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Hi guys. Um Thank you to those of you who have joined already. Um I'm just gonna give it a couple of minutes to let some more people come in before we get started. But for those of you who are here, I think it's only a couple of you for now. Anyway. Um welcome to today's talk. So um I'm Rimsha. I'm a foundation year one doctor at Royal London um hospital down here in London. Um And today I'm gonna give you guys a talk um on obstetrics. Unfortunately, we won't be able to cover both obstetrics and gynecology today just because it's a lot in one go, but we are hoping um as part of this final year lecture series to um do an uh do a gynecology talk at another point. So um just bear with us and yeah, I'll give it a couple more minutes before we get into it all. Um And also just let me know in the chat. Can you hear me? Ok. Um Cause there's only a couple of you so I just wanna make sure. Ok. Cool. Amazing. Um fine, few more people. Um Of course there's a few more people on here now. I think um we will just get started because we do have a lot to get through and I don't want to keep everyone for too long. Um So just to recap for those of you who've just joined. Um My name is Rimsha. Um I'm a foundation year one doctor. Um I'm currently working at the Royal London um in chapel. And yeah, today I'm gonna be giving you guys a talk on obstetrics. Um, not gynecology. We're hoping to cover that on another day just because it's a lot of content in one go. Um And essentially we'll be going through some of the commonest topic that comes up in obstetrics with a few SBA s dotted here and there. Um, you know, as usual if you can't hear me or there's any problems with all of that, then just um drop a message in the chat. Um Cool. So let's get started. Uh Yeah, so um this will all be recorded, so don't worry, it will be recorded and put on youtube or available on medal. So, um yeah, you'll be able to watch it later, don't worry. Um Cool and just a disclaimer, obviously obstetrics um is one of the medical specialties. So I'm no expert on it, but um I will try to answer all of your questions as well as I can and if there's anything I can't, then um we will, I'll collect all of your questions and you know, send out an email chain or, or something along those lines. So, let's get started. Um So here is just uh the different topics that we'll be covering today. Um So these are the commonest topics that tend to come up in final year. So, um hyperemesis, preeclampsia, um both antepartum and postpartum hemorrhage, we'll go through a few of the labor emergencies. So things like shoulder dystocia, cord prolapse, um rupture of membranes and then, uh, something that we've just started to introduce as of a couple of talks ago is we'll talk about a few sy related things at the end if we have time. Um So, yeah, so, um, to get started, we, we're gonna start with an SBA. So I'm just gonna create a poll in the chat for you guys. Give me one second. Um So you should be able to see a pole now. Um So we've got a 28 year old lady here. She was a Primi Gravida. Um She comes to visit her GP, she's seven weeks pregnant, um, and hasn't been able to keep down food for the last three days. Um You examine her and you notice that she's got reduced skin tiger, um, and dryness of the lips and then you do a few investigations. So her urine dip is highly positive for ketones and her beta HCG is positive. So, the question is, which of the following, um, treatment options is the single, best management of her symptoms and I will just give you a few seconds for that. Ok. Um, so we've got 11 responses so far. Um, so just to, um, go through this question. So most of you, uh, well, just under half of you, about 45% of you went for answer option. C, um, which was Promethazine. Um, and then a few of you are sort of split across all of the other answer options. So we'll go through it. Um But well done to those of you who uh said promethazine, that's the correct answer here. Um And we'll go through the management of hyperemesis in a second, but essentially um your antihistamines. So things like promethazine tend to be the first line management of hyperemesis in pregnancy. Um You could argue that some of these other answer options are correct. So, um metoclopramide, Ondansetron, there are also two other types of antiemetics that exist, but they don't tend to really be the first line option that we give women. So we'll try things like promethazine first and if those don't work, um And they have persistent nausea and vomiting, then we'll move on to some of these um second line antiemetics such as answer options A and B. Um Just moving on to e which a couple of you chose. So, prednisoLONE, um again, the prednisoLONE or steroids in general would be an option that uh we would consider particularly if women are admitted to hospital with severe nausea and vomiting. Um, but this would usually be our third line management option. So we'd start with promethazine and then escalate up to other antiemetics such as A and B and if all of these fail, it's all still uncontrolled, then we'd move on to the steroids. Um, for option. D um, so