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Hello, everyone and welcome to our primary care event this evening. I can see lots of you are saying hello in the chat, which is great. Um It's lovely to have you here tonight. We're gonna be talking. Um, well, I'm not, Jin is gonna be talking about um, miscarriage and ectopic pregnancy. So what we would love for you to do is pop all your questions in the and your gene will get round to those at the end of the event. As always, your feedback form will be in your inbox in an hour. Er, if you could fill it out, we'd really, really appreciate it. Um One thing I did want to mention is we want to do some teaching on M SK. So if you could highlight some teaching topics around that, that you're interested in, well, that would be really good, whether it's pediatrics or adult, you know, whatever it is, if you could please just communicate what it is you're interested in, then we can uh get some teaching lined up with regards to that. So anyway, without any further ado I'm gonna pass you over to Georgina. Thank you very much. Hello, everybody. Uh So as Sue said, my name is Georgina. Um Hopefully you can all see my slides here, but we're gonna be talking about miscarriage and ectopic pregnancy and particularly focusing that towards uh primary care and general practice a little bit about me. So I'm an obstetrics and gynecology trainee. Uh I'm a registrar. I work in Northwest London and I have an interest in um early pregnancy. So this is um interesting for me to give to you as well. And II hope you enjoy it. I hope you learn something. And, um, as sue said, if you just pop your questions in the chat, uh and then we'll come to it, uh come to them at the end. There are a couple of little times when I might ask you just to have a look and pop something in the chat. Um But otherwise it's just gonna be me talking. There's quite a lot um to cover in terms of early pregnancy. So I might be rattling through this a little bit because I don't want to keep you guys too long. So if there's anything that you're unsure of again, please just ask me at the end. So what are we gonna be covering? So we're gonna do a bit of background, bit of epidemiology. Um We're gonna be talking about the UK referral guidelines in particular and when do you need to refer from GP? And where do you refer to? We're gonna be talking about a little bit about PU L and P UV, which is pregnancy of unknown location and pregnancy of unknown viability, which I think, uh, people get quite confused about generally. So we're gonna have a little chat about that. We're gonna talk about miscarriage. We're gonna talk about ectopic pregnancy as the title slide said. And mainly for those, we're gonna be talking about the management. We're gonna be talking about the possible complications of management that you might see coming to your GP surgery. Um And we're gonna be talking about counseling as well and how to counsel these women who have complications in early pregnancy and who suffer early pregnancy loss. So just a little poll um to start off with. So how confident do you feel on a scale of 1 to 10 managing and counseling a woman with a suspected miscarriage um or ectopic pregnancy? So, have a little think about that and see what you think. I'm gonna give you about a minute or so. Just to pop an answer in there, maybe a bit less. Ok. So we've got some responses coming through there. We've got some slightly confident, we've got some confident, which is great. And we've got a lot of people who are not so confident and worried and unsure and that is totally fine because that's really what we're gonna talk to you about today. So those people who are sli slightly confident or confident will try and get you to the absolutely certain star and those of you who are terrified, very worried will hopefully by the end of this talk, get you a little bit more confident in this because really, it's something that we see very, very frequently. Um, both, you know, in, in A&E in general practice and obviously in gynecology. So let's talk a bit about the background cos I think it's important when you're counseling that you have a bit of background knowledge in this miscarriage is very common. One in five pregnancies in the UK end in miscarriage. And by that, I mean, spontaneous miscarriage less than 12 weeks. This is kind of one in five up to one in six, it's very age dependent. So someone who is 20 years old, 1920 years old, their risk might only be about 11 12%. Whereas if we go up to 40 then your risk is about 50%. So one in two pregnancies at 40 to 45 end in miscarriage. So it's very age dependent. And as we get older and as women are having uh babies in their late thirties and early forties, it's something we're going to see even more and it's something that people feel very worried about. So it's important to have this knowledge that it's very common. And unfortunately, it's probably going to get more common as we go along. Recurrent miscarriage in the UK is defined as three or more consecutive miscarriages. So that's three or more miscarriages in a row with no live births in between. And actually, that's quite rare. So that's only about 1% of women. And so it's important that people know that spontaneous miscarriage is common. But your likelihood of it becoming such a problem that it's recurrent is actually only about 1%. Now, about 50% of miscarriages are caused by chromosomal abnormalities. So that's just literally an abnormality in the division of cells, which means that this um pregnancy was not going to make it to a viable pregnancy leading to a live birth. And that's really important. It's kind of the body's way of doing some checks and saying that this pregnancy doesn't look right. So that's about 50%. Now, we don't always know the cause. In fact, most of the time we don't know the cause, but we're quite confident that about 50% of the time this is going to be the case. Now, your risk of ectopic pregnancy is a lot less. So only about 1%. So about 1% of women who get pregnant every year in the UK will have an ectopic pregnancy. There are plenty of um oh, so it says I've got a message. Oh OK. It's a question. Ok, no problem. Um I'll answer that at the end if that's all right. So um risk factors for ectopic pregnancy. So anything basically that's going to scar your tubes and make it more likely that an egg that's floating through the tube is going to get stuck. So, if you've had a previous ectopic pregnancy, then you may have some scarring within the tubes that caused that ectopic pregnancy. But you may also have some scarring from that ectopic if you didn't have surgery to remove it completely. So that's why if you have a previous ectopic, you're more likely for it to happen. Again, pelvic inflammatory disease, again, any kind of chronic or acute inflammation in the pelvis is going to increase your chance of having um, an ectopic, having abdominal or pelvic surgery. So, having any surgery in the abdomen or the pelvis, even if it's a straightforward appendicectomy is going to increase your chance of having an ectopic. We know that black women are at higher risk of having an er, ectopic pregnancy than any other ethnicity. We're not entirely sure why. At this point, we know that having IVF or any s any type of assisted conception increases your risk. We know that smoking. So anything that's going to damage any kind of endothelial lining is going to increase your risk. When we get older, you're at higher chance of having all of these other things. You're at higher chance of having scarring in your tubes. So you, that increases your risk as well. And if you have a coil in when you get pregnant or if you are sterilized and then find out you're pregnant, then that will increase your risk. Now, these two groups who have contraception or were sterilized, obviously, their risk of having an ectopic pregnancy overall is a lot lower because they have a form of contraception. But if they get pregnant, there's a higher risk that that could be ectopic. So we're gonna talk about the referral guidelines. So in the UK, we