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is. Bye. What have done for the first step? Step tricks Lecture is I need to get rid of that general approach to a patient so need to Okay, Mhm and managing. Yeah. Can you see that? Yes, ma'am. Okay. Thank you so much. So today is the first lecture of obstetrics. Um, and I'm taking this really baby steps because again, as I said, I don't know what you've been taught of. Uh, I don't know to whether I got first years or second years. I don't know, the level of the students were teaching, so I'm just going to take them baby steps. Um, And in order for us to what? Uh, to understand what happens in obstetrics, you need to understand that there are some unique physiological changes in pregnancy. Um, and the mother has to under bill these, you know, anatomical and physiological changes, because there's a whole foetus that's developing inside the body, and they actually quite subtly, they begin immediately after conception, and it's quite widespread. Every system in the body is affected, and this is quite a long lecture, so I'm going to have to do this in as a part one and part two. Um, so when we do the M. C. Q s on them, we'll do them after we've done the part. One and part two. Um after the pregnancy is over and done with, usually between about 4 to 6 weeks, most of the physiological changes will have returned to normal. The the the the woman would adapt, and she adapts at a very, very rapid pace. And it's it's a whole scale adaptation. So if you look in, uh, in any other situation, um, the the pace of adaptation is absolutely rapid. It's rapid, and it's it's almost the entire entire mechanism of everything from cardiovascular to renal function, too. Um, G I, um um and, um hematology coag coagulation. Everything across the board has to change. Does anybody understand the really reason why these changes happen? What is the need for these changes to take place apart from nurturing the baby? Any idea it's the Maybe it's because the accommodation as well they're It's a human. Yeah, but it has to accommodate the baby. And what does she need to accommodate the baby in her body? What kind of if we start at the top space and nutrition, space, nutrition? Uh, yeah. Proper proper vascular ization. Yeah. Vascularies ation. Yeah. And in order for that also, remember, um, there's the center, and there's a huge big uterus. So there's this uterus that's going to go from being absolutely tiny, non vascularized uterus to a massive big uterus that's going to need a whole load of blood supply. So there's a massive demand on the on the mother Bless her in the first and the second trimester. The third trimester is pretty static. It's okay because most of the changes have taken place, and all you're looking for is you're waiting for delivery. But when we do, uh, and that's why I did hypertension because I will take pregnancy induced hypertension in the next, uh, talk that we do because we've done hypertension. And once we understand how the changes take place in pregnancy, it will become easier to understand how they don't take place in somebody who has pregnancy and use hypertension. So, um, the other thing, too, which is really important to remember, is pregnancy is not a disease state. It's not. It's not somebody who has any kind of disease, so these are normal physiological changes. And sometimes when you're dealing with patient's in primary care, you have to explain to them that this is not a disease state. This is normal. So as a doctor is a GP, you want to know what is normal. You want to know what is abnormal so that then you will be able to refer this patient onwards. And the physiology of pregnancy is entirely unique. And in fact, it's still being studied. It's still being understood, but we know that there are certain things that will take place, so we'll go on to the next slide. Um, so, um, we've already discussed that, um, some of the parameters is certainly around the hematology and the biochemistry and and the the profiles will change. So as doctors, when you have somebody who is pregnant, then you want to be able to know that how much of this is normal? So you've got the nonpregnancy state, which is normal, and then you've got the the little bit of stretch that happens when the woman is pregnant and you need to be able to interpret even in primary care, how much is normal and how much is not normal and when to refer. Although now, obviously obstetrics has become very specialized and midwives take over the care almost directly. But we still see a lot of these changes in the blood blood pictures. So you need to be able to know this, and it'll help you understand what happens in obstetrics. What happens in pregnancy induced hypertension? Preeclampsia. Um, so the first thing that happens is that the plasma volume has to increase, and the majority of this 50% is almost done by be 34. And the bigger the baby, the more will be the increase in plasma volume. Okay, so women that have macroscopic babies, they will have more plasma volume. Okay. And if the plasma volume increases, imagine that you're getting a certain