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So everybody's moving roles this week, which is getting very tricky for the energy. Um So today is pregnancy complications. Now, there are millions of pregnancy complications. So this is a very brief overview of the main ones that are likely to come up in of skis and in written exams um So we'll go through what a normal pregnancy is from booking to delivery what kind of antenatal care person would expect to get and then I've very roughly split it up into 1st, 2nd, and 3rd trimester complications. Now, there's it's not an absolute some of them can occur in you know completely different parts, um but I think it's an easier way to kind of split it up in terms of going through content a bit on postnatal complications and then I have a quiz. At the end. It's only 10 questions on kohut, but I always think it's a fun way to end the session. So well, if we've got time at the end, we can do that um. And if you have any questions along the way, please I'm you or put it in the chat, I don't mind being interrupted to go through something that's fine okay, so antenatal care starts with the booking appointment well. I mean it depends on whether or not the pregnancy was planned or not. Because if the pregnancy is planned then usually people are taking prenatal vitamins before conception, folic acid is a particularly important one um and there's been a lot well a lot in the background recently with public health about getting folic acid put into our flour because the folic acid helps prevent neural tube defects um and the neural tube oops, sorry the neuro tree was pretty much fully developed by the time women people realize that they're pregnant and then by at that point, taking folic acid doesn't do anything so. Preconception folic acid is what's really important, so there has been this debate about whether or not it would be our flour that we usually fortified with it. Most other countries actually do that there's lots of different reasons why it hasn't been done here yet, but it's probably something on the way. Um So, yeah, if it's a planned pregnancy, then you know the antenatal care might have started preconception already with the vitamins, but usually it starts with a booking appointment which is around where around 10 weeks. It depends on when people find out that they are pregnant and when they decide to go to the gP about it, um So at the booking appointment, this is kind of it's quite a long appointment. If you've ever had if you've ever had a g. P. Placement or you're going to have one, I definitely recommend going and sitting with with the midwife for these, The appointments are about an hour, usually 45 minutes to an hour because it's going through literally everything so women will get these booklets that they take around with them. Sometimes, I mean some of them now have an app, actually which is really interesting that has all of their information and the booking appointment is essentially filling in the basics of this book, so it covers kind of family like their background and their family that they have at home already any medical conditions, medications they already take education on what they should be doing now, So the lifestyle, nutrition, and physical, mental health things that they can be doing to ensure that the pregnancy is healthy and that they are healthy. Other routine things like measuring Dni BP during doing your analysis, just so you've got that to compare to you later on and then your blood's full blood count because I mean anemia is going to be a problem pretty much the entire way through um pregnancy, but again getting a baseline hb is really useful blood group antibodies and recess D status is really important and that should all be done that booking these blood should be sent off and screening for things like thalassemia and sickle cell. You can offer things like hiv hep, being syphilis, but it's not a necessity and you know you can't really press them into doing it, but it's a good way of preventing complications and pregnancy. Later on that you could have picked up earlier, so that's kind of the beginning and then between 11 and 14 weeks, you'll get the first ultrasound which is to measure gestational age, so women might think they are 11 weeks and actually than they have the their measurements, it's more like 12 or 13, and it just gives you an accurate date of an accurate due date, as accurate as it can be because before that it would have been from the last menstrual period and if people have irregular cycles, then that might be off a little bit um so it's to determine gestational age and multiple pregnancy and also viability of that pregnancy. Um The anomaly scan doesn't come until about 18 to 20 weeks, so this one is literally just to see that there's a viable pregnancy, whether there's one or more and how old it is so at 12 weeks. This is when people who are at risk of preeclampsia, which we'll talk about in a bit more a bit in more detail and bit are started on, can be started on aspirin to reduce the risks 14 to 17 is when the anomaly scan can start coming up, so there's lots of different screening tests, antenatal screening test with a quadruple tests, and there's a couple of different blood tests as well um which is definitely worth reading up about like AFP and um hcG and things like that, but for now just know that the anomaly screening um so you can have the anomaly, blood test screening 14 to 17 weeks and then the anomaly ultrasound to look for anomalies so um and to look at the placenta location and the position which is really important for placenta previa, which will come onto it a little bit. Um 24 weeks is when we start measuring synthesis fondle height to make sure that the baby, if you order the ultrasound will also help, but to make sure that the baby's measuring roughly to the weeks that we would expect it to and to monitor the fetal movement 28 weeks in women who are give, so if they're resource negative, women will will need anti D. At this point because it's before labor any kind of sensitizing event which can be a PV bleed. Um labor itself, anything that kind of could go wrong that's when anti D needs to be given to a person who is recess negative, an f. B. C. Needs to be rechecked. Again, anemia can be an issue, blood group, and antibody levels because from 28 weeks, it's kind of planning for labor. It's not it's not all that far off and making the plans now means that everything is prepared, just in case it would be a premature delivery, um So having all of that there is important 36 weeks is another important appointment that they would go to either the midwife, it's an uncomplicated pregnancy or with the consultant if it's high risk um and this is to look to see if they're if it's in breach position, um and if it does feel like it's in breach position, you can get an ultrasound to kind of um confirm that there's a couple of different things you can do about breech position, so I haven't put it in this talk. Um. Specifically, this is kind of more I think about labor complications and it is about pregnancy complications, um but usually if they if you are unable to turn the baby with external cephalic version, um you usually would go to a C section. It's very rare to have a breach vaginal delivery because they are very risky um and it's quite it's quite uncommon that that would be allowed to happen about 37 weeks in some cases, and we're gonna talk more about those specific conditions in, in a bit, it's recommended for women to be induced around the 37 38 week mark. Things like obstetric metastasis, multiple pregnancies, preeclampsia, gestational diabetes excuse me the majority of these conditions. If they're not, if they're managed with medication rather than lifestyle, you're likely going to be told to be induced around the 37 week mark rather than waiting for natural delivery, um and if you go past 40 plus six um you will be offered induction, but that's because the baby would get much too big if it was let um to grow for much longer than that and then you'd be at much higher risk of things like shoulder dystocia and long term labor and having issues with that and then having to have an emergency C section during