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So should I try it now? I'm now on your very first page, but with all the sides of the side. Yeah. Has it gotten on? You know, I don't think it's gonna work. That's what I did last time. I didn't work. Yeah. Yeah, it's broken now. Yeah. Have you got the similar thing as before, where your answers come up? Well, I did, like, do it. Not so much like that. So just in case this happened again, um, but yeah, check out page. So I saved that one, and I'm sending it to you now. Okay. How's that? How's that? Is that working? No, I'm still on your main page, so that's just basically the same. Mhm. Yeah, Well, at least let's make these go away, right? Right. Bye. I don't if you can hear, like, screaming Children in the background, they're not my job. Yeah, I have no control over these Children. Yeah, Mhm. Yeah. I'm wondering why. I'm sorry it slides, but no, it doesn't. In pdf. So that's going to be any better. Really. We'll try to stay on the whole screen and see if that my gosh, look at that crazy. Okay? You see that? Oh, yeah. Does that work better? Do you think now it's like on the proper sideshow? Yes, it is. Okay. Perfect. I feel like that was way how that was so hard. I don't know. You sent me something about Yes, I have the chart as well. Lovely. Okay. So pleased. Yeah, we'll start in about two minutes, if that's okay. Helen. Mhm. Yeah, Yeah, yeah, yeah, yeah, yeah. All right. I don't know. Uh huh. Mhm. No. Uh huh. Are these Children very, very loud. I can shut the door. It's very hot, but I don't mind. I can do that if you think it's better. Oh, my report. Right. Oh, okay. Yeah. Okay. I'll do that. I will see you today. Uh, that way. Yeah. Yeah. Oh, sorry. Yeah. Okay. Yeah. All right. Hello. Good evening, everyone. Welcome to mind the options. Are these final series? Uh, we've got Doctor Helen Perry here. Some of you may have attended her previous session on early pregnancy, and I think we all found that really useful. So we've got doctor hello, Peri again here to talk to us about great flex and pregnancy, especially for non obstetricians. You'll be really useful. So thank you very much for coming here to speak with this. Um and you can take it away. Thank you. Okay. Thank you dot Uh, yes, My name is Helen. I'm ST three Cingrani trainee at Wiggin at the moment, Um, so I This presentation is mostly, um, for people who are non obstetricians. Hence the title. So these are the kind of pregnant women that you might see in A and or in a GP. Um, and that might have basically, if things look out for in pregnant women if you see them in a and the Orange GP. So I'm only going to focus on things. So some things are really obvious. Obviously, if someone's having PV bleeding or, you know, abdominal pain, these are obvious. You would refer those obstetrics. So I'm trying to think a bit more outside the box about other things that we might be interested in hearing about that. Maybe don't on first glance seem like they would be obstetric, we would be interested. So that's kind of what I'm going to focus on, Um, if that's all right. So I'm going to do mostly cases if people can put things in the chart. That's really helpful. Um, but, you know, I appreciate it very hot. You can just listen if you like. So, first case, um, all of these cases are real cases, by the way as well. So first case. So she is a 25 year old. Um, it's the first pregnancy. She has a low risk pregnancy. Only been seeing the midwife, and she's had the normal scan that she would have been 12 weeks and 20 weeks. But otherwise, she's just totally seen the midwife. She's 29 weeks and one day, Um, and in terms of her background, she's normally fit and well, young lady, she's got normal bm I know other concerns at all. So she comes to Anne with chest pain. So any what? What are we thinking or what? You know, what do we need to rule out or think about if we see someone with chest pain who's pregnant or a young person with chest pain in general, I suppose. Just wait for the charts, if any ideas. Yeah, I'm getting a few things. Um, so yeah, he Yeah, I think quite a few people saying that, um, which Yeah, definitely. That's definitely a good one for anxiety as well. Yes. A lot of young young women come with anxiety. Especially pregnant young women as well. Um, so that's another good one. Um, yeah. Ruling out myocardial infarction. You know, a C s that's often overlooked, especially in young women, I think. But it is important if someone has chest pain, obviously to do, uh, BCG, just in case you never know. Yeah, Someone else said angina. Um, so yeah, like a C s type pictures? Yeah. So I think that's, like, the main things we're going to be thinking about. Basically, I would agree with that. Really? Um, yeah, acid reflux. Someone said as well. So yeah, pretty much that covers. The most likely thing is that you're going to see in a young woman, especially young pregnant woman in any, uh, p, uh, anxiety and acid reflux. And then, yeah, rule out just cardiac problems as well. So what happened? Um, so this is just a bit more history. I guess you'd want to take more history to know getting differentials down a little bit more. She didn't have any shortness of breath or any palpitations. You didn't have any other symptom symptoms at all. No obstetric symptoms. Essentially. What? I'm going out with that. No abdominal pain? No BV bleeding. Baby's moving normally when she was examined. And that was all fine? No. Nothing standing out a new score was zero. So, uh, yeah, it's kind of following on from the differential. So I don't think we really, um, shortened our list of differentials that much, Potentially slightly less likely to be a C s and things like that. But apart from that, it's kind of not really ruled out anything. Um, So what kind of next investigation and things might we want to do for this lady? Okay. Yeah. You see, GI? Yeah. No, not the time. I'm going to come to that. But anyway, yeah, yeah. Bloods. Yeah. Yeah, that is another good one to think of. Actually, I I Sure, Yes. Um, sometimes if they have a very, very anemic they may get chest pain. I have seen patients like that before. Um, yeah, I could do an echo. Yeah, not normally transthoracic, but you could do an echo. Fine. So we move on, so Yeah, it's usual. Chest pain stuff. Basically. So you had blood stone, which were all normal, including troponin. Everything was normal. E EKG was normal. She had a chest x ray as well, because she was going down a p e pathway essentially, and that was also normal. So yeah. What next? Uh, the kidney doctor essentially was going down the pee route. That's what they thought it was, which is completely fair enough considering how she presented. So she had a c t p a. So this is my note here. Um, diamonds not don't do a d dimer and a pregnant patient, they will definitely be raised, so there's no point in doing that. Also, essentially all pregnant women are high risk for V. T. So you don't really need to do a well score. You don't really need a diamond because you already know that the patient is high risk. And so if you suspect to pee, you need to do a scan. You need to rule out p essentially the same with the DVT. Um, if you suspect that you need to just do the scan, there's no point doing this in between things that try to risk stratify because they're already they're already high risk. So wasting your time doing well, school and things like that. So basically, there's no point doing a d dimer. Um, often they do get done by a mg. I think just when they come through the door, there's just like a chest pain set of bloods that get done by the