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Everyone. Uh Welcome to Day three of the FT SSE M Preparation series. Uh My name is CJ and I'm the FT Sse M President. Um Sorry for the cancellation this morning. Unfortunately, our speaker for Obstetrics and Gynecology has called in Sick. Uh We tried to put a message out on social media yesterday. We hope this, it reached you. Um They've kindly provided their presentation, so Mara is going to cover what they, what they've been able to provide to us with their presentation and just go over that material. Er, so we'll do our best to, to give you some teaching for OBS and G er, we'll be starting shortly. Um just as soon as we share the screen, if you do have any questions, please put them in the chat and we'll do our best to address them at the end of the session. So try and hold them back for the end. And after this session, which we've left a lot of uh two hours to, but we may not take all of that time. But after this session, we'll break for lunch and then we'll resume as planned in the afternoon at 215 as for the messages in the chat. We hope you find this very useful. Um And please do remember to feel the feedback at the end of the talks and the end of the day, please. All right, I'll hand it to you. All right. Um, hi. Uh I'm Marrit. So like she just said, unfortunately, we had a cancellation. So I'm just gonna do the presentation that they've given. Um, yeah, so let's just go ahead and start. I hope you can see my screen. Um So when I'm doing this, I won't be able to see your questions. So please um refrain from all the questions until the end of the thing. And I'll take a look. Right. So, um what I've done is I've added just a few questions to these presentations, but it's not many because I didn't really have the time. But let's just go ahead and um get through the presentation, right. So let's try and answer the question. So mother attends the GP with her 15 year old daughter. She's concerned as the daughter has not yet started her periods, although she suffers from cyclical pain, secondary sexual characteristics are present. What is the most likely diagnosis? So I'm just gonna give it a minute cause I can't see the chart again. But yeah. Right. So the answer is imperforate hymen. So, um so this child basically has come in without starting her periods, but she has the pain and she has cyclical pain and the secondary sexual characteristics are present. So, imperforate hymen is basically um the, so there's uh imperate hymen. So there's a blockage to it. Like the the ovaries are still working, the endometriosis is still the endometrium is still proliferating. So basically, the periods are supposed to happen. But then because um there's a blockage from uh via the, via the because of the hymen, which has not really been perforated yet. So that's why the periods are not happening. So that's why the answer is impro hymen. So that's the next question. A 17 year old woman present to the GP concerned that she has never had a menstrual period on examination. She has minimal axillary and pubic hair and she has underdeveloped breast tissue for her age. She is of normal height and weight. She has no noted past medical history. Um So these are the blood tests that have been ordered. So there's a high FSH and LH and the beta HCG is negative, right? So the answer is Turner syndrome. Um I don't know if I gave you, if I don't know if anyone's answered, I'll check it out later. Um So we'll discuss this in detail in the coming slides. So let's go ahead with the approach to primary Aoria. So if a patient presents with primary amenorrhea where she's never had her period. So, what we do is we first assess for pregnancy, see if she could be pregnant. Um And then if the SCG is negative, we go ahead and assess for secondary sexual characteristics. Um So she could have had um if she has no secondary. So this is the definition of primary aoria. Basically, if the patient has no secondary sexual characteristics and no mench by the age 13, then we would consider it primary auria. And on the other hand, if she does have normally normal secondary sexual characteristics, then the age would be at 15, that we would think about primary auria. Um So let's just go to the next slide because I've just enlarged it. Um So what we do is let's go to the first part where there's no monarch, there's no period by the age 13 and the patient has no secondary sexual characteristics. So, what we first do is we do the FSH level. So we need to find out what the, if the FSH level is normal or if it's high. Um So, based on that, the next step would be if the FSH level is high, then