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Mind the Bleep : Obs & Gynae Series - Episode 5 - Abdominal Pain (Pregnancy and Non Pregnancy related)

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Summary

This on-demand teaching session is presented by Dr Samsadon, a Northwest trainee option lead with mine.com. Dr Sam will discuss the differentials for abdominal pain in pregnant and nonpregnancy related patients and suggest possible management plans. He will cover topics such as constipation, UTI, pelvic inflammatory disease, ectopic pregnancy, preterm labor, and placental abruption. He will give an overview of various antibiotics prescribed for pregnant women and discuss the possible complications from a UTI in pregnancy. Attendees will gain an understanding of abdominal pain in pregnant patients as well as useful information about the investigation, treatment and management of Pyelonephritis.

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Learning objectives

Learning Objectives

  1. Participants will recognize and understand common differentials for abdominal pain in pregnant and non-pregnant patients.
  2. Participants will be able to analyze common presentations and symptoms of digestive issues in pregnant patients.
  3. Participants will be able to utilize different options for management of constipation, UTI and Pyelonephritis in pregnant patients.
  4. Participants will become familiar with the impact of antibiotics on pregnant patients and criteria for utilizing them.
  5. Participants will have developed best practice strategies for treatment, tests and follow-up for pregnant patients with abdominal pain.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Dr Sampson. And if you just mind, I don't mind just scrolling through your slides just to see if they're moving on life, please. Perfect. Thank you. Mhm. Mhm. Yeah. Okay. Okay. So Good evening, everyone. I'm David. I'm one of the option kind of leads that with mine w dot com We've got Dr Sam starting today through here today with us from Mauritius. He is currently a Northwest trainee option kind of trainee. Um, and he is currently in ST to in Wigan Infirmary. Um, he'll be talking to us today about abdominal pain in pregnancy and nonpregnancy related patients. Um, and without further ado, doctor, something, you can take the lead. Thank you. Hi, Ron. Um, so my name is some sedation. I'm one of the ST to training is in outstanding. So I've got only a few weeks left. Three weeks basically start working as the registrar infection gone in a week and infirmary. So the topic of my presentation today would be mostly about abdominal pain, but more importantly, focused for pregnant for pregnant ladies as well. All together, because sometimes it can be quite difficult to diagnose different ecological courses for the pain. When someone is pregnant at that time. Um, sorry. My slides are mostly informative in nature, but I'll try to go through them as much as I can, and please feel free to ask any questions at any time on the chart, and I'll try to answer them as much as I as quickly as I possibly can. So basically the main differentials for someone presenting to the emergency emergency department with abdominal pain when they are pregnant. Um, those are the list of differentials. So basically, when someone comes being pregnant, presenting to a any, the first thing that we would do is, well, freak out initially initially. And then they will try to conduct the obstetrics and gynecology team as soon as possible to try to, um, make that patient go to the obstetrician gynecologist had to be assessed properly rather than starting all the initial assessment and investigation and possible management plan on a any. So the main differentials for someone coming to any being pregnant with Abdul pain or like normal differential differentials, really, So they can be constipated. Um, they can be having an acute appendicitis. Well, one in 5000 pregnancies will be presenting to eat the right iliac fossa pain and it turns out to be acute appendicitis. Um, and it would always try to make it sound like it's an ectopic pregnancy happening at that time. If they are quite early in pregnancy, we should always be careful about ruling out acute appendicitis because it has severe consequences depending on the gestation throughout pregnancy. It can also be acute cholecystitis, um or cholelithiasis. Basically, at that time can be acute pyelonephritis starting first with the UTI, then progressing to acute pyelonephritis. Um, around 25 in in 1000 pregnancies will present with pyelonephritis. At that time, another reason will be pelvic inflammatory disease, which is I'm getting more and more common now, Um, particularly where I'm working in the Northwest, um, of England over the last few years. Really? Um, it can also be an acne and adnexa alteration. Um, it's variants distortion happening as well. Um, usually, when it's quite early in pregnancy and they're having some abdominal cramps and possibly some bleeding or spotting, we tend to try to rule out. One will be a miscarriage happening, and the second will be What we really need to rule out is an ectopic pregnancy because depending on that stage of the ectopic pregnancy, it can be quite a life threatening for the woman as well. And now, when it's quite late in pregnancy, we need to rule out preterm labor and also placental abruption as well as uterine rupture. To be honest, for those late pregnancy complications, they usually tend to bring triage and present to maternity triage straight away, rather than going through a any. So so the first one, as I was mentioning, is constipation, which affects around, uh, around 40% of pregnancies at that time. If we allow constipation to carry on for a good sometimes it can last for five days to seven days. It can have a big consequences leader leading. Well, it can cause vehicle impaction. Uh, it can make the person going to urinary retention having some rectal bleeding, Um, because of the bulk of the thesis being there, and it can also lead to other fluid area as well. All together, Um, and these symptoms can be