have this document ectopic pregnancy and miscarriage diagnosis and initial management. And that is kind of our viable in terms of when early pregnancy units are writing their referral guidelines, what they're going to go off. And um it was written in 2019 and updated in 2023. So it's quite a recent document. They're quite clear in that with bleeding in early pregnancy if a woman is over six weeks pregnant. So six weeks from the first day of their last menstrual period, they should be referred to an early pregnancy assessment unit. Now, you might see early pregnancy assessment unit, early pregnancy unit, a early pregnancy and acute gynecology unit. They're all the same thing. Um anywhere basically that's specifically acute gynecology or early pregnancy for a scan. Some units will have an out of hours gynecology. If you're in London, then Saint Mary's has an out of hours gynecology unit. But most places you should refer these women to their early pregnancy units. Now, if they are less than six weeks pregnant, they don't actually need a scan and they don't need to be seen by us but if they have only bleeding and the reason for this is if they are less than six weeks pregnant, the pregnancy is probably very small. If it's a spontaneous miscarriage, then it's likely going to um all the pregnancy tissue is likely to pass on its own and it's not likely to need intervention from us. And the advice there is to take a pregnancy test 7 to 10 days after the cessation of the bleeding. So, if the bleeding lasts a week, take a pregnancy test, 7 to 10 days after that, if it's positive, then they, they can be referred to an early pregnancy unit for a scan. Now, I've put a little asterisk there because some women can find it very difficult not having a scan or not being seen by a gynecologist when they've had a miscarriage, particularly if it's their first pregnancy. So if they're very distressed, please just call your local unit and say this lady's very distressed. She's five plus six weeks pregnant or 5.5 weeks pregnant. Can she possibly come? And we will often see them, we might not do a scan, but we can often see them, examine them, make sure everything's ok. Now, the caveat for this obviously is if someone is hemodynamically unstable or bleeding heavily. So if they are bleeding and soaking more than a pad every hour, so more than er, a sanitary towel every hour, then they should be seen in A&E obviously, if they have unstable observations, they should be seen um seen in A&E now, any women with pain. So this is pain and bleeding with a positive pregnancy test at any gestation should be referred for a scan. And the reason for that is the risk of ectopic pregnancy. So, if someone has pain in early pregnancy, it is an ectopic pregnancy until proven otherwise, up to half of women won't have any of those risk factors that we spoke about before. So even if they have no risk factors, if they have pain, whether they're 3.5 weeks pregnant or they're 11 weeks pregnant and they haven't had their first scan yet. Please just send them to us and we will see them again if they are in pain and they're hemodynamically unstable. If they have abnormal observations or if they have severe pain, you, you examine them, they have guarding, they have marked abdominal pain. Please just send them to A&E we'll always be very happy to see them there. Now, what will we do? So say you see a woman, you're quite worried about her. So you send her to A&E, what will we do? Um And lots of women ask what would they do doctor when they send me when you send me in? And I'm seen by the gynecologist now, an important thing which I'm sure many of you are aware of, but many of our patients are not aware of is there's nothing we can actually do to stop a miscarriage from happening and lots of people find that very difficult. Um But as soon as the bleeding has started, there's very little that we can do what we will do. When we see someone in A&E, we will examine them. We will do a full assessment, we will make sure they're hemodynamically stable. We will most often do a speculum examination to check the bleeding and then are there is sometimes some pregnancy tissue that we need to remove, particularly if they're in cervical shock or if they're in a lot of pain or they're bleeding heavily. We'll do some blood tests and we'll do a venous gas. The majority of women who come to A&E if are hemodynamically stable, they're not bleeding heavily and we give them some paracetamol and the pain settles and we send them home and we arrange a scan. Now, a scan very rarely happens out of hours in emergency departments in the UK. Sometimes you will get lucky. There will be a registrar on who can scan and then we would take them for a scan overnight or over the weekend, you can call in a consultant who might be able to scan. But most of the time we arrange them a scan in the early pregnancy unit, which usually happens over the next few days more and more people are being taught how to scan. Um And so this may change uh over the next few years or so. But at the moment, most of the time we send them home to a waiter scan. Now, if they're hemodynamically unstable from a bleeding perspective, so if they're having a miscarriage and they're bleeding heavily, we might give them a blood transfusion or we might give them some tablets or we might do a surgical procedure to remove the rest of the pregnancy tissue. So if someone's bleeding very heavily and you're sending them in to A&E you can always warn them and say if the bleeding is very heavy, you might need a surgical procedure just to give them a little bit of warning. Now, if we think they've had an, if they have an ectopic pregnancy, if we think it's ruptured, they're very unwell, they're hemodynamically unstable, we will take them for a laparoscopy without doing a scan. Um because we can tell at laparoscopy if there is an ectopic pregnancy, particularly if it's in the tube or in the ovary. So, what do we do in the early pregnancy unit? So once they're sent home from A&E, what do we do in a? So most of the time, the most people who are referred to us, we diagnose a viable entry to around pregnancy. So actually an early pregnancy unit, generally speaking, is quite a happy place, which is nice. We diagnose P UV and PU L which I'm going to talk about in a minute. We diagnose miscarriage. Sometimes it's complete, incomplete my spontaneous et cetera. Um, but a miscarriage is a miscarriage and we, we manage it all the same way and we diagnose an ectopic pregnancy and molar pregnancy. We're not gonna talk about molar pregnancy today because it's a whole other topic in and of itself. Now, I'm not going to dwell on the ultrasound diagnosis of miscarriage because, um, I'm sure many of you aren't going to be doing your own scans and diagnosing miscarriages yourself. But I think it's important when you're reading a scan report that you have a little bit of a background. So if someone comes to you and says doctor, I still have bleeding, I don't really know what happens. This is the scan that I have. So you have an idea of what's going on. So, what we're looking at is we're looking whether there's an intrauterine gestational sac number one, when you see an intrauterine gestational sac, do you see a fetal pole? And do you see a little heartbeat? And we can usually see a little heartbeat from about when the um little fetal pole is about four millimeters, we'll usually see a heartbeat and usually that's from about six weeks. So that's another reason why under six weeks, a scan is not very helpful. Now, the diagnostic parameters of a miscarriage in the UK are very strict. And the reason is that once we diagnose a miscarriage and we offer management, we need to make sure we're not terminating a very wanted viable pregnancy. So, if there's any chance that that pregnancy could be viable, then we don't call it a miscarriage. But there are some situations where you cannot definitely say it's a miscarriage and you cannot definitely say that it's viable. For example, if you have a fetal pole, that's seven millimeters in size, uh