we consider hypergonadotrophic hypogonadism. Um So this is a condition where um the gonads are underdeveloped and the uh the gonads are underdeveloped because of some genetic condition. So then we do a chromosomal analysis in most conditions. And um so this part is basically if there's primary ovarian insufficiency, which is basically seen in um people where the ovaries are undeveloped and there could be Turner Syndrome as well. This uh that could be spy syndrome as well. If the genotype is 46 xy toner syndrome, the genotype would be 45 xo um Turner syndrome would be further discussed in pediatrics actually. But then this is just a picture of characteristics in Turner Syndrome. So you can just take a look. Um so the patient, the most common uh abnormality in the heart is a bicuspid bicuspid aortic wall, which which I think is important for the exam. So other characteristics are high arched palate, webbed neck, um low ses uh broad, widely spaced nipples, um underdeveloped, secondary sexual characteristics. Um there could be a horseshoe kidney as well and short stature. Um Let's go to the next part. Why syndrome? I don't think it's again, it's genetic abnormality where this uh where the condition is where the genotype is 46 xy. But then for the purpose of this exam, I don't think it's that important. So again, it'll be discussed in pediatrics in detail. So the next one, if is if it is normal or it's low. So in that case, we would consider hypogonadotrophic hypogonadism. So we would uh take the prolactin levels. And uh so these are the few conditions that can cause um FSH to be normal or low and uh patient do not have any secondary sexual characteristics. So one is pituitary adenoma. Um Another one is functional hypothalamic auria and another one is Kallman syndrome. Um So we checked the prolactin first. So the prolactin is high, which would point to a pituitary adenoma or prolactinoma. So, um these would usually have other symptoms along with it like headaches or impaired vision or glaur because the prolactin is increased, that could be uria and because of the uh because of the adenoma and the pituitary lesion, they could have headaches and impaired vision as well. Um Yeah. So we just, we do like the rest, we do a few more blood tests and we also do the MRI to confirm the diagnosis. So, in the MRI, you would see a pituitary adenoma which shows that um that's the cause for the uh primary amenorrhea. So, if the prolactin is normal, um so there could be possibly three situations. So this one is a constitutional delay in puberty. Uh PCOS would usually present after it, it wouldn't present as primary amoria. It would probably be either uh secondary aoria. Um Even hypothyroidism usually is secondary Amin, which we'll discuss in the next slides. Um So prolactin is normal and uh so Kallman syndrome is a condition where uh there's a genetic abnormality again. And one of the main signs of Kallman syndrome is that this decreased or absent sense of smell. So, in an exam and this question gets asked, it usually um this decreased sense of smell is usually part of the question. Um The third, the other thing that can happen is functional hypothalamic am anuria. So, in this, this could be due to psychological stress, weight loss, eating disorders, um and a very low BMI. So, in these situations, the hypothalamic hypothalamus is not functioning well. And because of this, the patient has primary amoria, right. So going to the other side is if there's no mino by the age 15 and the secondary characteristics are completely normal. So this is where the first question came, where there's an impro hymen or a transverse vaginal septe, that's just a blockage to the vagina region which is preventing the blood from flowing down. Um So, uh what we do here is we do a pelvic ultrasound to see if there's a uterus or there is no uterus. So if there is a uterus, then it could only be transverse vaginal septum or the hymen. Um So, this patient usually has cyclical pain present that could be lower back pain, uh lower abdominal pain because of the blockage. Um the heart. So, on examination, the difference is that they, you could see a blue bulge at vaginal enteritis in imperf tmen. Um and then trans vaginal septum, it would be just a shortened vagina. So, trans vaginal septum is just an additional, where tissue just forms additional tissue forms at the vaginal region which prevents blood from flowing down and an imperforate hymen, basically the hymen is just present. Um So if the uterus is absent again, it could go to two other conditions. Uh it could be the androgen insensitivity syndrome or malarian agenesis, which we'll