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Hello, everyone. Welcome to the Five Academy Revision Tutorials, which is a week long series that covers content relevant to the Edinburgh medical school curriculum. We'll be covering obstetrics and gynaecology today and we're very lucky to be joined by Alba final year medical student over to Alba. Hey guys. So I'll be doing obstetrics and gynecology today. Um So there's a lot of contact to cover. So we'll try to go quite quickly but let me know if I'm not leaving enough time. Mr Yeah, it's a lot of questions MCQ S and it's based on my Skies lines and uh the green top guidelines. I would also invite you guys to use past meant that was mainly what I used to pass my finals from. So, yeah, the first few questions are kind of just um write them down if you can if you're there with somebody else, just like tell them I, so pictures are quite common sometimes in Edinburgh exam. So I was not prepared for mine in year five. So it's important to kind of see the instruments, know their name and know what they use for. So, does anybody know what this is called do they want to put it in the chat and if not, it's fine because I didn't know. So, um, yes, well done is a vessel. Um, I don't even know how to see this Forceps. So, do you know what they're used for, to be fair for the interest of time? It's a very long widen question, but they used to grip the cervix uh, during like Gynie procedures, for example, like examining for like cervical screens and things like that. So, yep, well done. Uh Do we know the name of this one? And what specific type it is? Um So it's uh nearly. So it's a pessary well done, but it's a Gellhorn one. It's quite interesting to look at the different types. Um So you will see them a lot in G P practice as well in year six uh surgical alternatives to this. Um There's different ones like a Hysterectomy, Sakura Plexi, depending of which part of the uterus you want to kind of take back. Um Just use for uterus prolapse and finally picture three, no more pictures after this, I promise it will be much more and see us, but it's better to get them out of the way. So does anybody know what this is and what it's used for? Yes. So it's useful. Let's so large loop, excision of transformation. So which is a bit of a mouthful. Uh But it is a diathermy loop. So the bit at the end is warm. It's just like, um essentially bans the skin off a tiny bit. It's used for colposcopy. And short term complications can be kind of hemorrhage and fake infection and like fainting surveys or vehicle response. Long term. You do get complications such as like cervical stenosis and cervical, like incompetent incompetence. I think that's what it's called. So you can get like a premature delivery because of it. And sometimes earlier in the pregnancy, the cervix can be sewed a tiny Vicks to prevent that if the patient has had a lot of like colposcopy done in the past due to kind of like cervical cancer and things like that. So that's all the picture is done. We can talk a bit about cervical screening guidelines. So HPV testing is done before psychology. Now the guidelines have been changed. This is based off English guidelines. Lucas currently said that um so Scottish guidelines are a bit different instead of the three year and five year, everyone has tested every five years. So it's a bit easier to remember. Um So there's a good diagram here and I would also advise you guys to look at past med for it. The way I used to remember it is that they test for H P B and it was three strikes and you're out. So they test for H P B and if you're negative, you go back to regular kind of screening programs every 35 years and then if you're positive, you come back every 12 months. If you're positive three times, then they look at the cytology just to see if you've got any abnormal cells. There's also a problem if you haven't been tested, like if your test is kind of inconclusive, you're asked to come back a bit earlier. So I hope that makes sense. Uh I would advise you guys to learn the pathway and learn kind of this diagram because there is a lot of easy, easy questions. So we can skip this one right picture for um what does this Ovary show? And what would be the likely cause? Sorry, I said no more pictures. There was this picture. Um Yes, it is. Yep, chocolate cyst. So it's normally found. Does anybody know the condition? It's got a very nice name for something that doesn't look quite nice. Yes. So, endometriosis is well done. Um So we can do a few cases. Um So Jane 26 year old female presented to the Glue Gun Clinic following one week of odorless like white discharge and dyspareunia. She has a regular partner student from Nigeria company studying in the UK. They do not use very contraception. Jane also admits to taking her oral contraceptive pill less and reliably. So, out of this question, I'll just quickly start the pole. So which of the following tests is least appropriate to offer Jane her appointment? Also, apologies, guys. Most of these questions sometimes are like kind of false negative. So that makes sense and it will not be the type that you'll be tested on. And Edinburgh is just so much easier to test knowledge this way. So for the interest of simplicity, so I'll just wait a bit until like I see like half, around half of you guys answer it. Um And then we can carry on. Cool. So, um so we can talk a bit about it. So chlamydia, gonorrhea and um blood test for HIV and syphilis are always um always um how do you say always offered at a sexual screening? Uh HIV and syphilis, you can come back. So HIV, I think is one month and syphilis would be six months and then like the other way around pregnancy test is appropriate in this case, given that in the past a slide she has take like said that she takes it less than reliably. So there could be something that cervical smear is the correct answer. Like many of you guys said just because um that's offered as a regular screening. So it doesn't need to be done as kind of like an outpatient urgent thing. So, question too. All the following are considered risk factors for contracting HIV, except for also apologize. This is a bit of a weird question. But I think just in the fact that it's important to pick up on even what the like partner and when they come from and their sex. So