sorry, less than seven millimeters in size and you cannot see a heartbeat or if you have an empty gestational sac, that's less than 2.5 centimeters. Then we're not really sure if it's over seven millimeters or the or the sac is over 25 then we can say yes, this is definitely a miscarriage as long as it's confirmed by two operators and that takes me on to P UV and PU L. So P UV is a pregnancy of uncertain viability. This is diagnosed when we are not sure that it is a viable pregnancy. So we cannot see that little fetal heartbeat or we cannot see a fetal pole, but it doesn't quite meet the criteria for a miscarriage. Some of these women will go on to have another scan and to have a viable pregnancy. Some of these women will go on to be diagnosed with a miscarriage and we usually rescan them after 7 to 14 days. Pregnancy of unknown location is when the pregnancy may be ectopic. So they're quite different things. A pregnancy of unknown er location is when we look inside, we cannot see the pregnancy inside the womb, we cannot see the pregnancy outside the womb, but they've had a positive pregnancy test. There's a, there's a pregnancy somewhere. So, um, what we do in that situation is we do a HCG and we do a progesterone and usually we do it 48 hours later. Most of the time, we can't really tell from one level unless it's very high. In which case, we should scan them again. Because if it's over 1500 for example, we really should see a pregnancy somewhere. But these women who are kind of coming back and back and back for repeat levels. This is usually why because we don't quite know where the pregnancy is. These are just some pictures uh for you to look at. So what are we actually looking at? So in this first picture here, you can see this, these two pictures are just to show the difference between a pregnancy at six weeks and 12 weeks. So we're measuring a CRL in both pictures, which is a cranial rump length, which is basically from the head of the baby to the bottom at six weeks. You're just measuring the the longest diameter of the little fetal pole. But obviously, at 12 weeks, it's a very different story and the bottom is an example of an empty gestational sac. So that's a gestational sac, but there's no fetal pole, there's no yolk sac in there that we can see and we measure that using the mean sac diameter, which is basically just the average sac diameter. Um So you might see that on some scan reports as well. So how do we manage miscarriage? So you may have women coming to you and we've got some, I've got some cases in a bit who have been managed for a miscarriage and they may have complications of that management, which is why I've included this pretty much everyone um is offered expectant management. So if a woman comes in with bleeding, she's diagnosed with a miscarriage, we offer them expectant management, which is essentially that we do nothing. We wait and then we follow them up after 2 to 3 weeks, about 50% of the time, they will say I had a heavy bleed, the bleeding has now stopped. In which case you can do a pregnancy test in about 10 days time, 50% of the time it doesn't work and nothing happens either they don't get any bleeding, they just get light bleeding or they have ongoing bleeding and we need to scan them again and there's some tissue left inside. The two other options are active management. So medical management, which is that we give 200 mg of Mifepristone, which is a tablet. So we give them an oral tablet and then we give them uh vaginal tablets to take 48 hours later. Now, this is obviously a lot quicker than expectant management. So some people decide just to go straight for this, which is fine and I tell them to expect a heavy bleed within 12 hours of the miSOPROStol. Usually it's a little bit quicker than that, possibly around four hours. Some people actually have a heavy bleed, about 20% have a heavy bleed just after the mifepristone period, like bleeding after having medical management is totally normal and it's totally normal to have this for up to two weeks. And then after the bleeding has stopped, we say do a pregnancy test in three weeks. If all of the pregnancy tissue has gone, that will be negative. If it's positive. Please call us and they call us and we do another scan and about 15% of the time there is some tissue left and we need to talk to them about possibly having more tablets or possibly having a surgical procedure. So surgery is the third option and it's got about a 95% success rate. We can do that either as an inpatient um in the early pregnancy unit while the patient's awake or we can do it as an out uh sorry, as an outpatient or we can do it as an inpatient when they're under a general anesthetic. And that's a surgical management of miscarriage, but they're both essentially the same. It's suction curettage and we u we give them a bit of miSOPROStol as well just to soften the cervix before we do that. So what are the possibilities in terms of what can people come to you with issues after they um have their management? So if they have expectant management, the primary concern is of infection. So 50% of the time it won't work, but they also may have infection. So if someone comes to you with abnormal discharge with bleeding, that doesn't smell quite right, not feeling well, et cetera, it's possible that there's infection, the cervix is probably slightly open and there's a pregnancy in there that's not growing, that the vasculature is not great and it can become infected. Now, there may be unmanaged bleeding. So if someone has a large pregnancy, we may suggest actually, it's not very safe just to do expectant management and we should manage this actively. So if someone has a miscarriage, let's say 12 weeks, 1314 weeks, we may say it's actually better to stay in hospital and we'll do a surgical procedure or give you some tablets. So unmanaged or heavy bleeding is possible. Prolonged bleeding is again kind of if it doesn't all quite work, um then they can get some prolonged bleeding, incomplete management. As I said RP OC means retained products of conception. Um And I'm gonna talk more about that in a minute. That's basically where it's not completely managed. There's still some pregnancy tissue inside with medical management. The risk of infection is lower, but there is still a risk of infection until all of that pregnancy tissue has come out. It's possible to have heavy bleeding and pain at home. So we give them coal to take at home, but it can be very painful and sometimes the bleeding can be heavy. Now, heavy bleeding, requiring blood transfusion with medical management is rare. But it's possible. And so sometimes we see these women coming into A&E it's possible for it to fail. And again, it's possible to have incomplete management. But less likely if we've um gone for expectant management for surgical management. Again, infection is common. And when you're doing any kind of surgical procedure, there is a possibility of infection. You're introducing stuff from the outside into the cavity of the womb. There is a possibility of heavy bleeding. Um But if that's in the operating theater, that's much easier for us to manage. So, if there is um heavy bleeding to, so if there is a large pregnancy or the risk of heavy bleeding is high, then we may actually suggest doing a surgical management because it's much easier to control the bleeding in the operating theater with medications with surgical techniques. Um or, or needing to give a blood transfusion, it's possible to fail. The biggest um risk for surgical management is uterine perforation. So this uh picture here on the bottom left, that's actually a picture of a hysteroscope. Um So the little camera that we use to look inside the womb when we're doing hysteroscopies but it, I think it shows it quite nicely. So we're introducing something rigid into a closed space and it's a blind procedure. So we cannot see exactly what we're doing. And it's possible for that rigid instrument to perforate through the top of the womb. Or if the womb is acutely anteverted and pointing uh upwards, it's possible to perforate