amount of hemodilution so the hemoglobin will fall, so you'll have somebody who is pre pregnancy state, and then you'll do a blood picture. And we'll do this when we do the M. C. Q s. And I'll show you how it has changed in a real patient. Um, that the the hemoglobin concentration will fall. But the thing to pick up in these blood tests is there's no change in the MCV and no change in the MCHC. So the main capacity alert volume and the mean corpuscular hemoglobin concentration will remain the same. Okay. And the hematocrit will also fall because of him. A dilution. That doesn't mean she's had a bleed. It just means that she's him a diluted, um And, um, the platelet count tends to fall in pregnancy. And this is okay. It's normal. It's fine. And, um, sometimes it can be quite low. Um, but if it's a part of the help syndrome, uh, then of course, you need to monitor it much more carefully. You know, you have to look at the BP and liver enzymes and stuff like that. But the platelet count can slowly, slowly go down. So you need to monitor that. Um, obviously, the requirement for iron goes up massively because the body's manufacturing, all this extra plasma volume and all this blood, it's common for the hemoglobin to fall. But even if the hematocrit falls, remember the MCHC and the mch see? And the MCV is what you're going to look to see. If you're thinking that this woman has iron deficiency anemia, what would would be the other test you would do if you thought that she had iron deficiency anemia. Any idea what is the test that we do for for iron? You can run off some iron studies. And if the defense comes back below comes back, Uh, the MCHC is normal. What would you do? Would you replace her to see her? Ferritin is low and her MCV and her MCHC is normal. And it's the first trimester. Would you give her additional iron? I mean, you can counsel her. You have to talk to her that, um you know, she might be somebody who is vegetarian, or she might be somebody who doesn't have a lot of meat in her diet. For whatever reason, Uh, you can counsel her. You can repeat the bloods in another four weeks or in another six weeks. Uh, but it is anticipated that the ferritin requirement will go up. Um, so if she refuses to take the order, LionOre, she's intolerant of the order line. There are other alternatives that are injectable alternatives, but that would be done by the hematologists. Um, but you'd want to keep an eye on her ferritin levels. Um And then, of course, the folate requirement, uh, increases massively. And there's a two fold increased requirement for B 12. Um, the coagulation system changes in pregnancy. So pregnancy is a hypercoagulable state because what we don't want to do is we don't want a woman to bleed when she delivers. And what is the average blood loss in a normal delivery? How much do people lose? Any idea? On an average, they can lose about 500 mils. You know, that's quite 5000.5 liters point. That's fine. Sorry. Uh, zero point. It's 3.5 liters. Listen, I can't hear that. I said 0.5 it's about they lose about. They can lose about up to 500 minutes, even in a normal delivery. So you don't want a woman to bleed away there, you see, um, and because the pregnancy causes this hypercoagulable state, this HYPERCOAGULABLE state stays until about 12 weeks into the postpartum, and that puts the woman at the risk of getting a venous thrombosis. And, um, this risk is present from the first trimester. So if you have an M c Q where a woman is pregnant and she presents with leg pain, please think dvt Okay, and clotting factors. Um, 89, 10 fibrinogen. They all go up. Yeah. And endogenous anticoagulants like anti trump in and protein s. They reduce mhm. But if you're looking at a PTT PT and thrombin time, if the woman is not on any anticoagulants, the numbers don't change. Now you get venous Stasis in the lower limbs. Um and this is because the left eyelid vein gets compressed by the left eye like a tree and the ovarian artery, and that increases the risk of DVT in the woman. And it also causes varicose vein swelling in the legs pitting edema. So you just have to be aware of that that women are at a higher risk in pregnancy of getting a DVT now because the blood volume has gone up. Right? So when the blood volume goes up, there has to be changes in the cardiovascular system, because otherwise how will the heart cope so the cardiac output slowly starts to rise, and the way the body accommodates it is by increasing the vascular, uh, compartment. So there's peripheral vasodilation in. So as the vascular volume increases, the vascular resistance decreases, um, so that otherwise the woman would become hypertensive, right? If we had a fixed system and we start putting more fluid into the system, if we don't get partial base a dilation, then the blood pressures will go up. Um, and, um, the cardiac output would go up, but it's accompanied by razor dilation. So that's how the BP stays quite low. Um, then if you look at a woman in pregnancy, it's quite common to get an injection systolic murmur. Just because there is so much volume that is going through, um, you