nurses or whoever does the Bloods. So often we do get discussions about the diamond, but you don't think to do a d dimer. It has not been done. Don't bother, basically, because you will be raised. It doesn't tell you anything. It's raised in pregnancy anyway, so it there's no help at all. Um, so the CT pa on this lady was negative. So, um, because the CCP was negative, they said, Oh, it's probably heartburn because when you actually heard her story, um, the chest pain was more, um uh, like epigastric lower chest kind of area. So they said, Oh, it's probably just heartburn because you're pregnant. Um, so here's some omeprazole, which is which is fair. Enough is far enough, I think if you've done, they were very thorough and they did a CT, Be a, um and if that was negative I think it's fair enough to say it's probably heartburn or it's probably muscular. That's completely fair. What happened with the safety net? It her to come back, obviously, if anything got worse. So she did come back two days later, as the pain was. Still there was actually a bit worse than it was before again. Her new score was zero, and her examination was unremarkable. No real change. E EKG was done again and blood work done again, and they're both normal again. However, this time the patient says, Oh, actually, the baby hasn't been moving as much as normal. So after they finished assessing her in a and, um, they just referred her up to maternity triage, basically, just to check on the baby. Really, Uh, more than anything else. So she came up to the maternity triage when she got there to try to see which was normal. No, that was fine. Um, but this was a little pressure, and she had four plus of protein in the urine and often know when you actually look back. Her BP was this all the time? Uh, it was always this. The other times that she came as well. Um, and she hadn't had a urine dip down in A and B those other times she came. Um, so she had this ongoing chest pain epigastric pain. Uh, I'm doing the soft nontender. Really? Um, when you check the reflexes, they're brisk. And she had four beats. Clonus. So I don't know if anyone has done any obsession or anything or remembers from med school, but what's the diagnosis here? Yeah, pretty pretty common. Yeah, yeah, yeah. And this is an unusual presentation of preeclampsia. So I'll give you that, and I'll give you any of that, you know, completely fair that they it wasn't obvious. Um, usually, if preeclampsia will present with the headache or or with no real symptoms to be on a visual disturbance sometimes. But sometimes it can present just with epigastric pain. And that is what happened to this lady. So just a few slides about preeclampsia, obviously as non obstruction should not really going to be managing it that much. But it is a kind of thing that can be found as as as it was for this lady. So it's kind of worth knowing a little tiny bit about it So what I what, um, frequency is is, uh, hypertension. Uh, and in pregnancy, hypertension is is defined as above 1 40 90. So this is where it all went wrong and any if you like, because, you know, not on a normal, non pregnant patient. No one would even think about that. BP. That is not bad. Really. Whatever. You wouldn't even care about that. Especially in a young person. You're just like Okay, fine, whatever. Um, so, yeah, you have to have hypertension and be pregnant, obviously. And, um, protein. You were so more than one plus and be more than 20 weeks. Um, so sometimes I do get phone calls about women who are, like, you know, 12 weeks with these symptoms, and I'm like, Well, no, it's not preeclampsia. It cannot be Pre eclampsia. Less than 20 weeks pregnant is actually very unusual. Less than 28 weeks. Um, it can happen less than 28 weeks. We do see it, but these are very, very severe. Preeclampsia is the majority of frequencies will present later than 28 weeks. Generally, um, all right, so this I mean, we don't really know what problems serious to be honest, but basically it seems to be associated with suboptimal uteroplacental perfusion. And when that placenta is not embedded properly essentially into the uterus Um, there's, like, this maternal inflammatory response and maternal vascular endothelial dysfunction. So that's kind of what leads to the hypertension to the protein. You were there Just leaky, kind of from everywhere. Really. Um, so that's why a lot of the symptoms that they get in a lot of the, uh, complications that they get are based on that, um, can affect any organ system. And essentially, the percentage definitely has a pivotal role because we know that once we deliver the placenta, um, precancer results essentially immediately about over a few days for the results. So potential complications, So frequency is is very serious. I mean, a lot of the time we catch it very early these days because everybody is so hot on it, especially midwives. Very very. Um, they refer them in with the profession very frequently, um, so we don't tend to get to the complications side that much, but the potential complications if it's under diagnosed and not treated so you can have you can have eclampsia. I mean, that's that's the outcome of the programs are basically, um, clamps Here is a fit. Essentially, the high BP itself can cause a stroke or cerebral hemorrhage. Um, they can get pulmonary edema. So they're saying again, with leaky from everywhere, you can get help syndrome, uh, go into renal failure and, um, thinking about the baby, um, the baby can have can not grow as we expect. And in an acute situation, if it's a small baby And if you have very high BP, you can have things like a placental abruption or leaning to fetal distress. Things like that and a lot of other serious complications like that. So, preeclampsia, uh, it's a serious diagnosis. But the vast majority of preeclamptic ladies can be managed as our patients once we control the BP. But it really depends on the severity. Um, as I said before the earlier you get pre eclampsia, the more severe it tends to be. Um, so if you get very early preeclampsia, you tend to be quite severe. Uh, not really. How patients suitable. Um, but if you get later in the pregnancy, it can be a bit more mild. and you can get, like term, you know, 37 weeks, things like that. It kind of just depends. And sometimes it kind of creeps up kind of slowly. Um, we can manage it by, you know, keeping the BP under control. Um, so these are the anti hypertensives that we use in pregnancy, Basically, the Beatles first line. Unless they're asthmatic, and then they have nifedipine. Um, so we can give a beat of all, um, up to 304 times a day. Um and we can also add in the felodipine as well, which they can have 30 twice a day. So the very severe preeclampsia will be on that full maximum. Generally, we don't really use methyldopa anymore. Um, you know, if they're needing to antihypertensive and still hypertensive, we kind of We kind of call time on it then and just deliver the lady. Um, but occasionally we do use methyldopa if someone to say, for example, it's severely asthmatic. And then, um, they also can't tolerate the therapy mean sometimes the phentermine give people quite a few side effects, and they really don't like taking it. So these are the patients that might get methyldopa. Really? Basically, they can't take the other to see any time. Hmm. Okay. So I thought about how you coming. Myopia comes here, which is basically just that definition. I said before, you know, the higher BP performed 40 90 with some protein. Um, just is a definition of preeclampsia, but of course, it can be more severe. Generally, by the time you get symptoms, you are already in the more severe spect end of the spectrum. Uh, but this is the official definition of severe preeclampsia. I guess we're all right. Um, so either you have very high BP, uh, above 1. 