a labor, which increases your risks of lots of different problems. Um So yeah we don't really let we try not to let pregnancies go on more than 41 weeks and all the appointments it's important to do basic obs and things like that, so, BP checking the urine specifically for protein area for preeclampsia, which we talked about more in a second um and just generally checking up on this person and domestic violence comes up a lot in the your skis and often it can be situations like this where it's an anti natal appointment and actually it's kind of hidden within the antenatal appointments, so in real life as well remember this and also in our skis, it can definitely come up that just make sure the appointment isn't purely clinical um and screen for other types of things as well okay, so that's how it should normally go now in the first trimester. There's lots of different things that can happen, but these are the ones that are the most, I think the most important to know miscarriage. There's lots of different types of miscarriages that will go through hyperemesis, ectopic pregnancy and then um vt, so venous thromboembolism, which is a risk factor the entire way through so on all of my slides, you'll see that constantly because it is a really big risk factor and something that I think a lot of people forget. Um So miscarriages definition is a loss of pregnancy before 24 weeks, so it is kind of the first trimester problem. Um after 24 weeks, it's gonna still class it can be split into early, so less than 13 and late so between 12 and 24 24 is generally the point of viability so about one in 4 to 1 in five pregnancies actually ending miscarriage and I think it's a lot more common than than we're led to believe even as medical professionals because it's just not talked about. I think there's still a lot of stigma that's not to say stigma, not sigma, um surrounding it and people don't really talk about it. I think there's been a lot of movements lately to try and get this changed and get a lot more in the media and get people talking about it more. Um Because within the nhs, there is a um kind of rule that you won't get sent for in depth testing until you've had three miscarriages, but really people are kind of encouraging that that be done with you know minimum of two because it's quite traumatic to go through three miscarriages and then don't only then be sent for having genetic testing and other types of testing, um but currently that's how it goes you have to have three before you get referred for in depth investigations. There's six different types um but don't let that scare you. They really are quite um simple and one of them is literally just septic, so an infective, one okay so threatened is when somebody has bleeding and pain, but the ultrasound shows a viable pregnancy. The cervix is closed and there's no it doesn't look like a miscarriage is currently happening, but that doesn't mean it won't the pain and the bleeding, I mean there is a threat of miscarriage, but it is not currently happening so usually when people present with pain and bleeding and a closed cervix. If the pain is like, is not too severe and the bleeding is like, then you don't have to keep them there. Um You can reassure them and send them home and give them the number for the early pregnancy unit or just tell them to come back in if it gets worse, um and you can just refer them back to their gp as well. If the bleeding is really heavy, then admit them you need to make sure that they are not hemodynamically compromised um and if they're more than 12 weeks and you see this in absolutely every single one of them more than 12 weeks, 12 weeks and recess native give antibody inevitable, then is different, so they all really usually present with heavy bleeding and pain. Um The severity of the bleeding, the severity of the pain, kind of increases, the more towards the miscarriage. You are so inevitable is the same thing as threatened, but the cervix is open, which means it will happen this miscarriages inevitable. At this point because the cervix is open. Um The fetus at this point maybe viable or not you do an ultrasound, but once the cervix is open, the products of conception are going to be coming out for this, observing them and offering the different management options that will talk about in a minute. Um This is almost very, this is inevitably going to proceed to a complete miscarriage and again if it's more than 12 weeks and their recess negative give them an to do um so, I missed miscarriages when they're often asymptomatic or maybe they've got a bit of discharge of a little bit of bleeding or um a little bit of discharge, or they've been told a previous appointment that they're foetuses small or they've had a threatened miscarriage in the past and there might be risk factors, but really the thing is, they didn't have symptoms, It was quite a symptomatic um and the ultrasound would show no heartbeat or crown rump length more than seven millimeters. Now, you don't need to know all the specific numbers about crown rump length about that, but it's just when it's less than seven millimeters, it's very difficult to actually be able to ascertain a heartbeat in a pregnancy that is viable or not, so it's very difficult to say whether you can see one if it's too small. Um A second opinion is really useful on this because it is difficult to confirm that heartbeat in early gestations um and yeah you can offer them the management options that we talk about in a minute, so conservative, medical, surgical, depending on how well they are and again anti D for more than 12 weeks and recess negative incomplete is kind of the next stage after inevitable, so the cervix is open and the products of conception are being passed, but they have not fully passed yet. So on the ultrasound you might be able to see retain products of conception that's what p. O. C stands for and you may also have see proof that there had been an intrauterine pregnancy. There. Um The management of this will talk about expectant medical and surgical management just in a minute um and again anti D is more than 12 weeks and recess negative um complete then is that all of the products of conception have completely passed through the cervix. They may have a history of all of these symptoms, pain, and bleeding, and an open cervix and having an ultrasound with no viable pregnancy. Um So one of these this ultrasound there would be no retained products seen. Endometrium would be thin and you may see proof of intrauterine pregnancy, um but really the main point is that there would be nothing left, so with incomplete, you can get retained products of conception, which can then lead you to needing to have an evacuation of the retained products of conception with complete, that's not a risk because all of it has passed you can just discharge them to the gp with safety netting advice and again anti, d. If it's more than 12 weeks and recess negative excuse me septic, then is just when you get an infection because of the miscarriage, So often it's pain, bleeding, discharge fevers on the blood test, you get high inflammatory markers, the white cells, and crp on an ultrasound. You're likely to see features of an incomplete miscarriage because this is what this is the type that invites the most infection in, because there's something that is trying to pass that hasn't fully passed yet and then bacteria can kind of climb up that and get in so management as you would really any septic patient, iv antibiotics and fluids um and then deciding what you're gonna do about it, medical or surgical management. And again anti, d very important anti d, comes up a lot in our skis as well not as a full station, but it just comes up as a big point a big marking point to ask about it and to discuss it with a patient so remember that for your oscars as well, so the managements conservative or expectant. It's called both medical and surgical, so expectant is just to allow it to part naturally, but this is not always successful and may eventually need medical intervention. It puts people at a slightly higher risk of infection because you're kind of letting it go on for a long time, and people can then essentially they're sent home to