when you're taking a sexual health questions, like screening and questionnaire is important to cover everything in like, minute detail. I mean, that seems to be one. Yeah. Cool. So, that's correct. Um, I'll just stop the poll. Women who have sex with women are considered less risk for HIV, everything else. Um, is kind of something that you should cover, uh, when you're doing kind of a gum, gummo ski question three. So I'm not sure if you can see it clearly. I feel like with this kind of this surgical logo behind it, you can't, but microscopy shows this uh under the slide. So based on the symptoms and the slide, what do you guys think it could be? Uh There's a lot of weird names on the slide, but I would just focus on the one that you think it can be and then we can talk about the others once again, sorry if I'm going quite quickly, there is a lot to cover. Um So yeah, cool. I'll just stop the pole then. So the correct answer is Candida albicans because this is something called like thrush. Um is the white. If we go back to this kind, if the other less thick white discharge that's commonly associated with thrush is normally a bit like itchy as well, we can talk about the others. So for example, A C and E are all signs of bacterial vaginosis. And instead of this, you would find clue cells So what the side shows, I'm not sure if you guys can clearly see is like um large gram cells like all those purple dots. Uh Graham caucuses, which is the candidate Albig Unz. So I think you treated with fluconazole, whereas bacterial vaginosis, you would treat with Metro need a soul trichomonas, vaginalis is normally associated with like a yellow discharge. Um Normally quite offensive as well. I think. Um who? So ob set tricks and gynecology is kind of all over the place. So now we've moved on to uh contraception. So these are a few of like choose your best single method of contraception. In this case, for a woman BM I over 40 smoker, multiple fibroids who is in a stable relationship and whose family is complete, she's had peritonitis secondary to appendicitis in the past. With all of this, I would have advised you guys to look at the U K M E C like um three and four. So it's important to know the difference like absolute contra indication, relative contra indication, etcetera. It's also good to kind of like a main or like principles of those. So whether it's given like estrogen progesterone, how they work, like inhibiting ovulation or um thickening the cervical mucus, etcetera. So I would advise you guys kind of draw up a table with all the different contraceptive devices, how they work when to give them when to not etcetera. So I'll just stop the poll there. So if we go through the questions or like through the options. So firstly, C O C P. So not that many of you put that one down, which is good. Mainly she's got high B M I and she's a smoker. So that puts her already at high risk of thromboembolism. See OCP will already increase it. So UK make three, I think it's A B M I or like 8/35 smoking less than 15 and then more than 15 cigarettes a day puts you as you came back for being high B M I is also there somewhere if we talk about laparoscopic clips, sterilization and hysteroscopy. So both of them are contraindicated because she's had peritonitis secondary to appendicitis in the past. So she might have had some kind of uh um like adhesions. So if you do a further kind of invasive surgery, that can be a complicated surgery, it can lead to more risks. Now, if we talk about the marina call, that's contraindicated in fibroids. Um I'm not sure exactly why, but I'm guessing if you put something there, there's a high risk of rupture, that's a high risk of bleeding. Um So the answer here in this case is the P O P Cool. Let's try another one. So in this case, a 45 year old woman who presents to her G P, she's keen to convince some form of contraception. She's recently been diagnosed with osteoporosis. She's a non smoker, non drinker. Which one is contraindicated in this case? Uh, and what other kind of side effects could you have from it? So, I'll just wait a bit more. I'm not sure if my wife is stuck there again. Cool. Um, I think it's a rule of, um, if you have fibroids, they, it's probably only because you have been checked and you're either having menorrhagia or you've had an ultrasound if that makes sense, I think if somebody has a diagnosis of fibroids that probably big enough to disrupt the uterine cavity, if she was contraindicated of the P O P, then you would consider it. But in this case, it's better to kind of go by that rule of thumb. Does that make sense? So I'm just going to stop the poll there. So the answer here would be the metha progesterone. I am also called Depo Provera. So that one has been associated with osteoporosis and also delayed fertility. So you would not advise it kind of 30 year olds who are hoping to still get pregnant and it's also associated with weight gain. And finally the last contraception or maybe not, I don't know, 50 year, 52 year old when presents the surgery seeking advice regarding contraception. She has recently started in a new relationship but isn't sure if she requires contraception as she thinks she may be going through menopause. She's experiencing hot flashes and her last period was seven months ago what's the most appropriate advice? Cool. So I'll just stop there. So, because she's more than 52 contraception, it's only required for 12 months because that's kind of the definition made for menopause. If she was less than 50 you would need to wait 24 months after your last period, less than 40 is called premature ovarian insufficiency. And there you would taste test kind of FSH and the ovarian reserve, we can talk a bit further on about kind of primary and secondary causes of the menorrhea and the differences. And finally a mist pill question, which is quite common and probably really important to know. So your friend takes the C O C P. She's worried because she has forgotten to take three pills in the second week of her current pack. She's been having regular on protecting sex with a male partner. She has taken the rest of the pills correctly this month. So with this one, I would advise to kind of go back to first principles and I can try to try my best to explain it this way. That's the way I learned it with