61 10 with one loss of protein. Um, or you have moderate hypertension. So it's systolic above 1 40 diastolic above 90 with two plus or more protein or a PCR of above 30. And as well, you have to have symptoms as well. Uh, well, some symptoms of either a severe headache with visual disturbance. Uh, right upper quadrant pain. More than 33 beats of closeness. Platelets less than 100 or a l t of more than 70. Um, so, you know, there's different ways you can be diagnosed. Essentially, if you have very high BP, you don't have to really have the symptoms. They almost certainly will have the symptoms if their BP is that high, Um, or you can have slightly less high BP. But other things going wrong? Yeah. So what is your name and your GP? And you found somebody with BP That's high. Who's pregnant? And you're like, Okay, what do I do now? I've discovered this BP. I've done very well and I have not. I have ignored the news, and I've seen that she has high BP. So the key thing with a pregnant woman who's above 20 weeks is to check the BP reading properly as it might actually check the number rather than just like Oh, she's scoring zero, which is fine. You don't Normally that means she's fine, but it's important to actually check the actual number because, as I said before, 1 40 90 won't score on the general adult news. Um, in maternity, we use a a special maternity early warning score, which it would score for obviously, if you're on any or GP, you're not going to be using that. So it's important to actually check the actual numbers when you see a pregnant lady rather than just call in a new school. If you see that it is above from 40 90 I mean, to be honest, a lot of people's BP is above 1. 40 90 when they first arrive at A and E and also with the machines as well. Very often is more than that. But if you recheck it, you know, give them time to calm down from the whole, you know, just arriving in a and B, um, and ideally, do it manually, if possible. Amintgp. That's probably as possible, but I'm not sure in. And if you have any manual BP cuffs and I don't know, but ideally do manually. But it is okay with the machine, if that's all you've got. Yeah, check urine dip. Um, protein, uh, ask for the pre pre eclampsia specific symptoms. So I think if you saw someone with epigastric pain, you wouldn't necessarily ask them if they have a headache. So you can ask that as well. Um, yeah. If if the BP is still raised and there is some protein, then referred to obstetrics. Basically, I mean, if your BP is raised, even if there is no protein, I would still call Detrick's. Anyway, that's fine. I'm perfectly happy to see them. Um, as I say quite often the BP is raised in any But when the continental industry as it's settled down, um, and then they don't need to do anything more, which is fine. But I'd rather do that than not do that. And they'll be someone were pretty fancy and walking around other. And so yeah, so I have to put this one in because some of you might be absent Any s h o s, like the F two is rotating through or GP trainees rotating through, Um, so you might actually see them on maternity triage. You might actually be the one seeing them on maternity triage. I've kind of done it from that angle as well. So, again, the specific history, um, so it's mostly headache, visual disturbance, epigastric pain, but you can ask them about, like facial swelling or hand swelling. Um, obviously, today, that would not be a very relevant question on a really hot day, but, you know, sometimes they might tell you they will always tell you their feet to swell in. The feet are always swollen when they're pregnant. So that is not a good sign of preeclampsia at all, but hand swelling or having to remove rings. Um, or like the partner, for example, saying that their face does look more swollen, Um is, um, can be a good sign. Um, when you see someone who has really true severe preeclampsia that quite often are very swollen in the face. Um, I saw a lady in clinic who she was definitely high. She was severe. Preeclampsia, um, from the get go, um, referred her into this was in clinics. I sent her to the labor board. And then I happened to see her in labor or the next day, because I was on call the next day and you could see the difference in how much swelling she had on her face. It was she was unrecognizable almost how much swelling she had. So partners sometimes do pick up on that and say her face is really swollen, so that can help as well. Um, so another. It's just another thing to add to your examination. Would be obviously going to do an abdominal examination on a pregnant woman anyway. But reflexes and clonus, that's not something you routinely do want anybody, really, but especially pregnant person. But it's something you could do if you see them in the maternity triage when we see them on maternity, we don't just take one BP reading. We take three readings 15 minutes apart, and we usually ignore the first reading as well. For exactly the reasons I said when someone first arrived, very stressed, it's, you know, the whole thing. So the BP often is a bit higher. Um, so for us to diagnose is preeclampsia. I would take the lowest of three readings, and if that is still above threshold, then, um then I count that as high BP you're doing, you're in depth. If you're on triage. Um, and there's more than one plus protein. Then, uh um, PCR should be sent. Um, yeah, If those things are both true, then this lady is going to be admitted essentially. So you need to put cannula in and do bloods. And these bloods. Here are what we do as routine and what we call pre eclampsia bloods. Essentially, it's looking for help. And that's what that is for, really. Plus, we do you any because they can go into renal failure to have severe preeclampsia. And, yeah, someone who has precancer should have some GI. But you mean honestly, as the absence of any you'll never have to ask a midwife to do an EKG, see GI, they do them on everyone. They just everyone gets a CD, you walk in the door. If you're pregnant, you get a c g. So very unlikely you would have to ask if I have to do that. They also mostly routinely send the PCR without your without having. You have to ask them to do that as well. They're very good at managing BP. Um, to be honest with you, if if a midwife sees someone with high BP, mostly just gonna immediately just call the registrar rather than call the S h O. But just if you did happen to see them, um, this is just what you should do. And yeah, if you see someone BP and protein, you should always discuss it with the senior and they register a consultant. Whoever's around. So just more for just a background. You don't need to know this, but I just thought people might be interested to know what we do next when we have preeclamptic ladies. So as a senior, you know, what we're going to do is we're gonna admit them to the labor ward for h do you care? You give them. Obviously, you need to bring BP down is the most important thing. So we're going to give you normally, start with the oral hypertensive stat. Uh, normally the basal so we can give that again, Uh, if we need to. But if it's not improving after, uh, two oral hypertensives, we could consider giving IV anti hypertensives again normally labetalol Or if they can't have that hydralazine. Um, if they are needing IV or if we think you know the very severe preeclampsia, then they should have magnesium sulfate, which is for