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looks really flop. Uh, I think we might be life now and let me just see if we've got any Put the order 20 name, Hopefully second. Okay, but we've got quite a few people joining in. And can we just check if everyone can hear us? If you could just put on the check button to see if we can be heard? Yes, we can be hurt. Okay, so we'll just give it a couple of minutes about two or three minutes. Helen, if you want to just try and see if you'll presentation. Can be said it could represent now. Yes. Can you see that? I don't I don't see it. So and what? You can do it if you just press a prisoner and then try and see if it's your window. Shall we do with something? He, uh, answering the chef when they're it Doesn't leave like more permissions or anything. Does it like recording or anything? No. Long as you done the first one. Yeah, well, maybe I'll just try and tie a screen, see if that works. I don't know. Yeah. Uh huh. It's not doing anything now, you know, if you just try and, um, do your preferences again and then just cross out the whole problem, and then you come back on my little ones. You have to get rid of all the other car. This is the only one open, actually. See anyone, um, hum whether to try doing on safari, you will. That work? Oh, no. I'm going cold. So I'm not sure why it's working again. If you just try your preferences thing again and then just exit this whole thing and then just come back. Um, just waiting for a few more people to come in, okay? Yeah, yeah, yeah, sure. Here. Okay. Try and see your present. Now it's working. Perfect. No, it's I don't know what happened. That I didn't even change anything. I think it's just crossing out the whole thing and coming back in again. Yeah, Okay. Right. And just okay, we've got, um quite a few people attended already, so we're going to start the session now, So good evening, guys. I'm different. One of the option go. Any leads for mind the beep. We've got a doctor. Helen Peri, with me. She's there s t three in option Tiny, one of our Northwest trainees. Helen also that have foundation years in Western hospital. So she's going to be talking about early pregnancy, you know, combinations that we see. You know, I think I need especially now gynie units on without further ado. Take it off balance. Thank you. Oh, I'm sorry. One thing if we can just call it all our questions at the end and then Hello. Well, Highland want answered them if there's any questions at Helen's asking during the session prefilled for you to put the answers in the check box. Okay. Thank you, everyone. Okay. Um, good. And again, Um Okay. Hi. So, yeah, I'm on, um, salad. I'm coming in ST three office and gynie in Wigan Hospital. Um, so this session is just about early pregnancy and the kind of things that you might encounter. I understand that most people kind of s h o issue level. So there is a chance you might be, um, either another gyne Think so at some point for your foundation rotations, Or if you do gp training, then also, you come to the office and got any quite a lot of the time as well. Um, or you might be in a any or in GP, where you'll see women who are pregnant in the early pregnancy, and these are some of the kind of things you might come across. So hopefully it's helpful. I'm just a run through the kind of common things you might see in early pregnancy. So it's going to start with, like, basic principles off seeing a patient in the early pregnancy. You know, I know in med school we like we got talk a lot of different things that that we need to ask pregnant women. And it's quite complicated, really. It does boil just down to a few questions that I have a key question. So that's what we call here, so well, it's ah, stable is whether they're in any or GP basically. So the first thing with any patient, of course, is like, Are they stable? Um, with a pregnant person in particular and early pregnancy. Oh, someone saying this later? I wasn't working. It's not correct. Um, and, um So, um, yeah. So if someone were seeing someone in the early pregnancy, I think I'm sorry, Helen. I think if you just come out of power point and go back on this white show again. The secrets. Yeah. Now, do you want to just open up the the whole power points light? Show them I open it from here. Uh huh. Because it is it working now. And it's more fun to basic principles, if that's where you are. No. Is that and then did something just turn? Come on, then. When I pressed or no. And I think because it's not a nurse light show its on just like a and like when Power point. So, I mean, I just need to click your we can see you were on your power point screen, but no honest like show. Yeah. You know, um, we've got some one thing. If you press that that button it will present present it is that better? Just press five. Okay. Thank you. Food. Welcome to voiceover voices. The voiceover quit. Start practice, everybody. Location. Palestine's early voiceover off. Oh, my gosh. I'm one of those people. I was used to think with those stupid. They can't use powerful or anything. Welcome to voiceover. Voiceover speaks prescription. Not working occasionally. Just do it with, um I'll just do it like this. I guess Yeah, yeah, it's just me of those. So you don't get previous all those things. Okay, What is the one here? Um, fine. So the basic principles seeing if a woman in the early pregnancy, um, so, um, basically anyone you seeing in any, of course it was going to check. She's stable. With pregnancy in particular, you're always going to check the first thing you want to know. Early pregnancy is, um, when the last menstrual period was Just so you can know roughly how many weeks years, so it doesn't have to be, like, exact or anything. We're just roughly how many weeks did she think she She is pregnant? Basically, Um, another important question for a woman who's in the early pregnancy is if she's had a scan. Yet this pregnancy was she's had a scan than, um, much more likely to, um, I know exactly when how pregnant she is more reliable than the LMP. And of course, that also tells us the most important thing in early pregnancy Is the pregnancy in the uterus. Or is it not? So? That's kind of the main thing that we are worried about. The early pregnancy essentially, Um of course, with any history. Um, just asked generally with symptoms. What? She's come with examination for someone in the early pregnancy. Up do exam, depending on where you are. If you're a any s h o, you're probably not gonna do the speculum and by manual. But if your office and I need shor, then you would definitely be doing a speculum and by manual, um, and then just thinking about what further investigations we need to do or if you're in any or GP whether you need to refer the patient, too. Office and gynie Um, yeah, well, there's going to defend their swabs is going to depend on exactly how they've presented to you basically, So that's kind of further in the further investigations, um, so further investigation or things you need to think about in early pregnancy. So there's the usual things you always have to think about course. You know, if you're seeing someone in any, do they need bloods on Gilenya cannula with a pregnant woman? Very important, always to do a pregnancy test. Always, she may tell you she's pregnant, and she may not be pregnant. She may not think she's pregnant, but she is pregnant. Very important to do a pregnancy test in anyone who is, you know, whatever. 12. 