kind of like the logic behind it if that makes sense. Yeah, cool. I guess I'll stop the poll there. So firstly, you never take three pills just in case like that. All right. I don't know why it's contraindicated, but it's definitely not in the guidelines. Um Oh, you can't see an access support. Can everybody else see an access a pole. I hope so. I have been getting responses. I'm sorry, is if it's not been coming up. Um So it's definitely not number one and it's definitely not uh number five like d because um you should try to help your patient carry on the lifestyle as much as you can. Um Now we can talk about kind of the, so the C O C P works by inhibiting ovulation. So, as long as you've taken it at the start of your month correctly, is there like day one, you will inhibit the ovulation happening on day 14. I hope that makes sense. Which means most people take the C O C P for three weeks and then take one week interval where they don't take. It does allow in kind of the at the bleeding. You only need to have emergency contraception if you've missed two pills in a row. So more than 48 hours and you've had sex during that week or previously because there is a chance that during that point, you will half are related if that makes sense. If you're doing it during the second week and you've already taken the pill in the first week, you've inhibited ovulation during day 14. Therefore, even if you do have sperm in your uterus, you went get pregnant. I hope that makes sense. But basic rule of them is more than two pills. And the first week get emergency contraception more than two um pills messed on the second week. You're fine. As long as you finish the pack and have the usual seven day break. If you're in the third one, then I think you just carry on and you ignore the break, you just carry on taking it. I hope that makes sense. If not, it's important to look at the guidelines for this. Although I can understand why many would go for option B because I would also be nervous not to give them emergency contraception. So useful links here speaking medics and the H W I would also once again advice for pass met, right? More questions. So Emory presents to your Gynecology clinic with a one year history of menorrhagia and worsening dis minute region. She's using 15 sanitary towels a day, regularly experience experiences flooding. She and her partner Steve, which is your primary differential diagnosis. Of course, seems to be a competition more than anything. I'll just stop the poll there. So the correct answer here is you during fibroid, mainly due to the primes and menorrhagia and then a bit of pain. If it was endometriosis, she would mainly be having pain rather than heavy bleeding. So I hope that makes sense. Usually like both endometriosis and fibers are associated with lower rates of fertility. So it makes sense to kind of think that P I D you would think uh and discharge okay. So if we go on the basis that she's got fibroids. What is the most appropriate investigation? Cool, I'll stop the pole that. So, yeah, most of you guys are correct. Gold standard is a trans vaginal ultrasound. So, um diagnostic laparoscopy would be the gold standard for endometriosis. Instead. Uh blood test for C A 125 would be for cervical cancer and the cervical smear is just the screening used. So, fibroids are quite interesting in the way that there's muth muscle benign tumor. They can be found in different places in the uterine cavity. Um They actually grow during pregnancy and can go through something called like a red degeneration where they can bleed loads and they also make it harder to kind of do in like external cephalic versions or can sometimes be so big that they impede on the baby. Most of the time, they're only picked up when people experience heavy bleeding. So if somebody comes in, you measure the full blood count, you give them iron tablets and if not, you do other management for them. So I think that's the question coming up on this now. So the hysteroscopy shows a fibroid of two centimeters. What would be indicated. It's kind of first line for Emily of thinking that she does want to start a family as well. I think that was in the previous slides, but it might be important to remember here too. Cool. I'll just stop the poll there. Uh So yeah, the correct answer is tranexamic acid. If it was, if like that kind of first line tranexamic acid had um work, then you would think more about an artery embolization but kind of first line you would try a pill first rather than something invasive. Cool. We're moving onto prolapse. So 67 year old female presents with a grade two utero vaginal prolapse on examination. What would you expect the prolapse to be? Now, I like this question was in the slides. I don't think you definitely need to know this. But if you do, then that's great. If you don't, don't worry too much about it. The most important thing is that when somebody comes to your G P U screen for something like this, like a prolapse uh and you treated because there's something like really lifestyle debilitating and that you can make a lot of difference with it. So I'll just stop there if that's okay. So the correct answer is see. So between one centimeter above and below the opening of the vagina, I think here we've got the different grades and the slides will be sent out so you guys can have a closer look to it. So, cervical screening, um which of the following is false. So Scotland, one, between 25 49 a screen three yearly woman between 60 for a screen five yearly smear is best taken at the end of the menstrual cycle screening is a non diagnostic for cancer. And in the UK, non sexually active woman are invited for cervical screening. Oh, and, um, apologies. This question is actually wrong because yeah. So apart from a, we will ignore a is, um, so in Scotland is done five yearly, the guidelines have changed recently. Apart from that, I'll stop the poll. Now, otherwise many of you will have already answered. I don't think you can change your, change your responses. So, um, dismissed our best taken mid cycle rather than at the end of the menstrual cycle. So that's in Scotland now, is done five yearly. Don't get too confused. Is in England that you do 25 to 49 3 yearly and then up to 64 5 yearly in Scotland, just five years. I hope that makes sense. And non