herbal remedies, things like ginger, et cetera. Uh, they don't, I mean, they tend to help, they can help some women but you know, they don't really have any evidence base. Um Otherwise, and aren't recommended by um or advised by. Nice, so not much to say about how the remedy as in general. Um So we'll just go through hyperemesis now. Um So I've put the definition on here, sorry, there's a lot of text. Um but I'll try to highlight the key points. Um So when you're thinking about nausea and vomiting in pregnancy, um you get normal nausea and vomiting in pregnancy, but if that is very persistent and causes complications such as, you know, weight loss, um and all of these other signs that we've got listed on the right, then this is when we start to change the term from sort of normal nausea and vomiting of pregnancy to hyperemesis, gravidarum, which is much more serious. Um So yeah, so like I said, the vomiting has to be persistent result in weight loss and in terms of etiology, the reason why this happens in pregnancy is related to increased levels of beta HCG, which are released by the placenta. Um which is why also when you have multiple pregnancies. So, twins triplets um or you've got molar pregnancies. So, um uh yeah, or when you've got molar pregnancies and you get higher levels of beta HCG and therefore, women may have more nausea and vomiting than in singleton pregnancies, for example. Um So yeah, so, and then just underneath that, so I've already talked about sort of normal nausea and vomiting versus hyperemesis. Um It's important to just be aware that hyperemesis, although, you know, we have to learn about it, it's actually quite rare and is a very severe form. Um and most the majority of women will just have sort of normal nausea and vomiting. Um I've also, so in terms of diagnosing hyperemesis, um gravidarum, if you're in an ay or, you know, looking out for um particular features and SBA S in comparison to just, you know, normal nausea and vomiting, um look for a period of extended. So, protracted nausea and vomiting and then these three other things. So at least a 5% weight loss compared to the woman's prepregnancy weight, um dehydration, which will present with clinical signs. So things like, you know, dry mucous membrane, um you know, the obs might be a little bit off. So tachycardia hypertensive, et cetera. Um and then also electrolyte imbalances, which I'll go on to talk about. But basically the commonest are that you can get a low uh potassium and a low sodium as well. So, those are your sort of three, if you're gonna sort of memorize anything from this slide, I would learn that diagnostic criteria. Um And then, yeah, on the right hand side, I've just got a few uh symptoms and signs. So I talked about, you know, features of dehydration. So dry mucous membranes, reduced skin turgor, tachycardia, loss of weight, hypertension, et cetera. Um But then also obviously, the longer it goes on for you can get things like mallory weiss tears from repeated vomiting. Um, and if you're very dehydrated, then you can also get a prerenal, uh AK I as well. Um, and a bit like when you starve anyone, if you have a woman who hasn't been eating much because she's vomiting so much, then you can get the ketotic, um sweet smelling breath as well, which is a good sign to look out for. Um, so that's that. Um, and sorry, I apologize. I know I was speaking very fast, but we've got about 40 slides to get through. So, um, just trying to make sure that we cover it all. Um, so that was sort of what is hyperemesis to go on to investigations. Um, and just think about this in the context of an ay. So if you've got a woman in your ay who's come in, um, with hyperemesis and the examiner then asks you, so what investigations are you gonna send off, these are the kind of things you want to be thinking about. So, split into bedside laboratory and investigations. Um So bedside investigations will obviously include things like weighing the woman, you know, looking for that 5% prepregnancy, weight loss, um urine dipstick. So, and what you're expecting to see is ketones because they're in a starvation state and obviously very important pregnancy test as well. Um And then also a we always just good to check for blood glucose because DK A and diabetics um can present very similarly to hyperemesis as well. Um And then we move on to the laboratory test. So your full blood count will show you a raised or may show you a raised hematocrit rather, which is just a sign of dehydration because um you know, they'll have the same amount of hemoglobin but less plasma volume. So, um your hematocrit may be raised. I already about the E and S going off, important to check your creatinine and G fr to check for any prerenal A KS. Um And then, you know, for completeness sake, also your LFT S and T FT S hyperthyroidism um can also present with nausea and vomiting um and very similar symptoms as well. Um And then obviously, the main investigation in pregnant women is ultrasounds of the abdomen. Um You'll never really be wrong if you say that as a investigation for any, any woman in pregnancy. Um But very important to look at the fetus, you know, is it a multiple