worse. And, um, if they have, uh, associated hemorrhoids with it as well, all together. So the usual management for these pregnant ladies with presenting with constipation is after a good examination, abdominal examination and sometimes a PR examples. Well, depending on the severity of the constipation is conservative management with them going home to increase their fluid intake and dietary intake Otherwise can also help them with different kind of bulk forming agents or osmotic laxatives as well as stimulant laxatives as well. All together, that being lactulose or medical sometime center as well, All together. Now, if they got proper fecal impaction after doing a PR exam and you've diagnosed fecal impaction, you can always help them with a 4 g suppository of glyceryl suppository. At that time. Um, and if you're more and more concerned that they might have a possible power obstruction, which is quite rare, they need to be assessed by the general surgical team. At that point, in view of having uh uh, an abdominal X ray, bit more service, it is going to be able to rule out the small and large bowel obstruction. Um, another most common cause of abdominal pain in pregnant ladies is obviously a UTI. So so many times when pregnant ladies come to, um either a any or triage with the first time of investigation would be their BP and the urine check also. So a lot of them of these women will have a urine dipstick, which is positive for either local side or nitrates all together. But it can be a symptomatic at that time. So the general ruling is if someone is presenting if you're pregnant, that is presenting with a symptomatic back to your area, which is basically a positive urine dipstick for for them at that time. You should always have a low threshold to treat these women. Um, because it can easily progress to a proper UTI I cystitis, which will develop in about 30% of women at that time. And these cystitis can further on progress to pilot nephritis. Any UTI happening in pregnancy at that time increases the chance of that woman going into preterm labor further down the road. And if you if you're not catching it early at that stage, so this puts out even higher risk of entering pre term labor. Um, the main symptoms of the UTI would be as any UTI s anyway would be this area increase in frequency and some lower abdomen pain generally superpubic in nature now with regard to antibiotics being given to pregnant ladies having a UTI. Um, there are three main antibiotics that we usually use in the Northwest, which are nitrofurantoin Catholics in and also trimethoprim. But that changes depending on the gestation age at that point, um, so, as you can see on the next slide, the first line in the Northwest here would be nitrofurantoin 100 mg oral B D. But again, you shouldn't use it in the third trimester because it increases the risk of having of the baby developing hemolytic anemia. Not much research has been going into it, but the latest research has shown that there is an increased incidence of humility anemia occurring if you start with nitrofurantoin in the third trimester. Um, the second line is usually trimethoprim oral again 200 mg B D. But this one you shouldn't be using in the first trimester because in the first trimester, up to 12 to 14 weeks. Generally speaking, there's Organogenesis happening for the baby. So as you probably know, Trimethoprim is an antifolate in nature. So it would. It wouldn't be a good choice of antibiotics and the first trimester. At that point when all the organs are developing. You don't want any neural tube defects to happen, even though the chances of it happening is quite low. But you don't want to put the woman at the risk of, uh, her baby at risk of developing neural tube problems. Now, if you're sometimes if you're in a rush and you're unsure about the gestation age of the woman, the safe option would be Catholics in oral 500 mg three times a day. This you can use at any stage, uh, at any gestation age really with low side effects as well. Given that that woman is not allergic to penicillin or Catholics and Catholics, parents basically, um, on this slide, as you can see, clearly mentioned so for usually, for the UTI is in non pregnant ladies, you would usually give them for a course of three days persistent UTI. You would maybe prolong it to seven days if you have not changed. Uh, two different antibiotics. But in pregnant women, you should give them at least seven days of any of these, um, oral antibiotics that I just mentioned from before. Um, also, if someone is presenting with recurrent urinary tract infection. Um, regardless, whether she's pregnant and now most of that, regardless of whether she's not pregnant and now most of that, she's pregnant, you should have a low threshold, generally speaking, to book an outpatient or some K u B at that time to make sure that she's not developing any renal abscess or any, um, uh, any renal abscess or any renal truck? Um, animal is at that point. So, as I was mentioning, if you don't catch the cystitis early in my progress in Japan, arthritis. And as we all know, women are more prone to developing a pyelonephritis when they are pregnant and also generally speaking as well because of their short urethra. So Pyelonephritis can complicate about 2% of pregnancies, and they are most common in the 2nd and 3rd trimesters. Um, the symptoms are the same for nonpregnant as well as pregnant ladies, with them having costovertebral angle tenderness, moving to the loins and then to the groins, they will have fever, rigors, um, sometimes swinging fever if they're at risk of developing a renal abscess as well all together. That's why they should open discharge after having pyelonephritis as well have a follow up with an ultrasound. K u b to make sure again that this hasn't happened when he's starring as well as the arena truck has not happened. Um, and now the Pyelonephritis can develop into for sepsis and septic shock. Then you need to start treatment with IV antibiotics so regardless of whether it's turn into sepsis or initial phases of pyelonephritis should have a low threshold to start them with