discuss in the further slides. Um right. So, androgen insensitivity syndrome is an excellent recessive condition due to resistance of testosterone causing a genotypically male child. So, the genotype would be 46 xy. Uh but the phenotype would be female. Um So the features of androgen insensitivity syndrome, there could be primary auria. Um the breast development is normal usually um there's little or no axil and pubic hair. Um and because the patient has a genotype 46 xy, the testis is still there, so it could cause groin swellings. So the diagnosis is by chromosomal analysis which will xy and the clinical characteristics as well. So usually how you manage this is you raise the child as a female and you definitely have to go ahead and do a bilateral orchidectomy because the testes are still present and this could lead to testicular cancer at an early age. You can also give estrogen therapy. Um right. So it's moving on to secondary amenorrhea. Uh secondary amenorrhea has various causes as well. Um So these are just a few causes of secondary Amenia. So we'll discuss most of them uh that are important for this exam in the next coming slides. So few of the causes are that could be hypothyroidism which causes uh secondary aoria uh PCOS like I said is more of a cause of secondary aoria, which is important. Then there could be estrogen deficiency which could be either premature ovarian failure or perimenopause. Uh pregnancy is a cause um that could be reproductive tract obstruction, likes stenosis or Asherman syndrome. Um So, these are a few symptoms that are seen uh in various situations where the secondary amenorrhea. So, hyperprolactinemia usually uh hyper prolactinemia usually again, presents with headaches and visual changes because uh of the abnormal present. Um and that could be gia as well. Hypothyroidism has obviously other changes like dry flaky skin, um hair loss, nail changes, um palpitations, fatigue, and also intolerance to heat. Um PCOS again, has her acne weight gain. Um So, these are a few symptoms seen in PCOS estrogen deficiency. That's uh if seen with premature ovarian failure or perimenopause would have um other symptoms of uh menopause like hot flashes, mood changes and bone weakness. Uh pregnancy again, would uh you would be able to diagnose this with the pregnancy test because that's the first thing that we would do. Um So moving on to P CS. So, another is uh an important association with PCOS is that it's associated with metabolic syndrome. So, the features that are seen are you can see um so the you can present with secondary amenorrhea. Like we were discussing uh there can be issues with in uh fertility. Uh They can be hirsutism or acne obesity and acanthosis nigricans due to the insulin resistance. So, acanthes nigricans is darkening of uh areas of skin folds like the um axial lesion or the um absolute region or the next region. Um, so investigations that can be done in this situation, uh The pelvic ultrasound can be done which shows multiple cysts on the ovaries. Um, the FSH LH, the LH FSH ratio would be high. Um, insulin levels are usually raised and there's very high levels of luteinizing hormone. Um, so prolactin testosterone as these patients are usually normal or just very minimally elevated and you should always remember to check for impaired glucose tolerance as well. Um So PC is usually diagnosed by the Rotterdam criteria. So, um these are the three things that Rotterdam criteria checks for. So, one is the periods being irregular, that's clinically if you have um irregular periods, um or amenorrhea or uh or secondary aoria. Uh The second one is you do an ultrasound and on the ultrasound, if you see an ovary with uh multiple cysts, that's the second criteria of the criteria. And the third one is excessive androgens are seen um on the blood test. So the f is raised. Um So for the management of this, one of the main things that uh is advised is weight reduction if it is applicable. Um So other, so other symptoms can be treated like hirsutism and acne could be treated with AC op which would help with managing the um excess of hair. Um and the acne, so, infertility again, could um infertility is again a very um important problem with PCOS. So, in this, again, what weight reduction would help because it weight reduction usually helps um prevent the um the insulin, the impair glucose tolerance and it also regularizes your period. Uh And another medication given is clomifen. In most cases, that's the first line. And Metformin is also used. Um especially if patients who are obese. Metformin helps more. Uh gonadotrophins can also be given uh premature ovarian