50. Very important. Um, on then Yes, it has. You had a scan. If then this is going to depend on what kind of further management you might take from that point onwards. So if she has had a scan before, you know, depending on why she's come to you, she might need another scan if she's never had a scan. The most important thing is to do a serum hcg. Because then this is where we get our starting point about how many weeks this lady might be. Um however, if she has already had a scan that shown alive into you tried pregnancy, do not repeat hated JIA this point, um, hated the levels start to drop after about nine weeks. So if, um, if we're doing repeated Haiti geez, in someone who's over nine weeks, we may see the heat's you dropping. But that actually doesn't mean is anything wrong with the pregnancy? It starts with the natural curve off. Hated he at that stage. Um, so hey, jeez, really only useful for very early pregnancy. But when was someone comes to any or GP or to our unit. We don't know how many weeks she are. She is. We need to start with a C G. Okay, so I'm gonna kind of work through cases. Um, I think that makes it it clear of exactly what we were doing. Really Situations. And all the cases from this presentation are really cases that I've seen over the years. So hopefully they do make some sense. Um, fine. Yeah. Um, so first case. So, um, the 24 year old female goes to a any she tells you. She's about six weeks pregnant on she's come with lower abdominal pain on P V bleeding. So what? While we're thinking could be going on with this lady on what further questions might you need to ask her to get a bit more of a history? Really? Just watching the chop box. Yeah. Um, topic is always Yeah, more. That's the thing. Ever were all the most worried about a topic, but was getting miscarriage. Yeah. These are probably the main two things that we're going to be considering. Um um, it could have infection as well. That's that's true. Yeah. Um but so the other, the main things in it. But obviously we're gonna need to Yeah, abdomen pain. You could have a UTI. That's that's true as well. Don't only give you bleeding as well, but that could just be incidentally at the same time, it's always important to think about other reasons why pregnant we might have abdominal pain. That's very good. It does happen sometimes with the abdomen. Pain might not be an ectopic. Maybe it's appendicitis. You come because things can happen at same time. Um, so basically, when you get a bit more history doing because lower abdomen pain and be bleeding is that VEGF? Really? So this work better when it was a slideshow? But anyway, you got all the answers straight away. So first thing we need to ascertain is she definitely pregnant, so we definitely need to urine pregnancy test. As I said, it sounds very callous or heart or something, but essentially, you cannot trust anybody about the pregnancy status. Very important to do a urine pregnancy test, whatever they tell you, do it Anyway, Um, if you can tell you exact last menstrual period brilliant, then you can get an idea of 100 weeks. She is, um Has she had a scan yet? This pregnancy, always. I'm obsessed. Did that. Um, generally, you know, she's got pains. He gonna do a Socrates. You're gonna try and quantify the bleeding. Eso Is it heavy? When did it start? Is it fresh red? Other clots? Have they seen any products of conception? They may not have any idea about that. Um, but, you know, sometimes they will come and tell you they think that's what they've seen. Um, on then, any associated symptoms. Some things like dizziness, collapse, politicking, shoulders, hip pain, things like this on then, of course, you're gonna do an abdominal examination, and then if you're not gonna you're gonna do speculum by manual. But if you're just on any problems going to stop it up, Donald examination. So for this lady. So she did have a positive pregnancy test. That was good. Um, yeah. Any fellas know. Yeah. Yeah, maybe. But, um, there's unlikely to be infected at this earlier stage. Bought. Um, you know, you can ask them that question as well. So, um, your it actually had blood in the urine dip. Only showed blood, so no specific signs of a UTI um, last menstrual six weeks ago. She has not had a scan yet. Um, she's had the lower abdominal pain for about a week, gradually getting worse. It's moderately painful. Super cute, super pubic and crampy bleeding again. Also for about a day, um, fresh red getting heavier now. Very heavy changing parts flooding. So a good way to try and quantify leading is to ask how many times they are changing their pads, but also when they changed the part, Is it full? Um, flooding is another good question as well, because that is signifies definitely heavy bleeding. Some women will changed the pod very frequently, even if there's not much on it. So just the fact that changing pads may not mean anything, but if someone bleeds so heavily that they float through the part, then that is a lot of blood. Um, she's so she's mildly dizzy on standing, but otherwise she's okay. Abdomen soft is a bit tender, but no guarding. You can see. Um, you know, doing your overall inspection that there is some blood staining on the trousers, so that kind of makes you suspect the Yeah, Okay. She is bleeding pretty heavily, actually. Um, BP is on the lower side, but, you know, depending on the person that might be within normal range again. Heart rate a little on the high side, but not too bad. Or the robes. They're okay. So you're the an E s h o. What are you going to do? No seeing suggestions in the shop box? Yep. Definitely IV access. Both groups say I'm glad of one. Same group of say, that's very good. That often gets missed in a in a PSA group is a is very important. See, she's bleeding, so, you know, you should might need to have some blood. Potentially unjust. Yeah, IV access to school because it just sound like a family. Have you bleed? And the pressure is on the lower side. So I agree about that. Um, we don't generally give t x A in the context of a miscarriage. Not usually, but you could do it. It wouldn't do any harm on. Certainly when women come to was from by ambulance, they have often had t x a in the ambulance. Um, so that's so no home to give up. Yeah. Mm. fine. So what did? What happened? So, yeah, she had Bloods office. He hated you. Very important. Um, FEC unit on group and save. Um, cannula. Um, you know, she's bleeding quite heavily. So Really, um, I would think she needs to have a least a green personally. Um, but, you know, whatever you can get in, really is any is okay, but ideally of green or above then you on her headaches years? Um, yeah. Someone said stop blood thinners. Yes, but I I It's very unlikely that a 24 year old who is fitting well is on a blood thinner. But if she is on a blood thinner, then yes, to stop that. Always. Just about you. Um, so she's fairly stable. So she got referred to gynie. Um, so she was just in any waiting to be taken up to the gynie assessment unit where I was working. So however, she then suddenly says, I really don't feel very well. Pain suddenly much worse on you can see suddenly a big gush of boards. I'm on all three checks. Um, she's now, uh, bit more hypotensive. Heart rates. Oh, muscle. Not No, it's not too high. It's okay. And just otherwise she's okay. So now what do we think? Do you think this lady should continue her journey to the gynecology unit? Um, or should she stay in a knee or what? What were you couldn't do? Yeah, Um, potentially could need to have some blood. Yeah, that's good to think of. Definitely. Yeah, definitely. Stay in any. Or it was in, uh, since I got with this one, but