on IV antibiotics, really. But if they do develop sepsis afterwards, you should go down the Subsys six pathway, as you would normally do for anyone having so Subsys, so as I just mentioned in terms of investigation, should be obviously taking the bloods of these women, usually on a daily basis or, if any deterioration on nonimprovement of 24 hours of IV antibiotics, then possible 12 hour early bloods at that point taking urine culture, blood cultures as well in order to target the antibiotics to the right one. Um, hydration should be very important for those developing pyelonephritis as well. Um, yep. So in terms of the treatment for pyelonephritis, once you start them on IV, antibiotics should make sure that they have at least a good 24 hours, if not 48 hours of IV antibiotics and then based on the blood, step them down to oral antibiotics. Um, if their if their observations are getting better, bloods are getting better. And generally speaking, they are feeling better in themselves at that point, but also on discharge. You should have should be thinking more of leaving them on. Finished a course of oral antibiotics for about at least a good 10 days. Usually of urologists would discharge them on a course of 14 days of, uh, oral antibiotics if they have been admitted and had sepsis with balance arthritis at that point. Um, so the next slide is another main because of abdominal pain in pregnancy. Is appendicitis really? It's the most common because of the acute abdomen in pregnancy occurring, occurring in one in 1000 pregnancies a lot. Most of them actually. Okay in the second trimester. Uh, as I mentioned here, it can present a typical in an in an atypical nature in pregnancy because of the distorted anatomy of the caused by the gravity uterus, Um, at that point. So based on previous research, the has shown that it usually the appendicitis. If it develops as from the second trimester onwards, it can present with right upper quadrant pain rather than right lower quadrant pain, which it would typically present at that point. Because the appendicitis, the appendix, can move as higher. Um, as the right hip, The country, uh, region hypochondria, um, at that point, but but usually speaking, they would present with the right iliac fossa pain. So the signs and symptoms are central, uh, abdominal pain and migrating to the right iliac fossa. Um, due to referred pain at that point starting from the central abdomen, um, they would be systemically and well, with a lot of the time they will be systemically and well with nausea, vomiting, fever, having deranged inflammatory markers. We've raised white cell count and raised CRP. And yeah, those are the main symptoms that they usually present with. If they are coming in with appendicitis, that's why so, um as I was mentioning, So these first three slides have been talking mostly about UTI is constipation and appendicitis. That's why it's very important for me when I get a call from a any to ask about these three main presentation. Really? I always ask them if they've done a urine dipstick to try to rule out if the woman is actually having a UTI. Um, firstly, Secondly, I always ask about the bowels with regards to try to rule out constipation. And third, if they if they call me from any telling me all the women complaining of the right lower quadrant pain, I always ask them to be seen by the general surgeons first, that they can lay hands on a woman's tummy and to rule out appendicitis straight away. Because so many times they have been getting referrals from a any right lower quadrant pain. Um, they're around 5 to 6 weeks pregnant, have accepted them. They've come to get an assessment unit, and it turned out to be an acute appendicitis that they're having. So it's a waste of time, really, I know, and it can be quite busy, and you're trying to do their best by basically triaging those patients and to make sure that they are seen by the write specialty. But they need to first of all, do the basic investigations. And as per hour, I mean, I still Wiggins hospital policy. Any one of the acute abdomen with the Rituxan should be seen by surgeons. First two out appendicitis then come to us to try to rule out an ectopic pregnancy at that time. Unless obviously the patient is hemodynamically stable, unstable with a previous known ectopic or higher risk factors for atopic pregnancy, and is having increased BP bleeding at that point. And obviously we'll be going down to see the patient first. So coming back to the Ascites picture in terms of investigations, you would do the Bloods to find out what the inflammation markers are doing. Try to arrange a note. Some scan as soon as possible. But obviously, uh, this can be quite tricky to arrange if you're working out of ours, so CT scan would be your best bet at that point, I always remember. For a pregnant woman you should always counsel them over. Goes to risk of high radiation to the breast tissues. If they are pregnant, as long as you're explaining or the giving them all the information explaining all the risks versus benefits and the patient's capacity is accepting the city. Then you should be going for a CT scan if if it's out of hours, and you're really worried with regards to the aquarium appendicitis at that point. But I'll leave that to the surgical team to make that kind of decision really now in terms of management. So for appendicitis, antibiotics are not usually sufficient if it's an acute appendicitis. Um, surgery is usually indicated at that point because if we don't treat the acute appendicitis, the risk for fetal mortality and having a miscarriage at any point increases to a high level up to 36% at that point. So we need to make sure to treat the appendicitis at an early stage rather than waiting towards the end, where it can lead to a perforation and then a miscarriage as well in in even late miscarriage. Um, so in terms of surgery, they would usually proceed with either laparoscopic or open, depending on whether it's ruptured or not, depending on the age of the patient. Um, but it needs an MD decision because it depends on the gestation age of the women as well, in