sexually active woman are still invited for cervical screening because even though the highest risk it is HPV, that is just because you're not sexually active at one point doesn't mean you haven't been in the past. So I hope that makes sense. Uh Screening processes, non diagnostic for cancer. No, it is diagnostic, which is the aim of the screening. If that makes sense. It's a bit of it. Double full, right? So what is the loot your secretary fees? Unlike, what day would you find it? And does somebody know the name of the other face too? Cool. So I might stop the poll there. So, yeah, that's correct. Days, 14 to 28 there's a nice diagram at the end of these slides just to show that. So when should serum progesterone be measured to confirm population? And this especially done in IVF. So I'll just stop the pole that. So the answer is the so day 25 in a 32 day cycle. Previously, it was just day 21 for everyone. But now they recognized that women have different um kind of ovulation length, not lengths, but like period cycles. So now it's seven days um from your usual length of the cycle. So if your usual length is 32 days, then it would be day 25. If your usual length is 28 then it would be day 21. I hope that makes sense. So which hormone is best used as a measurement of a variant reserve. This is something also used in IVF to be fair. You don't really need to know this one. This is a bit more like highly specific. Cool. So yeah, the correct answer is uh A M H anti-malaria hallway and this is the nice uh graph. So you've got the follicular phase and then the little secretary phase. Uh and then we got like the negative feedback system of FH and LSH and like the different cells. I mean, it's important to know the background to this, but I wouldn't get particularly caught up and our Pecos have really important condition um which of the following are likely findings and Pecos except so sorry, another false kind of question. So which one wouldn't you find? Yeah. Oh Once again guys, this is like a negative question. So which one wouldn't you find in Pecos? Not? Which one would you find? Cool. I'll just stop the polar. So the correct answer here is see. So Peco's has a high LH two FSH ratio. So most of the time you will find a low FSH in comparison to LH, they do have raised testosterone, which is why they sometimes experience kind of like um her growth and mail associated areas like the face. They have an increased serum hormone binding globulin, which is why they're at higher risk of like insulin type two, like like type two diabetes and they normally have normal TFTs. But it's something that you normally check when you do like the GP referrals and things like that. So I hope that makes sense, low, high LH two FSH ratio, but low dosage. And this is kind of the background behind it. I don't really understand it, but I just try to remember the facts. So a 34 year old presents complaining of men in region following dilatation and curettage for as well, but which one of the following would be most likely diagnosis. So this is secondary amenorrhea. So we can talk a bit about the causes once again, thinking about kind of the symptoms that you would experience and we're halfway through. So we're doing great. Cool. I'll just stop the poll there. So, the correct answer is Asherman's syndrome. Yes. Just so she's had the look direct ege, I'm not sure. I'm saying it right. But you can get loose of her. He Asians because of that. And that can lead to a secondary mena region P I D. You wouldn't really consider unless she was presenting with symptoms of fever. And, um, what is that? Discharge long term, it can lead to adhesions and infertility, but it wouldn't particularly be of course, a secondary in it. That makes sense. I'm glad none of you put on as in commons because that's primary like genetic disorders now onto menopause and HRT. And so which of the following is false. Once again. So, patient's at risk of venous thromboembolic disease are increased of endometrial cancer, complaining tenderness at an increased cancer, order, increased risk of cervical cancer and which one of those is false. So, whilst you guys answer, HRT can be given your oral or transdermal. Um menopause is a condition that affects basically for women at this point. Um they can have physical and cognitive changes. Um You can have hot flushes. Um HRT is given us estrogen and progesterone. You don't give unopposed estrogen just because of the high risk of endometrial cut one away. Um So that one is true. I'm sorry guys. But so most of the time you give estrogen and progesterone combined, you only give estrogen to women who don't have a uterus. So if they've had like history oscopy beforehand and don't need it. So let me just stop the poll there. So I can tell you guys which one is true and then we can talk about which one is false. So yeah, the correct answer is, yeah, patient's are at increased risk of cervical cancer because that's not at all associated with HRT. The rest of them. BT ease endometrial cancer, breast cancer are associated with HRT. Just because you're giving people increased estrogen, they often complain of breast tenderness because you're giving them progesterone. So similar to kind of any contraception we think of that has progesterone, that's also a side effect. Um What was I going to say? Yeah. So HRT can be given oral transdermal if you give it transdermal, then apparently there's a low risk of venous thromboembolic disease. So that's also interesting. So this is a very highly specific one. So if you know it, great, if you don't, don't worry too much about it, it's more about being able to kind of see how unwell somebody with ovarian hyper stimulation syndrome is also called H S S. So this condition normally happens 3 to 3 to seven days. Post kind of the injection of HCG is to trigger kind of use, I'd release that then can be picked up and used for IBF. So once again, don't worry if you guys don't know this, this is not really it's like detail. Um I'll just stop the poll. Uh So yeah. Correct. Well done guys. Um So jaundice is not found, the rest of them are associated with it. So interestingly, you do have facilities but you don't have jaundice and like like other gi conditions treatment for it is mainly conservative. So, analgesia fluids, um BT prophylaxis or stockings. So