I'm Ah, yeah, yeah, attention moved to be. So that's that's good ideas. Well, monitor observations. Yeah. Um, depending on your for the major hemorrhage protocol, someone said in your hospital, she probably not there. Yeah. Generally, it has to be a certain volume of blood loss before, but before you can activate that but that certainly you at getting access is on blood or potentially getting the least them the oh, negative blood could be. Good idea. Um, hum said prep. It's a It's a yes, Probably good idea to, you know, keeping your mouth things like that. Um so did what it happened. Yeah, Yeah, I get a gun. He read? Yeah. Get gynie. I think it's from born a disappointment. If you're If you're working in any and you're comfortable that you're a speculum, then brilliant. You could do that. But essentially, what this lady needs is a speculum. That's the key thing speculum on. Probably some fluid at least. And maybe bloods. Um, so yeah, so she had some fluids. Gynie came straightway speculum products is and cervix come out any when you just remove thumb, Um, with spongy forceps. If so, then following that, her pain and bleeding stopped on the same daily and following that are observations were Okay, um, when the bullets came by, obviously, this was like a bit of delay by the time you know, she was quite well by the time was came back, but, um, h b was okay. Hated you moderately raised about, consistent with six weeks. Everything else was fine. And then, basically, she was fine after that. So the main point of this taste was that sometimes if there's something stuck in the cervix and that could make them suddenly drop the BP on, they suddenly have increased pain and bleeding. That is a sign that there's something stuck in the cervix and that what we need to do is look at it and get it out. Basically, um, essentially, when you cervix some for some people, not for everybody, but for some people. When the cervix gets a bit distended, they have a vasovagal essentially or vagal response. The BP drops, and also the heart rate drops a bit lower, not low. But you could see you. DiMaggio you would think with sepsis or something like that. And the blood pressure's low heart rate is high. But when you get a vagal response, you get the normal heart rate still with a low BP. Um, yeah, On this lady, essentially, you know, this is a good, uh, I could solve case off how resilient young people are because she lost a lot of blood, but, you know, she just went home later on that day. She was fine. Um, so no. So the key points from this essentially is you. If you see an acute increasing pain or bleeding that can signify that they're actively passing the products on, basically need to respect him management. So it you know, if in this case, if we've done a speculum and I hadn't been anything visible, then yes, theater would have been the next step for her. But because we could remove products, we could kind of do that there. And then that's makes sense to do that. If there's nothing there to remove, then the next stage would be to go to the theater to remove. Um, yes, the management is essentially just supportive care and stop bleeding. It's fairly straight forward like that. So generally you know why she's bleeding when you suspect why she's bleeding. Um, it's from a miscarriage or from pregnancy of some kind. So you to stop bleeding base of them. And your, um, bleeding can be very rapid on the candles. Quite a lot of blood. Even though they offer a resilient, they can only be resilient for so long s. Oh, yeah. Need to consider the blood transfusion early, which a lot of people said, which was really good. Um, someone asked, would she still get a scan to exclude any retain products? Essentially, we would look at the products that were removed, Um, and if it looks like the majority, but we wouldn't do a scan. Be honest if she ended up staying in the hospital because she was on well then yes, we would do a scan if she's well enough to go home. Um, we probably just I go home and then, um after do pregnancy test in three weeks, and it should be negative. If it was a negative, then we do a scan at that point for retained problems. Um, I need some said next step would be DNC. Yeah, if if we if we have still weren't able to control the bleeding. So that's that case. Yeah. This lady had a miscarriage, so I'm just going to briefly go through miscarriage, classifying and things like that and you get confused with in med school. Well, that would be honest. It doesn't really matter that much in real life. Eso miscarriage. So a miscarriage is a loss of a pregnancy before 24 weeks. Eso You know, the majority of them are really obviously what they can happen. It's still classified technically as a miscarriage, even if they're 23 6 weeks pregnant. Um, so the very common probably about fifth off pregnancies and in a miscarriage, it may be even higher than that. If you have a very early miscarriage, you know, four or five weeks, you may not have even realized that a lot of movement may not realize they were pregnant and just thought that they had a heavy period that that month. Um and, yes, the majority of miscarriages happen before 12 weeks. Um, if you have bleeding after 24 weeks, it's doesn't come as a miscarriage. It would be an antepartum. Hemorrhage it upward. Okay, um so causes I mean most of time. We have no idea, really. Why a certain particular woman has had a cause. Um, miscarriage was very important. When if you ever see these women very important, too. Be clear that there's nothing that the patient has done toe have their miscarriage, and there's nothing they could have done to prevent it. Either they get that the women ask this very, very commonly on do it causes an incredible amount of distressed, if any. If there ever told that they have caused it, um, women remember this for the rest of their lives, so it's very important not to say to them, Um, we don't really know most the time, but the most likely thing for most women is that there would have been something wrong with that pregnancy on that, that basically meant that it was not going to be able to be a viable, um, baby at the end of the pregnancy on the When that happens, the body will miscarry rather than continue on on. Some women can have certain things I antiphospholipid syndrome or from affiliate is that that caused them to be more likely to have miscarriages and on. But it's very rare for infection to cause the miscarriage. Really be honest. They'd have to be very sick. Um, we did have what I have seen. One who was 18 weeks who did miscarry. But she was She had a bowel perforation. And also it's so you know, this is like a serious infection, not just like the thrush or committee or something you know is in serious septic infection. Potentially us. Um oh, you're later on incompetent cervix. So say, for example, if they had lots of treatment to the cervix from the smear program, something like that. Sometimes this service could be bit more like to open and risk factors are all the usual risk factors for everything. So being older, smoking, drinking brought drug use on control, diabetes, um, there is a link. A well with low pre pregnancy B m. I slightly more like having miscarriage as well. Um, the connective tissue disorders is mostly because they're more like have under false for lipids and drink. Um, so then that is more likely causing discourages. Well, um, find someone asked in the chart. So just for a move on, what's the death off a baby after 24 weeks? So now would be just a stillbirth or into you. Try and death, depending on