terms of what would be the safest option for the surgery, where they serve a oh Laproscopic because her being pregnant on that stage changes a lot of things with regards to risk pregnancy. So this we needed an m d. T discussion with the obstetrics team and, um, the General Surgical Team. Now, the third presentation, which I actually had last week, um, someone presented to any being 32 weeks pregnant. At that stage, we have right upper quadrant pain was seen by, um, General Surgeons. Um, the first referred to us because obviously she's 32 weeks pregnant, and they would want her to be seen by the obstetrics team straight away. But it turned out to be, um, acute cholecystitis after they've done a CT scan on that woman and with her raised her deranged inflammatory markers. So generally speaking, um, with increasing the estrogen and progesterone happening in pregnancy, this predisposes any woman to increase risk of having Goldstone's. A lot of women would be symptomatic with this cold stone when they are pregnant. So basically, with the rise in estrogen and progesterone, um, at least to a lot of stagnation with bio um, in the common bile duck and increasing cholesterol secretion which again, um, makes you at a higher risk of developing Goldstone's. And there's a reduced that these rise of the two hormones of estrogen progesterone reduced the smooth muscle motility for the gold bad and the common bile duct as well, again making that woman at the high risk of developing gallstones in pregnancy. Right? So now, in terms of investigation for ocular society, we'll do the Bloods, uh, checking the FTC inflammatory marker CRP and also the LFTs, which is more important. But often as you progress in pregnancy, the plus center would give rise to a deranged LP anyway. So any deranged LPs can be quite normal in pregnancy because it tends to rise to 2 to 4 times its normal value to a max of 400 international units at that point. So it may not be very reliable in determining and obstructive picture for the bile ducts. So that's why a lot of surgeons would rather and do an ultrasound scan as soon as possible. If during working hours or otherwise, a CT scan if out of ours over the weekend, when an ultrasound scan is not available now in terms of management for the acute cholecystitis or cholelithiasis, would be well for acute Cholecystitis would be generally speaking admission for antibiotics, um, to make sure that they're recovering quite well. And how it would this would be determined would be by doing daily, um, bloods on that woman to make sure that she's doing better. Um, so surgery can be indicated if this colecystitis, um develops into cholangitis further down the road. Um uh, other woman is really unwell with the policy studies developing into sepsis afterwards. But again, as always, it needs to be after a discussion with the MG team involving involving us as the specifics team. At that point, it would. The surgery would usually be done as a laparoscopic intervention, Um, rather than an open intervention. Anyway, um so any questions so far it goes to work up, just talked about. You can feel free to type anything in the chart books that can have a look and answer any of your questions as we go along. Right? So the next one will be I'll be talking about pelvic inflammatory disease and so P i. D. Usually an upper genital tract infection occurring in a woman which can be in the form of endometrial. He's self inject. It is inflammation of the troops basically uh, varieties. Inflammation of the ovaries or development of the tubes? Ovarian abscess. Um, in the UK I mean, the prevalence is generally quite high. It's 1.7% of the general population is getting higher and higher as the years of progressing, because there's been a recent rise in the gonorrhea and chlamydia not sensitive too many of the antibiotics, um, particularly in the Northwest, for some odd reason. Um, they've been quite resistant too many of the antibiotics. So it's very it's P R. D is a very common GI GI present. Um, it's very common presentation coming to GP land, um, for women age under 45 years. And they always, um, would send them to the guy to go to assessment unit for a quick check of double swabs and initial treatment at that time. So, as I was mentioning the most, the most important risk factors is a previous history of pelvic inflammatory disease or in the previous chlamydia organ, your ear infection. In the past, um, most of the P I. D. S in the UK, of course, by the medial infection and then followed by gonorrheal infection. Another risk factors the risk factors is vaginal dosing where some people will tend to do vaginal dosing two or three times a day with, um sweating some vaginal, uh, some vinegar, live liquids and other, uh, antiseptic, uh, sort of soaps, um, inside the vagina at that point, which is not recommended. So another risk factor would be smoking and coming from a low socioeconomic group. And another one will be recent insertion of an eye. You c d usually over the first four weeks of insertion of either marina coil or a copper coil. Um, and also any recent guy, any procedures, be it surgical evacuation of a miscarriage and transfer or hysterosalpingogram, um, at that point. So how do they usually present? Um, They usually come in with vague symptoms of lower or generalized abdominal pain, usually with uh, vaginal discharge, which can be quite pure lint, um, or sometimes quite thin as well, depending on the stage of the public inflammatory disease. Um, if it's been there for quite a while, they can also. It can also lead to systematic, um, symptoms science as well, with them having fever, malaise and loss of appetite. So, in terms of examination, finding you would want to do a speculum examination to see how the cervix is looking, how the cervical mucus and vaginal mucus are looking. A lot of the time you would see some mucus up your and discharge from the cervix, inflamed cervix and china walls. Um, and sometimes some bleeding. Um, so you would want to take double swabs bit the hive channel swab and the and the cervical swab at that point. And you would want to do a vaginal