can get a loud heart First Heart sounds Sometimes the third heart sounds, so that's not abnormal in a pregnant woman. And sometimes, because of all the hormones that are going through in all of this, they can get a few ectopic beats. So pregnant women will present to you with saying I'm getting palpitations, so you need to know what is normal or not. You would still do an E. C. G. There are some small E c G changes. You can get a small Q wave or an inverted T wave inlayed three. Um, sometimes you can get an ST segment depression or TV conversion, but still, you would be guided by the patient's symptomatology, right? So if she comes to you with the chest and you're not going to ignore it and say, Well, this is normally in pregnancy But there are some subtle changes that take place. You just have to be aware that those those can be there in the background. Um, and because of the increase in the stroke volume, mhm the ventricular wall, muscle mass increases and the end diastolic volume increases. But not the end diastolic pressure because of the peripheral validation. Um, and towards term, the stroke volume declined slightly. But then the heart rate is maintained so that the cardiac output remains the same. So the BP decreases in the first and the second semester. But coming back to nonpregnant levels in the third trimester nearing the delivery, it reaches normal levels again. You just need to know that that's the variation. So you get a bit of a dip in the first and the second semester. Then by the third trimester, the BP begins to normalize again. If you don't see these BP changes, then you'd really be worried, Um, and then because that you've got this massive uterus is this gravity use. The uterus is putting pressure on the inferior vena cava. And if the woman is lying in a super imposition, it compresses the inferior vena cava. So the venous return to the heart can fall. Now in labor, we nurse a pregnant woman in the lateral position, usually the left lateral position. We put a a wedge because if you don't put a wedge and then she lies on her back and she compresses the interior vena cava that reduces the stroke volume to the heart and reduces cardiac output. It can have catastrophic events in reducing the uteroplacental blood flow, especially in labor. You must make sure that the woman has a wedge behind her. Um, because otherwise, then you'll get fetal distress and you'll start seeing dips on the CTG. So the midwives are very good. They're very careful, and they make sure that that doesn't happen. And and for those of you and I, I don't know how many of you have ever had the experience. Um, you feel like you're choking. Um, if you ever lie, if you're pregnant and you lie on your back, you feel like you're choking because the pressure of the weight of the uterus is significant and the reduction in, um, cardiac culture it's very dramatic. Um and, um, then we're looking at vascular resistance. So imagine that the vascular resistance has to reduce because you're increasing the whole plasma volume and you want to maintain a low BP in the first and the second semester. Because if we don't have a low BP, if you get hypertension, we won't get good perfusion of the uterus and and the placenta. So we need to maintain the low blood pressures and that it's a trade off. And it's achieved by a reduction in, uh, vascular resistance. And the pulmonary vascular resistance decreases significantly. Um, so that puts women who are pregnant at a risk of pulmonary edema. So if you know when you're in the labor ward and you're trying to perfuse a patient because she's had a hemorrhage, you really need to be careful and watch, watch the urinary output and have a central venous line because you will precipitate pulmonary edema. But the anesthetist are really good with that, and and obviously they monitor their, um, the, uh, parliamentary capillary wedge pressure stays the same. Uh, but the because of the hem A dilution. The keloids osmotic pressure does go down. Um, and because of that, that's another additional factor. Why people can go into pulmonary edema in pregnancy. So it's something to watch out for in the labor world. Um, when women are in labor, um, you get an increase in cardiac output, and some of that is because of the increase in the heart rate and certainly 50% in the second stage because of the contractions. Uh, when the uterus contracts and the uterus doesn't just contract, it will contract, and it will retract. So each time the uterus is contracting, Um, uh, it is actually not returning back to its normal stage state. So it's getting smaller and smaller and smaller, and when that happens, it's actually pushing a lot of blood out into the circulation. And then pain and anxiety raised the heart rate, and then it raises the BP. It raises the cardiac output. So can you imagine if you have a woman who has undetected cardiovascular disease and goes into labor and we haven't, um, diagnosed it, then it can have catastrophic consequences for her once. Um um, the woman has delivered. Then the whole pressure of the uterus and inferior vena cava is, uh is taken