failure. So, premature ovarian failure is seen in patients um below the age of 40 if the patient starts presenting with menopausal menopausal symptoms. So, causes of premature menopause are um usually they're idiopathic, that's the most common cause. Um could be because of bilateral oophorectomy where the um the uterus is still present, but the ovaries have been um taken off have been surgically removed. Uh radiotherapy chemotherapy is another cause infection and autoimmune disorders also cause premature ovarian failure. Um So, again, clinical features that are seen are very similar to the features seen in menopause which your hot flushes, night sweats, usually um bone density loss can be seen in fertility, uh secondary auria. So, blood test that we do to diagnose it is we uh measure the FSH LH level which would be raised and we need to take it on two samples and they're taken 4 to 6 weeks apart. Um When you ma the estrogen, the estrogen levels also decreased. It would be below 100. Um So management is again, like menopause, we give um hr until 51 years of age. Um You should always remember that we cannot give on a post estrogen, but because this does um lead to rise in cancers like uh endometrial cancer, right? Let's try and answer this question. So, a 28 year old woman prescribe presents because she has not had a period for the past nine months. She also describes fluid leaking from her nipples. What could the answer be? So, A is Ashman Syndrome B Sheehan syndrome, C. Polycystic Ovarian syndrome. Uh D is premature ovarian failure and a prolactinoma. I'm just gonna give it a minute and move on to the next slide. Right? Ok. Right. So the answer is platino. Um so it's milky fluid leaking from her nipples and uh she has not had a baby. So she's basically presented with secondary amenorrhea, right. That's the next question. 25 year old woman presents five months after having dilatation and cure touch for a miscarriage. Since this procedure, she has not had a period. A pregnancy test is negative. Hysteroscopy is performed which reveals the diagnosis. Um A Ashman syndrome. Uh B Sheehan syndrome, C Polycystic Ovarian Syndrome. D is premature ovarian failure and prolactinoma, right. So, the answer is Asherman syndrome. So, um yeah, I don'tt think the Ashman syndrome is explained in detail. I'm just gonna give a um slight explanation on it. So, Ashman syndrome is basically an acquired uh uterine condition that's caused uh which causes scar tissue to form um either in the uterus or in the um or in the cervix. Um So what happens is when a procedure like dilatation and curettage is done, which is a risk factor for Ashman Syndrome developing, there can be a chance that scar tissue forms because of the procedure. Um So usually when a question comes, there will be some procedure is done and um because of that patient has developed um aoria. Um so um the diagnosis is done via a hysteroscopy. So that's why they mentioned that the hysteroscopy is done, which showed the diagnosis, right. That's the next question. So, a 74 year old woman presents to her GP complaining of urine leakage when she coughs, sneezes or laughs for the past year on and off. There's no dysuria or hematuria, no abdominal symptom symptoms. What is the most likely diagnosis? Um So urge incontinence, stress, incontinence, neurogenic bladder or deer in stability? Mhm. Right. So the answer is stress incontinence, we discuss it in the further slides, right? So, urinary incontinence can be of four types. It could be either stress, incontinence, urge incontinence, overflow, incontinence, or Urogenic incontinence. Um So stress incontinence is usually due to weak pelvic floor muscles. Um, so the muscles of the pelvis are weakened and because of that, um, whenever there is any sort of stress like coughing or sneezing or laughing, um, that when there's increased abdominal pressure and because of the weakened walls, you have incontinence. So, urge incontinence is due to involuntary contraction of the bladder muscles. Um So this is, again, it's seen, it's not seen due to stress, but um occasionally the uh bladder involve into contracts and it uh leads to incontinence. So, overflow incontinence is basically the bladder gets full and um because of some blockage in the urethra, the um urine does not pass as it normally should. So again, it would have incontinence there. Neurogenic incontinence is due to um any disturbance that's uh functional, basically because of the nervous system. So these are the treatment of the um different incontinences. So, in case of stress incontinence, because uh it because stress incontinence is caused due to weakening of