exactly how you want a word. It basically, um So classifying miscarriage in practice is not really that important, but just to kind of make it a try and make it a bit clear on go. A threatened miscarriage is if they have any pregnant, they have bleeding. Um, but when you examine them, service closed on on the ultrasound. The baby's okay. So it's a threatened miscarriage? No. Oh, I'm looking at all to do this because it's they have to move these other way. Um, inevitable miscarriage were bleeding, but when you examine them, the service is open. But if you were to do a scan, you will see that there was a pregnancy. Unfortunately, it's going to be overseeing Siri. Um, yeah, um ist miscarriage is, um, they might not have any symptoms. Potentially, actually. Sometimes women unfortunately, do go to 12 weeks can on, but there's no no heartbeat. Um, but there's not been any bleeding or anything like that. If you were doing something, these women that would have closed cervix on the scan would basically just show a baby that is big enough where we should be should be able to see a heartbeat. But there was no heartbeat. Don't drink more boxes all the way now a complete miscarriage if the pain and emboli and bleeding have settled or improved, so that will be closed this point. And if you did a scan that be nothing there on an incomplete miscarriage, it's bleeding. Pain service could be open or closed. And if you didn't understand, that would still be some pregnancy tissue there. But, um, you know, not all of it's pastor's. Yeah. Um, yes. And sorry. Eso bleeding after 24 weeks is an anti partum hemorrhage. No miscarriage. Right? So how do we manage miscarriage? So this is a bit more, you know, when you're actually on the gynie know, do this in any or anything, but if you want to go any place ah, office and getting rotation. So basically like everything. Like most things anyway, Um, management is conservative medical. Such a surgical so expected management is essentially just waiting to see the miscarriage happens spontaneously. Women will often choose this course, actually, especially if they're already bleeding. They may just want to wait and see. What happens is fine. You just have to make sure they understand what's gonna happen so they will have bleeding and pain. Essentially, once the miscarriages complete, this will settle. This should expect resolution of bleeding by three weeks on, and they need to repeat a pregnancy test in three weeks time. And it should be negative, not signals that the miscarriages complete, um, with anyone who is having an expectant management at home. Any deviation from the above on the patient basically need to call that local unit for advice, pros and cons of this women quite often like it's, they feel like it's natural. They say that a lot. That's a natural, just that things happen naturally on getting messed around with too much which is another pro. Um, it does work eventually. Most most pregnancies will pass, even though it Mr Miscarriages, eventually they will bleed on. They will pass them the pregnancy. Course you don't have any of the side effects medicational surgery, which is good thing the cons off expected management, however, is that can take a very long time. Um, it's unpredictable. You don't know when you're gonna start bleeding. You know, when you're going to stop bleeding, you know, could be bleeding for three weeks. Could be quite heavy for weeks, even potentially. Um, you're slightly more likely to have an emergency admission having bleeding. Then if you have the medical assistant call, um, some hope patients could find the process of having Ms Code very distressing. Of course, this is what contemplated to the surgical way of doing of dealing with the miscarriage. And basically, um, so some women don't really just don't want to believe that I want to see anything on D. Sometimes I'm expected management will not work, and they have tough surgical medical in the end, anyway, yeah, if it goes on for a very, very long time, it's well they are. They can get infections? Well, sometimes the medical management of miscarriage is essentially medication that we can give either vagina or orally to help accelerate the miscarriage. It's usually my prostate or coming down as outpatient impatient. Everywhere you go get this like different. Most of the time it's outpatient. If, however, they're over about nine or 10 weeks, and generally we would do is in patient that they could be quite heavily at that point. Um, so it's patch of thumb to be in. It is in the early pregnancy. They can have this outpatient. Essentially, it's very much like expected management. Just the idea is you have the medication it brings on the miscarriage, like within the next couple of days, rather than waiting to see how you know waiting have a long it takes for the body to decide to have a miscarriage again once they think they fast the pregnancy. They were just advising to repeat a pregnancy test three weeks afterwards. Don't necessarily need a scan or anything like that again. Some units will vary in that, um, you know what they do with that? The pros versus calms pro. You avoid an operation anesthetic? Um, it's more controlled and expectant. Basically, you kind of know what's gonna happen in the next couple of days rather than attention in the next three weeks or whatever. And it is very successful around, you know, 80 90%. Um, will miscarry with this with misoprostol. Um, Cons. So you got some side effects of my prostate, especially if you take it orally. It just may feel that sick. Really? Um, you can have diarrhea as well. Um, you can be a bit more painful is that the process is a bit more accelerated again. Some patients find the process distressing off seeing the blood and seeing the pregnancy tissue Onda again. It doesn't always work, and she may end up having surgery 100 anyway, The surgical management is offer called, like GNC or surgical evacuation. Something like that, depending who hear from a lot of patients will call it DNC. And it's not really You have what we call it, uh, any more. But a lot of patients, we call it that. Okay, so it's two different ways. Essentially, they're very similar. Um, but you basically you can either do it for the local anesthetic or in theater under general anesthetic very similar in Hollywood. Really? Essentially just putting a tube inside the uterus with the suction of some kind to remove the pregnancy tissue. Um, if a patient is in stable or her very heavily bleeding, then surgical management is the way to go because that you just get it done there and then basically, um, and you so pros is usually quite convenient for the patient. They kind of know what day they're going to go. And that's gonna be the day they have their miscarriage, if you like, or their management s Oh, they can, you know, work around that. It's, um it usually a day case procedure, often only just the morning or afternoon procedure really on. Generally, they don't have a lot of pain or bleeding afterwards. It's kind of like a one day, and it's done sort of thing, Um, which is very convenient. New If you have women already have Children, and already you know it can be inconvenient to bleed and be on well for a week. You know, it's not. Everyone can do that. Um, there's, you know, this could be done in a day. Um, some patients prefer not to be aware that said something. You just really don't want to see anything. They don't want to believe. They don't want any of that's and they prefer just to get down without having to really think about it too hard. Um, cons, of