off. And then you get this rise in cardiac output. Uh, and usually about, um, I would say, within about 12 weeks all the extra fluid. And, uh, in fact, it's faster than that. Very soon after delivery in the 1st 23 weeks. Uh, there's a lot of diaries is and the woman would shed a lot of that additional fluid. Um, so if you have a woman with the cardio vascular compromise, the biggest risk is the second stage, an immediate post partum, and the risk is of pulmonary edema. Um, so you just have to be careful with your patient's if you're pushing a lot of fluids, especially in a situation where you're trying to resuscitate somebody who is, uh, just hemorrhaged, Um, and you need to be guided by the central venous pressures that you're not overloading them. Um, now, because the systemic vascular resistance falls, uh, it affects the renal vasculature also, and the plasma volume has increased. And in order to maintain the BP, the SVR falls. So what happens then is that the renal blood flow increases. So, in no other condition do you see this? Uh, because normally what happens is that the kidneys are getting perfused and they're auto regulating. But you see a blunting of this in pregnancy. So, uh, you get increased renal blood flow despite there being a fall in systemic vascular resistance and an increase in plasma volume. So, um, uh, relaxing is secreted by the corpus luteum and the decide you and the placenta. And it's not just relaxes all the ligaments, but also it, uh, stimulates the formation of endothelin, which, uh, causes base a dilation of the renal arteries. And this is really important because, remember, the systemic vascular resistance has gone down, and, um, uh, the, uh, rennin angiotensin system is activated in early pregnancy, but it gets blunted, so there's a blunting of it, which allows the space a dilation to, uh, to to to occur. Um and, um, as I said before, it's mediated through the relaxing, Uh, and, uh, the placenta vasodilators are really important, um, in in the maintenance of the space, a dilatory state and you'll understand when we look at pregnancy induced hypertension of how this all comes together because some how this doesn't work very well in pregnancy induced hypertension. Um, so the renal plasma flu, of course increases. And the woman wants to go pass a lot of water. So she continues to pass water also because of the pressure on the bladder. And she's also excreting on behalf of the baby. Um, the vascular resistance decreases and the pressures remain stable. Um, the G f r will rise, obviously, because the, uh there is no reduction in the renal blood flow. Um, but the creatinine and the urea concentrations decrease because the woman is passing more water because she's excreting more water both for herself and and the child. Um, the kidney actually enlarges not because it's enlarged, but because it has an increase in the renal blood flow. And, uh, the the the uterus Um uh, the the progesterone reduces the tone of the ureters. Um and, um, you can get some almost, I would say inertia in the ureters. Um, and that can, uh, appear if you did an ultrasound, uh, that the ureters and the renal pelvis. They appear hydronephrotic, um, and it's more prominent on the right side for reasons given in the slide and because the progesterone reduces the ureteral stone, you get urinary Stasis. Um, and pregnant women they can get more asymptomatic bacteria because you've got infected urine that is just pulled over there, and it can cause an ascending infection. So the chances of pyla nephritis or getting an infection or high in pregnancy Um, and the resumption of glucose um um is less effective. So whereas when the kidneys are working and glucose is freely filtered, it doesn't get re absorbed back as nicely as you would normally want it to. So it is possible. Sometimes you can get dipstick, uh, like Assyria and, uh, the exclusion of protein. Um can also increase, um, in the union. But in normal pregnancies, it doesn't increase above the upper limit of normal uric acid. Excretion also increases because there's less tubular re re absorption. Because, remember, the woman is also excreting for the baby. Um, nausea and vomiting common in pregnancy. Um, mainly mediated. Unclear through hate, C g estrogen and progesterone. Uh, hate CG will peak in the first trimester, and after 12 weeks, then you won't have the HCG there. Uh, nausea is always common. More common interim pregnancies. Uh um, there is some association of the TSH because it shares bio similarity in its molecular structure to hcg. Uh, and HCG and TSH can cross react. But there are some genetic factors, and H pylori has also been implicated. Uh, but pregnancy, usually the first trimester is the worst time for the nausea and vomiting. If it carries on beyond that, then it becomes pathological. So we wouldn't worry so much unless the woman is absolutely not keeping anything down. In which case you might have to admit her. Usually, after the first trimester, the morning sickness will settle. Um, it's about 20 weeks. Um, and small proportion of patient's will continue to feel dyspeptic, uh, nauseated. But