the posterior wall. If it's a acutely retroverted and pointing downwards, it's possible to perforate the anterior wall. And if this happens, and you're using a rigid suction curette, it's possible to damage other things in the abdomen, including the bladder, bowel, blood vessels, et cetera. So this is something we always counsel for the risk realistically is low. It's probably around one in 1000 but it can be up to 15 in 1000. Um The risk of having significant damage for an example of bowel injury is a lot less than that. But the rate of perforation is about 1 to 15 and 1000. It's possible to develop scar tissue, but it's the likelihood of that scar tissue being problematic is very low. And as you can see, it's the same across all of the um options and actually having one option over the other doesn't make any difference to your risk of adhesions. So I'm gonna talk about retained products of conception cos that's probably our most common issue in terms of ma managing uh miscarriage. So this happens when it's incomplete management and there's still a bit of pregnancy tissue left inside. It can also happen after birth. So after a woman has a baby, then some bit of placenta or a bit of membranes can be left inside. And that is also termed reca retained products of conception. It causes bleeding at the site of the tissue because the tissue has exposed blood vessels, there's exposed blood ves blood vessels on the endometrium. And so you get this persistent bleeding, it's usually persistent and light or persistent and bothersome. Um, but it can be heavy, particularly if, um, there's a, a large piece of pregnancy tissue left inside or there's infection and sometimes there can be bleeding to the point that it fills the whole of the uterine cavity and that causes a kind of balloon and the uterus can't contract down and tamponade it effectively. And if that happens, that's when we need to do a surgical procedure. Most of the time, it just causes light, bothersome bleeding. The management, we can either wait and wait for the, um, and wait for the body to, to pass the tissue on its own. We can give tablets or again, we can do surgery and if they have an infection, we need to give them antibiotics. If it's severe infection, then through the vein and if not, then we can give them tablets. So I've got some cases for you here. So, um, feel free to pop some answers in the chat. So case number 1, 28 year old woman presents to you a surgery after being diagnosed with a miscarriage at six weeks. So this lady had a miscarriage at six weeks. She was given tablets which she took a week ago, she had a heavy bleed after the tablets and now she has some ongoing spotting and she comes to you and says, I don't know what to do. What do you tell her? I'm gonna give you about a minute to think about it. Pop some answers in the chat. If you want. If you don't, that's fine. I'm gonna give you the answer in a minute anyway, but have a little think about what you would do. Ok? Ok. We've got some options there. Ok? So I'm going to give you the um answer in a minute. But let's have a quick look at the second case. So a 34 year old woman presents to your surgery after being diagnosed with a miscarriage one week ago, she opted for expectant management and has been bleeding for three weeks. Now. She comes to you. She says I'm not feeling well. The bleeding smells strange. Now, I have constant lower abdominal pain and you take her temperature and it's 38.6. What do you do? Yeah. Loads of lovely correct answers. Ok, brilliant. So for the first case, so lots of people got it right. This is perfectly normal after having medical management of miscarriage. So period like bleeding or less is totally normal for up to two weeks. And I think I saw some people say uh once the bleeding stops, then she can do a pregnancy test after two weeks. That's perfect. 2 to 3 weeks is fine. In the second case, all of you got it right. Refer to a, well, I would refer her to A&E. So this lady is septic and she has septic retained pregnancy tissue. The correct response is to send this lady to A&E. I do understand. You probably want some more information and obviously in real life you would. But ultimately, if she's got a temperature of 38.6 she's got a source of infection. She needs to go to A&E. If you're being really helpful, you can call your local gynae reg and say um this lady needs to come in and uh I'm sending her to A&E for antibiotics and that's very reasonable. So this lady needs to come straight to A&E. So case number three, a 24 year old woman presents to your surgery with persistent bleeding following a termination of pregnancy. Four weeks ago, she reports ongoing bleeding since she took the tablets, she's changing two pads per day, but she feels generally well and her observations are normal. So what would you do? Now, a termination of pregnancy is very similar to having a medical management of miscarriage. It's a very similar regime. Yeah. Yeah. Got some lovely, lovely answers. Coming through here. Brilliant. Ok. And so case number four, a 38 year old woman presents to you a surgery three days after having a surgical management of miscarriage at 10 weeks gestation. In her fifth pregnancy, she has ongoing lower abdominal pain. She feels like it's getting worse rather than better. And she reports some vomiting and diarrhea. She said she does have bleeding but it's just light but she does feel dizzy and feels quite unwell. So what do you do? Is there actually some quite mi some quite mixed responses here but most people saying send the patient to A&E which is the right thing to do so for case number three. So this lady probably has retained products of conception. So it's probably an incomplete termination of pregnancy. I saw people saying do a a pregnancy test that's very reasonable. Um But I think if this lady's got abnormal bleeding, prolonged bleeding, it's very reasonable to send her to the early pregnancy unit for a scan, but she's quite stable. So she can, she doesn't need to go to A&E she can just be sent to the early pregnancy unit. Case number four, most people um very rightly said, refer to A&E. So this lady's had a surgical procedure and this is very suspicious for a perforation. So she's got this really bad lower abdominal pain that's getting worse, which is not normal for a surgical management. You shouldn't really have much pain after a couple of days and if you do it should be getting a lot better. Um, and the vomiting and diarrhea is very odd, isn't it? So she needs to go to A&E, she may have a uterine perforation and I would be worried about a bowel injury with this lady. Um, but most people got that right. So well done. So we're gonna talk about ectopics now. So we have, yeah. Ok, we've got kind of 15 minutes ish. So we're gonna whizz through this slightly. So an ectopic pregnancy um is a pregnancy which is not appropriately placed in the uterine cavity. As I'm hoping we all know generally it will present with pain and bleeding most of the time you'll see bleeding but not always shoulder tip pain if they have hemoperitoneum and hemodynamic instability, if it has ruptured and they will have a positive pregnancy test, over 90% are within the fallopian tube, but the other 10% can be dotted around elsewhere. They can be interstitial. So they can be in the little bit of the tube that goes into the myometrium. They can be within a ce cesarean section scar. They can be within the cervix, they can be elsewhere in the abdomen or they can be in the ovary. This picture shows uh this poor lady who had bilateral ectopic pregnancies. I've just shown it to you because this is what it looks like when we laparoscope them. So this kind of big swollen tube and you can see kind of on one side and on the other side and then blood within the pelvis. On scan, it usually looks like a heterogenous mass. So it's a, a mass with mixed echoes within the adnexa. That's with no significant um convincing pregnancy within uh within the uterine cavity. So, within the womb or you can sometimes see a gestational sac. Sometimes you see a yolk sac, sometimes