the pelvic floor muscles. What we initially do is we give pelvic floor muscle training um which is done three times a day for three months. So that's the first initial management. So if this doesn't work, we would have to go for either surgical management or medical management. So, in surgical management, you can do a retropubic mid urethro tape. Um One of the meds that we try is DULoxetine. Um It's no adrenal and serotonin reuptake inhibitor and DULoxetine helps with stress incontinence. Um So, in overactive bladder or urge incon continence, what we first do is we try bladder retraining for six weeks. And if that doesn't work, we give antimuscarinics which are oxybutynin tol or darienine. Um So these medications uh usually prevents incontinence. Um because the anti muscarinic. And, uh, these are the first line medications given. Um, if there are too many anticholinergic side effects, Miron can be tried as well, right? So menorrhagia. So, uh, if a woman presents with menorrhagia, um, what we first do is we obviously take a history, we do a full examination and we do a blood count to check for anemia. Um, so if the patient has symptoms that are suggestive of underlying pathology, then we need to again further arrange investigations like ultrasound or transvaginal ultrasound. Um If the patient does not have any other um underlying pathology, um the treatment for menorrhagia is uh depends on whether the patient requires contraception or not. So, if the patient requires contraception, the first line is um IU which is the intrauterine system. Uh second line is cop um if the patient does not require contraception, then we can try tinic acid or nsaids like mefenamic acid, right. So, moving on to endometriosis, um endometriosis uh is basically when the tissue inside the endometrium is has proliferated and it's found somewhere else other than the endometrial cavity. Um So these are some of the regions where the endometrial tissue can be found. Um So it can be found uh outside, just outside the endometrium can be found at the ovaries or the uterus can be found um at the vagina as well, right. So, how do patients present? So, patients usually present with chronic pelvic pain and secondary dysuria, which is pain that starts just before the bleeding. Um You can also see deep uh pain, deep dyspareunia, which is pain. Uh uh You can also see deep dysuria. We can see subfertility as well and urinary symptoms like dysuria, urgency hematuria, uh this painful bowel moments as well. And you can also patients also present with uh bleeding, uh irregular bleeding. So, the Gold Standard investigation uh for diagnosing endometriosis is laparoscopy. Um How do we treat it? We uh treat the pain with nsaids or paracetamol. Um Nsaids, mefenamic acid is most commonly used or you can give CCP or progesterones. So, if analgesia and hor hormonal treatment does not improve the symptoms. And if fertility is a priority, then we can give additional treatment like GNRH analogs like Australin um or surgery to remove the excess endometrial tissue. So, um what we do by surgery is either excision or ablation of endometriosis. Uh moving on, let's go to fibroids. So, fibroids is basically uh seen. So risk factors for fibroid is people, fibroids are usually seen in uh people uh in people after puberty. So it's a cause of secondary auria um or it can cause irreg not secondary auria, sorry, it can cause irregular bleeding. Uh patients may be asymptomatic. So, menorrhagia is one of the most common symptoms seen. Uh it's usually seen in uh people of the Nigerian descend and seen after puberty. Uh So symptoms that can be seen as menorrhagia, which may result in iron deficient anemia can be seen in bulk, relate uh bulk related symptoms can be seen like lower abdominal pain or bloating or urinary symptoms. Um Fertility is also a major issue in people with fibroids. Um The investigation of choice is a transvaginal ultrasound. Um and the management of fibroids is uh so if mania is the most important is the most concerning uh symptom, then you can give I US or nsaids like mefenamic acid, you can also try cop. Um So for patients where fertility is the most, uh the biggest concern. So the only treatment for fertility is myomectomy where you go in and you uh basically surgically remove the fibroid. Um So prior to surgery, we do use GNRH agonist like Goslin to shrink the um fibroid tri art embolization can also be tried. So, one of the complications of fibroid is red degeneration where uh where the fibroid basically causes a hemorrhage and this turns into a tumor which is commonly seen only during pregnancy. So let's move on to cervical