like hyper in your stockings. So there's a main IBF criteria and then it can change in other kind of trust, but more or less is the same thing. So, cohabiting normal weight, um nonsmokers and no alcohol, you've also got rules about the number of cycles there. Um uh This one gives the answer away, but it was kind of interesting to note what a teratoma of the left every would look like. Um So you can see you can even see it on the X ray too. Once again the slides will be given up. So no stress. Um So now on to a bit more obstetrics rather than gynaecology. So, prenatal day, which one of the following is false chronic spillers sampling is you performed 11 to 13 weeks. I mean, as in Jesus carries the risk of miscarriage around 1%. Reese's negative women are given anti D following am innocent. He says over risk of miscarriage following chronic bill of sampling is less than a mere a synthesis, unload. PPA suggest potential down syndrome pregnancy. So which one of those is false if it Down syndrome. You do a combined test and then you can do chronic villus sampling or amino synthesis. If that's done, I was going to go ahead and talk but I might give the answers away then. Cool. I might stop the poll. Uh or not. Okay. Yeah, it takes a bit to update. So the incorrect answer if makes sense is the risk of miscarriage right there. Yeah. The risk of miscarriage um in chronic bill of sampling is higher than immuno synthesis. The advantage of chronic villus sampling is that it can be done earlier. So chronic villus sampling is done 11 to 13 weeks where Ximino synthesis is done at 15 weeks with all of these procedures, there's a risk of blood from the fetus going into the mother. So, visas negative women are given anti D to prevent that production of antibodies and the combined test shows so higher nuclear translucency, high B B C H or that that word and lower P P A for Down Syndrome. So what's the recommended dose of folic acid? And I guess I can add here for like the usual normal person, not thinking about exceptions or any conditions. And then we can talk about what you would give for exceptions and what the dose would be. So, folic acid, you give up to 12 weeks, it helps information of the neural tube defects. Sometimes women are also like advice to eat folic acid calcified, like fortified foods like sometimes cereal have like cereals have that as well. So I'll just stop the poll there. Yeah, clear weight net of 0.4 mg, 400 something is the equivalent 5 g is what is given to individuals at high risk of neural tube defects. So that can be due to a family history of it. A past pregnancy with a neural tube defect if they're like um demands are greater. So, obesity or if you have medication such as anti epileptics that prevents the synthesis. Uh Also if you've got lower absorption. So for example, any gut problems. Um Yeah, and you're not able to absorb it as well. So that's 55 g instead. So stays. Lee is the pair of one plus two. Um blah, blah, blah presents to her antenatal clinic at week 34 for pregnancy. She's helped shows an ultrasound which shows baby is currently in breach. Would we be the most appropriate step? Considering she is at 34 weeks, isn't it 5 mg or did it? Um Did it? Oh my God. Yeah, sorry. 5 mg. Never mind. 5 g might be a bit of an overload. Sorry. That was my cool least going into um cool. Right. I might stop the pole of that. Cool. So yeah, the correct answer is to watch and wait and re scan in two weeks. So external cephalic versions have normally done at 36 weeks, week, 34. You can just wait um if you guys, um hopefully you guys have been able to see one is actually quite cool. It's much more violent than I thought it would be. They literally do push the baby to decide like, yeah, it's quite intense. Um C section is not immediately needed because she's still like there's still the chance that the baby might turn on, on its own. You don't not do nothing. So you do something just because there is increased risks associated with a breech baby, for example, like cord prolapse or like foot long when one like that comes risk of hypoxia and there's no need in now. Um just because 34 weeks is still quite young, like the lungs are barely matured and things like that. So there's a type of different things in the foot ling like I was saying like sometimes that can push through. So which of these is not a risk factor for teacher contra indications for E C V just uh it's like previous bleeding. Um if you've got multiple pregnancies because obviously you would just like put the other one the other way around if that makes sense and also fibrates. So we'll just stop the pump and yeah, so maternal obesity is not a risk factor for breach presentation. Maternal obesity is a risk factor for gestational diabetes, mellitus, which means they're at higher risk of polyhydramnios. So excess amniotic fluid, the rest of them uh already just for breach and fibroids. If you know, there's a large uterine fibroid in one way in one place, then they go further up or they move around percent of previous just because you can't really do the external cephalic version. Like we've talked about polyhydramnios because they can move round uh due to the excess fluid and twins because you can't, you can't sort them around if one of them is in breach. So which is not a complication associated with breech delivery. And here we can see like there is a lot of things that are, I guess anything as well with pregnancy, all of these are complications that can occur during breech delivery. It's just which one is less likely to occur if that makes sense. Sorry, what was the answer for the previous question? So maternal obesity. So that's mostly associated with gestational diabetes. Smell attar's rather than breach presentations. So I think I'll stop the poll there and yeah, shoulder dystocia is um not normally associated with breach. The rest of them are shoulders. Ast OSHA is associated with um a lower hip to baby size ratios. So for example, if you've got small hips, if you've got a big baby. So micro somnia due to diabetes and things like that, there's actually a theory going on that due to IBF our general um kind of hip to baby sized ratio is being slightly dysregulated. Um that yeah, right case for so young woman undergoes diagnostic laparoscopy, which would indicate a condition for pelvic pain, which one is the most likely diagnosis. And we can focus on all those tiny dots on the, on the picture. And that should tell you the answer. I might stop the poll there and yet correctly. That's a picture of endometriosis. It's kind of the growth of uterine lining outside the uterus and those lows of theories of why that may occur like retro great bleeding and are the ones that you don't really need to know. So case five, question one. Oh oh, that's a, that's another question, but I don't have the slide, right. 