course, is anesthetic risk. Um, obviously these days I mean, it's like, difficult to get the It's getting a bit better now is gone better. But, you know, for a while it was almost impossible to do surgical management for patient choice. Anyway, um, and then the surgical risks of the procedure There is a small, very small risk of perforation of the uterus is about one in 1000 risk chumps. Um, and of course, you know, we're introducing something into the uterus, so that's a potential of infection. Onda, of course you can have bleeding at the time of the surgery is Well, I'm just looking at the shot. Um, yeah, I I don't think there's really much evidence of whether it's better to do just misoprostol or to do my possible on my feet for stone together, a scond been a shin when they are. If we are fortunately, have someone who does have a stillbirth. Um, later in the pregnancy and when they're more like 30 weeks, something like that we use, um, if you persist own a miser. Prostrate. Um, but in the early pregnancy, there's not much evidence. What's better? Whether she used both or whether to just use my prostate? Most units just use my prostate. I void. So anyway, as cheaper. Probably heard of it. Right. Okay, so two. So I'm going a bit behind us. Well, I'm sorry. And so little bit quicker. So got a 28 year old female that she comes to any with left a lot for pain. And she vomited once. No bleeding. She tells you she's definitely pregnant. No way you could be pregnant, so I mean, the differentials of the same as always before really? On. They, um, on what we're going to do next is the same as well, really, isn't it? We're just gonna do a nice history that we talked about. We're going to do a urine pregnancy. Just, um So she was seen by a doctor in a This is again a really patient was referred to me. That's why it's very specific. Sorry about that. eso she's seen by any doctor. And then I got a call as the dining reg trying referring this patient to me. So I was told this patient, she's 28. She's only fitting. Well, I left a note for Spain. Gradual onset, great, but acutely worth last few hours ripping and in waves. No bleeding or discharge. Bowels opened on pressing urine. Normally, the bomb it'd once with pain but otherwise systemically well, observations are normal. Um, abdominal abdomen is soft, tender in lower abdomen with guarding and left it foster, but they're essentially normal on it was referred to the query a very intelligent, which is kind of, uh, um, you know, if it's just addictive, that's fair enough, especially vomiting with pain, gripping things. Things are quite commonly, um, a very intelligent um On I asked the doctor specifically if the pregnant patient was pregnant on they said no. So except for the patient up to our unit, she comes up the S H O covering the unit says I should know how to bring this test done. Actually, so she doesn't want it is positive. Scholl's freeze. Um, so we added on the serum energy history was the same. Basically, as in any on, you know, the examinations seems well on the speculum. It wasn't remarkable. There wasn't a bleeding on by manual. She waas tender in the left adnexa. However, when she was then getting off the bed after being examined, she had presyncopal. There's a little, um, episode. Um, and then we so we have to lie down. Um, when Propecia was checked, um, she had, uh, uh, pressure was a bit low. How it was a bit high, gave her IV fluids and kept my mouth. This was on a Saturday night, obviously, of course, on just it's just so happened. That was a nurse in August for on the unit at the Times. If she scanned the lady on, there was a left side electronic pregnancy on a lot of free fluid in the pelvis. When he sees you came back, it was quite raised. Essentially, she was taking two theaters emergency, and it was confirmed. Roach, that topic and a liter of blood, um, section from the abdomen. Um, so basically, my key point is do a pregnancy test. They can tell you whatever they like about how pregnant they are. for you must always do a pregnancy test. Also, this case is a good case to show how women compensate very long time. You know, she probably had most of that later of blood and abdomen the whole day, really. But she was fine until right, The very end on. If you do see that there is a sign of compromising the patient, it's very well on. You need to act quickly to manage the patient on with the next topic. Pregnancy on. Who's going to theater? Um, she'll need anti if she is the recent negative. It's always important to remember. It's kind of like everyone forgets it. I forget it is. Well, um, a long time. Boys are important, so topic pregnancy. So extra pregnancy is a pregnancy anywhere outside of where it should be, essentially, which should be in the endometrial lining off the uterus. Um, the vast majority are in the tubes, and the majority are in the polar part of the tube that they can be anywhere. Um, really. I mean, that's the most majority majority of them in the tube. Him about 1 to 2% pregnancies is quite high, really. Wasn't urgency. You kind of should always be suspecting it really on D Women do still die from ectopic pregnancies. Unfortunately, in the UK, so risk factors are things like IVF all the kinds of the cells for fertility treatments. History of ST I see if they have a coil into chew. Um, if I have according to get pregnant, the most likely thing is that the pregnancy will be in the uterus, but they just slightly increase the chance of having a topic. If you've had a previous ectopic or previous Jubal surgery, then of course, they're gonna be more likely to get another topic. Um, smokers generally well, um, however, around a third will have no risk factors. It'll so you really can't go on whether they're high risk for an ectopic or not. This one's going to be ruined despite night little books as well. You move all the way. Eso signs and symptoms. Eso they can be asymptomatic, both quite rebel. They can be a symptomatic. Classically, they have lower abdomen pain. That's on one side. However, in reality, is often very vague and very mild can be very vague. Um, generally, the bleeding is no heavy. That is generally true that they either have no bleeding or they just have, like brownish discharge or very light bleeding. Um, if they're it worse, they could feel like a little dizzy shoulders. Hip pain collapse. Um, often no specific signs that will be tender again on one side, classically and again, classically. They have cervical excitation, a lab next tenderness, but doesn't happen very often, really. If they're ruptured, then they might have parasitism, and they actually might be unstable. But the point in my box I moved was that essentially, you could never rule out that topic pregnancy just from examination. They have to have some investigation. You can't. The only way to know for sure is a scan or or laproscopy, so you have to investigate anyone if you it's like a pea. If it crosses your mind, you have to investigate it again. The same with the topic, so to investigate. Ideally, they have an ultrasound pelvis of trans vaginal. But if it's constant available, say it's out of hours. Then you do a serum hcg and then repeat it 48 hours later. Um, a rise of more than 63% suggests a viable into your trying pregnancy. If it's less than that, then it's kind of makes you bit more suspicious that it might be a topic but again, hated years. Such an imprecise science. If you have a big topic, the sitting right on the edge of the tube that has lots of space to grow, it can grow very quickly, like a