screening. Um So the vital screening is done in the UK and it's offered to all women between the age of 25 to 64 years. Um So patients between 25 to 49 years are screened every three years and from 50 to 64 years, they're screened every five years. So, in Scotland, um it's a little different. Uh screening is offered every five years from 25 to 64 years, right? Um, ok. Um, so what we, ok. All right, let's go through the chart. So, what we do is for screening, we send out the screening and the first test we do is the itch. Oh, ok. I think you can see it a little bit enlarge it a little more, right. So the first test we do is an HPV test. Um, so based on if the HPV test is negative, then we just go on to normal recall. If the HPV test is positive, then we carry out the cervical cytology test. So uh based on one second, sorry, right. Um So yeah, so if the HPV test is negative, we go to normal recall. If the HPV test is positive, we get the cytology done. So if the cytology is abnormal, we we go ahead for a colposcopy. So if the cytology is normal, uh what we do is uh so basically the HPV is positive but the cytology is negative but the, but the cytology is normal. So what we do is we repeat the test in the next 12 months. Um If the repeat test is again negative, then we return to normal. You call again. If it's still positive, we have to go ahead and do it repeat it again in the next 12 months. So we try it for two times where we uh give it 12 months and we repeat the cytology. But if it comes back normal again, but HPV is again positive after 24 months, um we would go ahead with the colposcopy. So if HPV is negative and cytology is negative after 24 months, you can return to normal recur. Ok. Um So once we do the HPV and it's positive and the cytology is neg uh inadequate, then we repeat the cytology again in three months. Um If it's inadequate again, we'll go ahead with a colposcopy. So, uh patients who are treated. So, for example, patients who have C and one C in two or C and three and they are treated um usually by the LL E TZ. Uh then we would repeat the cervical sample again in 4 to 6 months. It's right. So, postmenopausal management. So, um patients that uh are undergoing menopause and have uh menopausal symptoms like hot flushes at um and uh vaginal dryness and vaginal symptoms uh can be treated via uh so it's depending on the symptom it's treated. So what we first do, like always, we do the history, we do the examination. Um We see if there's any underlying pathology or any other reason, we're suspecting another diagnosis that's causing the amenorrhea and then we manage the symptoms according to the symptoms. Uh So, in the management of the symptoms, if there's vaginal dryness, we try vagina lubricant or moisturizer. If there's vasomotor symptoms, we can give SR S like FLUoxetine or citalopram or Venlafaxine. Um Another treatment is hormonal treatment that needs to be given for patients. Um So, again, for vaginal symptoms, we can give vaginal estrogen. Um If there are systemic symptoms, we would need to give uh uh tibolone uh which is uh HRT to replace the estrogen, which would reduce the symptoms of menopause. Um So the the pre, so if the uterus is still present, patients need to be cannot be given on a post estrogen. So, if the, if the patient has undergone a hysterectomy or uh the uterus has been removed and endometrium is absent, then patient can have just estrogen. But if the endometrium is still present, then we need to give estrogen as well as synthetic progesterone to prevent patients from getting uh a variety of cancers like endometrial cancer or ovarian cancer, right. Um So this is just an approach to abdominal pain in gynecology. So, um when a patient presents with abdominal pain, um the that it will be the um it can be either an emergency condition or it can be a non-emergency. So, the few emergency conditions that can be seen would be either pregnancy related or no nonpregnancy related. So, emergencies that are because of pregnancy could be either ectopic or miscarriages, uh which could cause postpartum hemorrhage, uh which which would cause hemorrhage, um or degeneration of fibroids, degeneration we spoke about earlier. So, non pregnancy related complications are either ovarian cyst or pelvic inflammatory disease. Um Again, both of these complicated ovarian cysts, meaning it could have a torsion or something that would be a surgical emergency. Um It could also be pelvic inflammatory disease which needs to be immediately treated. Um None emergencies could be benign conditions like ovarian cysts that are uncomplicated, um which could either have expectant or surgical