pregnancy? Is it a molar pregnancy? Is it actually viable? Um And just is very important as well because you expect hyperemesis to be present in the earlier weeks of pregnancy, typically around weeks, 7 to 10. So if this is happening a lot later, then, you know, you might start to think of some other diagnoses or have a, have a broader, you know, range of differential things that you're thinking about basically. Um So, um and then just going on to manage, I there's a question on the chart which I will come to in a second just after I finish this topic. Um but just to talk about, so then managing hyperemesis, which is what our SBA was mainly getting at. Um don't forget conservative things, they're super, super important. So, and it can actually fix a lot. So ensuring that they get enough rest, ensuring that they're um still taking in loads of fluids. Um because obviously they would have a lot of losses through all that vomiting. Um Small, frequent meals are often advised as well and, you know, considering plain foods. So things like plain bread crackers, biscuits rather than um heavier meals and sometimes just a lot of reassurance, you know, explaining to women that this um why this happens in pregnancy and also the fact that it should 10, it should subside. Um And you just sort of have to get through this, this particularly common period of 7 to 10 weeks gestation. Um So that's all super important. And then moving on to our more sort of medical things that we can do in hospital. Um So, obviously, lots of um IV fluids, you may be asked in an ay to write up um maintenance fluids for a woman who's come in with hyperemesis. Um and then antiemetics, which is the thing that we will never forget, obviously. Um But um like I said, first line is always promethazine, then we move on to the other type or other antiemetics. Um And then your last option is usually steroids and we tend to start with IV steroids. So IV hydrocortisone and once they're tolerating things orally a bit better. So once the nausea and vomiting are settled a little bit, we can then switch to oral um prednisoLONE or other oral steroids as well. Um Then it, it's just, I just want to highlight that. Um always consider your route of administration because if you're, it's easy to just, you know, prescribe oral tablets for everything. Um But if you've got a woman who's vomiting, then actually, they may not be keeping those antiemetics down. So, consider your IV roots, your IM roots, your subcut roots, um et cetera and you can always step down to oral a little bit later on when they're a bit more settled. Um Don't forget thiamine um you know, a bit like um with malnutrition in alcoholics, um high dose folic acid if they're not taking it already particularly important because um most women will present before uh 12 weeks of pregnancy. Um And also if they're admitted and admitted for a long time, then definitely VT E prophylaxis because you have a higher risk of blood clots in pregnancy anyway, and then dehydration may also put you at a higher risk of blood clots as well. Immobility if you're, you know, throwing up and not able to move around much. Um So I've just seen a question in the chat um about um cerebral space occupying lesions. Are they more likely to show symptoms um during pregnancy? Uh I don't, I mean, I'm not really sure. Um I don't think them, I don't think they would be more likely to show symptoms in pregnancy because I think the symptoms of the space occupying lesion might, might mimic the symptoms of um hyperemesis because you can get vomiting in cerebellar lesions and you can get vomiting in hyperemesis. But I don't, I don't think it's, you're more likely to detect things in pregnancy. Um Anyway, um So we'll move on to the second SBA. Um So let me just create a poll before we talk through it. Um Give me one second. Ok, so I've made another poll for you guys for this question. So, um Rowena is a 30 year old female. She's 20 weeks pregnant and during her clinic appointment uh with the midwife, uh she, the midwife does routine abs and her BP is recorded to be 1 58/92. What additional feature would support a diagnosis of preeclampsia? So we're now switching topics to preeclampsia and again, I'll just give you a couple of minutes. Ok, cool. Um We've got quite a few responses. So um let me see what you guys have put. Um So just to answer the question that's been asked before we go on to talk about this. Uh second SBA. So with respect to fluids for hyperemesis, what would be a typical regime? Um it would just be so um I'm sure you guys have all seen the nice guidelines on uh maintenance fluid prescription um which involves, you know, needing 50 g of glucose um every 24 hours so on and so forth and then you need a certain amount of all your electrolytes. So your um sodium potassium chloride, et cetera. So it wouldn't be um anything different to your normal maintenance fluids. What I can do at the end is just put a, it's really good to just look through those guidelines. Um I can put a link to that um at the end but it's nothing special. Um Yeah, just making sure that they get um everything um cool. Um And then fine, so let's just go through this question. So