let this happen and you couldn't have heavy bleeding and heavy pain and just kind of be alone or without a medical professional at home, which some people really don't want. Um After two weeks of diagnosing the miscarriage, you'll have another scam, uh which is quite a long time really to kind of be bleeding If it's taking that long, um and if you still have retained products of conception at two weeks, then it moves on to over medical or surgical management. Contra, indications to this is a infection that is already there or risk of severe bleeding, so say if you have a clotting disorder or you know any kind of hematological problems Really medical then is when you are given vaginal misoprostal, so a prostaglandin analog which stimulates the cervix to open and the myometrium to contract, so essentially it mimics labor. Um The side effects of these are quite nasty. Some people experience really bad side effects, so nausea, vomiting, the bleeding can get worse and the pain can get worse. You can imagine essentially with stimulating contractions like it would be in delivery, which are severely painful, um but that is done as an inpatient. There given the medication they're monitored, ensured everything is passed how do an ultrasound to make sure there's no retained products of conception and the follow up is usually a pregnancy test 2 to 3 weeks later and as long as that's negative, then they can kind of be discharged back to their gp and um no further managements really needed surgical then. Um is so you have a manual vacuum aspiration with local anesthetic if it's less than 12 weeks which can just be done in the clinic room. If you um have a particular interest in early pregnancy unit um complex early pregnancy complications. It would they have a good clinic at george's um where there's a there's a recurrent Miscarriage Clinic, but there's also a clinic where they just um people just turn up it's kind of like a a and e for early pregnancy and then you can kind of see all of these different procedures being done and people in the different stages of going through miscarriages or not, um so the manual vacuum aspiration is local anesthetics, local anesthetic into the cervix um and then manually aspirating anything that is left in the uterus out, um and if more than 12 weeks, then it's an e. R. P. C, so, evacuation of retained products of conception not to be consumed with confused with an e. R. C. E. P, which is completely different and got me very confused. um If the patient is unstable in absolutely anyway, then this is really the only management that you can do so if they're if they have an infection, if him is unstable, any kind of trophoblastic disease at all or risk of endometriosis. Anesthetic complications. All of these things um often not often, but sometimes what can happen with these is it scar tissue conforms called Asherman's syndrome within the uterus, which can then make it harder for other pregnancies to become viable and to grow properly because of kind of adhesions essentially within the uterus itself. Um Obviously, this is going to cause bleeding and some pain and if you can also have damage to the surrounding structure, so bowel or bladder damage, especially um so they're all of them come with their own risks. It's usually unless there's complete contra indications, it is usually up to the person to decide for themselves what they would like um and it really it drastically varies and a lot of people if they want to have the products of conception uh um tested for genetic abnormalities which a lot of people often do on the NHS. It's only really done after three, but if you wanted to have it done privately, I guess you then need to make sure that you're able to um kind of keep the products of conception after they've passed and that's very difficult to do at home um So usually the people who would like to have it tested tend to do it as an inpatient with medical or surgical um okay so that's a lot of information um it does come up. Doesn't really come up in oscar as much. I don't think um but miscarriages, it can come up in the written exam Quite a lot. It's definitely something that's useful to know about, has anyone got any questions on that before I move on. I think that's really one of the biggest topics we'll kind of go through a lot of depth, nice cool ok, go on then so hyperemesis gravidarum is and I think the big misconception with this is people think it's just nausea and it's just vomiting and that's normal in pregnancy. Morning sickness is very common. I think about 90% of people a pregnant people experience morning sickness, um but this is very different from that. This is a constant severe nausea and vomiting um and it prevents somebody from getting adequate already any nutrition or fluid and it can also be associated with more than 5% loss of their pre pregnancy weight, which is you know this is an extreme nausea, vomiting situation. It's not just you know throwing up once or twice a day, it's throwing up constantly at the sight of food and the smell of food, Can't do really anything apart from being sat next to the toilet being sick um And it's important to take these people seriously. I think a lot of people go to clinics or their gP and they say I'm throwing up and I'm pregnant they go yeah well, that's normal. Um you know make sure you're not missing these patient's because you know they will become really unwell, really dehydrated, really malnourished, and that doesn't just put them at risk. It puts the pregnancy at risk as well, um so it's about 1 to 2 and 100 pregnancies. I mean the statistics vary wildly when you look at different studies, but it is about 1 to 2% roughly and it is thought to have um to be caused by high levels of HCG which will be high anyway, um which is what causes the slightly lower level of morning sickness. It's still the HCG that causes it, but h g can occur when levels are really high, which occurs in things like multiple so twins because more of it is being produced. Trophoblastic disease Down syndrome is a big one actually uh more hCG is produced in Down syndrome and that can be one of the first indicators or something like that management. Typically, Iv fluids, antiemetics can be used, but like I've put here It's risk benefit because some of them might be potentially harmful to a fetus, but at the same time if the person who is pregnant is not able to eat or drink, and they're losing weight and they're not getting any nutrition. You know you have to do the risk benefit what would be worth. Promethazine is um an anti emetic well. It's an anti histamine that's not often used as an anti emetic. Really cyclizine is more, um but this one is thought to be safer. There are other options. There's loads of different types, but, and it really depends on local guidelines, so if you were in an Oscar station where they're asking you what you would give, I wouldn't say promethazine I would say an anti emetic that is compatible with pregnancy as per local guidelines, which really is what you should probably probably always say in your oscars rather than giving a definitive, unless it's a very simple, straightforward definitive medication, really you should always be saying with further local guidelines. Okay, so ectopic pregnancies again more common than you think one in 90. Um So you know, it's not rare typically occurs in the fallopian shoe and pillar isthmus kind of around that area. There's lots of different reasons why it might happen um And sometimes we've never really know, pelvic inflammatory disease can be a risk factor so that endometriosis because of the adhesions that conform contraceptive devices that people who've got pregnant without meaning to maybe you have an IUD and I us in place, which is going to disrupt where the fetus can actually where can actually implant and if it's implanting in the wrong place because there's an Iud in the way, then you're more likely to get an ectopic pregnancy if somebody had a tubal ligation and still managed to get pregnant somehow. Um progesterone use as well can also cause this because of a ciliated cell discs, l, dysmotility, so essentially it's not kind of wafting the egg as far as quickly as it should be and then it