normal pregnancy. Be ectopic and equally a normal pregnancy that's in the uterus can sometimes, um, have slow growth. Or it could be to start miscarriage or something like that. So it doesn't mean it's definitely a topic, Which is means you need to get a scan. Definitely, um, again, if ever unstable. If you if there's no facility to scan, um, than the only thing you can do really is. Go to theater and see what's going on. Management of ectopic pregnancies Again You got expectant medical and surgical, so it's factor management a little bit come to use. They have to be quite quite rigid criteria to have expected management. So you can imagine. Obviously, that risk of rupture is always there. Even very small on the top, it's can rupture. I've seen, um ah, a neck topic with Hated. You have 70 rupture. So it it just you know, it's not precise science. But if the hated he is on the lower side on the it's falling, then these are good signs that the topic is going to spontaneously resolve. Essentially, um, the one obviously has to be clinically stable. She has her very minimal symptoms as well. And there are some ultrasound criteria has to be met as it has the, um, ruptured, obviously fairly small on not being live ectopic. If you're going to do, um, expected management of topic, they have to have a serum eating every 48 hours initially until we're sure that it's it's resolving and then weekly until the HDLs and 20 eso. Essentially, this requires quite a lot of commitment from patient on. You kind of need to know that they're going to come because you don't really want these ones to be lost to follow up with on a topic pregnancy. So it's kind of comes in my pros and cons, so the pros of it obviously is. It avoids Monday or avoids the downsides of having methotrexate on surgery. The cons is it can take quite a long time long follow up. Coming for Bloods every two days is quite a commitment on is certainly no appropriate. And in anyone who cannot speak English, um, well, no very well. Or if you feel like they're not likely to attend regular follow up, it's not really appropriate because we really don't want these women to not and follow up on rupture in the community. Um, medical management back topic. So medical management is essentially a single dose of methotrexate. Eight I am, which is adjusted for the patient's body mass. Um, about 25% might need a second dose after a week. If the bullets they're not improving as we would hope again, they must meet certain criteria is pretty much all the same as for the exciting management. But the hasty just has to be less than 5000 rather than less than 1500. Um, again, they need regular hey, should be monitoring. So when we give methotrexate, we do blood on Day four on day seven, and we expect the blood they hated you to drop between Day four and a seven. If it doesn't, then that's when we give a second dose of methotrexate. If it does, then they just have weekly Entergy monitoring until it's less than 20. Um, generally, um, you know, the hasty should half every 40 hours. So if you hate to geez 4000 something like imagine, this could take quite a long time to be less than 20 and the majority is about a month. Um, but I've seen them go three months sometimes having to have weekly blood tests. So again, it's quite lengthy. Follow up process pros is that avoids surgery. Obviously, that's good. It is as effective assert as surgical option. In terms off the is very effective treatment for, uh, atopic pregnancy. Very few fail. Very few need to go to surgery after 22 doses of methotrexate thing. Um, common side effects of methotrexate, a again northern vomiting, methotrexate A itself can actually give them some abdominal pains. Of that. Completely confusing is, you know, they've got a topic, and then they come with abdominal pain, so they can be challenging sometimes. Um, if you have both tracks A, um you know, we need to check on the allergies that can affect those on this option is not really appropriate. for anyone who has liver sees already, um, is long follow up again. And if they've had methotrexate, the most use contraception for three months after the methotrexate eight because of the obviously the whole. How it works is to destroy the fast dividing cells of the pregnancy. So it's not going to be is going to be Tradjenta for any new pregnancy as well. So, again, some people, if they, uh, desperately a program right now, then the three months is too long for them to wait that I want to do that. Um, surgical management is basically a self inject to me generally, um, ideally, a laparoscope it if they have had if the other tube has is also damaged or they've already had to remove some of the reason and then we can do to stop in gotta me, which is basically just removing the pregnancy from the tube, but that she was doing very damaged after that. So that's not really going to be great for that until it e um, but we can do that if the other two book is has gone to some of the reason. But if they're the tube looks healthy, then we just remove the tube all together. Mm only office. If they're unstable, that's the only way to go. Can't give me one message saying you're not going to solve one meat of blood in the abdomen with methotrexate. Um, and also it could be quite good for people who can't really come for follow up or who don't mean. Obviously, if it's too big or the he's used to high them, then they can't have the methotrexate. So pros is that it's very quickly resolved, obviously, just there and then pretty much within day on. No follow up is required, so that's good as well. Um, cons. I was the anesthetic risk. Um, surgical risk is done. You know, any kind of like risk OPIC risk and damaged all the structures. Infection, bleeding. And of course, they won't lose that tube, which is just slightly reduced their foot fertility, but not by 50%. It reduces it by so the cell of about 80% fertility about her before, So it's not by 50% but it obviously does reduce sightly. And then, of course, if they have another ectopic on, then you know the choice of the comic more limited. So, uh huh. So undo a case by premises because they were putting the same. So it's really boring. But, um but basically, I just go through it because it's very common presentation to any under GPS. Well, so you know, think. And if you work again, if you work in office and Johnny it you're gonna see all the time Hyper, missus. So just excessive vomiting, any pregnancy. What the patient will say is, I can't keep anything down. I can't even keep water down. Um, the important thing again is a check the urine. So if they have to close or less of key tones than they don't need to be admitted for hydrea hydration. If I have three pulse, then we might need to admit him for hydration. So if you see a lady and, uh, ketone is a lesson too, um even give her an anti emetic tt oh of the first line of things like cyclizine and, uh, prochlorperazine second metoclopramide on, um chlorpromazine. Um generally we avoid on guns drawn. The first trimester as there's a very small room is really small increased risk of palate, so we tend to leave it till the last. If someone's really, really struggling, really? Well, talk about the risks with them. Um, and we can give it to them. Um, if if they really need it. But that's not for, like, a a a need you to give a urinating. You're such a It's not going to decide to give up. Um, if they are so sick that they can take it up. But right now, you can give them a born off I am injection, usually of stem until, um and then the t t o on that will give them