that's also because the uterus is pushing on the stomach that's not mediated through the hormones, but that can be mediated mainly through the, um, the anatomical changes that are taking place very small proportion developed hyperemesis gravidarum. And that continues. And when a woman vomits and vomits and vomits all the time, she can become dehydrated, become hyponatremic hypokalemic Uh, ketotic, um, and these patient's they have to be admitted. Okay, um, given some timing supplements, um, and kept in until they are back to eating again. It's a It's a difficult one, because, uh, you know that there's also a psychological element, and you need to screen these people properly. Uh, just to make sure that there isn't any other factors that are causing them to have this. So you'd be looking at a full and complete assessment. Um, And as pregnancy progresses, the mechanical changes in the in the in the elementary track. Um uh, cause, uh, sort of, uh, Stasis. Um, the s official sphincter tone is decreased, so you get a lot of reflux. Um, um And, um uh, there is a sort of delay in gastric empty, and this is particularly important when you're taking a woman into labor. Uh, that if she's eaten, then you can expect it to take much longer for her stomach to empty. That's something which the necessities are aware of. Uh, because then she can have reflux, and then she can vomit and aspirate. So, um, uh, if there's a pre existing disease, obviously it will make it much, much worse for her. Um, so it seems that I have run on time. Got half an hour, so I could have done a bit more, but I wasn't sure how long the lectures would take. So, um, I've done most of the talking. Um, can we see how how it has been so far? Nope. Yes, it's going great, Doctor. Thank you. I did have one. Um, in terms of postpartum, you just said that patient's, um, normally, um, have a higher risk of DVTs. So would these, um, higher risk patient will also get anticoagulants postpartum? Or is it in just particular cases? Could Could you put that in the chat, my dear? Would that be posture? Hmm. So you're saying, would post partum patient's be prescribed with anticoagulants to, uh, to decrease the risk of DVT. So you must remember that if you put patient's, uh, willingness, what you're saying is should we be putting everybody on anticoagulants to reduce the risk of DVT? Then it's probably not a great idea, because why would you want to do that? Um uh, it's only people that have a problem. I mean, we wouldn't be putting them on do X we do. Putting them in heparin. Uh, but if somebody has had, say, a previous DVT. They've got protein s deficiency. If they are already somebody who is at a risk, then you would give them prophylaxis. Yes, certainly you would. But you wouldn't put the whole population on them now. Or would you? Why would you do that? I'm not sure I wouldn't do that. I wouldn't put the whole population on them. There's no evidence base, uh, to do that. And actually, that does remind me we could probably do a little bit about how evidence Have you had any talk? Has anybody done a talk on evidence based medicine? Has anybody had any? Do you? Did you Did you get taught in university evidence based medicine And how how the hierarchy of evidence works? Um, Ms Patel has asked us the e c G changes women experience. Is there a way to reduce these changes and ensuring that iron changes are optimal? Right. So there is, um there is a thinking behind doing what is known as a pre pregnancy clinic. So high risk patients' patient's who've had previous, um, miscarriages who've had poor obstetric outcome. They are seen in pre pregnancy, um, clinics and, uh, the whole idea of a pre pregnancy clinic is to optimize the how shall I say, to optimize their physical health, uh, to do the blood test, to counsel them to ensure that they are adequately replaced, that they've got appropriate levels of folate? Uh, folic acid, uh, iron that, You know, all the parameters are optimized, so we do that in what we call pre pregnancy clinics. So we've not done pre pregnancy clinic because we started this in obstetrics. We could probably do a small mini, uh, couple of slides on what you do in a pre pregnancy clinic. I'll just make a note of that that I'll make that ready for next time. Is there any particular topic you want me to do in OBS and Janie? Because I'm literally working from zero station forwards because we've done the changes in pregnancy, and the next thing we will do, we'll just build it up from there. But if there are any gaps that you want me to talk on, I'll build a lecture towards that. I have a mission. If you can put it in the chat because I can't hear anybody. Uh, hello? Yeah. If there's any stages of labor. Okay, that's fine. Yeah. I mean, we're going to do pre eclampsia anyway, because we've done hypertension today. We've done the changes in pregnancy, so I think, yes, we should take, uh, preeclampsia. Because preeclampsia builds up on all of this. It's actually the maladaptive mechanisms, uh, of pregnancy. That would that would be the physiological basis of understanding why preeclampsia