examination to try to for two things, really. One is to try to elicit the cervical motion tenderness. How you would do that, uh, is just by gently flicking, um, the Actos cervix region and close to the cervical loss. Uh, and you should see, uh, well, unfortunately, a bigger reaction from the woman, The only been severe pain at that point. And you would know that this is the actual cervical motion tenderness that you're eliciting at that stage. You should also try to pop it the adnexa for any palpable masses, which can be a sign of any trouble. Ovarian abscess at that point, uh, investigations you would want to do. Um, as I mentioned the swab double swabs, taking some blood to make sure that inflammatory markers or not to raise this can tailor tailor your management plan in terms of whether it would be as an outpatient versus as an inpatient. Um, Ideally, you would want to have a transvaginal ultrasound scan to make sure to know if there's any trouble ovarian abscess and more so to know the size of the tube ovarian abscess and whether it's a hydrosalpinx or a pie or pyosalpinx as well all together to get a baseline of the size as well. So in terms of the treatment as I was mentioning, you can either go for an outpatient management plan or an inpatient management plan. This will again be based on a few things. How stable the woman is is that present all the observations of the woman, the bloods of the woman with regards to the inflammatory markers and also the size of the Triple Very an abscess. Generally speaking, when we talk about ovarian abscess, there's no hard rule about the tubes, ovarian abscess, but a lot of places. It's based on surgeons preference, but a lot of surgeons I I find if the tubes ovarian access is anything less than five centimeters that can be managed with just, um, antibiotics on its own. And can, most of the time be managed as as an outpatient regime, if it's quite small, usually less than three centimeters on average, and the patient is really well in herself. So in terms of the outpatient management plan, you would usually give an I am dose of contraction, followed by oral doxycycline and metronidazole for 14 days. Um, and most of the time, if it's s t i coast, if the if the cause of the p i d e s t I, you would want a test of Q as well further down the road. Um, Now, in terms of inpatient regimes, it will be IV ceftriaxone, followed by, um IV doxycycline. Then, depending on the improvement of the blood and the observations of the woman, you can, um, step it down to oral antibiotics again to doxycycline and metronidazole for a total of 14 days, um, of antibiotics for her to go home. But if they are with a tube ovarian abscess, a lot of the time you would want them to have a follow up. Our son standing maybe 4 to 6 weeks Time to make sure that the size of the tube ovarian abscess is regressing. Um um, quick question to you guys. So if someone presents to to you with a suspected pelvic inflammatory disease as that your main working diagnosis. And she has, um uh, my arena coil inside you over the last two years, Um, what would you guys be doing in terms of the management plan for that particular lady? Anyone? Yeah. So I've got someone saying, um to not remove the intra. You try and device at that time and start the antibiotics, Correct. So you would usually leave the IUCD inside you at that time. Start the IV. Uh, oral antibiotics. See the clinical picture, how it's improving. Um, So when when would you guys think of maybe taking the marina coil out? Okay. So, basically, you would want to see how how the so how the How the lady is improving over the next 48 to 72 hours. If there is no clinical improvement on blood and observation or she still keeps on spiking temperatures after 40 to 40 72 hours, you would want to take the coil out at that time because obviously it's not responding well to treatment. And that's when you would want to take the Mirena call out because there might be a chance, uh, of the infection being caused by something one of the bacteria called, uh Actinomyces is Israeli, Um, and then you would want to send the call for culture. So but you need to cancel the woman properly in terms of prior to you removing that Mirena coil. So make sure that you probably counselor, because to her not having had unprotected intercourse of the last week, really, because she's at risk of falling pregnant. If you take the coil out and if she still insist on the factor of taking the coil out, then you would need to cancel her with because to emergency contraception as well, if she would want to consider it. And as I as I was mentioning, So if you take the call out, send it for culture at that point. Uh, and also specifically also specifying with regards to, if you can specifically test for acting, um is is like organisms on on that coil, So the next slide I'll be talking about our next attention. So ovarian, um, and, uh, tube to the ocean. So about 50% of the ovarian torsion will be quite bad people because ovarian torsion is likely to happen for an ovarian cyst, which is usually, I'm saying, usually more than five centimeters in size, because anything less than five centimeters has a lower risk of, uh, torching. Um, the one sister is at a higher risk of talking when it's more than five centimeters, usually dermoids cyst at that point. So and weirdly enough, once it's a cyst or shin has occurred, it's mostly the arterial supply, which is compromised. Uh, sorry. Uh, the which is. It's mostly the Venice supply, which is compromised, but the arterial supply is usually maintained at that point. Um, and the risk of having further two options if someone has had one in the past is around 10% so they usually come in with a sudden onset of moderate to severe pain, nausea and vomiting. Uh, sometimes if the torsion has occurred quite a long time ago, they can also have high temperature as well all together. In terms of investigations, you would want to do blood tests on that woman, So doing the Bloods will. You will tend to focus more on the white cell count and CRP. But again, it can be quite confusing. Someone coming in with right iliac