kind of gets stuck in the middle place, so and sometimes it can be our fault any kind of surgery, so acrogenic is our fault any kind of surgery around that area because it will cause scarring and adhesions, and that's a big risk factor, This especially any kind of tubal surgery, so a risk factor for it is having an ectopic pregnancy before instead of having the fallopian tube like removed, You try to um fix it instead, which it will hopefully remain patent, but then you're at a higher risk for more ectopic pregnancies, ectopic pregnancy being one that implants in the wrong place and then it's not viable, but as it keeps growing, um it's pushing on other structures and eventually it can cause a fallopian tube to burst. Um Ivf assisted conception is another because essentially with your transferring the embryo, you're putting it in a very specific place, um which is probably a little bit higher up than it may a naturally implant, so that's another one. The main symptom is pain and something that comes up a lot in uh oscars and written exams is shoulder tip pain and it's not just ectopic pregnancies that cause this a lot of different things that cause peritonitis can cause shoulder tip pain, because it's caused by irritation of the diaphragm by this inflammation and the bleeding that you end up having within the abdominal cavity and the diaphragm has a shared nerve, so the super crevicular nerve transmits pain, but it also supplies the shoulder tip c three to c fine. So you get this referred pain to the shoulder tip um which is a very common finding and it's one that you should always screen for it, not just in you know pregnancy, o. N. G. Situations, but any kind of abdominal thing. It tells you about peritonitis, uh they may have discharged typically brown from the decision were breaking down, but it really can be any kind of discharge. If it's ruptured, they are likely to be very very unwell and hemodynamically unstable and like I said can have signs of peritonitis, so the shoulder tip pain, but also rebound tenderness and guarding. If you were to do a vaginal exam, you might find fullness in the pouch of douglas because of the blood, um and other fluids are accumulating there, so it can be something that is picked up routinely. During you know, scans and booking appointments and things like that or it can be a life threatening emergency coming through the doors of a and e, um so the management really of ectopic pregnancy or that there is not much to do it is not a viable pregnancy um and so needs to be removed if it has ruptured essentially the only thing to do is to go to surgery and to kind of get rid of the part that has ruptured um which means women often lose a fallopian tube and then it's a lot harder for them to conceive again after that and they are also at risk of having more ectopic pregnancies because of the surgery, so it's quite a vicious cycle that goes around, um but I said this is always something that needs escalating to a senior. You know this is a very specialist thing. It's a very specialist surgery and yes it's relatively common, but it's not something that can really be managed by anybody below a registrar level, so always always refer this up as quickly as you can in the noski, it would be I would get a senior, I would not do anything else, I would get a senior and I would ask them to have their input on the conservative, medical and surgical management. VCU then as I said it's always a risk. It's a hypercoagulable, states there's about five times increased risk of having a blood clot in pregnancy than there is normally. Um a. P. Is actually one of the leading causes of maternal death in the UK, so and about half of those a current postnatal, so it's not just the 1st, 2nd, or third trimester problem. It's it you know can go on postnatally as well, um so it typically would start with a DVT a deep vein from both, this commonly in the lower leg veins in the calf, so they might present with car, swelling, pain every theme or warmth. All of those kind of tell tale signs and then that can spread a part of it and um part of it can break off and then travel to the lungs and cause the pulmonary embolism in the lungs, um which can it can go from a very small clot that dissolves quite quickly with the molecular heparin or a big saddle embolus, which kind of goes across the entirety and makes it really difficult for people to well do anything and it can cause death very quickly, it can cause death because it's hypoxia, so it's treated with treatment dose low electronic heparin, which depends on the patient's um creatinine clearance for their kidney function and also on their weight depending on which trust you run urine it could be dealt, a parent or a knox paren, and their dose slightly differently, but low molecular weight heparin is what you need to remember um and where possible teD stockings should be used, so we're not going to prescribe women's head stockings. When they go to their booking appointments, they wear them constantly, but when they do come in for any kind of procedure and especially when they come in to deliver, they will be at least offered unless there's contraindications and prophylactic lomb elektronik heparin. If they have a lot of risk factors, um So these are the official risk factors from this nhs with the document so antenatal e. A. B. M. I. Of more than 30 age of more than 35 more than three um more than three children or three births or being pregnant three times um a smoker having varicose veins. We know that it's varicose veins aside from pregnancy is also another big risk factor for having a DVT because of the turbulent flow of blood. It's not a land on a flow, it's very turbulent that could be stasis um any previous or current issues with blood clotting being a mobile which could be from any manner of reasons, antenatal e, um family history of unprovoked or estrogen provoked VT, so what estrogen provoked means is being on estrogen related contraception or being pregnant, and that was what caused the VT to happen in the first place, low risk thrombophilia multiple pregnancy, and IVF. All those postnatally, very similar things um Current systemic infections, So once you know after delivery often not often, but it can happen that women can get infected with korean United um and that is another big risk factor for this um preterm delivery in this pregnancy, not in previous pregnancies in this one. Still birth um any kind of operated operations, any kind of operative delivery even like just want to use or four steps or anything that you have introduced, um could introduce infection and could cause moist juice with blood clotting, prolonged labor, postpartum hemorrhage, having a blood transfusion, being a smoker. There's so many um but essentially if you have more than four then the patient should have prophylactic dose low molecular weight heparin for from the first trimester, three, prophylaxis from 28 weeks and 2, 10 days postnatally, so really everybody will get it for 10 days person lately um okay, and as I mentioned earlier with the preeclampsia risk If they're at high risk of preeclampsia, then they'll get started on aspirin around 12 weeks, but they can be on both okay, so second trimester complications, so preeclampsia, just angel, diabetes and again, vt we won't go through, viti, again, I just put it on here to make a point that it is kind of always an issue, so preeclampsia is do well. There's there's lots of different types of thought, lots of research that's gone into it. We don't have time to talk about now, but it is essentially due to inadequate remodeling of the spiral arteries, which causes a high resistance and reduced flow through the presenter because the walls of the artery still have really constrictive muscle, and that that resistance and that strength is maintained, where it shouldn't be um so inadequate remodeling of the spiral arteries. It's diagnosed it has to be at more than 20 weeks gestation. If it's high BP at less than 20 weeks gestation, it's just hypertension, it's not preeclampsia because it hasn't progressed to that stage yet so the bp has to be above 100 and 40 systolic and or 90 diastolic and at more than 20 weeks gestation with at least one