some relief that they can then take an aural tablet. So then they can get on the right path towards feeling better. Don't have to come into the hospital. Did you stay in the stool? Um, the important thing with on anti emetic dios is to give them to, um on to tell them to take one every eight hours, regardless, and then they have one as a breakthrough, if you like taking between, um, the important thing with my purposes is getting on top of the vomiting. Once they start vomiting, they can't keep it tablets down, and then they they're never going to get anywhere from dehydrated. Um, but if they can keep on top of it and see, that's a key thing. Um, women often think that they will have No, that we will solve the nausea, which, unfortunately, they often will still feel very sick or still be sick. But it's just to make sure they can still eat something. Um, so, unfortunately, we're not going to completely cure everybody, but, um, just improved things, Really? So they do have three prosecutors and firing off. They can have a candy learn bloods me to check, obviously, because I got dehydrated. Just check the, um, the analyses again. You know, as with anything if they had a scan yet than hcg, um, give them some anti emetics and then give him some fluids, so you could really be quite aggressive. They are young women on, but they are, um, very dehydrated, so you can give them about start. I mean, Elvis is going to depend on the size of your cannula. How fast that's gonna be A but ideally, you know, it should be start and then, um, second bag over now. Uh, the drug over two hours in in the unit. We try and aimed to have done three units within 3 to 4 hours. Um, three units are three liters within, treated with an, um 3 to 4 hours. Once they get to keep his lesson too, or two, they could go home with the anti emetics with two of them. I said if they are sick enough that they needed to be admitted or half rapid hydration, then we should really do have viability scan. Just check. And it's not twins. Isn't if she's in any or wherever you can try calling you be a year of your local, you know, on they can arrange that. So hyperemesis key points know everybody needs to be hydrated, dehydrated and admitted. So not everybody needs to come. Um, from gp to it to come in. And we got quite a lot of GP referrals like that. But you don't know any key to it. Doesn't need to make the track up to the hospital. Just give us a 90 sickness tablets. Essentially none of them are contraindicated in pregnancy. Only ondansetron is the only one with a little issue, but they're safe in pregnancy. You could be very aggressive IV fluids on your important to give a t t r anti emetics right cycle. I I realize I'm going over, so we were very quick. Um, with these ones that I only the end be honest in general, this is just a quick one s. So again, that's another patient. I've seen that she's 34. She was about 10 weeks from a LMP. Shouldn't had a scan yet. She came with an episode of very heavy bleeding, but with minimal pain And however the bleeding and not settled. And she's otherwise well, on observation for normal. Um, so after myself nontender when I examined ah, very small amount of old blood, but no active bleeding seen and by manual waas on. Remarkable. Um, these are the bloods that came back. Um, they won't have any thoughts about those bloods. Anything interesting about them? Yeah, just she was good. Yeah. Yeah. I mean, could be Ms Ms maybe couldn't treat honest with the history. It will be a complete miscarriage, you know, um, could be Ms Ms Martin miscarriage. Oh, yeah. Like my just said, The thing that I'm getting up is that this hcg is very, very high. There's no really, like, exact science, as I've said many times about ACG. But if you hated years in the hundreds of thousands, that is very high on higher than we would expect in a normal pregnancy. So she handled Sounds, um, this is how is described Balk Uterus had to judge in half a genius mass with snow storm parents, no fetal parts. And this small this isn't her. Her is, obviously was roughly what it looks. Well, it looks like so yeah, as some people suggested, it was a complete more pregnancy. So, um, gestational trump blasted disease from all the pregnancy. More pregnancy is kind of like, um, a subsector off of gestation trophoblastic disease right now. Anyway, so it's kind of a spectrum. So the what you classically get these things like the complete with the partial more the pregnancies on These are pre malignant stages off this soft spectrum of disease, if you like, um, it's like when you have, you know, pre malignant cells on your cervical smear. You've CIN whatever. Um, it's not cancer, but it has the potential if left to become cancer or to become invasive. That's why it's important on, then the malignant side of things that the gestational transthoracic neoplasia are just basically the other end of that scale. So firstly, you get the invasive mole and then it this can turn into choriocarcinoma. And this can, um, this kind of the testis size, different parts of the body as well, if left against very, very unusual in the UK To see this these to see like, um, metastatic choriocarcinoma. Very unusual. Um, but you know, there's occasional one here enough, but generally. But it's not that uncommon to see the moles because, as you can see, they are rare. But the same time, you know, one in every 1000 pregnancies. I mean, that's, you know, that's, um that's still significant. Um, but really, you know, if you consider, you know most I mean, I'm like a week in, which is ah, a small unit. And we have about 2 to 3000 births a year, so, you know, that's, you know, three small pregnancies a year on More than that, really. But anyway, so a bigger units, you're going to see a lot more than that. So I'm going to going to do tell with this because This is like a bit too much for me as well, but essentially a normal pregnancy. You haven't egg. You have a sperm that come together and they make a baby that if you have a complete mole, it's not very clear on this picture. But essentially, the egg has no no maternal genes inside there for some reason that we don't really understand and about sperm gets into an empty of on empty egg on D is in there, but it just duplicates itself within the within the empty egg. So it's all it's all paternal tissue, no maternal genes, and then in a partial, you have a normal egg. But two sperm fertilized exactly the same time, pretty much on then you. So then you basically get three sets of chromosomes, so triploid and then you get a 69 here and then that, uh, it's like a possible so with a partial mall, sometimes there can be a baby as well or features all these beginnings of the fetus. Um, but mostly it it it's We normally catch them in the early because everybody has a 12 week scan now in the UK, so is very unusual Teo get much further than that. Um, really On generally, that fetus would know, but would normally not actually progress beyond a certain point anyway. But you may see on the scan that there might be like a little pole or something well, as the snow storm. So how do we manage these? Basically, they should all have surgical evacuation because we need to get the histology to confirm the diagnosis, especially the partial mall. That can be quite difficult. Sometimes it's not always clear. It could just look like a Ms miscarriage, Um, but if there's any suggestion that there's any more changes, then they need to have us surgically vaccine. But we can send it to look under the microscope on, basically, for for diagnosis, um, on