you see a fetal pole outside the uterus and usually within the adnexa, there can be free fluid in the pouch of Douglas. So you can see this lady here has lots of blood uh in the pouch of Douglas. This is um usually due to bleeding from the fimbrial end of the tube. So from the free end of the tube, you get bleeding, but it could also be from rupture. So it's one of the things we think of in terms of management. So how do we manage ectopic pregnancies? So, depending on your area and where you work and where you live, some women may be walking around happily with ectopic pregnancies that are being managed expectantly um or with uh medication, they don't necessarily all have surgery, but there are some areas where people present quite late depending on the patient population, depending on what the scanning facilities are. And they actually present quite late with a rupture and that needs to be surgically managed. But some patients can be managed expectantly if they have a very small ectopic pregnancy with a very low HCG, then we leave them, we don't do anything and we check their HCG and that pregnancy tissue gets reabsorbed by the body or it passes down the tube and then passes out through the cervix. The success rate can be up to 100% but that's very case specific. So that's as I say, these people with very small ectopics and very few symptoms, they have to be contactable and they have to be able to come in for follow ups and have to understand all the safety netting medical management we do with methotrexate, which I'm gonna talk more about on the next slide. Again, it has to be a relatively small ectopic pregnancy and they can't have too many symptoms. We can't be worried that this person has already ruptured. Ideally, the HCG has to be less than 1500 but it can be up to 5000. And again, we review that H CG um and see how it goes. Sometimes they can have a second dose. If the first one doesn't quite work, they need to avoid alcohol and folic acid for um the duration of treatment and then for usually a few months afterwards. And some women, what some people don't like is that you have to not conceive for at least three months because of the risk of teratogenesis. Um And because of that, some people don't go for this option at all. The majority of women um are managed surgically so that this is either with a salpingectomy. So by removing the fallopian tube, if the other tube is healthy, if the other tube is not healthy, then we do a salpingotomy, which is to do a small incision in the tube, remove the pregnancy and then close the tube again. And that's if the other tube is diseased. Sometimes if the other tube is very diseased, we may take that out because it's got such a high risk of having an ectopic pregnancy on that side. But that's quite rare. Most people have a normal other tube and they have a salpingectomy. It's definitive management. If they have a salpingotomy, though, we need to keep checking their HC GS, there are lots of indications for surgery. Is it a big ectopic? Do they have a high H CG? Is there a heartbeat? Which means that it's still growing? In which case we definitely have to take it out? Um Does it look like it's going to rupture or are the clinical features suspicious of rupture or is this just what the patient wants? And lots of patients just want definitive management. So they want surgery and that's fine. Now, the main um complication that I want to get across is that women with um expectant and medical management can still rupture. So even though their cases have been selected, um in that the risk of rupture is very low or we're not worried about rupture, they can still rupture even if the, um, HCG is very low and even if it's a small ectopic. So if someone comes to you and you're worried about them and they've had methotrexate the day before or two days before. Don't be reassured by that. If you're worried about someone who has a known ectopic, please send them in for us to see them. Now, there are plenty of side effects um with methotrexate, excessive flatulence, bloating, um mild transaminitis, stomatitis, excuse me. Um but that has um got some severe adverse effects. This includes bone marrow suppression, pulmonary fibrosis, liver cirrhosis, renal failure, gastric ulceration. So if someone comes to you with a strange constellation of symptoms or anything that you're worried about, in terms of these adverse effects, please send them to A&E if they've had recent methotrexate and please send them to A&E with advice to see the medical team because although we've given them the methotrexate, I can promise you, you don't want a gynecologist managing your liver cirrhosis or your nonspecific pneumonitis. Now, with surgical management, um it's always possible to have a laparoscopic injury. So anyone that has a laparoscopy, for any reason, you can injure vessels, you can injure bowel. Um you can injure the ureters. So these are all things to keep an eye out for um, bleeding, infection, increased risk of VT E particularly if they're pregnant and then they have a laparoscopy they have an increased risk of VT E and that lasts up to six months after surgery, whether they're pregnant or not. Now, they may well lose a fallopian tube and they may well lose an ovary. So, if it's adherent to the ovary, sometimes we remove that as well. Now, I would imagine that most women that come to you who are not, well, or you're worried about them after they've had an ectopic pregnancy, regardless of management, you would send them to A&E um but this is just all of the possible things after having management for an ectopic pregnancy. Now, we've got a little bit of time, I'm gonna talk about counseling. So plenty of people feel very uncomfortable counseling women who have bleeding um or who suffer an early pregnancy loss. And I think it's really important as medical professionals that we feel comfortable talking to these women because they often don't feel comfortable talking to their, even their spouse, their family, their friends. But actually, it's so common and almost everyone on this chat, almost everyone that, that we know will know someone who's gone through some form of pregnancy loss and particularly in the UK. I don't know where people are looking from around the watching from around the world, particularly in the UK. We're very bad at talking about it because it makes some people feel uncomfortable. But the main thing to remember is that these women um their feelings are valid. So it doesn't really matter how they feel, they may feel sad, they may feel angry, they may feel guilty. Acknowledging those feelings is really important. Um And them understanding that that's pretty much how everyone feels as well. Some people feel absolutely fine and that's, that's great. But some people don't. There are lots of support groups, I'm gonna put some links up here at the end. There are plenty of support groups out there and every early pregnancy unit will have a support group as well. So just make sure to sign post women and say there's plenty of help. Um, if that's what they need. Now, in terms of what I tell them, I always tell them, it's highly unlikely to have been caused by anything that they have done. Whether, you know, smoking alcohol, exercise, stress, heavy lifting, et cetera. All these things are highly unlikely to have caused your miscarriage. There is a reason that there are, you know, Backstreet abortions in lots of different countries and in the UK. And it's because inducing a miscarriage is incredibly difficult. It's highly unlikely to be something that the patient has done. Now. They, they're obviously smoking, drinking alcohol, et cetera can increase your risk of having a miscarriage. So if they are smoking, they are drinking alcohol, that's something to go through with them once they're planning their next pregnancy, but it's highly unlikely to have caused it. And there's nothing that they could have done once that process started, as I say, 50% of um early pregnancy loss is caused by chromosomal abnormalities. There's nothing we can do to prevent that