management. Um There can be chronic pelvic inflammatory disease, uh endometriosis or fibroids. Um All of these can be medically managed. Um They can also be malignant conditions like ovarian tumors. This would not be an emergency, but it would require a two week referral um to see options for removal. Um So the next topic is vaginal discharge. Um So vaginal discharge uh can is usually uh because of three conditions, uh abnormal vaginal discharge. Uh So three infections can cause abnormal vaginal discharge. It can either be due to Candida can be a bac bacterial vaginosis or it can be trichomonas, vaginalis. Um So, Candida would present with a cottage cheesy kind of discharge with a lot of itching and inflammation and redness around the vulva. Um How we manage this is we can give uh management for candidiasis is um an antifungal which is oral fluconazole, which is, which is given as a single dose of 1 50 mg. We can also try clotrimazole which is a 500 mg single pessary uh which would not be an oral treatment. So, in pregnancy, this would be helpful because fluconazole is contraindicated in pregnancy. So you would need to give a local treatment. So, if there are recurrent uh episodes of candidiasis, then uh we can we do a high vaginal swab to confirm that there's no other this to uh basically exclude other differential diagnosis. And uh so we manage with uh induction and then we go for maintenance therapy to, to, to completely eradicate the candida. So this would be oral fluconazole, which is given three doses in three days and then one dose is given weekly for the next six months. Um So trichomonas, vaginalis um is again a cause of offensive yellow green discharge. Um So in this, when a question comes, usually the patient, something about a strawberry cervix is usually uh mentioned or a green frothy discharge. Um So this is treated by oral metroNIDAZOLE, which is given for seven days. Um This is um oral mezo is safe in pregnancy. So, even if the patient is pregnant, you give the same treatment. Um So bacterial vaginosis is again um a condition that causes uh vaginal discharge. So this is seen due to overgrowth of anaerobic organisms um like ella vaginalis. So, and so this is an organism that's actually usually seen in a vagina. But uh uh in some conditions, uh there's an overgrowth of these organisms and this causes a fall in lactic acid which basically raises the vaginal ph. So, for the diagnosis of uh bacterial vaginosis, um it, we use the answers criteria. Um So if three of the following four points are present. Then we diagnosis a bacterial vaginosis. So the first one is thin white homogeneous discharge. Um clue cells on microscopy will be seen. Uh vaginal ph is again raised because of the fallen lactic acid and a positive V test. So these patients, the discharge that comes out is usually has a fishy odor uh with the addition of potassium hydroxide, right. Uh management is uh again, if there's, if it's asymptomatic, then it does not require treatment. If the patient is pregnant, we will probably need to treat it. Otherwise, asymptomatic patient does not require treatment. If the patient is symptomatic, we can again give oral. So for 5 to 7 days, um so moving on the next uh next condition that is seen in gynecology is pelvic inflammatory disease. Uh So these are a few symptoms of pelvic inflammatory disease. You can present with lower abdominal pain, vaginal discharge, uh painful intercourse, fever, chills, painful urination and irregular menstrual bleeding. Um So, causative organisms can be either chlamydia or nyyia. The most common cause uh of pelvic inflammatory disease is chlamydia. Um So what we do is we investigate and we uh investigations, we do um we uh we exclude pregnancy via a, a test uh to exclude an ectopic and we screen for chlamydia and gonorrhea. So this could be negative. Uh But if we have high clinical suspicion of P ID, we manage it as P ID. So the first line treatment because it's, it's an emergency and it needs to be treated. So, the first line treatment of P ID is you give a stat im cefTRIAXone and we give 14 days of oral doxy and oral metroNIDAZOLE. Um So uh that's the first line treatment. The second line treatment is oral ofloxacin uh plus oral metroNIDAZOLE. So I think for the purpose of xam, the first line is usually ask which is um cefTRIAXone, uh oral doxycycline or oral metroNIDAZOLE. So, complications that can be seen as in pid is Fitz Hugh Curtis syndrome, which is uh adhesions in the liver region which causes perihepatitis. Infertility can be seen chronic pelvic pain is uh usually chronic pelvic pain is another complication and ectopic pregnancies can