fossa pain because it can be a few things happening. I mean, if she's whether she's pregnant or non pregnant if she's pregnant, the differential would be appendicitis. Uh, ovarian torsion, uh, atopic pregnancy at that time. So torsion is more of a clinical diagnosis at that point to try to differentiate between appendicitis. Because if you think about it, if you're looking at the white Cell count and the CRP, both would be raised an appendicitis and torsion most of the time. Ideally, you would want to have a transvaginal ultrasound scan. But again, this is not very specific in the Transvaginal ultrasound scan, because you would want to look at whether she's got an enlarged, uh, cyst over there. You would want to apply the Doppler flow to see and the arterial supply and and the Venice flow as well, all together. If there's any compromise in any of them and any signs of free fluids and and if obviously out of hours again, Uh, you can also requisites cities going to try to make sure that this is it. An ovarian torsion happening. But again, CT scan is not very specific, um, insensitive at that stage. So it's mostly a clinical diagnosis based on previous, uh, sounds kind of gynecological history altogether management of the torsion. So, in terms of preventing that ovary and tube to undergo complete necrosis, you should be aiming for laparoscopic intervention, obviously, depending on the size of the cyst. Um and so a lot of the time, a lot of the consultants would rather go for a cystectomy and stopping, stopping the oophorectomy, um, at that point. But a lot of the new cases with exertion a lot of evidence have been showing that you should usually go for a ditch or shin at that point rather than a cystectomy or an oophorectomy, even if it's engorged. And also all of this will depend on the size of the cyst altogether. How much can be salvaged or goes to preserving ovarian function now, Yeah, any questions, guys, so far, with regards to what I have just been explaining through these slides before we go into a miscarriage and labor. Yeah, so early is asking. So basically, then, is non surgical management option? Yeah, with regards to Sorry, I went straight into the surgical management. So we've got to If you're really suspecting, is a torsion happening at that time and the patient is on, well, then you should be doing um um laproscopic intervention regards to being a surgical intervention. Because if you're not really suspecting it ocean, uh, then you can manage these patients conservative as I was mentioning anything less than five centimeters and you're not having and you're not really suspecting a torsion. And the patient is quite well in herself able to stand up, walk non deranged inflammatory markers. Then, yes, you can manage it conservatively, asking her to go home and then to re attend. If there's any complications, can also have a follow up ultrasound scan in three, uh, three months, usually to make sure that this cyst has not increased in size all together. But if you're already thinking of admitting someone with that kind with that much of discomfort, uh, and you're suspecting a torsion happening time is of a limiting factor. Unfortunately, at that point. So it needs to be a big discussion between you and a consultant or senior registrar in terms of whether you should be going for a diagnostic exploration, sometimes not necessarily needing a cystectomy and affecting me or not even a ditch or shin, but just an exploration to make sure that no necrosis has happened. And this most of the time would usually occur during the weekend or out of hours where you've got limited access to scans. Um, mostly so now, with regards to the next topic will be miscarriage. So in the in the UK, miscarriages defined as the loss of an intrauterine pregnancy less than 24 weeks, this can be further subdivided into whether you're having it in the first trimester for it to be an early miscarriage or in the second trimester for it to be defined as a late miscarriage. A lot of the time, women will ask you a bit confused about why they're having a miscarriage. But 50% of the time is mostly because of chromosome animal is happening, and this is basically the uterus detecting those, uh, chromosomal abnormalities and then stopping pregnancy on its own. So, essentially, unfortunately, survival of the fittest, which is happening at that time. If there's no other risk factors like smoking, increased maternal age as well what you got? So there's different types of miscarriage, depending on this, the cervical loss, whether it's open or closed and if you can see any tissues of pregnancy if all the tissues of pregnancies have been passed, or some of them or none at all. Um, as you can see on this slide where the first one is the threatened miscarriage, where the cervical office is closed and there's no tissues that you can see and nothing has been passed inevitable miscarriage would be one where the cervical is open. Uh, this can be quite tricky to diagnose, sometimes particularly in women who has had a few normal deliveries in the past. Where if you've not been examining many if you've not been doing many speculums in the past, you can easily mistake a multiple, uh, multi gravity gravity, um, cervical us for an US being open. So yeah, so inevitable. Miscarriage is cervical is being open, but there's no passage of tissues of pregnancy at present so far, but again, higher chance of it to develop into a complete or incomplete miscarriage further down the road, and you need to explain to them. And it's an inevitable miscarriage. And unfortunately, um, the chances of miscarriage happening over the next 24 to 48 hours is quite high on that stage. In complete miscarriage now is when the cervical, the cervical office, is open. Uh, some some of the tissues of pregnancy has been passed where a lot of women will take pictures of the pregnancy. Ensure that to use that you can confirm that these are actually, um, teaches of pregnancies and not only blood clots that they've been passing. Um, third one would be a complete miscarriage where the cervical loss is now closed because all the tissues