most of you, let me go back to the pool, put a poll, put answer answer option C protein urea, and then there's a few of you that are um a bit more torn with um the others. So, um so the correct answer here is protein urea. Um The key part, the key thing to this question is recognizing that we, that I'm asking for what supports a diagnosis of preeclampsia. Um because protein urea is one of the diagnostic factors that are required alongside two other things which I'll go on to talk about. But a lot of the other things here. So peripheral edema and headaches are symptoms of preeclampsia and should make you suspicious about a woman being hypertensive and um you know, having preeclampsia if she's pregnant, but they're not necessarily um part of the diagnostic criteria. Whereas protein urea is um and then for answer interruptions, DNE. So a history of having seizures or hyperreflexia, this would make us more worried about eclampsia um which is different to preeclampsia and is eclampsia is basically a progression of um the preeclamptic state. So let's just go on to talk about um preeclampsia a little bit more and I can see there's a few more questions in the chart. Um I we will come on to those in a second. Um But just to talk about the diagnostic criteria for preeclampsia that I was mentioning. Sorry, the font's a little bit small. Um But basically, again, good to memorize um these three things that are super important. So a woman must be more than 20 weeks, gestation must have pregnancy induced hypertension, which basically means that the high blood pressures should have started after 20 weeks of gestation or within pregnancy. If you've already, if you've already got a high BP or if you're already hypertensive before you become pregnant, um, then that is not, um that's not pregnancy induced hypertension, obviously. So, so, yeah, so we're looking for these two things and hypertension is basically anything in pregnancy. It's anything uh more than 140 systolic or 90 diastolic or in women who, you know, possibly have a lower baseline in the first place. Anything that's um any BP that jumps more than 30 millimoles of um 30 systolic or 15 diastolic would also count as pregnancy induced hypertension. Um And obviously anything is worrying, but when we have blood pressures in women that are more than 1 60/100 and 10, then we count that as severe um severely high BP and you should be a little bit more cautious in these women and they would definitely require admitting um to a hospital. So, so yeah, more than 20 weeks gestation, pregnancy induced hypertension and protein urea, um which could either be from a dipstick or it could be from doing a more formal albumin creatinine ratio, for example. Um So yeah, I would memorize that. Um And then, so I've taken this directly out of nice guidelines, but essentially um there are certain risk factors for preeclampsia and we split these into high risk and moderate risk. Um, and I'm not, I won't read all of those out to you because you can sort of do that in your own time. But the important thing is that um if women have more, more than, or equal to one of the high risk factors or more than, or equal to two of the moderate risk factors, then ideally, you should be recommending that they have aspirin. Um somewhere between 75 to 100 and 50 mgs. The dose is usually just consultant dependent. Um but they should have aspirin as preventative measures. So, to prevent preeclampsia from 12 weeks, gestation until the birth of the baby. Um and essentially all of these risk factors put you at a higher risk of developing um high BP. So, um so yeah, um good to just know those um and good to remember that and it comes up in SBA is often, you know, what would you give to prevent a woman from developing preeclampsia if she's got any of these risk factors? And the answer is aspirin um symptoms of preeclampsia. Again, very important to look out for and ask about if you're taking a history of a woman with a headache or abdominal pain or um you know, swelling or any of those presenting complaints that come up. Um And yeah, so things to look out for is actually often preeclampsia can be asymptomatic and might just be picked up at the booking visit when a midwife, um you know, incidentally does a uh does a BP, does a urine dip? Um and asks about these symptoms. So, um just be aware that, you know, that it's not, so it's not so obvious when a woman has preeclampsia. Um and then you've got all of these generalized features. So things like headaches, changes to the vision. Um Sometimes women will complain about um upper abdominal pain. So, epigastric or right upper quadrant pain, um nausea and vomiting, um swelling of the extremities. So the hands and feet in particular, um and in more severe cases, like with hypertension in a normal um person, um you can also get reduced urine output because of the impact and the strain on the kidneys. Um And then in terms of signs, um obviously, unfortunately, preeclampsia has a lot of complications for both the mother and the baby if not controlled well or not picked up and can include things like growth restriction, stillbirth, um problems with the placenta. Um And if