happening. Now, the next pregnancy as well is highly likely to be straightforward, particularly if they've had one or even if they've had two miscarriages, three consecutive miscarriages warrants further review. Um and they can be referred onto a recurrent miscarriage clinic. I'm going to put upload. Um All the links this, these quotes are from the Miscarriage Association. Um and they have loads of quotes from women and I've actually found it really helpful reading through them because it's exactly what I've heard from my years of counseling women having miscarriages. Um So have have a little look at that. Now, I'm going to answer your questions. Um but these are just some Fa Qs that, that I hear from patients. So loss of pregnancy symptoms can be very distressing in the first trimester. For example, I've been vomiting every day up until now and now I've had two days and I feel fine or I had really bad breast tenderness and now it's gone away. It can preclude pain and bleeding. It can be the first sign of a miscarriage, but most of the time a loss of pregnancy symptoms isn't anything to worry about. Just like always our um it's not just our hormones that affect symptoms. It could be that you were distracted for a few days. It could be that the kids are playing up. You know, we will notice symptoms much more. Yeah, one day and then not, not at all the next day. So generally speaking, I try and reassure people who've just had a loss of pregnancy symptoms and also just having a loss of pregnancy symptoms isn't an indication for a scan. Um, an increase in white physiological discharge is totally normal even from the early stages of pregnancy, if they're a little bit further on, if they're kind of beyond 10 weeks and they're passing clear fluid, that's not as normal. So, I would um contact your early pregnancy unit about that, but presenting just with clear fluid in early pregnancy, um is quite rare. Usually if a pregnancy is miscarrying its pain or bleeding, candidiasis is also common. So please um check for candidiasis before referring to early pregnancy. It's uh not dangerous to a pregnancy, but it should, well if it's treated so it should be treated and it's perfectly safe to treat it in early pregnancy. Does having had a previous termination or abortion affect your fertility or risk of miscarriage. Absolutely not. So, there's plenty of studies that show having a previous termination doesn't affect your fertility and that can be AAA significant source of guilt and worry for women who had um a termination when they uh in the past and now they're struggling to get pregnant or they've had a miscarriage. So you can reassure people about that sometime there are some studies that suggest it increases the risk of preterm birth, but that's usually with um far later gestations at termination. Um When can I start trying again? That is always the number one question on people's minds. So you can start trying again as soon as you feel ready. So as as long as the bleeding has stopped, um you've had a negative pregnancy test, if you've been asked to have one, you can start again as soon as you like. It's very helpful for us. Um If you have had a uh normal period, that's purely for dating purposes. Now, some people don't want to start trying again for a while. They've already been through a difficult time in early pregnancy. They've had a miscarriage and now they want a break and that is totally fine. You can read places on the internet or you should start trying straight away cos you're more fertile. Other places will say you shouldn't start trying straight away cos you're not as fertile really. You can start trying again as soon as you feel ready. That is the best thing for you and the best thing for the patient. So let's have a look at your questions. So OK. Oh Is there someone there? Me, I'm back. So if you want to stop sharing, you can just click on the middle button again and we'll stop shit. There we can go. So now those people that are familiar with our middle education and middle primary care, they'll know that I'm not very good at pronouncing words because I'm not medical. So if you are happy to read the question and then answer it, that would be great. Yeah, not a problem. So would a chemical miscarriage uh count towards recurrent miscarriage? Uh If woman has this persistently, I would say yes, as long as this is after the time that they are expecting their period. So if this is a um very brief time of having a positive pregnancy test, um if the period comes on time, I wouldn't necessarily count that as an early miscarriage because your period has come on time if it, your period is late and then you have a positive pregnancy test and then you have a bleed. Yes, I would count that as an early miscarriage. So I think that can be um counted towards the recurrent miscarriages. Uh Do I click next? Yeah. Uh do all ultrasound at a er, or some don't get it if the beta HCG is not above a certain threshold. Um, the answer to that is yes. Really? So over um under 1500 H CG, we usually can't see anything. The, the it usually has to be over 1500 for us to be able to see anything. Um, but if someone comes in with pain, even if their HCG is 100 and 50 or 200 we will still scan them. So if we're worried about an ectopic, we will still scan them if, um, we're worried about a, a miscarriage and it's early and the HCG is um very low, then we might not. So it really depends on what they're presenting with uh any other complications apart from bleeding or contraindications from the, for the medical approach. Um, so there, there might be times that we suggest surgical management as, as the first option. Um, so this might be if the pregnancy is very large, if there is any concern about molar pregnancy, if they have had two pregnant, er two miscarriages before and we want some tissue as part of the recurrent um miscarriage investigations. Then, then we may suggest um we may suggest surgical management. Um So there, there may be times when actually we say medical management is not very appropriate. Um But usually if, if it's straightforward, it's usually because of the size of the pregnancy itself. Um and that is mainly the issue. There is mainly because of the bleeding. Uh What happens if SM M fails. So if SM M fails, you can have um another SM M. So we can do it again um with a senior practitioner and we would do it under ultrasound guidance. If it's a little bit further down the line or we think it's just a small bit of tissue, then we may do a hysteroscopic resection. So we might have a look in with a hysteroscope. So with a camera and then remove that little bit of tissue directed with the camera. Um, so it, it really, um, depends again, but, uh, those are the two options. Really. Why is it advised to do a pregnancy test? 10 days after stopping bleeding in expectant management and after three weeks of medical management. Um, so the reason for that is that, um, in, er, medical management we're doing something active. So we're giving the tablets to try and induce uh, all of the tissue to try and pass on its own. So, um, it's far more likely to work and the likelihood of having a, a positive pregnancy test is very unlikely. Um, whereas 10 days after stopping bleeding for expectant management, we've usually given it a lot longer time and if it's not worked, we want to know about it a lot sooner. Um, so to be completely honest, 2 to 2 to 3 weeks for either of them would be acceptable. Um, but with expectant management, we're doing much more of a kind of watch and wait approach. So we do it a little bit quicker. Um, if our P AC is suspected, a pregnancy test is usually positive or can you have RP AC with a negative pregnancy test too? For example, for case three, with her pregnancy test result, have made a difference to the decision to send her to EPA U. Would they decline to see if it was a negative pregnancy test? I think most of the time it will be positive, but it is possible that it would be negative. I think that anyone um, who has um complicated bleeding. So if they have persistent bleeding after having any kind of