of pregnancies have been passed. Um, so far, um, if you're so coming to the next slide so the presentation would be coming to usually do an assessment unit with abdominal pain and PV bleeding, you would do a speculum examination again to try to determine, to classify it as whether it's a threatened, uh, inevitable income, incomplete or complete miscarriage. Ideally, you would want to do an ultrasound, uh, scan as soon as possible again if if It's a case of, uh, threatened miscarriage. You would want to do that. All sounds can mainly to assess the viability of the fetus. Uh, there are few markers on the on the on the ultrasound scan that you would want to have a look at. Usually, if someone is technically more than five weeks, ideally more than six weeks, they should have a fatal heart and your son's cancer if they don't have a fatal heart when the gestation ages more than six or seven weeks, Um, there may be a possibility of miscarriage happening, but that is not definitive. So you need to see something called the Crown rump length. Usually so. The threshold is seven millimeters for the crown rump length, which is documented on the ultrasound scans. It's from if someone hands your energy can report and you see that they have been documenting that the crown crown rump length. Basically, the CRL is less than seven millimeters, and you're not seeing a fatal heart activity. That's perfectly fine. It just means that it's way to early in pregnancy for fetal heart to be present. But any CRL more than seven millimeters, you should be seeing a fatal heart. So you can say if you've got a CLL more than seven millimeters on an ultrasound scan report that no fetal heart, it's a miscarriage that has happened. Unfortunately, now they can also document about something called main gestational sac diameter, So the cutoff mark is 25 millimeters at that point. So anything more than 25 millimeters, you should be seeing New York side and, ideally, fetal pole at that point and the CRL as well all together. So anything more than 25 millimeters and you're not seeing York sac, fetal pull or CRL, you can be thinking of it being on embryonic in nature, and obviously you won't see a fetal heart, so you can, um, start. You can start thinking that the miscarriage it has happened for that lady so many times when you have a discussion with those ladies with regards to a miscarriage happening at that point, and they are not entirely sure. Mostly, for example, the CLL is just seven millimeters or the main gestational sac is just 25 millimeters, so basically both on the exact cutoff point. What you can do is repeat the ultrasound scan in a week's time to make sure that, um, there's nothing has changed because if you repeat the ultrasound come in a week's time. Usually the C O L should increase by at least a good two millimeters as well as the medication is actually increase by at least 332, Well, three millimeters on average. And if at that time you don't see a fetal heart activity, then you can safely diagnose uh, miscarriage At that point, um, in terms of management of miscarriage, there are three main management plans for miscarriage one, the first one being expected. Second is medical thirties surgical. So in terms of how in terms of when would you come So for these different forms of management for miscarriage, it depends on a few things, Really. So, for example, it depends on how hemodynamically stable the patient is at that time if the patient is having heavy period bleeding. Um, so you should be thinking of going more for surgical, um, management plan because, uh, this patient can be compensating for now because she's quite young. But then, if she carries on having heavy bleeding at that point, we can start decompensating. After having bled a liter or two, so you should be thinking of going for a surgical back straight away. Um, now, if if nothing of this is happening with regards to human dynamics, human dynamics, stability and observations are perfectly fine, and there's no heavy bleeding from down below now you would need to be to base it on the ultrasound scan findings basically So in terms of the size, um, of the products of conception, basically generally speaking there to cut off marks one is being 25 millimeters. The second one is being 50 millimeters. Anything less than 25 millimeters. You can safely advise the woman, um, for expectant management of the miscarriage if she's willing to go for it. Um, now, anything in between 25 to 50 you can offer medical or surgical management with medical being giving the woman misoprostol, um, can be one course of misoprostol than 40 hours a second course of misoprostol, depending on how she's reacting to it now for the foot in terms of where the products of conception are. For example, if the products of conception is that the funders, uh, it may be quite difficult to to go for the expectant or medical management because it can be quite stuck at the funders. Then you would probably be needing to consider surgical management of miscarriage at that stage. Um, so coming back to the different kind of points 25 50 if anything, is more than 50 millimeters in size. And ideally, you would want to go for a surgical management of the miscarriage. This can be either in the form of manual vacuum aspiration or surgical evacuation. Now, it also depends on the gestation age. You can You can always go for this the expectant and the surgical management, uh, safely up to 13 weeks of gestation at that time. But anything more than this, you would need to consider more of the medical management where you would be depending on the path where you can be giving mifepristone first and then 24 to 48 hours after getting misoprostol. Okay, but all of these needs to be after a good discussion with the woman and taking the woman's preference into consideration. Um, explaining all the risk and benefits of these different forms of management. Uh, any questions so far, guys. Okay, Now, um, the third thing. The other thing I wanted to talk to you about is, um, someone coming, um, to any with query labor at that time. So labor is characterized by the onset of regular