of the following so high bp and one of these typically it's protein urea that's pretty much if you if you go to a pregnant a pregnancy clinic and you see preeclampsia patient's or at least people being screened for preeclampsia that that is the most, it's the easiest way to do it, really because the urine dip takes a few seconds and it's very quick to see blood test can take some time or any other kind of sign of kidney injury, so lymphocytopenia, elevated liver enzymes, which we'll talk about more with help syndrome, in a second adama, pulmonary or peripheral headaches that are resistant to medication and new onset visual disturbances. Now, often people have the majority of these they might present. Their first presentation might just be with a headache and then when you probe them, they say oh yeah I've had a little bit of swelling in my ankles and yeah I do get a little bit of funny vision sometimes. Um So you have to really probe to talk about all of these things, so you can't ask them if they have elevated liver enzymes or from beside the pedia, um but you can ask about the other ones management, then anti hypertensives really is the main thing the beetle or is the first line um past that nifedipine. If it's going to be for somebody who's asthmatic or allergic to be two blockers. For some reason, um regular follow ups are really important. It would be a consultant led um pregnancy and delivery essentially, and they will be safe to get it and given lots of advice to come back immediately. If they have any of the following symptoms, it become really unwell. Education is really important because with these aren't in patient's, you can't watch them and monitor them constantly. They need to be able to kind of monitor themselves at home and know when to come in to reduce the risk anticonvulsants. We don't give automatically if they are at risk of it developing to eclampsia, which is when you start getting seizures, then we can start using anticonvulsants, but it's not something that we routinely give to everybody. We don't say here your your you have preeclampsia, have the labetalol and have magnesium sulfate and off ago it's something that we really save until eclampsia. Um If premature delivery is likely and we'll talk about this a lot. When we get to the third trimester complications, but I am cortical steroids will mature the baby's lungs, so if at any point you think ok delivery could happen soon and it's premature, I am cortical steroids, maternal cortical steroids will be specific. Delivery is the only definitive management and like I said earlier, there's certain reasons to induce around 37 weeks and this is definitely one of them if the pre, if they've gone through pregnancy with really no complications and they just have a high BP and protein urea, and they don't need any medications or anything to support it, then they may be able to go on to have a natural birth that is not induced. Um It really does vary case to case, but if they were to ask you in a noski, it would be that the advice is to induce at all just before 37 weeks to prevent complications. Really, it's a consultant decision with input from the patient. Um yeah these are the medications that we can use um from teaching jobs and go, any, which is fantastic. I definitely recommend so louisa was the first time which is a beta blocker, but it can cause postural hypertension, which is probably the biggest issue with it, especially when in pregnancy. You're kind of prone to that. Already fatigue, headache, nausea, vomiting, epigastric pain not suitable for people who are asthmatic, which is why nifedipine is also a good option, calcium channel blocker. It can make peripheral edema worse, though which is not great because they may already have peripheral edema from the preeclampsia itself, and the methyldopa really very rarely used as alpha agonist has a lot more side effects than the others like hepatotoxic toxicity, bradycardia, uh gi disturbances, edema, headaches that it almost can essentially worsen the symptoms whilst making the BP better, which is you know you can argue which is better which is worse. Ace, inhibitors are contraindicated in pregnancy because they are, they are teratogenic, they're associated with congenital abnormalities and yeah like I said in women who are asthmatic or diabetic, the beetle would not be the first line, so I would know the 1st and 2nd line for that. Michel doper honestly, I wouldn't worry about too much so help syndrome, then is hemolysis, elevated liver enzymes, and low platelets. So that's I think it's quite a handy new monitor have, which is a complication of preeclampsia um and some patients may this may be their first presentation of preeclampsia. You know you go and have a blood test and this is what you find um they can get abdominal pain with this especially right upper quadrant pain as you can get liver distention, elevated liver enzymes and liver distention and liver damage essentially, and you can also get shortness of breath. For the same reason, is you've got a very full abdomen. They may need a blood transfusion. Again definitive management is just delivery you really can't fix. This is not a fixable problem, It's a problem that will go away once the placenta has detached, and it's no longer the spiral arteries that have not remodeled properly are gone and not causing any more problems again like inducing it really is, it's a big decision to make about whether you induce earlier you wait. Um There's risks to both there's benefits to both, and it's just a conversation with the patient and with, were probably the consultant as well about when makes the most sense for that particular person, so an eclampsia is when you get this onset of seizures, which can lead to loss of consciousness. It can lead to prolonged loss of a lot prolonged um comas and eventually it can lead to death. It can be fixed um so in people with pre eclampsia, about one in 200 people, so about 4.5% would actually would be affected by eclampsia. Um Risk factors are very similar to the risk factors for developing preeclampsia anyway, um So chronic or gestational hypertension and gestational hypertension is just BP that is high before 20 weeks of pregnancy, that was not there before, over 35 years old or less than 20 years old, having a multi multiple so twins, triplets, etcetera, first time pregnancy, diabetes including gestational diabetes, any kind of kidney disease, any kind of disease affecting the blood vessels. Um There's lots of different risk factors um but essentially for the seizures like I said earlier anticonvulsants, magnesium sulfate really the first line that we talked about. Um This is very severe. This should never in a country with such a thorough screening as long as the person has gone through that screening, they should really never happen. We should be on top of it by their 20 week appointment or they're 28 week appointment. They should be on anti hypertensive. They should be on constant monitoring and they should be aware of when to come in and then they should be induced before this happens, so it is very rare that it actually does happen. It might affect somebody um but it being allowed to go to seizures and loss of consciousness is very rare, okay, so gestational diabetes, then if any degree of glucose intolerance that started in pregnancy, which is why it's important to make sure that you've got blood kind of from the beginning from the booking appointments all the way along incidents is increasing. Actually, I you know there's a lot of different studies and there's a lot of different incidences, but can be up to one in five in the uk in pregnancy. There is an increased insulin resistance under progress, progressively increasing insulin resistance, so at the most, the insulin requirements increased by about 30% which is a lot and some people just cannot keep up with that need and so you end up with hypoglycemia because of insulin resistance, but it is not insulin resistance that would normally be there if they weren't pregnant, so people who are a higher risk, higher bm i, somebody who's previously had gestational diabetes or macrosomia, so very large babies before family history of diabetes um and typically