neuroprotective for themselves and to prevent fits. Essentially, that's clumsier. It does also bring the BP down a little, but only a little bit. We're not really using it for that, but it's more for your protection to prevent fits. Um, yeah, someone with severe preeclampsia should be fluid restricted. As I said, they're very leaky. They're like they're like someone in heart failure. You know, you would fluid restrict them. Um, and yeah. So as part of that, you know, you you're probably gonna put a catheter in, so you can have an accurate monitor of urine output. Um, so if they're very severe, they have blood every six hours because they can really deteriorate very quickly. Um, especially if they're if they're needing IV, um, antihypertensives or if they're on magnesium sulfate, they definitely would be having six hourly bloods. If they're not as severe as that, then they might have 12 hour early blood or daily bloods, depending if their outpatient they usually have twice weekly or weekly bloods. It kind of just depends how severe they are. But they're impatient and on all of these IV medications. Then we'll be doing six hourly bloods on them, and we should consider delivery. If they're that severe, we should consider delivery, even even if they're very early. If they are that severe, you know, they're really the cure for preeclampsia is to deliver the baby. So that's what we have to do. And we, um The mother always comes first. So even if the baby is very preterm, um, you know it If the mother is, that's fairly hypertensive. You know, we don't have to have a stroke or something like that. It's obviously much worse. So if we're considering delivery, Yeah, we would give the baby steroids, um, as well. So just to finish off this case of this lady, um, so she did get admitted to labor Ward. She was managed with the oral hypertension antihypertensive so she didn't need to have IV. Um, she did. She was on Taxol. So, uh, the blood. So if you remember the blood that she had an A and B were normal. Um, although when you actually look at them, you could see a downward trend, but they were still in normal range. Um, but, um, six hours later, platelets are 95 L2 65 HB one Oh. One, um, crossing anywhere near normal. However, because she has low platelets and elevated liver enzymes. Um, she, uh that's helped. Sorry. H b was around that. Before that I hadn't dropped massively, but it's quite normal to be anemic in pregnancy. So that No one has really thought anything of that. And I wouldn't also think much of that either. And 101 is not too bad. Really? Um, in pregnancy, But yeah, it's more the platelets, um, and the a l t. They said they were normal six hours later, so you can see how quickly they can deteriorate. Um, so she actually had my knee themselves. And you had steroids for the baby at 29 weeks, if you remember. And she had a cesarean section the following day, and, yeah, she got better after that, then I don't know. I'm sure the baby was okay as well. Um, I don't actually know. If it was, I'm sure it would be all right. It's very good these days. And, uh, and a two unit. So, um, three times a key points for the non obstetrician Hypertension in pregnancy does not score on the adult news. So if the pregnant patients over 20 weeks look at the actual number, not just the score. I'm not sure if it would have changed much. Um, you know, But as I said, when you look back, the BP was actually, uh, above the 1 40 90 both at the time, all of the times that she came to A and B um so, you know, could've potentially found it a little bit earlier. I doubt it would have changed any of the outcome. To be honest, as I said when they get it that early, they're usually very severe anyway. Yeah, if it's high, repeat it ideally manually. Always, you're in depth if you're pregnant, even if there are any symptoms. And not just for protein but for, you know, urine infection. Things like this. They can often be asymptomatic, so it's always, always important to do a urine pregnant woman and you were referred to us. Or, if you're already OMG referred to a senior MG and do it earlier. If your pressure's raised as they can deteriorate very quickly. So that's case one. So moving onto case to that at all as intense as that, I'm still gonna probably finish at eight o'clock. That was just the biggest one, because the cramps is very common. Um, you know, it's sort of it's something in the region of like 3 to 4% of pregnancy, So it's common, Um, the rest of the things are very more rare. But they're just, you know, important to find if you if you see them important to find so that so I spend more time on that one case to so again, this is a real case. It happened. A hospital not in northwest, in Wales, in rural Wales. And it didn't happen while I was working there, but the repercussions were felt, um, from it. Um And it is a real case. So she was 33 years old. First pregnancy normal. Bm i you had a history of a DVT, um, following I I can't remember what she had some kind of minor surgery and appendix out or something like that. And you had a DVT following that. But otherwise she was fitting. Well, she wasn't any long term, um, anticoagulants or anything like that. She just had a history of a DVT. So she went to the guy in the assessment units around seven weeks from her LMP with heavy bleeding and abdo pains. It was suspected miscarriage. Um, she came back the next day. That was fine. A bleeding settle. The pain settles, so there's no more concerns from that side. of things. Um and yeah, the pregnancy was viable into trying pregnancy. So she so she was advised to book in with the community midwife and she was discharged from the early pregnancy unit. The PT risk assessment was not documented The time when, About a week later, she had a booking appointment with the community midwife. Um, the community midwife did write down that the lady had a previous DVT in the booking documentation. Um, the midwife arranged dating scan and clinical appointment with a consultant at 12 weeks following the dating scan to discuss the previous DVT and what that would mean for her pregnancy. Three days later, she went to her GP. She had mild shortness of breath. I don't know if it's really relevant, but it was sort of mentioned in the case. So I guess I'll mention it as well. It was the middle of July, very similar weather to now. It's very, very hot. Um, so basically, the GP wasn't really that worried. Um, reassure. The patient did kind of tell her. It's probably because you're really hot. Um, so, you know, just like drink plenty, that kind of thing. Everything else was fine. your examination was fine. Everything was was okay, so he just reassured her. Um, the GP did not ask about if she had a previous CT, and they did not check the medical records at 10 weeks and six days. So a couple of weeks later, patient collapsed at home. Partner rang the ambulance. Um, this is rural Wales, as I mentioned. So she went to the hospital by ambulance, but then she was airlifted to the tertiary center in Cardiff. But she never regained consciousness. And three days later, life support was withdrawn. So when she had an autopsy, the cause of death was hypoxic. Brain injury caused by cardiac arrest as a result of bilateral pee. So as we talked about before, it kind of was hinting that way in the first one. Um, yeah, he is very important. Um, cause of death in pregnancy and cause obviously morbidity as well. In pregnancy, it's always important to consider um, as I say, you know, I feel I think that most of the time were very good actually at, um considering pee and considering Bt and pregnant ladies, we