takes place. Yeah, we can do labor. Labor is easy. Labor is dead easy. So do you want me to go in the way that we are going, Or do you want me to do, um, lectures that are on specific topics? It's your choice. Yep. I mean, my intention is to go through the whole of obstetrics. My intentions will be to go through the whole of obstetrics in, um, in a sort of, uh, in the same manner as we would teach medical students in this country. Uh, but if there are, uh, you know, if you're close to exams and there is some urgent need to do a particular topic, then I'll be I'll be happy to. Yeah, that That was my intention to take the whole of obstetrics. So? So we'll go through the whole lot of that, that I'm happy to do that. And I just wanted to ask everybody. How are you finding it so far with the lectures? Are you finding that it is helpful? Oh, great. That's very good. That's very good. And is the time of the lectures um useful in the sense that do you like these midday sessions or do you prefer later evening sessions in case some of you might be doing jobs in the day Because I am conscious that, uh, some of you might be working. So is this the best time for you? So for some people, later evening is better. So if you can put that that in the feedback Because, um, uh, I'm quite happy to do lectures in the evening. If evenings are easier for you, I'll have a word with Hannah and see what she she can suggest. Uh, because if those of you who are working, uh, might be doing jobs, etcetera, you can't attend the lectures. Or you might be doing other things so we can do them in the evening to I'm quite happy to do that. Also, Sharon wants midday. Okay. Either is fine for Shefali. Okay, so you just put it in the put it in the lectures and, uh oh, by the way, be ready for some. MCQ is next time I'm going to be bringing some blood tests, so everybody needs to have read up on this. Let's see what fun we have in the next lecture. I believe we're meeting up on Thursday. Is that right? Excellent. Excellent. So, um, how many people are in finally or if I may ask, who is actually going to be sitting their exams this year? Do you know? I see. So, Mr Assad, how are your exams being conducted in Ukraine? Are you going to be doing it all online? Is that how it's going to be? Uh, currently? Right now, I'm in my home country, Mumbai, and I need to go back if you just put it in the chat. Could you hear me now? Yes, I can. I can hear you much better now. Okay. Uh, currently, Right now, I am in Mumbai like my home country, and I need to go back by March. Right now, the exams are not held in a manner of a semester exams. We usually have, uh, exams in a manner like subject rice definition subjects, and we do a final test for it. So are they expecting you to Ukraine and do your exam in Ukraine, then? Yes. Yes, ma'am. Because last last year, students who were in the final year they were given compensation due to the war. But we were like, the second last. We were the fifth year, and the six year is the last one. So there's no clear that because it's a very it's a license exam. It's a state exam. So you cannot conduct state exam online basis. You need to be physically present. I completely understand. Yes, yes, yes. No, no. I completely understand. When exactly is the exam? By the time of June or July? Because, uh that, like three exams like us, Emily step exams like three exams like crop 12 and three. As a foreigner, we only have to give crop one and two due to the pandemic crop. One was born to the next in the fourth year. But I don't know whether the example occur or it won't occur. It will occur after the war is over. If tomorrow the war is over, then it might definitely the example. But war is still continuing. Then I think, uh, they might take they they will definitely take exams. Or else we will not be able. We will be considered as a liability in our country. No, no, of course you have to graduate. I do completely understand. But do you know what blocks your being examined on next? Do you know what blocks that? Take your clinicals. It will be all like medicine. Surgery of china, internal medicine, Everything okay? Okay. Know. Then that's very useful. Because if if you want me to go into exam mode, I can do that also, I can shorten the lectures and do more MCQ. Uh, whichever you prefer because this might be a slow burn. The way we're doing it now might be a much slower burn. I can make them shorter with more MCQ s, if that helps people. Yeah, we don't mind, Doctor. Whatever is best Sorry about that. Um, I believe somebody's put a note there to say the exam is today. Good God, Are you all in the exam or your, uh so it says obs and Janie Pete's internal medicine surgery, hygiene. So absentee knee is certainly relevant. Um, pediatrics. I don't know if anybody is doing Pete's for you. Right. You need general pediatrics for that internal mints in surgery. Hmm? Mm. Okay. Fair enough. Gives me some idea of what to do. Okay, Fair enough. Okay, so then shall we say goodbye until Thursday? All right. Thank you, Doctor. Thank you, dear. Bye bye. Thank you, Hannah. Bye bye. Thank you.