as well. If these women they can be very, very heavily from, uh, from this tissue as well if they were to be left. Um, if the histology does confirm all the pregnancy, they have to be registered with just a shelter of Facet Disease Center in the UK There's three of these is one in London, one in Sheffield, Malindi. On that hit that those products will also be sent their for their special is the pathologist to look at was well, to confirm the diagnosis. Um, so then the patient after the surgery back and that will be done obviously locally, Um, they were followed up by the gestation difference it disease center. So generally the low cost doesn't have any more import. Apart from that, they may take the blood. You know, they may take the book, but then get sent off to these units. Usually the patient doesn't have to ever go to. These places are interested there. Their blood or the urine gets center on they get, especially once they start doing urine tests. They just get sent the pots and then they have to post them. Basically, that's because they don't ever have to actually go to these units. If they just have a moral of pregnancy that resolves, then after actually go, um, yeah, once once hated, she's negative. Then they just have a month. They have monthly urine aged you sent to the center for six months after their back or six months after it's gone down to negative. Um, but however, why we need to monitor these women is that a small number will off. The complete molar will invade little bit deeper for these women were invades a bit deeper. They may need chemotherapy to get rid of the, um of the mola tissue is the invasive kind of tissue. So about eight Well, it's very broad is an 8 to 20% of complete more on only about 0.5% of possible. Um, I need to have chemo. Basically several criteria for meeting even, really don't need to know this slide better even need to know this, But, um, basically, just yet, if the levels don't drop a Z should or other criteria like they've got Mets or anything like that, and then they need to have chemotherapy. But there's a very good prognosis. So if you have a smaller that's absolutely brilliant. Prognosis. You know most of the more be treated or not need to have chemotherapy. As you see, uh, if they have had, um, older, they should not get pregnant again for six months after the hunt. Negative hCG or for a year after chemo, the fast majority. Always everyone will have a normal pregnancy after a mole pregnancy. There is a slight increased risk off recurrent, um, Mullah, but it's it's not very not very high. Most women would just have a normal baby next time. If they didn't get to appointment, they needed to have chemotherapy because of invasive disease. If it's low risk, January don't need to know what low risk is. Essentially high risk of things like this distant metastasis ease and things like that. So it is. It is low risk than everyone gets cured. On the you came is like 300%. Um, but if a bit more higher, it's not. Everybody gets cured. But most people. So this particular patient of mine, she had a surgery, a viper, and she was referred to share across for Haiti was negative within three weeks and six weeks, she had her follow up, but it stayed negative, so it was all good ending in the end. I don't know what happened after that, and I thought, well, somewhat sure if she's had a baby since then, but probably okay, this is really brief, just cause, um, in GP, you gonna see pregnant women in the early pregnancy and they're gonna ask you, can I continue on medication? Um and also naming the see women as well. So just a very quick list. I'm having to send the list if anyone's there. Eso definite nose. Tetracycline's floor quinolones chroma through in the first trimester City of operate really should be a noble Occasionally, women are on it these days, but it's very unusual these days. Um, obviously methotrexate a know on. But they shouldn't be on ace inhibitors on, we should avoid and said's in pregnant women books. Basically, most medications are safe in pregnancy. That is the summary of this slide. All pain relief you can think off and says is fine. Um, all the anti emetics you having cough or fine from down strong us in 12 weeks. Almost all the antibiotics are fine for child's fine members or Gaviscon. Fine. These the and have tenses that we use on pretty much all off. The anti depressants are fine on mostly and psychotics to, you know it's with these women. It's very important, especially under psychotic medications. Teo. If they're stable on them, it is much better than to stay on that medication and remain stable and to become unstable. Um, even if there is a small risk off you know, fetal abnormalities or anything like that. The risk of them, you know, having a relapse of the schizophrenia is much higher than the risk of this very small risk off problems with the medication with anything. Always, just if you have any doubt, we're always happy. I'm always happy to get a believe to ask if I could send, think and be prescribed or not, or for advice about medications. That's absolutely fine. I don't mind to hear about that on. I don't think many people would have a problem with that, so just bring codeine was also fine. Um, these days, if they're about to give birth, we give the 100 codeine rather than go go to mall. But, um, it's only because the baby's of it see if they have coding, um, just before birth. But literally I mean, like in labor, like before birth, you know? So if you're seeing them somewhere and they're in labor, then they're probably going to not be staying with you anyway. Convertible. If the know in labor, they can have codeine, Um, yeah, really useful place. If you ever wonder about medication, is the bumps website. If you just type in bumps, and then the medication that you're thinking off it will come up is a patient leaflet. But you know, it's so beautiful feet you was. Well, it tells you about how likely how, what the medication is like in pregnancy. We're going to take it in pregnancy. That's was a good resource. Well, the VNS rubbish will just tell you never to give you anything, so don't bother with that on. But bulbs website is good. It's not. So, um, I think I've been, like, answered most the questions as we go along. So if anyone has any other questions and I'm happy to answer, I'm sorry over around a little bit, but it started like it's well, them about to this. Probably could have kept this up. Actually, no, I use my home. Just give him and it also see if anyone wants to ask. You think it's have a whistle stop till about that? Pretty much is all there is to really pregnancy, To be honest, it's not that complicated. Yeah, you do see these. They're everywhere. For women. Um, and what way? More comfortable. And I don't know, um you mean I pay only for Brown and sorry here. Yeah, I am happy. Decide. Share the slides, if only if you want them. I guess. Davey, I consult. Yes, definitely. Well, what will swell put up this recording when you do best well on mine. Think off the beginning bit. Well, we can do anything for, like 15 minutes. Yeah. Is yeah. So family. If they can have pretty much anything. Just not not, um And said so you can give him morphine. No problem. If you need morphine, then the morphine. We give morphine in labor, so you know, they could have morphine. Oh, yeah. Codeine got a mole. Um, plus coupon, anything. Let me know. Paracetamol. Yeah. Yeah. Okay. Emma, there isn't any more questions than I guess. That's, um So thank you, Helen. And thank you. Have a good evening. Thanks. I I um