definitely over investigate, But it's better to over investigate than under investigate. So v t a. So that's including DVT as well is 10 times more common in a pregnant than a non pregnant woman at the same age. Um, so these are the numbers, and of course, it gets more likely to happen if you get older as well. Um, so I don't know if anyone has worked and embrace, uh, in obstetrics in the UK, you would hear a lot about embrace and whatever so embraces. Basically, a report that's made every year about the pregnant pregnant patients have died in the last three years. Um, so it goes, you know, calculate it goes through all the deaths in someone who was pregnant or who was postpartum, uh, and just sort of analyze why why these ladies died. Um, so thrombosis and thromboembolism is the leading direct cause of maternal death. So, um, when we think about maternal deaths as well, we also think about direct. So that's something that that basically, the pregnancy has caused that woman to die. Um, and then we can think about indirect causes as well. So in direct cause would be it wasn't the pregnancy itself that caused the woman to die but the pregnancy exacerbated that problem. So something like epilepsy is indirect because they they die of sudden death and epilepsy during while they're pregnant. They didn't die because they were pregnant, but they their pregnancy probably made epilepsy worse. Anyway, That's an aside, really, basically, is the leading cause of death in a direct cause of death. So it is important 20 women died in those three years. Obviously, not very many pregnant women die in general. As you can see, that's the leading cause. And it was 20 women, so there's not very many, but, um, still, you know, we don't want any know pregnant woman should die? Really? You know, they're young women. They shouldn't die in pregnancy. Um, so basically all pregnant women are high risk. Bt. I feel like I've already talked about this and you should have a lower threshold for suspecting and investigating tea. So as an aside, everyone should have a CT. All pregnant women should have a CT assessment on that booking, and depending on their risk, some of them might have low molecular weight. Heparin prophylaxis throughout the pregnancy was starting from 28 weeks, and that was the big thing coming out of the case that I talked about. Essentially, that woman, having had a previous CT, should have been on prophylaxis as soon as she was confirmed a viable pregnancy. So she should have been on it from seven weeks or whatever it was, she had a scam. Um, you know, if we know they have a previous CT, they should really have an early scan so that we can start the prophylaxis as early as possible. So that was the big what came out of that case. It was a really big deal at the time, because, you know, basically, that woman should have died. Um, she should have been on prophylaxis. And also the GP should have, um, considered referring investigation of the PDE as well. Um, but depending on your risk, they have to start right at the beginning, or they some of them start from 28 weeks. Um, PT risk is even higher postnatal. So you have to have an even higher in the suspicion if they recently had a baby within six weeks. This is the very prime time for PT, and a lot of women score for the prophylaxis postnatally even though they didn't score antenatal. So we have a I'd say most women go home with with at least 10 days Clexane. Um but, you know, uh, so if you see them in any if they just had a baby, like a week ago, definitely. You need to suspect pee or or a DVT. Um, so, in terms of how you would manage them in a and B or GP, Um uh, investigating a dvt is exactly the same as if they're not pregnant. Apart from don't do the timer. Don't do timer. Just the high risk. Don't bother with all that. Just you suspect it that high risk already. Just do the doctors and give them the treatment dose while you're waiting for the doctors. So if you think p um, you know, there's a debate about CT pa versus the Q for a pregnant woman. Um, so basically, CTP A. There's a very small increased risk of maternal breast cancer in the future. Um, from the radiation. If you have a VQ scan, there's a very small increased risk of childhood cancer for the baby and that, to be honest, I should have put very, very small because that is a very much smaller risk than the risk of breast cancer. Um is very, very, very tiny. We're talking something like 0.3 or something percent. It's really small. Um, but yeah, there, I guess, however, both of them the amount of radiation that they deliver below the threshold for safe amount of radiation in the pregnancy. So they're both completely fine to do in pregnancy. And you should definitely do them if you suspect the normally in my experience, um, CT. Basically, VQ should be first line, but most units won't do the accu. So you have COPD because the key is quite difficult to get a hold of, especially out of hours, almost impossible. Um, so most women will have a HEPA really have a choice, but essentially can do either, and the key is probably better. Um, just briefly on the radiation in pregnancy. Um, there's no, you know, studies, obviously, because you can't really study that. But essentially, a woman can have a CT, thorax, abdomen, pelvis during her pregnancy and still be below the amount of radiation, that safe amount of radiation. So, you know, you should definitely do the scan. If you need to do a scan, same with If they need to have a CT head, they should definitely just have it. And, you know, sometimes the delay waiting for, like, MRI, head and stuff. It's not worth it. Like, you know, just just do a CT if that's what if that's what they need to have, Um and of course, always risk benefit, isn't it? So you know, we have to always think about that. So other key points we see in pregnancy uh, generally, when we give treatment doses a pregnant lady, we give it as BG dose. Um, and based on the booking weight, not the current weight can give it once daily. I don't really know why we do the D, but we can't generally is d D. If they are diagnosed with a P or a DVT in pregnancy, they will have their, um, like saying throughout the pregnancy, even if that is, even if they're only eight weeks, they will have it for their whole pregnancy. And they will have it for at least six weeks after they delivered the baby as well. If they got their pee when they were 36 weeks. Then they'll have it for three months in total, as long as it's three months in total. Um, then they might have to continue it after the six weeks post lately as well. So they just need at least three months, and they definitely need to be on it all through the pregnancy. Um, if you have a massive pee from Dallas is is safe if they need to have it. Unfractionated heparin is also safe if if they need to have it, um and yeah, postnatally so anti In Italy, it's always low molecular weight heparin. Unfortunately, so they have to inject. There's no, uh, we can, uh, warfarin definitely unsafe in pregnancy. Um, and, uh, the newer, uh, the newer anticoagulants. There's just not enough evidence to say one way or another, so we don't use them in pregnancy. But postnatally they can change the oral anticoagulant, and it depends if you're breastfeeding or not. So if they're breastfeeding, they can have warfarin. That's fine. Um, but they can't have again. We just don't have enough evidence yet for the newer ones. So we generally avoid them. I suspect they will be safe, but we just don't We don't know that yet. So generally, if they're breastfeeding, they have warfarin. Um, if they want to change to an oral