preeclampsia progresses to eclampsia, which is the most more severe form, then you can also get things like seizures, um hyperreflexia and a lot of neurological signs, basically. Um So, yeah, good to know all of these. Um And just before we move on to the next SBA, um the question about the C TPA versus VQ scans, I think it's um it's a really good question. And basically, II don't really want to answer it right now just because we could talk about that for ages, but there's no right or wrong as to what is safer. Um, VQ scans are arguably safer, um, for the fetus because there's not, um, as much radiation there. Um, whereas CTPA S put, uh, you know, babies at high risk of radiation and therefore future malignancies and therefore that's a little bit tricky. Um, but, um, but I think that's a very complicated topic. Um, and I, you know, outside of the scope of finals, for sure. So we'll talk about it at the end if we have time. Um, can you give, uh, cyclizine in hyperemesis? I think theoretically you can, but in practice, we don't do it very much. I'm not sure why. And then the other problem is, um, if someone is vomiting, um, then, so if someone is vomiting and you want to give them something intravenously, we don't really like giving intravenous cyclizine because it has a risk of addiction and can in women in particular can give them this, um, feeling of being high. And I've seen lots of patients being well, not pregnant women, but I've seen lots of patients in general being quite addicted to IV cyclizine. So that's why I think sometimes it's just avoided a little bit, um, pole issues. Hm. I hope it fixes for the next one. But if lots of you are having that issue then let me know, maybe you can just answer, uh give you answers in the chat instead. Um I thought it and then the next comment was I thought edema is also a diagnostic factor. Um As far as I'm aware, edema is obviously a very common symptom of preeclampsia, but not a diagnostic factor. Edema is a sign of um you know, protein loss and protein urea. But you need to formally measure that in the form of, you know, protein urea on a dipstick or a cr um rather than just the clinical sign. And yes, there will be a feedback form. I'll come to that um about halfway through and at the end as well. Um And oh yeah, I should have said actually, um if you want me to send the feedback form earlier, let me know like if any of you have to leave because you do get a certificate for um attending the talk. So, yeah, if anyone wants a feedback form a bit early, then just let me know. All right. Um Cool. So let me make a pull for the next SBA. Um So you should be able to see a pole um titled SBA Three, but let me know if there's any problems. Um So yeah, so in this question, you're on Fy Two doing an obstetrics clinic. Um You see a 32 year old female who's got known preeclampsia, she's 30 weeks pregnant. Um She's come in complaining of easy bruising and feeling extremely tired. Her partner also mentions that she's been looking really yellow. Uh What's the definitive management of this condition? Um And I've been very vague with this condition. Um But if, if any of you know, um if you have any ideas what condition we're talking about in particular, then do just um put a, put a message in the chat. OK. Um Wait for a couple more responses. Ok. Cool. So um so a few different possible diagnoses that you guys have mentioned mainly Hellp Syndrome and acute fatty liver of pregnancy. Um Both really good ideas. Um So the uh condition that we're talking about here is Hellp Syndrome. Um The reason being uh so, so what Hellp syndrome stands for, for those of you who haven't heard of it before is so the H stands for hemolysis. So, hemolytic anemia basically um and the hemolytic anemia results in jaundice. Um and that is what is causing this really yellow appearance of the woman. Um the el stands for elevated liver enzymes um which again, you can get in acute fatty liver pregnancy but not to the same extent. Um and the LP stands for low platelets, which again, you can get in severe cases of liver injury and liver cirrhosis. But I don't think it would be as um because the acute fatty liver pregnancy would be a very a acute condition. It just happened over the pregnancy. I don't think you would really expect platelets to have fallen so early or so, so quickly, but it tends to happen when you have prolonged liver disease. Um So, yeah, so the hemolysis is causing the yellow complexion here. Elevated liver enzymes can cause the, um, feeling of tiredness and then the low platelets is what causes the bruising can also cause tiredness. Um, but yeah. Um, and yeah, you're right. Um, for the majority of you said answer option, a delivery of the baby. That is correct. Um Yeah, the others we wouldn't really do unless antihypertensive management. If they've got um a a very high BP, obviously, we would do, but it wouldn't be the definitive treatment, definitive management. It wouldn't get rid of the Hellp syndrome whereas delivery of the baby um would um and then with the platelets transfusion, again, it is something that can be considered if a woman is, is bleeding and has very low platelets. However, um it