present for the very same beeches as type one or type two, though diabetes, polyuria, excess thirst, fatigue, weight loss you can also get thrush, flood eyesight. I mean that's going quite beyond and going quite late signs, um but it's very it it will present in the same way, the only difference being that they're pregnant, so it's diagnosed with the oral glucose tolerance test, so fasting glucose measured so 10 8 to 10 hours we're not eating fasting glucose, serum glucose is measured, then they're given a drink that contains 75 g of glucose and then after two hours the glucose is monitored again so to diagnose it both of these must be present, so fasting glucose above 5.62 hours post oral glucose above 7.8 and it's really annoying because they are not easy numbers to remember um but the way I did it was 5678, so 5.6 are fasting and 7.8 for two hours post this test is offered at booking. If you have previous history of g. D. 24 to 28 weeks, if there are risk factors or at any point, if there is glucose in the urine more than once because, if there's glucose in the urine. Once you know, it could be due to any number of things, but if it happens more than once, then you want to be testing for this management and the first line is lifestyle and diet advice, which is difficult to do in normal diabetes and incredibly difficult to do in gestational diabetes um medication starts with metformin. Really that's the one we want to keep it at, we don't want to move it from anything else um because that's the most the one that is safest for pregnancy and for breast feeding and just generally it's the best one to use, but we can move on to other things and it can eventually go on to insulin, which may be appropriate if the fasting glucose at this screening at the oral glucose tolerance test. If it's over seven at screening or pre meal is more than six and post meals more than 7.5, then insulin you may just immediately start with insulin to bring it down delivery. Unless it's only managed with lifestyle and diet advice. If it's managed medically at all, delivery should occur between 37 38 weeks to avoid complications. Macrosomia, so a big baby, essentially such shoulder dystocia. The baby, the baby getting stuck is a really big risk and it's it's a big risk to the mother and it's big list for the baby and it's definitely a situation, nobody wants to be in. Essentially if you don't know it's the shoulder getting stuck, um so the head delivers one arm usually delivers and then the other shoulder is stuck, it just can't get through and there's really not many options at that point, if the mother can't you know kind of push it out and we can't get the shoulder out, it becomes a very dire situation. We really want to avoid that as much as possible without treatment. So, if it's just lifestyle and diet advice, it's just the normal delivery before 40 plus six, just to avoid the microsomia issues that might be there anyway, even if you if you let any pregnancy go on for too long, you'd have issues with big babies. Um You test them again 6 to 8 weeks, post pass them and then test yearly. If that one is normal, it is about 50% of people with gestational diabetes, will go on to develop type two diabetes later in their lives. It's important to keep testing them yearly to get on top of that early and if they have further pregnancies and they need to be tested for this at booking really okay, so third trimester complications, we have the central complications, obstetric prosthesis, premature labor, and again, VT, which we won't go into again, just making that point that it is constantly a risk, so when we talk about placental issues, placental, placenta, previa, and placenta abruption is really are the ones that come up in our skis and in written exams again and again and again for central abruption is when the placenta partially awfully separates from the uterus before delivery, so that's meant to happen after the baby has been born and then the consent to is delivered that it is something that is supposed to happen but it's happening too early and it reduces or completely cuts off the supply of oxygen and nutrients for the baby and it will cause bleeding. So typically you get really horrible pain and I don't know why it's described like this in all of the text books and all of like past met and everything, but it's described it described as a woody you, too it's but what they just mean is hard tense. You know you touch it and it, it feels I guess like wood Pv bleeding and you will often get maternal and fetal compromise, so reduce fetal movements is quite normal, so you could get somebody coming in. Saying I've had a lot of bleeding, I've got a lot of pain in my tummy, and I haven't felt the baby move in a couple of hours and it's really barn door for percent of eruption. The cause often we don't really know I mean trauma is a big cause of it. A rapid loss of amniotic fluid can be part of it, um but usually it just kind of happens. We don't really know why and we don't really spend a long time hanging around to figure it out. We just treat so hypertension and obviously then preeclampsia, So you know an extension of that is a big risk factor saying that help syndrome having an abruption previously, trauma as I said smoking premature too, early rupture of membranes and calmly, and amnionitis which kind of goes hand in hand with that, which is the infection that you would go as a student or junior or anyone who is not a specialist, you would not do a vaginal examination. This is just likely to encourage more and more bleeding and you just make it worse. Um So really all you're going to do is get senior support and you can do an abdominal not a trans vaginal ultrasound and abdominal ultrasound to assess the state with the baby. While you provide resale support to the mother, which really is probably the main point for you as a junior when you're coming towards something like this, you know, your main thing is going to be to resuscitate the mother likely in a hypovolemic shock. You're going to need to treat that there's different types there's revealed, and there's concealed, so revealed is where you get lots of PV bleeding because the blood can travel through, can travel down and through the cervix, and then you actually see the blood that is coming out concealed, though is a little bit more dangerous because you might not pick up on what's happening until it's very late. So you little or no PV bleeding at all because the blood is kind of accumulating behind where the percenter is peeled off and it can't go down to the cervix to come out and so it kind of just stays there and you can get a retro placental clot essentially that forms there and you just don't know what's going on until you've done an ultrasound you just have a patient who is very he's hemodynamically unstable for a, you know unknown reason, so it's important to remember that it doesn't always present with bleeding um maternal complications like I said hypovolemic shop emerge. It's an emergency situation. Regardless, so you're gonna go through your rater. We probably need blood transfusions, lots of fluids, um a medical emergency, or an obstetric emergency. We probably need to go out at this point, so it can lead to death, probably much off, completely bleeding out fetal complications. Are you know there's lots, but these are the main ones growth restriction because you're reducing the nutrients and that is going to that baby, but realistically that's not the biggest problem premature birth and stillbirth are the biggest things with this, So, I really the only thing to do is to deliver the baby. C six c section is pretty much the only management for this, so placenta previa is slightly different. It's a presenter that is low lying that either partially covers or completely covers the cervix, So minor is when it doesn't cover the cervix at all, It's just very low and major is when it completely covers the internal cervix, It's a big risk factor for bleeding at any point during pregnancy, um but especially after 24 weeks. Risk maps for it's a previous C section and you've got all that scottish in the adhesions, any kind of previous abdominal surgery, Ivf, so assisted conception multiples