or obviously continue with low molecular happen if they want to do that or if they're not breastfeeding, they can change that apixaban or whatever. I've got a few like questions. Yeah, our patients. Given the choice between two investigations, uh, sometimes some units, they do get the choice. But to be honest, a lot of the time the choice is made by the radiologist who's like, Well, I'm doing a week you can generally. But if they if they do have the choice, then yes, we do discuss the risk of them and give them the choice. We should discuss the risk of them anyway, um, you know, But yeah, I just about the potential risks that there is in the pregnancy, to the pregnancy and to themselves for the longer term. But also the risk of, you know, potential risk of not diagnosing a P E is essentially the or, you know, they just have to stay on the treatment dose. If we're not going to do basically, if we're not going to do a scan. They just have to stay on the treatment dose. So if they rather do that, then that's fine. They can do that. Um, that's fine. But you know, most people don't want to have to be honest, right? So that's PC bit quick, and we'll do. The rest is going to be even quicker because, as I say, we're getting much rarer now. So next lady, 38 years old, she's grabbing a two part of one. She, uh, 35 weeks she's normally fitting well, low risk pregnancy or midwife lead. So she goes to and me with the right upper quadrant slash epigastric pain kind of all across the top. Really? Um, those are vomiting, fatigue and feeling generally unwell for two days. So just tell me what I mean. What differentials have we got from that? It's pretty vague, isn't it? Yeah, he comes here. We've learned from this from this talk. Yeah, he is. Well, yeah, these two, all my women are presenting the same. I didn't kind of realize that until now, but they are kind of all Yeah, you definitely need more history. Obviously, this is not very, you know, it is very much. The very read it on the line in A and B, You know, the top line of what she's coming with? Yeah, liver disease. So the cystitis? Yeah. We have to think of things that are not pregnancy as well. You know, not not everybody is like going to have pretty clumsier, you know, they've got right upper quadrant pain and vomiting. Or, you know, you normally go for gall bladder of some kind or liver disease of some kind. Yeah. Lower lobe pneumonia. Yeah. Hi. Premises. Bit unusual. 35 weeks, but, you know, Yeah, like gastroenteritis or something like that. Um, toes. And I'm not sure what contortion you mean? Uh, pancreatitis. Yeah, that's another one. So definitely not ms Yeah. Anyway, so basically, there's loads. That's that's the summary. It could be anything from that. That's you need to follow up on history and everything else. So it could be heartburn. And also gastroenteritis, gallstones, pancreatitis, hepatitis. Just generally, a viral infection. You know, just generally feeling run down. Uh, yeah. Any kind of a C S, p preeclampsia, etcetera, etcetera. Goes on and on. So this lady on examination generally was unremarkable. She's slightly tender in the upper abdomen, but that was it. She's pregnant, obviously. So these are the bloods. So, um, white cells slightly raised platelets a little bit down each, you know, bit anemic. But that's quite normal. Pregnancy would be that worried about that. Um, AARP is high, but it's always high in pregnancy. So that's not that's normal. But her a l t is also high, and a bilirubin is also high. Uh, yeah. Those are fine. Um, but creatinine is raised and your ears raised. I'm lazy is normal. Uh, glucose is a little bit low, and these are prolonged. I didn't know the reference range is either, but they are prolonged. So if we're looking at these bloods, nails just come with the upper abdomen. Pain. Um, just got deranged. LFTs. Um, she's got a deranged uni deranged clotting. Uh, white cells are slightly up. Let's lie you down. So, what do we What do we think this could be? Do they help with all these blood's really so Yeah, It definitely could still be helped. Yeah, I agree with that. Yeah. Not really. Upset called Stasis. You really get, um, to arrange your knee with that um, already. But, you know, you don't tend to really get deranged bilirubin with college, either, Actually, but yeah, basically, um, it's very specific, so you probably wouldn't know that, But looking at her, you see, she's obviously got some kind of liver problem because she's got the range clotting as well. Um, you know, so that's concerning for something like a liver pathology. She does have, you know, a kidney injury as well. Um, you know, just from that you don't really know if that's, uh, come from the liver failure or from the you know what's what's causing what? Um, but basically, this is a cute fatty liver of pregnancy. This is the only non real. This is the only non, um, real case, because I've never seen this because it's very very. I haven't seen this, but it's an important thing to pick up. Um, if if you do, if you know, if you do see someone with deranged LFTs who's pregnant, also with drainage, Um, it's very important to refer and consider this as a differential. Um, it's often a very vague presentation, especially at the beginning. Is that often just fatigued? Um, you know, a bit run down A bit of a you know, epigastric pain. Very vague. Very pregnancy symptoms. To be honest, the vast majority of people who present like that have absolutely nothing wrong with them. Um, however, they do deteriorate very quickly. Um, so generally they'll progress acute liver failure within about one or two weeks. It's very quick, um, deterioration. So the first time they come, you probably you might not get it, which is there. But then when they come back, the next time you see the blood and you feel like something is definitely wrong here because they will deteriorate very quick very quickly. Um, and it's like proper acute liver failure, you know, joined us with hypoglycemia, coagulopathy, ascites and cardiomyopathy, acute kidney failure. So 90% of them get all of those things within within one or two weeks. So it's very quick deterioration. So as people rightly pointed out, they initially can present very similarly to preeclampsia, including with raise BP and protein urea as well. Uh, and the blood derangement is very similar to help initially as well. So a lot of the time, that is kind of the route we go down first, Which makes sense because the cancer is like 4% pregnancies rather than you know 005%. You know, um, but the key difference. If you want to like, you know, I think, why? What is? The difference here is the hypoglycemia is you do not get hypoglycemia with preeclampsia, So if you see someone who's also hypoglycemic, that should make you think about acute fatty liver of pregnancy. So how is it managed? Basically, is life threatening to imagine it was It's, you know, liver failure. So it's life threatening, and they tear it so quickly. It's mostly supportive, but they often need to go to I t. U. As you can imagine, they've got multi organ failure. Essentially, early delivery is the real treatment, because again it's pregnancy related, so it often resolves completely after they are delivered. A complete recovery with no long term is clearly often if you do it early enough. Of course, if they have more lasting liver damage, they might have to go through the normal acute liver failure, long term problems you're having. Um, I have like a liver transplant, things like that, but no, it's not very usual um, you know, if you deliver the baby, usually they will recover completely. So I