procedure should be seen by gynecology, um, that's my professional opinion. I, I'm sure there are plenty of people out there that would say it was a negative pregnancy test. It's highly unlikely to be um, retained tissue. Um So it's, it's a reasonable question and I think you could kind of argue it either way. But ultimately, if someone has had an intervention like a, a termination or a um medical management, um and they have problematic bleeding that they didn't have before, then I think they need to be seen by a gynecologist. Um And I think the most reasonable place would be um in early pregnancy. Why no folic acid if given methotrexate? Um because it's, it's an anti folate. So that's how it works. Uh So if they continue to take their folic acid, um then it can um affect the um the function of the methotrexate. And also the folic acid is, is to promote um it is to reduce the risk of spinal cord defects and things like that in early pregnancy. So they don't need the folic acid at that stage. So it's important that they stop it. What is a hydro hydro coping toy? And how is this done? So, I I've never seen it done. Um, but it's, it's where they kind of push some fluid through the tube, um to try and expel the ectopic pregnancy. Um, I've never personally seen it done. It's not within the guidelines to do, uh, in the UK, I'm sure there's um, plenty of research and things like that going on, um, to do with it. Um, but not something that you would see very frequently. Certainly not. Um, not here. If the HCD S don't decline with management. Is this an indication for surgical removal, ectopic? That's a very good question. Um So if you're yes, if you're sure that there is an ectopic pregnancy and they're given methotrexate, if the, you can give a second round of he of methotrexate. Um So if the first round doesn't work, um you can give a second dose. But um yes, ultimately, then surgical management would be your next step. Can you refer after three consecutive miscarriages? It's difficult to reassure a patient who's had two. II know this is really difficult. My advice would be check with your local unit because um at my trust. So at London uh Northwest, we are now accepting people to recurrent miscarriage. After two, the nice guidance remains three. Um and II agree with you. It's really difficult to, to counsel people after having two miscarriages that they need to have another one to have further investigation. Um So check with your unit. Um There are, there is a school of thought that ma miscarriage needs to be thought of much more as a spectrum rather than one or two miscarriages being normal and three not being normal. Um, which I do agree with. So this may change over the next few years. What I can say is if you've had two miscarriages, your next pregnancy is, is highly likely to be normal. Um Whereas the stats, I can't specifically remember the statistics off the top of my head. But once you have had three, the statistics are far worse. Um, so you can reassure people after two a little bit more. Um, they can always pay for private investigations. I know that's really not easy to, to suggest, but that's always a possibility and if people are really insistent and there's nowhere that accepts people after two, I will say, you know, you can go privately and, and have investigations that way. Um, but unfortunately at the moment, that's, that's the only thing we can suggest unless your unit does accept people after two, does a pregnancy loss at five plus four. No scan. Just positive pregnancy test resolve with episode of heavy bleeding count was. Yes. Yes, it does. Um, so it doesn't have to be confirmed on a scan. If someone's had a positive pregnancy test, um, that and then had a miscarriage in early pregnancy at all, then it, it all counts whether they had a scan or not. That's absolutely fine. Can you manage a suspected early miscarriage with light bleeding only remotely. Um, do they need to be face to face examination with observations? Um, if they're less than six weeks and it's only, um, er, and it's, er, only light bleeding and you're not planning on referring them. I don't, I don't think you really need to see them face to face. Um, I guess that's up to you really, we don't tend to do remote, um, consultations in early pregnancy. So I'm not really sure what, what you kind of need to see face to face and what you don't. So I'll leave that one up to you. Um, but certainly light bleeding less than six weeks. We're not going to um offer them a scan necessarily. What is a chemical miscarriage? So a, a biochemical pregnancy I is something that you will see. It's basically where someone has had a positive pregnancy test before the time that their period is due and then their period comes on time. It's basically a false positive pregnancy test. Um And it's where probably a pregnancy has attached a little bit, but then the period has come on time. Um So we don't really count that as, as um, a miscarriage. It's more, it's a biochemical pregnancy more than anything and examining a patient with bleeding in early pregnancy. Uh in GP, do we have to do a speculum? Um I think it depends how confident you feel with speculums. If you think that it will be helpful. So if they have heavy bleeding and you want to quantify the bleeding, you want to have a look at it. Um, or if you think you might be able to remove some tissue, say if they're in cervical shock, I think it's very helpful to do a speculum, but it really depends how um confident you feel we're going to examine them anyway. Um, if they're coming to A&E if they're coming to the early pregnancy unit, we don't actually always do a speculum examination ourselves. If it's just for a bit of pain or just for a bit of bleeding, we usually just scan them um unless there's any indication to do an examination as well. Um So it's, it's really up to you and, and how um comfortable you feel doing your speculum examinations. But I don't think anyone that you refer to is going to be annoyed for not doing a speculum. Does ectopic equal pu L no, an ectopic, an ectopic pregnancy. We can diagnose when we specifically see an ectopic pregnancy and don't see an um a pregnancy inside the womb. Apu L is a pregnancy of unknown location. It could be an ectopic but we haven't. So it could be an ectopic, but we haven't been able to diagnose it yet. It could be um an intrauterine pregnancy that's too early. Um or it could be a complete miscarriage, but they just never had a scan to actually see anything inside the womb. That's the three options for PU R. How do we support patients wellbeing? Um Yes. Very good question. So lots of support groups making sure they're well supported at home, asking, asking them who they're living with, what their relationship is like with their partner, whether they feel they can speak to their partner. Um I am a very, very big fan of written advice, so I always um print off. Uh There's lots of uh I'm gonna, can II can share it again, can't I sure PDF. Um So these uh these guys have loads of really excellent resources um and er leaflets that you can print off and give to patients, they often don't listen to you when they've been given really bad news as I'm sure everyone on here is aware um and particularly the Miscarriage Association. Um and SAS, if SAS is very good, if it's later pregnancy miscarriage Association is very good for early pregnancy and Tommy's have some really good ones as well. Um So I would um print those off um and, and give those to the patient as well to have a look at later. Uh I think we have looked at that patients still bleeding after a termination or a miscarriage. Uh would you start contraception with the UT is still positive? No, you wouldn't. So, um if the U PT is still positive, if the pregnancy test is still positive, they need to be referred to the early pregnancy unit. Um, and it's not appropriate to start contraception yet on them because they need management of that probably retained tissue. Um, before they start any contraception progesterone supplementation is um an area of, of a lot of research, we offer it