twins, trip that smoking more than 35 years old you can really see a pattern. I think in these risk factors, they come up again and again it's also associated with placenta accreta, that just a not a creech, sorry, but that percent to recreate, So there's different there's different um severity of it, but essentially it's when the placenta grows into or through the wall of the uterus, so it shouldn't be growing into the wall of the uterus at all. It should just be attached, um but this is when it kind of grows too deep, um and then it can't fully detach after the baby has been delivered, so some of it might come away, but then you'll let you left with some placental tissue that would just bleed and bleed and bleed. Um So it's a big issue with postpartum hemorrhage is specifically um and placenta previa is really for a reason that I don't know they might be a specific reason, they are quite linked. So whenever you're speaking to somebody about a low lying placenta placenta previa have it in the back of your mind that actually they might have the creature as well. Um With these, patient's always send a cross match slash group and save when they are admitted um for anything, if they're admitted for pv bleeding, cross match group and save, admitted because they're in labor, cross match group and save um which is to get their um uh cross match is about getting blood quickly um So it identifies their blood group, allows you to order how many units you want and we'll get it sent to group and save it's just about finding out their blood type, so cross match is kind of an urgent one. I need blood now and group and savers. I want to know what their blood type is for later on. Um These patient should have a C section for safety because labor, unless it's a minor like, I said earlier, a minor percent a previous, that's not covering the cervix, you're likely going to need a C section because as soon as you go into labor. If the service is fully covered, I mean firstly the baby can't actually get through, but the contractions are going to kind of be squeezing it and you would just bleed C sections as well are also very risky because if it's a low relying anterior percenter, then it's completely covering where we would normally um operating where the surgical site would normally be, which is where sometimes they might do a vertical incision rather than what we would normally do. Um If symptomatic easy bleeding, we aim for delivery actually really early 34 to 36 weeks, which is what we call late preterm. Um It's probably one of the earliest deliveries that we suggest because there is just such a high risk of severe bleeding and then the compromise of both mother and baby. If they're a symptomatic, we can maybe leave it 36 or 37 weeks, but definitely not leaving getting longer than that and this is another situation where you definitely don't want to do a p. V. Exam, a pv examine placenta abruption is bad. A Pv examine placental previa is deadly because you are essentially probably going to irritate and touch the bit of the the center that is bleeding and just make it worse, so again senior support, resuscitation of the mother, checking um doing an abdominal ultrasound to check the status uh of the baby and then going from their senior support incredibly important mhm, okay, we're nearly there obstetric coolest ASIS intrahepatic cholestasis of pregnancy is a liver disorder where the flow of bile is restricted. It is uncommon. Again studies differ, but it can be between two and seven out of 1000 pregnancies, so it really is uncommon, presents with really you'll just get a patient saying I'm really itchy and they might also say oh and my partner thinks my eyes look a bit of a funny color that's your typical Loski presentation um and it's because of the bilirubin that's building up so they might have jaundice, very itchy skin, but they won't have a rash. They might just have marks where they've been scratching, nausea as well. And then all of the signs of obstructive jaundice, so pale still dark urine, extreme fatigue, right upper quadrant pain because of the nausea, very likely reduced appetite as well. It's increased levels of estrogen progesterone in pregnancy that can affect the liver's ability to transport bile and the liver is processing toxins from the maternal and the fetal circulation, So if the maternal liver is not doing so well, then it can play stress on the fetal liver. It's very complicated there's much more to it than that, but this is all you really need to know. It's treated with something that I've never been able to pronounce, so I was very glad that it didn't come up in my oscopies, earth, so deoxycholic acid, um and it improves the flow of bile and it reduces the flow of harmful bile acids across the percenter. Um Really that's the key that's the catchphrase you need to learn how to say so deoxycholic acid. I might not even be saying it right google. It find out um there are also other medications that can help with the itching and the nausea, so antiemetics, anti histamines, but again it's that risk benefit of, is it safe for the baby, or is it is it is the risk of a mother higher done that risk, labor will likely be induced about 37 weeks. It's very highly associated with stillbirth and fetal distress at birth and meconium aspiration. If it's left later than 30 several weeks, ok premature labor is labor before 37 weeks, so they may present with contractions, so severe abdominal pain associated with contractions, any kind of TV discharge, which could be amniotic fluid, so they're water's breaking before 37 weeks. Again, corticosteroids given to mature the fetal lungs, so I am corticosteroids, maternal corticosteroids to call ISIS is when we give medications to try and reduce or stop contractions. It is not used commonly. It's used in a patient's who have a lot of risk factors and are very very premature Because if if they're 35 36 weeks, it's yes it's premature, but it's late preterm, it you know it's safer to kind of just go with go with it and not try to stop it, but 24 to 26 weeks or 26 to 34 depending, if the membranes are intact, um that's when we kind of start to panic a bit and we want to slow it down and try and keep the baby in there for as long as possible, um so nifedipine for 24 to 26 weeks. If the membranes are so, the waters have broken, but you can use it up to 34 weeks of the membranes are still intact. Always look for signs of infection. Because if the membranes have been ruptured for a long time, there's a high risk factor there's a really high risk of getting an infection and a lot of people don't realize that they're waters have broken because they think I'm only 28 weeks of course that wouldn't happen, I must be having some discharge and then they only present when they start to get pain and at that point it could be a long time since the membranes have ruptured. I'm sure that everybody is informed about what's going on um the risks and what will happen during their labor and the immediate and then immediately what will happen after that, So I think a lot of people are going to come in and they're gonna be very scared about what's happening, it's not time for this yet um And they don't know what's going to happen but actually there's really good outcomes from premature labor now. Um You know even I think gestations of 22 23 weeks have survived um which you know. It's kind of passed our point of viability where we kind of talked about 24 weeks, but babies born younger than that are kind of some of them are surviving, so it is a positive outlook. Obviously, there are other risks associated with preterm birth, but on the whole, the outlook is quite good, so make sure to don't overly reassure, don't promise anything, but make sure they can put their mind slightly at ease, explain everything that's going to happen explain to the best of your ability um or get it obviously get senior to do it at our level um what might happen next, especially talking about what might happen after the baby is born about the pediatric team being there about, maybe going to the like you and all of these things uh Very quickly, we're not going to talk about them in depth, I'm just going to quickly listen postnatal