aged 24 and 64 years. Um, so, yeah, at age 24.5. Yeah, women should receive an invitation and then between the ages of 25 and 49 you'll be offered screening every three years and then 50 to 64 every five years and then 65 and over, er, women, um, should be screened if recent cervical cytology is normal or if they haven't had a cervical screening test until 50 uh, three investigations are involved in the cervical screening program. So, like I said, the high risk HPV testing only then if it's positive we do the cytology and then if needed as well, then you'd have a colposcopy done. And then within that procedure, they look at the cervix and they may, and they will put acetic acid as well to um look for any dysplastic areas. And then based on that, whether you need to just be put back into the routine recall system or whether you need further um intervention. And then just a note on vaccination as well. Um So, you know, this could come up with peds as well, I suppose like um HPV vaccination cos that's obviously when it's mostly done, it's in 12 to 13 year olds. Um So it started in 2008 and mainly uh to prevent infections due to type 16 and 18, which are the highest risks. Um And it's been offered initially to girls aged 12 to 13. Um And then the vaccine has also developed over the years and now also protects against six and 11 which are responsible for genital warts. And then in 2019, um 12 to 13 year old boys are also offered the vaccine and it's really good. So, yeah, by mid 2019, I just got this figure from her, a research paper there. So, um it's prevented several counts in nearly 450 women and c in three in nearly 17,000 women. So that's extremely effective. Um And yeah, there's some further information on who else is eligible for it, possibly examinable, but just for your information there as well. Ok. Moving on to question nine. So we've got a six year old female presenting with a two month history of postmenopausal bleeding, no postcoital bleeding or dysuria. Last menstrual period was four years ago. Smear tests are up to date. They've always been normal. She's never been pregnant. She used the combined oral contraceptive pill for 10 years in her twenties. Her past medical history is hypertension and PCO S. Which aspect of this history shows that she has a protective fac factor against endometrial cancer. So just have a look at this. Um And I'll put the pole up. Excellent. Got some responses in, I'll give you a few more seconds. Anyone else wanna give it a go. I promise we're nearly finished by the way. So um nearly done a excellent say. I think most the most popular answer there is correct. So that is answer d well done. Um Yeah, it's just basically a test of your knowledge on risk factors for endometrial cancer basically, and protective factors. And I think if you understand the sort of science behind it, it makes it just easier to remember um why that is the case. So with endometrial cancer, um the most common type of endometrial cancer is basically um estrogen sensitive. So any prolonged periods of unopposed estrogen will be the main risk factors. Um So things like late menopause, no liar. Those are both risk factors where you would have increased uh exposure to unopposed estrogen. Because of that um hypertension is basically just an another risk factor sort of combined with obesity and those kinds of things. And then PCO S specifically is um because it increases, you're basically at higher risk of having er, periods with an, an, an an ovulatory cycle. So basically where you don't pass an egg and that you need that basically to release some progesterone. So the Corum will release some progesterone and that will obviously oppose the um the estrogen. So that is why and then combined oral contraceptive pill actually happens to be a protective factor um against endometrial cancer in this case. So let's go into a bit more detail of it. So, like I said before, it's a common estrogen dependent gynecological cancer which mainly affects post menopausal individuals. There is a type two type of endometrial cancer, don't worry about it. But just so, you know, it's, it is not estrogen dependent and it's quite rare, but just so you're aware, but for the sake of exams, er just remember endometrial exam, er sorry, endometrial cancer is er estrogen dependent. Um and just a note on sort of post menstrual bleeding because I think, you know, if anyone presents with that, it will send alarm bells through your head and you will obviously have to rule out the worst case scenario in this case. But just for your knowledge, so 90% of women with post menstrual bleeding don't actually have endometrial cancer. But majority of women with endometrial cancer will present with post menstrual bleeding. So, it's just something you always have to rule out first and then you can think of other causes after that. So what causes it? So, presence of unopposed estrogen. So this is from a lack of progesterone and that can be er endogenously or exogenously. So, endogenous causes can be um PCO s um anovulatory menstrual cycles, all those sorts of things and then exogenous can be uh hormone replacement only containing estrogen tamoxifen. Um and that's used in the treatment of breast cancer. So, risk factors there. So we've already been to a few of them. Um but yeah, just be aware that anything that basically causes unopposed estrogen is or an an ovulatory cycle is gonna cause is gonna be a high risk factor for endometrial cancer, but in terms of protective factors. So things like um parity. So obviously, there's a surge in progesterone during pregnancy. C OCP exercise. I think smoking actually is a protective factor. I've got that down there. You know, I don't actually know why, but now, you know, um OK, and then clinical features. So it's abnormal uterine bleeding, typically post menopausal bleeding, but it can be in the, in the form of other uh types of uterine bleeding, but you are typically gonna see it in the postmenopausal age group. So that's why postmenopausal bleeding just always think it could just be endometrial cancer. Um You can have other clinical features there which are sort of shown there. But the main thing is this postmenopausal bleeding and you obviously do examination. Um and then transvaginal ultrasound scan would be the investigation of choice and you're looking for an endometrial thickness of more than five