21 year old woman, a tense Gynie triage with lower abdo pain and PB bleeding pregnancy test is positive. There's some and the cervical process close ultrasound scan shows an empty uterus and identix or mass 2.5 centimeters and free fluid. The beta HCG has raised. What's the most likely diagnosis? Cool. I'll think I'll stop the whole so correctly. It's ectopic pregnancy. Um It wouldn't really be threatened miscarriage just because the scan shows an empty uterus. So there's no pregnancy there. Therefore, it's already an ectopic pregnancy definition. And I'm glad none of you another one in complete miscarriage you would have um the cervical ox open because like pregnancy will still be like the products would still be being expelled. Which of the following is true regarding the management of ectopic pregnancy. So it cannot be managed conservatively. Uh they need to use reliable contraception for three months after medical management. Platyrhynchos HCG should be treated. Medically. Laproscopy is a method of choice of humor, dynamically, unstable patient's and all patient's require anti D regardless of their status. Let's see which one of these is true. Cool. I might stop the poll there. So the correct answer is option B they need to use. So, methotrexate is the medical management. Actually, we can talk about the three types. So conservative, medical and surgical, conservative. If it's, you've got no symptoms, the levels of um beat HCG are falling. And if you're relatively well, there's a cut off number for HCG which is quite important to know surgical you would do if it's got a heartbeat. If it's human dynamically and stable, I think if it's more than five millimeters in size and if it's very, very high levels of B T H C G and it's showing that it's grown. So medical management is methotrexate and you need to use reliable contraception for three months after medical management, I think it might be even more as well, the rest of them. So pregnancy can be managed conservatively. It just needs to be very low risk and you need to give kind of safety netting advice, plateauing HCG should not be treated medically. Just because if it's pottering, there's a chance that it will for. And that means the pregnancy is kind of resolved on its own and you don't need to do anything. Laparoscopy is not the method of choice in a hemodynamically unstable patient. You do. So there's a difference between self inject a me and stuff and try to me, I think the way I remembered is is that self inject me, you've removed the fallopian tube himself, inject me. You keep it. If a person has already lost a previous Philippine troop, they normally try to keep it otherwise. Um the way to go is to take it out just because of risk of further up topics after that and risk of scarring and patient's don't require anti D just because that is a treatment and if they don't need it, um it's better not to get too. So I hope that makes sense. Oh I'm not sure if you guys can even read the slide. So this shows a complete hydrate form mall. It has like a snowstorm appearance that's some size associated with it. Uh They present with menorrhea and PB bleed. So is is consistent with the diagnosis of the hydrated form form. So this one once again is the least associated. It doesn't mean that people don't sometimes experience it. But this is not the classical you would find on kind of your exam question if that makes sense. So at least associated sorry, there's a lot of like false questions that make sense. Cool. I might stop the pole then. So most of the time you're going to find hyper methods. So loads of vomiting, uterus, large for dates, symptoms of thyrotoxic osis and high serum levels of HCG. So the correct answer here is crampy, lower abdominal pain. That doesn't mean people won't have it. It's just least associated you get symptoms of thyroid toxic osis, which I thought was quite cool when due due to the high levels of HCG, just because they can act like a TFT or TSH. Let's say that's quite interesting to note question three. Um They like to test about walking. That was yes, I hope that's working. So which one of these incorrect? So that the 46 premises and our patino and origin high zero levels of HCG symptoms of hypothyroidism or less than 1% to go on an effective contraception is recommended. So which one of these is incorrect? I say the management for trophoblastic disorders is methotrexate. I think once again. So we can have to think about that. I might stop the pole. So the correct answer is less than 1%. So in reality, more than 1% go on to develop a choriocarcinoma, which is what they're important, get rid of it and to avoid pregnancy in the next 12 months, um, complete moles are all paternal origin, incomplete are the ones that have X X Y Y, x X X Y. So those are the mixed ones we've talked about in the previous slide, most of HCG um symptoms of hypothyroidism. So I hope that makes sense you do need effective contraception in the next 12 months. And this shows a baby with gestational diabetes smell like or whose mother will have diabetes mellitus of H D M. You need to test for this condition. Um There's several risk factors previous H D M family history depending on your ethnic origin. Um The way I had it explained to me was that pregnancy was kind of a stress on the body. So if you're susceptible to some things, it will show up then. So for example, preeclampsia, if you're susceptible to high BP and have a family history of it, it will probably show up if you're susceptible to diabetes, it might show up, which is why it's important to follow up afterwards to because they do have high recurrence of it anyway, which one of the following is not a risk factor for shoulder dystasia. I'm conscious of the time. So that's only like around 20 more slides