complications again, v. T. Like, I said earlier 50% of those fatal ps occurred after delivery. Postnatal depression and psychosis is a really important topic. Make sure you go and read up on it. There are some antenatal psychiatry clinics, I think I wasn't they were online When I was doing my um psych placements, I don't know if they're still happening, but that they're really useful to have to listen into infection's not just infections related to directly to delivery, but UTI as well are very common severe bleeding, So postpartum hemorrhage is when you lose more than 500 North blood, which is a significant amount of blood um and then you can also have other things like breast feeding problems like mastitis, etcetera, So there's lots of different postnatal complications, which is probably a different talk. Um The v. T. Comes up all the time okay, so sorry that was definitely a whiz through all of those things, has anyone got any questions before we go on to a quiz. Yeah no cool, I'm gonna stop sharing this screen and I will share the cahoots so if you haven't used to who before, essentially just go on your phones, typing cahoot, and when this um when I share my screen, it will give you a code and you just put that code in what's happened. There's a question in the chart um something I read somewhere that babies are still at risk of the camps here following birth. Why is this the case, so the babies aren't at risk of the clampsia, but the mothers are um it's because at that stage, it's kind of yes, Sir percent has kind of been delivered, but the effects of the high BP have already taken place. The end organ damage has already occurred, so you can get rid of the presenter and get rid of the actual problem, but the effects are still there all right let me get this slipped id one second uh mg, where is okay maybe that would work now okay, let me share my screen on the new one and hopefully that works sorry everything is taking ages to load. I definitely need a new laptop. It's past its expiration date, can you see that yes you can it's dulera, yeah okay, so it will play in classic modes. If you go to cahoots on your phones, this when it loads the game, pin will come up there and then you'll all join this and you'll just use your phone to tap on a multiple choice multiple answer question. Um It's quite good fun if you haven't used it before. It gives you like a leaderboard and certain points if you answer quickly um. And then you get more points, there is no prize sorry the prize is knowing that you listened and you know a lot about pre pregnancy complications. Oh I like the mascot, so I haven't seen those before. Actually they're quite cool cool. How many is that I reckon that's probably as many as we're gonna get nine oh No maybe a few anti d. I like that we did talk about anti d a lot fetus nice oh all right let's get started with it then uh so the question should come up on your phones and on here as well so what must the bp be above two classes pre, accounts, yeah I've been um it mean here, cause I've given you all very similar values oh, perfect yep, everyone got that right 100 and 40/90 well done, very nice, very close so what other features must be present to diagnose preeclampsia as well as that bp over 100 and 40/19. Yeah exactly so, I have kind of tried to trick you and it worked. At least one of all of these protein area is the one that is most common, but it can be multiple things. It just has to be at least one of those plus the high bp, yeah, so what is the first line medical management of preeclampsia. Perfect yeah labetalol, so ramipril is completely contraindicated because it's an ACE inhibitor and it's got teratogenic problems. Nifedipine is the one that we use second line if they're allergic or diabetic or asthmatic, ramipril don't use in pregnancy. The only other one i can think of at the time oh it's the help is still winning, so what's the purpose of getting maternal cortical steroids in premature labor. Such delivery. Hopefully, that one started to be fair, I've tried not to make them too difficult, yeah, exactly so the maturation of the fetal loves okay, so what fasting glucose level was diagnosed. Gestational diabetes with obviously the oral glucose tolerance test yeah well done. Most you, there. Um Again, I've been mean because I've put very similar numbers altogether, but yet 5.6 is the fasting glucose level that would give you half of the criteria to diagnose gestational diabetes and then of course the next question with the other half, so now fetuses winning, so then what is the two hour post or glucose result of the diagnosed gestational diabetes. As long as the other fasting one is also yeah perfect 7.8. So you remember it, but the by saying 56782 fasting 5.6 post two hours post or glucose 7.8, water very nice and it's very close at the top, so what's classed as a major percenter previa, yeah fantastic, so it's fully covering the internal cervix, so it would be minor if it doesn't fully cover the internal cervicals um and a high presenter is what you want to hire an anterior, I mean high impostors will be a little bit better because only really for the reason that it's easier to scan them and then if they need a c section, you're less likely to make the presenter cause bleeding so high and posterior is what we prefer. A low lying placenta is not is an issue. If it's very close to the service that would be you know minor because it's not covering the internal cervix okay. Nearly there questions seven, so how is cholestasis of pregnancy treated. Yeah exactly so, deoxycholic athlete perfect Yeah, immediate delivery is not needed, so 36 to 37 weeks when we would likely induced or do a c section, lifestyle advice and I mean they might be advised to not not to eat such fatty foods like you would if you had any kind of gallbladder bile disease, so not to do you know, it's kind of like a p. P. I wouldn't do anything okay. Last few questions so when, is labor classes premature, Yeah yep exactly before 37 weeks okay, last question so Kinney is still winning so when is v. T. A. Risk for pregnant pain that's pregnant, sorry, yeah yeah absolutely well done. It is always a risk um throughout all the trimesters and postnatal, some people like to call it the fourth trimester In terms of being put the early postnatal stage, but yeah always a risk, nice. I try not to make the questions too tricky because I know it is late on a tuesday and you just listen to me talk for an hour, so in third place is K second is my rock and fast kini, nice, well done. I like them did you get to pick your character's they're very cool. If you did the penguin the hat cool all right, we will leave that be let me stop sharing my screen well that's cool. Actually, I didn't see that 76% correct. Every question was answered correctly by most players very cool. This is a really good way of learning like if you get bored with the learning that you're doing just doing, passed it or whatever if you make a cahoot quiz and you go and do that with like your work your um study friends or something and you take it in towns making them it really is good fun um all right, so we've gone slightly over. I hope that was useful. I know it was a lot of information quite quickly, um but I'm happy to be contacted about any of that stuff or just medicine or life. In general, I did put my email on the slides, but I'm not showing them anymore, but it's just madeleine dot whitcomb at any chest or not dot dot net You can have the slides If you like but pretty much all of it is on the teach me obs and janie website. It's the same company is teach me anatomy, whom I relied on very heavily in 1st and 2nd year and they they have um created loads of resources for all the specialties, so I'm definitely going to have a look at that cool. No problem. Thank you all for listening to me. Thank you so much for delivering the session, taking your time out, they really appreciate it and I'm sure everyone found it useful. I found it very small, self good. I hope so yeah and uh all the students thank you for joining in. We've got another session next week um on infertility and uh hopefully uh we can see you guys then as well cool. Thanks, everyone have a good evening too, bye bye.