may not be likely to be that successful because your platelets are being constantly destroyed. Um Anyway. Ok. Um And that leads me to talk about some of the complications of preeclampsia because Hellp syndrome is one of the complications that we worry about. Um But I've just listed a few of the other things here that we would want to think about. So, obviously, progression to eclampsia with all of those neurological signs that we spoke about. So fits seizures, clonus, um et cetera. Um You can also just get place placental ischemia, which can cause fetal growth restriction due to, you know, less nutrients, less blood reaching the baby. Um And then D IC is obviously another very big one that we worry about. Um And then yeah, multi organ failure, placental abruption. Um Lots of things basically preeclampsia is bad and we want to do as much as we can to control that BP um to reduce the protein urea in order to prevent these complications from happening. Ok. Um So in terms of investigations for preeclampsia, um so when a woman comes in for all of her antenatal screening, so at the booking appointment and then future visits, um midwives will always check the BP, the urine nip the fetal heart. Um It's good to just sit into a few of these clinics because you'll learn all these investigations very quickly. Um And, and yeah, especially the um you know, the the screening, the bloods, et cetera. Um But yeah, so loads of bedside tests, um A as written there and then blood. So um obviously keep an eye on the full blood count because if you've got a drop in your hemoglobin or in your platelets, then you might be thinking of Hellp syndrome. Um keep an eye on the use and need for that kidney function, um LFT S as well. And then like I said, D IC is obviously very, very concerning and would be very bad. So clotting is always a good one to send off um as well. So, clotting profile, um and um we don't do this very often in clinical practice, but it's always very good. It's good to send off uric acid in the serum um as well because this can often be raised in um preeclampsia for reasons that I can't remember. But there's a good explanation as to why uric acid um gets raised as well. Um And then in, in um clinics um often uh doctors will also do things like umbilical artery Doppler to check for um you know, placental function, placental ischemia and whether there's any um potential complications that could occur to the baby as well. Um Oh another SBA, so um let me make a pulse. Yeah, so we've got another SBA here, just done another poll. Um So uh Gemma is 21 weeks pregnant and comes to see her GP because she's needed to use her salbutamol inhaler increasingly frequently up to six times per day. So very uncontrolled. Um The GP does some obs and notices that her clinic, BP is 100 and 57/91. What medication should the GP prescribe? Um So the single most correct medication basically, and I'll give you guys a couple of minutes. Ok, cool. So we've quite a lot of responses there. So um about half of you have gone for an option D which is Nifedipine as have you Rachel. Thank you for putting in the chat. Um And then there's um a roughly equal split between labetalol, oral and methyldopa oral. Um with a few of you going for A or C as well. So, um let's go through the answer options. So um Ramipril po well, actually, firstly, I should say the correct answer option is answer option. D so Nifedipine orally so well done to those of you guys who put that. Um But let's go through them also. Um a Ramipril po we don't give um Ramipril would be first line for a non pregnant woman. Um but we don't give Ramipril or ace inhibitors or, or Arbs in general in pregnancy because they have side effects. So things like fetal heart defect, so completely avoid ace inhibitors and Arbs. Um So B and C labetalol um would technically be the correct answer. But um this is a bit of a trick question because the main history here is that this woman has been using a salbutamol inhaler very often which indicates that she er probably has a diagnosis of asthma. Um And in cases of asthma, obviously, you don't want to use beta blockers because you can further um you know, worsen the asthma basically and, and you know, if you're using a salbutamol inhaler, it would completely counteract the effects of that. So um we don't want to give labetalol to this woman. Um and regardless you wouldn't give labetalol IV unless you're in a you know, life threatening situation, it would, it would be oral. So that's why it's not B or C Nifedipine. Er we're gonna give her that because she is she has asthma. Um And so the key thing to remember is basically in women who have a diagnosis of asthma or in Afro Caribbean women, Nifedipine tends to be our first line a bit like we had normal hypertension management. Um Calcium channel blockers tend to be our first line in Afro Carribean patients there as well. So yeah, the two indications in pregnant women are either asthma or being a Caribbean. You would start Nifedipine instead of labetalol in that case. Um Methyldopa, it would just be a bit too extreme for now, let me something like methyldopa would be added in if uncontrolled on Nifedipine. Um and