millimeters. Um So if it's four or more, an endometrial biopsy should be obtained or it also if persistent bleeding in individual with maybe not a a second an endometrial um endometrium, sorry. Uh You may also then consider biopsy but definitely if um if it's four millimeters or more, uh and then in terms of referral criteria, um again, sorry if this is too much information, but just so you're aware of where we're getting this information from. So this is from IC Ks again. So, um if they're age 55 and over with postmenopausal bleeding, um you're gonna refer and then consider if they're under 55 with post menopause bleeding, cos you can get early menopause as well and then consider uh direct access if they've got unexplained sort of symptoms of vaginal discharge or hematuria. But that's less common. I'd say just focus definitely on the post menopausal bleeding. Ok. And then here's just another nice image just to describe um the process of how endometrial cancer develops So you go through um sort of hyperplasia stages first. Um So in sort of simple or complex hyperplasia, you can actually use uh progest progestogen. So, like the Mirena I US or surveillance biopsies before going into any sort of management and then you've got atypical hyperplasia and that should be treated with um, abdominal hysterectomy and other operations as well. Um If survey, sorry, if surgery is contraindicated, then you're just regularly survey and then this is what happens when it goes past the hyperplasia stage. And then you've got different stages there, uh depending on where it's metastasized to or whether it's stayed within the uterine body. Um and typically it's gonna be surgical management. Um Oh, got a few questions. Oh, amazing. Thanks, Kashmir. Um Yeah, there we go. Anti. It's all about the estrogen. Thank you. All right. So, um important differentials. So we're just good to have an open mind um about what could be causing it. So once you feel you've ruled out any malignancy also, depending on the age of the patient, um You can think about other causes. So, vulval causes, uh this is to do with post menstrual bleeding or abnormal uterine bleeding. And actually, vulval atrophy is one of the most common causes for post menstrual bleeding and post, oh my God, I keep saying post menstrual bleeding. I'm so sorry. I mean, post menopausal bleeding. Um Apologies. So you can consider that once you've sort of ruled out malignancy, um, cervical cause as well. It may depend on sort of age there. And then, like I said, endometrial causes and there's a really useful pneumonic. This is actually more to do with any sort of abnormal uterine bleeding, but it can be used to think about post menopausal bleeding as well. Um So let's go through it. So palm, so it can be a polyp adenomyosis lays malignancy, coagulopathy, ovarian dysfunction, anything to do with the endometrium, iatrogenic and not classified. Um It's a lot to think about but don't worry, the, the exam questions will make it fairly obvious and don't worry, you're not expected to know all this detail. Um but yeah, OK. Moving on. Oh for note. OK. So the reason I put this question is cos I think it could be quite an examinable uh topic. So just so you're aware, so you can compare and contrast with other er cancers that um you may be expected to know about. So, breast cancer actually have very similar risk factors because increased exposure to oestrin is a specific risk factor for breast cancer. However, in breast cancer, the use of cop actually slightly increases the chance of breast cancer because synthetic versions of the estrogen and progesterone can stimulate the breast tissue growth and then that can encourage cancer to grow. It's a very small risk but it is there. And if you stop using the C ACP for 10 plus years, the risk sort of becomes negligible though than looking at ovarian cancer. So, again, similar risk factors, but the theory behind uh why these risk factors increase the risk of ovarian cancer is because of the theory of incessant ovulation. So the more times a woman ovulates in a lifetime, the higher the risk of ovarian cancer and that's due to the increased damage on the epithelium. And then cervical cancer HPV is obviously the biggest risk factor there. But C ap actually does slightly increase the risk of cervical cancer due to er, changing the susceptibility of the cervical cells through persistent infection. Um, but like with er, breast cancer, um if they've stopped for 10 plus years, the risk is manageable and the evidence is not as good um for as, as, not as good as it is with, with breast cancer, but just have it in the back of your mind. Um Oh, yeah. Yeah. Good. Exactly. Yeah. Don't start smoking just to prevent uh the cancer. There's other ways. Ok. Right. Ok. Moving on to question 10. So our last question, I promise. Um, so 25 year old female presents with heavy periods associated with passing clots, which she struggled with since he was a teenager, regular menstrual cycle, no intermenstrual or post post coital bleeding. She does not want to be pregnant in the next five years. No significant past medical history takes no regular uh medication, ab abdominal and vaginal examination, all normal obs bloods, all normal. What would you offer as a first line management? So have a read of those and then I'll put a poll up. Ok. Off you guys go, ooh, quick answers. Oh, no, sorry, I was ok. Question one. But yeah, have a think. Ok, so you've got a bit of a split response. But on the whole, I think most people have gone for b which is the correct answer. So the key bit in this question is first line management. You've heard it a million times, but just always, always read the question because a lot of the times in the finals exam, especially a lot of the answers could all be correct. But the key thing is what is the question asking you? And that is first line management. OK. So what I'm trying to get at in this question is um that it's a young female with heavy periods, no other sort of red flags or risk factors here. Um that we can see. Um So first line management would be the I US system and unless they don't want that or that's, you know, not their choice or obviously she, you know, wants to conceive, you wouldn't offer that. Um But yes, so that is why it's the I US cos it's the first time management and that again comes from guidelines C and D are also correct options, but