to go. So I think we can power through in half an hour and I hope that's okay for everyone. So cool. I might stop the pole of that and yet correct. So excess maternal alcohol consumption is associated with microsomia rather than macrosomia. The rest of them are associated with. Yeah. So previous shoulder dystocia, you're more likely to have it pregnancy post on pregnancy, the baby is more likely to be big. Therefore higher chances, shoulder dystocia, diabetes, mellitus. We talked about microsomia, an instrumented vaginal delivery just because you someplace need to use rotational forceps and things like that. So the correct answer here is maternal alcohol consumption. This is the management of the shoulder dystocia. So first for, especially if you're a student or an F I one who doesn't know what they're doing, you call for help you evaluate for episiotomy. So you, you think about cutting them a bit more just to increase the space legs into mcroberts, which is what the woman in the picture of slowing and you apply superpubic pressure, there's loads of maneuvers you can do. And if you've been replacement in the borders, they've got a really useful model they can show you on. Um So I would recommend asking, we can talk a bit about people h you know, the forties, turn trauma, tissue and Truman and secondary PPH due to infection. So after this question, we can talk a bit about the management of PPH. But which one of these should not be used in somebody with history of hypertension. So P ph you give Santuzza, you give ago, Matron, you give car, car Prestol and you do by manual maneuvers. Um Then you can carry on to give tranexamic acid. You can do a si like you can go back to a C section and revise what you've done. Check for the forties again and you can do a history ostomy history test. Could be goddamn loose. My 12 thought. If you think it's really extreme or kind of an artery ligation just to conserve blood flow. Um All of this you do, you're a two E you put loads of blood, etcetera. So I'm just going to stop the pole here and yet the correct answer is a good veteran. So you should not give that to somebody with a history of hypertension. You get down to pregnancy is the only condition that you treat for a symptomatic bacteremia. Sirin Msu Allah beetle. Yes, use to treat is the treatment of hypertension in preeclampsia, apart from hydro seen and things like that. So this is a picture of um pre polymorphic eruption of pregnancy is normally found abdomen like that is normally quite itchy too. We can talk about about her purse siblings. Um I say what would you give the newborn and all the mother? Interestingly, the difference between HIV and happy is that for happy you can breastfeed, which whereas for HIV, you cannot breastfeed just to prevent transmission. It's cool. I might stop the poll there. So the correct answer, yes, you give the newborn the vaccine and you give them, you know, global in just in case, ask prevention and treatment. So two for one, cool more questions. So difference between placenta previa rather than placenta abruption. Which one is the symptom of which? So tender tense uterus is sometimes described as woody if that helps anyone very quick responses for this one. Cool. So I might stop then. So yeah, the correct answer is no pain difference between. So, placenta previa is an antepartum hemorrhage normally happens around 28 to 30 weeks, is normally painless. Um When people come in, you do not vaginal exam, you do a chance like an ultrasound. There's different grades on it depending on what they cover the cervical arts and the management differs because of that. Um tender tens uterus are normally associated with placental abruption, which interestingly is associated with cocaine use. Shock is also placenta of corruption and distress. Fetal heart rate is normally abruption as well rather than placenta previa. So these are the different grades. Um and yet do not be until placenta location is known. It's interesting you can truck um the progression sir as a way I'll start the pool for this one and then I'll chat away. But um so for a placental previa, you can track it and re scan every two weeks. Grade one, you can attempt to deliver vaginal e whereas the other one like higher up grade three and four, you need to do an elective C section. You normally do it 38 weeks, I think just to prevent it from like a bit earlier on. So they don't go into labor. But anyway, so this pregnant woman, heavy vaginal bleeding, she's currently 29 weeks pregnant. She's got low BP, high heart rate, pale and claming to touch this one to be fair. It is a bit of uh tricky one just because that you could do two things. But in the grand scheme of things, you should prioritized one and then the next. But yeah, we can talk a bit about what you do with the results. So I'll just stop the poll there. So yeah, the correct answer is IV, access and urgent flowed, resells just because of her low BP. You need to stabilize the mother because before you do anything with fetus, otherwise, it's a bit counterproductive correctly though you would use CTG to examine the baby. So if the base in distress, um then you immediately go to a C section. If the baby is okay, then you assess if it's less than 36 weeks, then sometimes you can give to Coral Itics and okay stop after you. OK, coming up. If it's more than 36 weeks, you can also just attempt a vaginal delivery if that makes sense. Um So labor, so the difference between the first stage, second, that stage, what normally happens during it? I would say you guys don't really need to know the difference between the actor for latent stages. Uh As long as you know, the main differentials like the main like difference we're doing 1st, 2nd and 3rd and labour stages. And what's the pain and that the future state? So which one of this is falls? We can talk a bit about Bishop school, which is coming up later and what happens with at each stage. So yeah, um correct answer is the second one. So first stage of labor is um dilatation of the cervix up to 10 centimeters. So what you need, the second stage is the actual delivery of the baby and the third stage is the delivery of the placenta. So in movies and tvs, they always skip out the placenta. Um So it's always a bit confusing people and yeah, they do have a passage from mucus