requires a lot more monitoring. Um So yeah, that's why that's the answer. Um And we go straight into another SBA. Um Let me just do I call sorry, I don't remember there being that many SBA S that I made. But apparently so yeah, you've got SBA five here. Um So yeah, you attend an emergency assessment of lydia who is a 35 year old pregnant woman. She's at 34 weeks gestation. Um You notice the following. So her blood pressure's raised, it's 100 and 80/100 and that's severe hypertension. Remember I said anything over 100 and 60 systolic or 100 and 10 diastolic is severe. So that's bad. And then you examine her and she's got swelling of her ankles and she's complaining of a bad headache. So, um she's been given a bolus of 4 mg of magnesium sulfate. Um And the consultant declares that she needs to have an emergency cesarean section. Whilst all of this is happening, the magnesium has gone in the team are then alerted that her respiratory rate has started to drop. What is the most appropriate management? So this question is obviously a little bit more complicated. So if you've got any thoughts of what's happening, um in terms of, you know, why is her heart respiratory rate dropping or what's going on in general? Let me know in the chat. Excellent, excellent. So we've got quite a few responses in and a few um very good ideas, correct ideas rather in the chat, so well done. Um So just to start with the poll. So the majority of you have so 40% of you have gone for abruption d calcium gluconate and then there's um rough, roughly an equal split between the um are the answer options. So, um the key thing to know here, like a couple of you I mentioned in the chat um is that, so let's just talk about the whole question. So we've got a woman who is very, very hypertensive systolic of 180. She's obviously symptomatic um as well. So all that swelling, the headaches um magnesium sulfate is given to basically an eclamptic seizure and also prevent any neurological effects in the baby. And the way we give it just for knowledge, I guess is that you tend, we tend to do a four mg bolus over 5 to 10 minutes and then give a, give an infusion of 1 g per hour for 24 hours. So anyway, so she's been given the magnesium sulfate to prevent those seizures. Um And then you notice that her respiratory rate starts to drop and this is actually quite a um commonly seen side effect of magnesium sulfate, which is respiratory depression and dropping respiratory rate. And the most appropriate management option. I can't tell you why it works, but it works is um calcium gluconate and this sometimes comes up in SBA S um as well in terms of managing it. So, um so yeah, so that's why that's the answer option. Um And just to talk a little bit more about the management of preeclampsia. Um So good thing to know is that um uh preeclampsia always requires um emergency secondary care. So, if you're in an osk and they say this woman, uh if you're in a GP setting in your osk and they tell you, you know, this woman has come in with preeclampsia, what should you do? One of your management options should definitely be referring her to secondary care and sending her to, you know, either a um either be seen as soon as possible in a clinic or go to maternal A&E. Um, so admit the woman basically, um, and definitely admit her BP is more than 100 and 60/100 and 10 as well. Um, targets that we're aiming for a little bit more vague, can sometimes be dependent on the woman. But on, in general, you want to aim for a target of 100 and 35/85. And we've already talked about the medications a little bit, but first line um is usually uh oral labetalol, you can give it IV in emergencies. But remember as I said, asthmatics, Afro Caribbeans, um give oral nifedipine instead and methydopa comes um as your sort of third line option. Um And then um the reason why, so I've written my methydopa must be stopped within two days of birth. The reason for that is that methydopa can cause sort of mood, mood side effects and things like depression and isn't great from that perspective. So you shouldn't be on it for a very long period of time and you should stop it. Um As soon as you can really, um and the risk of, you know, uh seizures, et cetera drops after you've given birth, the treatment for preeclampsia is delivery of the baby. Therefore, you don't really need to continue with the antihypertensives once you've delivered. Um And then we talked about magnesium sulfate to prevent the seizures. Um And Yeah, like I said, definitive management is delivery. Don't forget your calcium gluconate and relate in relation to a previous SBA avoid your ace inhibitors. Your Arbs Zartan and Thiazide diuretics are not recommended in pregnancy as well. Ok. So another SBA for which I'll create another poll. So, uh the previous lady who um oh, has that worked? Yes, it's worked. The previous lady delivers her baby. She's about to be discharged. Um We've spoken about this already. Um So hopefully everyone's clear on this, but she asks what can be done to try and minimize the chance of her getting preeclampsia in her future preg or in her second pregnancy. What would you advise? Ok, amazing. So, uh the majority of you have