to women who have had bleeding in early pregnancy and have had a previous miscarriage. So, if they've had a previous miscarriage and they come to us and we do a scan and it's a viable pregnancy. We give them progesterone. The evidence around it is not brilliant. Um, the promise trial showed that there wasn't that much evidence to support it, but it is the only time at the moment on the NHS that we can give it. Um, and the, the lots of private clinics will give progesterone because it's not going to do any harm and it may be of some benefit. Um, so yes, we do sometimes give progesterone. Um, so I'm conscious we've gone over 830. Are you happy for me to keep going? I think there's only another few. Yeah, if you're happy, I'm happy and they'll be happy. Um, I've always been informed to suspect ectopic pregnant pregnancy. If around 6 to 8 weeks pregnant having symptoms, it's very unlikely to display symptoms. Um, I would still refer less than six weeks. Um, you're absolutely right that it's usually the kind of 6 to 8 week mark that they tend to present. However, lots of people are very unsure about their dates. I had a lady who came in who was, um, who said that she was three weeks pregnant and had lots and lots of pain and actually it turned out that she was seven weeks and she hadn't had a period, she'd actually just had an implantation bleed. So I think it's very important. Positive pregnancy test, pain is an ectopic pregnancy until proven otherwise. So, don't worry about referring if they're less than six weeks, prenatal mental health is the same as stillbirth or advanced pregnancy loss. Um I don't know about the statistics, to be honest, um that we're moving a lot more. Um There used to be quite a big separation in gynecology between miscarriage, you know, early miscarriage and late miscarriage and stillbirth and IUD and fetal death and things. But we're looking at it much more as just an overall pregnancy loss. Um So I'm not sure about the statistics in terms of, of depression and things like that and how many women um develop depression after an uh an early miscarriage. But I would say that it's important to absolutely, to think about their mental health. Um And to really remember that for some reason for some women, this was a very wanted pregnancy and they can feel a very genuine sense of loss and they may feel similar to someone who was much more advanced in their pregnancy. Um But I'm not sure about the, the specific statistics is there ongoing PV, bleeding after miscarriage termination? Should we be doing speculums? Take swabs or just send for an ultrasound? So, um I think if you're going to refer to an early pregnancy unit, that's a one stop, that's going to do everything, then you don't need to worry so much about taking swabs, et cetera because we will do that if you're in a place that doesn't have an early pregnancy unit and you're just referring for a scan. So if you're not um in the UK, or if you're in a place that doesn't have a speci a specified early pregnancy unit. Absolutely. I would take do a speculum and I would take some swabs um just to make sure that there's um nothing untoward and actually, it's just a bit of retained tissue. How long would you continue? Weekly HD GS and PU L. Uh currently someone who's HD started at 4000, slowly declined, but three weeks ago, 72 last week, 67 this week, again, 67. Very good question. Um That's, it really depends on the level of suspicion I think. And that's very much an MDT discussion. So it depends on the, the specifics of the patient. So every um early pregnancy unit in the UK will have a, will have a weekly MDT or at least everywhere I've worked does. Um And these tricky cases are often discussed and all of the scan images are reviewed. Um And um often they will have many, many scans and sometimes we will end up having a laparoscopy just to get to the, get to the definitive answer. So how long do you continue weekly? Hate C GS technically until it's less than five. And it's difficult when it, when it tapers out at those, at those low levels and they're often the really tricky cases. Contraceptive pill can compromise fertility of taking for a long period of time. Uh It can be a risk factor for miscarriage or any other condition related to pregnancy. Um There's, there's not really, I, as far as I'm aware, I don't think um there's that much evidence that any um contraception taken over a long period of time um can increase your risk of miscarriage or any other issue issues with your pregnancy. It can um delay your fertility if you've been taking it for a while. Um But most of the time it will, it will come back. I think the coil I think comes back with once it's out less than six weeks, the pill, I think might be three months or so, but I haven't looked at the statistics on that. Um So I I'm afraid I can't give you a proper definitive answer. But as far as I'm aware, um there's no contraceptive method o obviously, apart from sterilization, um that will um definitively affect your fertility. What is the main difference between a molar pregnancy and a missed abortion? Uh I don't quite know what you mean by a missed abortion. Do you mean a missed miscarriage maybe? Um, so, um, a molar pregnancy I haven't gone into because it's a totally different subject. Excuse me. A molar pregnancy, um, is where there is a growth of abnormal tissue which is not a vi it's never a viable pregnancy and it's never been a viable pregnancy. Um, and it's, it's either where there's, um, an, an egg and two sperms or there's a, an egg with no genes and one sperm. But, um, it's, it's where you get a, a growth of this, um, tissue that is, er, that has, um, come from sperm and egg but is not a viable pregnancy. Um, and you can tell I've not prepared to talk on this cos I'm not, not explaining it very well. Um, but it's a totally different thing, um, than a miscarriage or a missed miscarriage, spontaneous miscarriage, et cetera. Um, maybe that should be my next, my next talk. So I don't know. What do you think? Well, maybe, maybe they could answer. So, would everyone let me put in here molar pregnancy and if anyone's interested in that, could you just take it or heart it, or like it, put an emoji beside it and we'll see how many we get you go. Yes, please all just say yes in the chat. We're happy for that too. Um, I've actually put, there you go. Now they're creeping up. I've actually um, popped your slides up already. Cos obviously there's, you had quite a few hyperlinks as well and I've added those to the event, uh catch up as well so that people can easily click on them. Um, so please do everyone, all our delegates, please make use of those. They're great slides. It looks like, looks like we might have you back, Georgi. Is that all right? Well, we'll see. No, I've had, I've had a lovely time. I'd be very happy to come back. We give you a couple of weeks rest and if you can come back and chat on all the pregnancy, that would be amazing. So anyway, um delegate. So we have your feedback. It should be in your uh inbox right now, please. Um All that feedback I will pass on to Georgina. So please pop anything. Most of the feedback Geina has about um uh presentation skills and that kind of thing. It's good feedback for yourself. We pass it all on to you, but there's also a question in there about further teaching topics. I'm actually in the process of looking at May June, July. Um We have April sorted. Um So I'm looking at May June, July at the minute. So delegates, if there's any anything that you want popped in, um you know, us to think about bringing up for teaching, then we will find incredible people like Georgina to host talks and you can come along and gain more knowledge. So that would be amazing. So please fill out your feedback form. I'll puzzle on to Geina and I'm sorry, we've kept you a little bit late, but hopefully, it looks like everyone is more than happy with everything that they have gotten this evening. So, thank you very much, Georgina and we'll say goodbye to our delegates now. Thank you very much. Everyone take care and we'll see you soon.