plug, which apparently is supposed to stop bacteria coming up. So it's quite cool. Which one of these is not component of the bishop score. So it's a station of the fetal head position of the fetal head, cervical dilation length of the cervix consistent. I would say you don't really need to know the specifics of the Bishops School. More than eight is a sign that pregnancy is slightly and there's several things you can do to kind of um increase the chances. So you start off by doing like a membrane sweep. You can also insert vaginal prostate landings. You can do a cervical ripening balloon. You can do an artificial rupture of membranes with like a thing that's a bit like hook and then you can also do kind of last line Oxytocin infusion. But you need to be quite careful with that. So I'll just stop pull over there. And the correct answer is position of the fetal head. So station of the fetal head in relation to the issues. Spines is sometimes mentioned, debilitation, length of the service and consistency are all part of the bishops school. I'm not sure if I if there is a table here, but if not, it's worth checking that uptick. So which maternal condition is a contra indication for eventual anaesthetics? I know you too. For this one, I would recommend thinking a bit more about like the practicalities of what an epidural means. So an epidural means going into your spine at a specific point and inserting the analgesia there several problems that are associated with it. For example, you can, you then have like you're able to push less. So there's a high likelihood of having to use forceps during the procedure. You can have urinary retention. You can sometimes have paralysis very rarely and most likely you will have like a poise dural headache just because you have tapped into the spinal fluid. So I'll just stop the poll with that. Um So thrombocytopenia is the correct answer here. So having low platelets is a contra indication due to the risk of not being able to clock afterwards. Um If you've been heparinized recently, if you've got spinal like scoliosis or other clotting disorders, those can also be contraindications, which is a contra indication for ventures delivery. So, chanteuse, I hope you guys have seen it emplacement. It's also called a Kiwi Cup. I found it quite cool because it's essentially attaches itself due to suction to the baby's head and just pulls it out. Um So which one is a contra indication? Um I would say the positions of the babies, I always found quite hard to learn. Um So I can't really explain them, but I would look up the picture and try to remember if the baby is facing towards the mother's spine or facing away. Uh So I'll just stop the pole then. So they're correct. So, so the contra indication would be presenting minus two to the spines. This means it's uh put in kind of the uterine segment, you could say. So the venter's, even though you can reach that fire can be quite dangerous to everything else you can do with the venter's delivery. Previous C section is a bit risky, but there are people that do have vaginal deliveries after C section be back, I think it's called and that's okay as long as you take the safety precautions um session on mastitis. So four weeks, post bottom warm, render red tender patch on the right breast just lateral to the areola, which has been getting worse for the past three days and feeding is now painful. She's mastitis with no obvious absent, what is the most appropriate stage? Uh Let's think she's not logic to anything. Um Alongside this question, it's probably a good shout to look at medications that you can give during pregnancy and medications that you can't, particularly, for example, for epilepsy, some medications can change. And I don't think we covered in this presentation, but the guidelines are important. Stop there. Um So yeah, big work done. So it's free Cox and you continue breastfeeding, which I found a bit counterintuitive. Uh But apparently is supposed to help the baby's gut as well, get used to different bacteria. So now on to see T G one of my least favorite um topics. Uh So I hope you guys will know about doctor do. Uh it's quite a good acronym to land. It's useful. I do remember in my exam, there was a C T G we had to interpret. Um So it's normally a very obvious thing. Uh but they do give you the CTG and then expect you to come up with management. So which one is true to feed your heart rate? So I might stop palm huh? So veto heart rate is normally 160 to 100 and 20 or 100 and 10. So bratty cardio is incident something less than 100 and 10 BPM. Everything else is correct. So early decelerations can occur with the onset of a contraction. It's just because the uterus shifts and the court can be slightly like um pressed upon and then that leaves you tachycardia, bradycardia, but it's just like a tiny moment and then it resets itself and both tachycardia, bradycardia can be due to hypoxia. Uh So what is shown on CTG here? And I think this is the last question. Um Just a hint is not a normal CT GSO. I'm not trying to trick you guys. Cool. So I'm my stop the pole that so correctly. Yep. So that shows variable decelerations. Um Sinus Odio pattern would be a bit more extreme. Um And it was just kind of constant up and down but big variations, variable decelerations sometimes called shoulder rings as well. Um After and, but like for each contraction. Um So yeah, I would definitely learn Doctor Sue Bravado. I think we've got a slide here. There we go. So defining risk, uh contractions, baseline rate, variability, accelerations, decelerations and overall impressions. If they ask you guys to interpret one, that would be very mean them. So that's the end of the Asian. I hope that was helpful like around a bit. If you guys have any questions I'm sent, I'll send my email in the chat if anybody has any questions too. And yeah, good luck with all the questions and, and your exams. Thank you very much, Alber. Um Just before your leave, we'd appreciate if you can fill out the feedback form in the chat. Uh and upon completion, you'll gain access to catch up content for this event. We'll be running formal sessions throughout the week. So be sure to check out our Facebook event link that I've popped in the chat otherwise, thank you very much for joining and I hope you have a great Evening.