regular, frequent contractions associated with any cervical changes. I dilation of the cervix or shortening of the cervix as well all together and progressive descent of the presenting part. So labor less someone going into labor less than 37 weeks is termed as preterm delivery. Preterm labor, I think more than 37.0 on words is term labor. At that time, they usually wouldn't present to a any, Uh, on that stage, they usually come maternity triage, where we would usually put them on continuous fetal monitoring. I, CTG and someone will pop it for the abdominal contractions. Uh, and it will also be picked up on the taco for the CT G. At that point, it's very important to diagnose freedom labor because it has different implications in terms of whether you would want to start a few things depending on the gestation age, which is whether you would want to give steroids for lung maturation. Uh, maturation of the baby give magnesium sulfate to allow for proper neuro development for the baby, Uh, and so that's why it's very important to make sure to diagnose preterm labor. The investigations you want to do is do speculum examination to see the cervix, whether you can see the cervix being closed or open, whether it's long or short. Uh, if it sometimes can be quite tricky to determine whether the cervix is open or closed or long as well all together. For example, if someone else had 55 normal deliveries in the past and the vaginal wars or literally collapsing while you're doing the speculum examination so you can possibly possibly at that time, do a gentle internal examination to determine whether, uh the cervical asses open. You shouldn't technically do any vaginal examination because you can stimulate inadvertently, uh, labor by giving and inadvertent sweep. But if you can't see that service and you need to make a diagnosis in terms of then to whether start a few management plan, then you're left with not much option not to do a gentle, um, vaginal examination. Now, um, there's a test called fetal fibronectin. It depends on whether it's available in your center or not. So it's a small swab, basically where you do it, um, at the for posterior for next. Ideally, uh, take the swabs and it can be done any time from 24 plus 0 to 33 plus six really at that time, and it would give you a value for or to calculate for whether that woman is going into preterm labor or not. So different values based on different centers are usually used, but you can also enter the value of the fetal fibronectin on an app called quip up Q u I double P, which will where they will ask you a few questions with regards to the risk of that woman going into preterm labor can fill in, um, those boxes, and it will give you a percentage of delivering within the next week. Usually, if that value is less than 5% then it's It's reassuring in nature, but again, you have to take it with a pinch of salt because things are very dynamic in nature and this can progress. Essentially, doing the fiber and acting and entering the Requip value will help to let to make you make a decision of whether, uh, to start a localizing to prevent that cervix to dilate any further with giving nifedipine or after supper. And depending on where you're working, uh, this to localizing will help to to halt, to hold labor basically for a period of time that you can administer steroids and start magnesium sulfate at that point. Okay, so now the last part of the slide, which I'm not going to talk much about, is, um, someone coming to a any with, uh, sometimes can be quite hard to distinguish between labor and abruption happening altogether. So you should be really thinking of placental abruption or uterine rupture. If if, obviously, you've had a previous cesarean section if the pain that the woman is having is continuous in nature, not giving her much respite in between because labor in itself will be more of contractions and then period of having the contractions and again contractions again. So it's quite intermittent in nature now for the abruption. Um, it's generally, uh, tender all over the abdomen, and it would be of a woody feel to the abdomen. But this is when it's quite a significant abruption happening. That would be quite would in nature would you feel in nature. So these women need to be transferred to maternity unit as soon as possible because it need continuous CTG to for fetal well being. And also depending because they along the time these obstructions can present with no TV bleeding at all. Um and then because it's only when it's quite significant, then it can be, um Then it would be when the absorption is quite far down the road. Then you would have a PV bleeding because otherwise it can be quite concealed nature. Um, so, yeah, what I would say is, if you're suspecting abruption or you try and rupture, then you should be ideally sending them to maternity unit as soon as possible, or or asking the registrar to come down to see that that patient as soon as possible. Risk factors for abruption would be previous abruption. Smoking is a very big risk factor, any trauma to the abdomen and also preeclampsia. Um, I also wanted to talk about the topic, but that would be a long topic for me to have a discussion about, but I think this has already been covered by one of my colleagues Helen in the past or will possibly be covered in the future. Um, so yeah, that's that's it. Really From me. Um, Trump. So yeah. Any questions from you guys? Okay. I'm sorry. This was quite an informative session, Really? Where I've talked, I think way too much. And it must have been quite overwhelming to you guys having that massive influx of information. But hopefully you can go through the slides again. Um, if you need any clarification, um, at some point and all those statistics and percentages and management plans have been based on the Royal College of ob Cingrani, based on their latest papers and the learning and everything all together. Okay. All right. Here. I don't think I've got any more questions. Um, thank you very much, Doctor Kangaroo and hope everyone have a good week ahead. Thank you. Problem at all. Have a nice week ahead.