mean, I'm not expecting any one A and B to really kind of find that diagnosis. I think I wouldn't even find this diagnosis on maternity triage. But basically, the key point for someone who is a non obstetrician is if you have a pregnant woman in your age and the or your GP has deranged blood, just discuss it with us, and then we'll decide what we think. At the very least, someone with them to arrange liver function like that with any kind of deranged liver function we would want to follow up in the clinic. You know, something like cabs Collie, which someone mentioned, Um, I'm sorry. Obstetric code status. As someone mentioned, um, we would see them weekly in clinic. So, you know, even if it's only just the lt that is raised, we would want to be No. We want to know about these people and we would see them in the clinic. So that's probably how we would pick it up, because we would be repeating that blood every week. So that's that one case four, which is the last case. So she's 35 year old. He's the first pregnancy. She's also 35 weeks. Slow risk pregnancy, no medical problems. This is a real case. Not one that I've seen myself personally, but it's a real case. Um, so she went to her local a Andy on a Saturday evening with shortness of breath, palpitations and coughing up off the pink sputum. She was very anxious as well. Um, on examination, BP was okay. She was tachycardic and take a picnic. And she had a low SATs. On examination, she had reduced air entry at the base of the right lung. So what? What's the differentials with this one? A little chest I just realized Just an upper optimist. Never mind. Yeah, lower lobe pneumonia. Yeah. I mean, I'm sure someone's going to say pee as well, because it could be P. Yeah, TB. Yeah, that's really our the left field, I guess if you were in London or something like that, I work in Wigan. So no one has TB and let me wiggle so But anyway, basically chat something long were thinking right, r p which makes sense. So that is exactly what they thought she was admitted under the medics so that they're differentials were chest infection or pee or just a panic attack generally. But I think she was, you know, she was She had low sat. So even if she was even if it was a panic attack far enough, they admitted her, uh, I can see. Well, yeah, I guess it could be. Yeah. Um, you know, pregnant. That's another thing to think about. You know, pregnant women. Do you still get cancers? Do still get everything else, especially breast cancer. Things like this still happen in pregnancy, So yeah, it could be like I met from a breast cancer or something like that. So that's a very good out left field thought, but it's We should think about it. Um, at least, you know, do a chest X ray. So I really know why there's nothing mentioned about the chest x ray. So I assume that she did have a chest X ray, but it was probably normal. Um, anyway, so they kind of went down the route of pee. Um, so they did order a CT pa. But it was Saturday, and the radiologist said, No, I'm not doing that of hours. She can have it on Monday, which is quite standard in the DVH. I've experienced that as well, because they say, Well, she's on the treatment dose Clexane. So it doesn't really matter if we do the CPK, which is fair enough. So she was to start on antibiotics for a chest infection, anyway, um, and given treatment dose Clexane as well. Uh, so I didn't really get better. And actually, she started needing a bit more oxygen, If anything, When they did the ward around the following morning, um, the patient complains, uh, she had to sleep in the chair all night because she couldn't breathe when she was lying down. Um, so through sunday, she just got worse and worse and worse. And then she had a cardiac arrest. In the early hours of Monday morning. She had a perimortem section as part of resuscitation. Baby was fine. That's not an issue. Um, so yeah, So that is something that we would do if if someone has a car, if a pregnant lady is over 20 weeks and she has a card cardiac arrest, if there's no, um, return of spontaneous circulation within three minutes. We should do a perimortem section. Um, which basically just means it's not for the baby is for the mom. It's part of the resuscitation. Essentially, the uterus is putting a lot of pressure on the, uh, you know, the aorta and the the, um and then cover. And, um, also, you know, the body is also trying to supply a baby with blood as well. Which, you know, really is the least of its worries at that moment. And so we we would do a perimortem section to help with the resuscitation mom, not to save the baby. Um, so it and it does help to to, uh it does improve outcomes for pregnant women who have cardio thoracic. And this is very rare. To have a cardiac arrest is pregnant woman, But you know, if it does happen, um, So once you've had the paramedics section, um, she was she was resuscitated, and she had Rusk. And then, obviously, we want to talk to you After that, um, she was reviewed by a cardiologist, and they did an echo, uh, which showed a severely reduced ventricular function. Essentially. So despite I t u management, patient became increasingly stable and died later that day. So, So sorry. These are really depressing stories, but basically, it's the key thing is to think about cardiac disease and pregnancy. Um, we think about P. I think we're quite good at thinking about P. Um, we think about chest infection, things like all these more. You know, things are common. Um, we don't really think of young people having cardiac disease. Um, and they don't most of the time, obviously. But it's important to consider cardio disease in pregnancy, especially cardiomyopathy. A lot of women have been completely fit and well, um, and then this is pregnancy is a real stress on the body. So when they become pregnant, these, um, these underlying conditions can surface basically. So again, this is from all from embrace. That story is from embrace. They have little like stories of women who died, you know, because it's not that many. So they can just write them all down, basically. But this is one of the women who died. Um, So cardiac disease is the number one in direct cause of maternal death. And so, as I said before, that basically means, um it wasn't the pregnancy itself that cause of death. It was, you know, heart failure, the cause of death. But the pregnancy made it worse. Um, and actually, cardiac disease is the number one overall death, cause of death as well. So it does. It kills more women than from QVC, mostly because of being diagnosed and people missing it. Really? Because, you know, also, it's more difficult to manage someone in severe, you know, in severe heart failure that is a lot more difficult to manage than someone with Basically, that's another reason as well. So in that time there was 36 deaths. As you can see, that was more than the V C, which is 20 deaths in those three years. So it does seem to be increasing as well. Um, this is probably because we're getting a lot of people getting pregnant when they're older. Uh, you know that shift towards having babies in your thirties and even in your forty's not that unusual to have a baby in your early forties now, Um, also, of course, increasing levels of obesity and other bad risk factors for for cardiac disease. And of course, another thing is that we see that people who were born with congenital heart defects who in the past wouldn't have survived to the age where they could have a baby themselves, have actually survived and having their own babies now. So if they already have an underlying condition, obviously they're more likely