they should not first line and then again, a could be an option, but that's that's further on down the line. And that's also in the treatment of, um, uterine fibroids. So, not, not, we're not suspecting that in this case. Um, and then Cob Coil actually could make things worse. So you wouldn't use that in this case. All right. So that just leads us to our last topic of the night. So that's menorrhagia or heavy menstrual bleeding. And this is the definition from nice again, so, excessive menstrual blood loss which interferes with quality of life. So there's no sort of specific amount that you need to be bleeding. It's just that it's excessive and it's affecting quality of life and depending on what's causing it, um it, you, it can be associated with other symptoms. So like with everything detailed history, examination bloods and then depending on what you're suspecting, you would go down different routes of examination also depending on age, depending on sort of any red flags. Um But yeah, those are just other things to consider that and like I showed in the other in um sort of the endometrial cancer slides. Again, you can use this um Pneumonic to just think about all the different causes. Again, I know it's overwhelming, just try and digest it. And again, I'm hoping that the questions will be fairly obvious with regards to G cos it can be quite niche to be honest. Um But yeah, just have a think what could be causing the abnormal uterine bleeding. Um So you obviously wanna try and consider, are there any medical causes? So any coagulation issues, thyroid issues, PCO S and those should be managed uh alongside this. But for women with menorrhagia, no identified path pathology or fibroids less than three centimeters which are not causing any distortion of the uterine cavity. Um or suspect to diagnose adenomyosis, you're gonna use um A I US as the first line treatment. If it's declined, not suitable, then you can go for a pharmacological treatment. So, oxamic acid nsaids can be used and they can also be used if maybe they're waiting to have the I US fitted or waiting for a plan. Um just to help with symptoms uh during periods, um or other treatments can be the combined hormonal contraception pill or the progesterone pill. Ok. And then this is if you have women with fibroids of more than three centimeters, as if you're thinking fibroids are causing um the issue and they are um more than three centimeters. You're gonna refer to specialty and again, pharmacological treatment whilst they're waiting for that appointment. Um And that will involve, you know, the nsaids tram acid, you can also use the hormonal treatments. You may use the uterine artery embolization and that's what one of the options there. So that's basically where you remove the uterine er fibroids er through this process. And there are other surgical treatment options there as well. Again, just when to refer to it. Just important to just have it in the back of your head. Um So just alarm bells ringing. If there's a pelvic mass with other red flag symptoms there, um, 55 postmenopausal bleeding just always think. Uh could this be malignancy? Um If on examination, we just see that something's not quite right with the cervix. Um And if there are sort of more worrying features on a sort of abdominal examination, sort of ascites pelvic abdominal mass. Um, so you could just gonna think about referring. All right. So I think that ends my bit. Um I obviously couldn't cover everything. Obs and Gynae is just a huge topic and from the gyna side specifically, there are so many important topics all in their own rights, just a medically just so you have this knowledge so you can treat patients well. Er, but also for exams as well. Again, it's just tricky to know what exactly is gonna come up. Um, obs and Gynae can be quite niche. Um, but these are topics that I didn't cover specifically, but you may just want to have a look at um, in your revision if you have time, just try your best. Um, but you're not gonna be able to cover everything, but just so you're aware, these are things that I didn't cover from the Gyne side of things which you may may be examined. Um, you'll get access to these slides. So don't, you can have a look at all of this in your own time. And just as fy, I like where I got a lot of this information from, um, and where you can use for revision uses for anything, to be honest, just not just going everything articles. The question bank is excellent. It has a sort of UK MLA specific question bank, which is great. And if you're not already aware, the AY Bank is fabulous as well. Um, teach me OBS and Gynae website is is great. They have it for surgery and other teach me pediatrics as well. So always a really good website. Nice C KS. The Bible um Green top guidelines are good for obstetric side of things. They don't have everything but I know the antepartum hemorrhage and placenta. Previous guidelines are on there patient info professionals article for anything as well, but also Dobson Gynae Boo og for I think they have some good ay stations on there which are ob specific um obs pod. If you're interested in obstetrics, there is a CTG interpretation video which is great if you didn't attend the um session where I talked to her about CTG S this where it's got information from. So have a look if that is relevant for you guys and your Aussies cos it was for ours and then FS Rh guidelines for contraception. So that that could be examinable. Er BS HH guidelines support sexual health conditions, three sub guidelines for any sexual health condition or um infection basically on there. So just have a look. And then when I was looking at this cos I did the uterine in er, sorry, not uterine, u urinary incontinence side of things. I realized pelvic stuff is quite confusing. To be honest. I don't think it's covered very well in medical school, but if you're just interested, um there's a really good podcast there as well about sort of pelvic health. Um Anyway. All right, that ends my bit. Thank you. Um Have, can you please fill in our feedback form? Here's a QR Code and if you have any questions or emails there or you can ask for now. Um But yeah, please, please please leave some feedback. Um And yeah, thanks for listening. Thanks for coming guys. Oh, I didn't realize you extra incentive is that you get the, the slides and the recordings. That's good. Yeah.