said a aspirin from 12 weeks gestation um and very few have chosen um other options. So you're, you're right. Absolutely. Um You know, um having, if we just, if I go back enough, um just to show you guys from the risk factors. Uh So, um I hope you can also see the preeclampsia risk factor slide now, but you can see that the high risk in, in the high risk category previous preeclampsia is a, is a risk factor for having preeclampsia in future pregnancies. And all you need to give a woman aspirin is more than or equal to one of these high risk factors. Therefore, she would qualify um to start aspirin from 12 weeks of her pregnancy until the birth of the baby. So just going back to the SBA. Um Oh yeah, so just going back to the SBA, that's why answer option A is correct. Ok. Um So the next topic, so we've talked about um hyperemesis, gravidarum, we've talked about preeclampsia. Um And the next topic that we're gonna move on to is talking about antepartum hemorrhage. Um So um antepartum hemorrhage is basically any bleeding from the genital tract after 24 weeks of pregnancy. But before the delivery of the fetus, because anything after the delivery of the fetus would be classified as postpartum hemorrhage. Um And then your three main causes of antepartum hemorrhage are placenta and I'll talk about all of these or we'll talk about placenta previa and placenta abruption for sure. Um But the three main causes of antepartum hemorrhage again, to just learn is placenta Praevia, which is a low lying placenta, placental abruption, which is when the placenta separates from the wall of the uterus and vasa Praevia, which is where your fetal blood vessels um that connect to the mother and the fetus basically lie very low near the cervical os and therefore, when they get irritated, it can cause bleeding um as well. Um Now, in terms of the severity of antepartum hemorrhage, the definitions of this are a little bit different to postpartum hemorrhage. So, just be aware of that. Um But basically, you can, you, a woman could either just have a little bit of spotting or she could have minor bleeding, which is less than 50 mils, anything from 50 mils to a liter of blood, but no shock becomes major bleeding and then massive bleeding. Worst case scenario is more than a liter of blood. Um plus or minus any signs of clinical shock or deranged obs basically, you know, tachycardic hypotensive, um et cetera. Um Just the question in the chart. Yes. Calcium gluconate is a stabilizer of the cardiac cell membranes. You're right. That's why we use it in hyperkalemia um as well just to protect the heart. Um and someone said it's an antidote of magnesium sulfate. Oh yeah, that would make sense. Um Good. So just uh talking, let's talk about placenta previa then. So like I said, it's um a low lying placenta um in the lower part of the uterus. Um And the way that we diagnose it is usually with a transital ultrasound scan which is why um it's very good that it will actually be picked up very early um in a woman's pregnancy when they have their routine um Antenatal scans um and something to look out for in SBA S that might sometimes be mentioned is placenta previa in a woman who has not been very compliant with attending her antenatal care appointments because if you're not attending your appointments, then this can get missed and then cause the complications of um you know, bleeding, et cetera, et cetera. Um And I've also just put in some images here to show you. Um So if you look at the image at the top, a normally sighted placenta will be a little bit higher up and not in the way of the cervical of the internal cervical os. Um But with placenta Praevia, the placenta just implants itself a little bit lower down. Um And therefore can cause bleeding. Um you know, either during the pregnancy or during birth as well and these patients have to be managed a bit more carefully. Um And then sometimes you'll hear in the image at the bottom, sometimes you'll hear of people referring to partial placenta previa or major placenta Praevia. So partial is where only a little bit of the internal cervical os is, is covered. Um And major placenta previa is when the entire cervical os is um covered. So, in terms of management, you don't really need to know the management of placenta previa in detail. I've just put it in here for completeness um sake. Um But um key things to know is that essentially um the anomaly scan that's done in all women at 20 weeks will identify any women that have a low lying placenta. And by that point, the placenta would have established its position, um you know, in the uterus. So, so that's when it's usually detected. If you identify a low placenta, you rescan the woman at 32 weeks, sometimes the placenta. Um can, you know, as it grows or as the uterus grows in size as the baby moves around can actually just move. Um So when you rescan at 32 weeks, that's to confirm whether the placenta is still low lying, um, or whether it's, you know, now moved to a normal position in a high position. Um, and then women are rescanned at 36 weeks to determine how you're going to deliver her. Um And obviously in between, if you've got anyone who's hemodynamically.