to, um, that's more like to be exacerbated in the pregnancy. As I said, um, most women had no previous history of any cardiac conditions. They didn't know they had a cardiac problem. Uh, 17% of the women who died from cardiac disease did know they had a cardiac condition already. Um, but 77 had no previous history. So it's important thing to suspect if you have any doubt or any any consideration of it, really? So how do women who have cardiac death and it's very vague, isn't it? So what? What do they actually die of? So, um, they have arrhythmias or they have cardiomyopathy. These are the most common one reasons for death in pregnancy. They can also have, um, I as well. It's something we don't think about in young women, but that's why we should be doing EKGs on them as well. Still, um, if you have chest pain, Um, other cardiac causes. So if they have a valvular heart disease, usually the lady's already know they have that. But you know, they can die from it from pregnancy. There are certain diseases heart disease that are advised to never get pregnant. But sometimes they decide that they want to try. Anyway, Um, and also a little dissection is important not to miss in a pregnancy. Not you would not expect that. But, you know, obviously it can happen. And they can have coronary artery dissection as well. Um, so actually the most of the deaths of postnatal rather than antenatal. So I think if we saw a pregnant woman were very worried about her. Whereas if we see someone who had a baby three months ago, we were not really bothered about that. That's like, Well, you know, she's just a normal woman, right? She's just a woman, a young woman, which should be fair. I would have also thought, Yeah, and I do kind of think, but the majority we should think about cardiac disease in people who are post natal as well. So when you actually get the breakdown of the deaths, who are women who died from cardiac disease from pregnancy, only 15% were actually antenatal, 21% on the day of delivery. Imagine that's a high stress day, isn't it? Um, 34% were between day one and six weeks. So that's the real danger. Time is immediately post Natal, however, 30% still between six weeks and one year post Natal. So that's still a very dangerous time, Um, for a woman who's been recently pregnant cardio disease. So basically, if you see someone who has recently postnatal and they come with palpitations or other signs of cardiac disease, then it's important to just consider a cardiac course as well. Of course, most of them won't have this. It's still quite a rare thing, but just sort of should flip through your mind. Maybe so. The key points. Um oh, I mean, obviously all women who have known to have cardiac conditions should be referred to cardiology during pregnancy. That's obvious. Um, but basically, cardiac disease should always be a differential in a pregnant patient or recently postnatal patient, essentially, who has symptoms of the or any other kind of chest symptom, especially if other differentials are ruled out. So it's fair enough to go down the P route first, you know, fair enough. But if the if the CT is negative and the patient's still quite symptomatic, then we should consider doing an echo as well. Echo is easy to do well, relatively as outpatient. You know, it doesn't have to be inpatient. And if the echo is normal as well, then we can be fully reassured that something went wrong with me. And we can just say, Okay, fine. It is reflux, then or is muscular. But really, if we're going to go down the whole route enough, if we're worried enough to do a CT pa, we should also be worried enough to do an echo. That's that's the key. Take home point from this. So this is the last slide. Just very quick. Go through other things that as an option, County Reg, I want to know about if you see the pregnant person in your age and your GP. So generally I like to just know if there's any pregnant person admitted to hospital. Um, if there's more than 24 weeks, not really that interested, if they're only five weeks or whatever But if if they're if they're viability, basically, we should let us know. Because we would generally would, um, send a midwife to monitor the baby daily while they admitted, um, and of course, we've talked about the T. V T v P. T. Any pregnant patient who is admitted, you should always have Clexane unless they're about to go to for an operation. Um, so if the very least, let us know we can at least remind you about that. And if you see a pregnant patient that has any kind of deranged blood, mostly things like LFTs you and your clotting women pregnant women have deranged fbc all the time. So I mean, that's just pretty normal. Um, but you know, LFTs, Are you any and clotting? If that's the range, I would like to know about that, please. Um, if they come to you with itching without a rash, especially if it's on the palms of the or soles of the feet. Um, so that's a sign of obstetrics prosthesis. That's why, um, you know, we'd get We'd like to see them Be honest. Most of these people come to us anyway because all pregnant women get given like this boulder that just says all the red flags for them to look for, and this is one of them, so they usually self refer anyway, if you see a pregnant woman who has definitely got chickenpox, we want to know about that just because the baby needs to have some scans. If yeah, if she's had chicken pox during the pregnancy, we want to know you don't have to come in. I just like to know about it. You know, just tell me and I'll write the details down and I'll arrange a scan for her. Yeah, any kind of newly diagnosed medical condition during pregnancy. So something, anything like, I don't know, crows, disease or fibroid disease or whatever. Something like that. Not like an acute episode necessarily, but like some kind of long term medical problem that's been diagnosed, It's always good to know because we'd like we will see her in our clinic. If that's the case, obviously, any special concerns, just tell me. You know, I'm sure you would always bring us about that. Anyway, we just moved and things like that. And basically, if you're worried about pregnant patient, I'd rather you just call me and we have a chat about it, and I can tell you it's fine. Don't worry. And then that's fine. You know, I'd rather hear about it and not need to do anything. Then you just not refer. Um um, there was something wrong. So any questions about that? So it's like a random scattered on things, but it is quite interesting things you might not think about in a pregnant woman that might be concerning. So yeah, Any questions about anything? Yeah, I'm glad it was helpful. So, yeah, my key to take home point is, uh, do an echo and, uh, give it, like, another day. What? Terrible pressure. Yeah. Thank you, everyone. And thank you, Helen. And if everyone could just fill out the feedback form for Helen, that would be really, really useful. Um, and if there's any more questions, we'll just wait on a bit more and there and then thank you very much. Helen worries. Yeah. Okay. There's no more questions. I'm sorry for that. Let me unsure that. Yeah. Yeah. So, um, I'm happy to share the slides of people want the slides. A lot of it's from that embrace report, which you can just Google. It's like three to access. So if you wanna like, those are basically the things um, the women die from in pregnancy. So they're obviously the biggest red flags, but there's other things in there as well. Um, it's quite useful, I guess. There's no more questions, so thank you very much, Helen. And I hope everyone has a week ahead. Thank you. All right. Thank you. Bye bye.