happen. Um So, yeah, so let's move on to emergency contraception. Ok. Right. Um Right. So, uh contraception, uh we'll discuss a few of the contraceptive methods. Uh We'll talk about emergency contraception first. So, emergency contraception is basically to reduce the risk of pregnancy. It does not replace effective regular contraception uh but it can be used in emergency situations. Um So females of childbearing potential who do not wish to conceive can be offered offered emergency contraception. Um So if the, if you had unprotected intercourse in any day of the menstrual cycle, uh emergency contraception should also be given uh for unprotected intercourse after 21 days of childbirth because in the 1st 21 days, uh you're protected. Um and from day five after abortion or miscarriage, ectopic pregnancy, um emergency contraception should also be offered to females whose regular contraception has been compromised or has been used incorrectly. So for example, if you've missed the people s for two days, you would have to be provided with um or the po ps you would need to be provided with uh emergency contraception. So in there are three ways to drug forms for emergency contraception. The first one is levonogestrel. So we can give a single dose of uh levonogestrel. That's 1.5 mg. Um This dose is doubled if the BMI is more than 26 or if there's any enzyme inducing drugs, it would need, need, the dose would need to be doubled. Um So this is given only in the first three days. Um It's 84% effective in 72 hours. So, if vomiting in three hours and we need to give a repeat dose. And uh yeah, so it's only given for the first three days. So, if the patient has had unprotected uh intercourse in the last three days, then leven drug can be used. Um uh One of the advantages is that it can be used more than once in a menstrual cycle and you can start hormonal contraception immediately afterwards. Um The next uh medicine form that is used uh for emergency contraception is ole Prestol, which is also called L1. So this is a selective receptor modulator and we give 30 mg and it can be used for five days, which is what, 1, 20 hours. So, if the patient presents, having unprotected occurs in the last five days, you can use oleol. Uh So, ulipristal reduces the effectiveness of hormonal contraception. So we can't immediately start the regular contraception. After giving ulipristal, it can be started only after five days. Um So that's one of the disadvantages. Um Again, one of the advantages is that ostol can be used more than once in the same cycle. Uh breastfeeding should be delayed though, for one week after. Um So another thing is if the patient has severe asthma, then we cannot give ostol, we need to either go with Leven or IUD. Um So, IUD is the most effective method of emergency contraception. So it can again be inserted within five days. Uh So patient can be given trip, I take antibiotics if there's ast I risk. And uh another thing is it can provide long term contraception as well. So if the patient wishes for it to be kept, uh we can just provide the sa we can just give long term contraception with the same IUD. Um So this is you, so this is uh you can, so this is a UK medical eligibility criteria for contraceptive use. Ba basically what it is to see the risk in using a particular contraceptive. So category one is a condition for which there is no restriction for the use. So for example, if the, if there's no side effects linked to using the contraceptive that comes as U KMC category one, and it just goes on. So then category two is where there's advantages and there are few risks. But then the advantages outweigh the disadvantages. Category three is where the disadvantages outweigh the advantages. So the risks are technically more than the advantages of the uh contraception. So uh and category four is where it presents an unacceptable health risk and we don't give the uh contraceptive at all. So in category three, if the, you can see categories three or four, we would not give, we would not suggest that method of contraception for uh preventing pregnancy and we would go with other methods of contraception. Um So this is basically uh how, how soon the contraceptive becomes effective and for how long you would need to uh be taking additional contraception before having unprotected intercourse. So, for iuds, that's copper iuds, it's instant. So the moment you insert a copper IUD, you would have a protection against uh pregnancy. Uh for pop, that's predone only pills, it's two days. Um So after starting predone only pills for the next two days, you would have to use additional contraception as well. And for cop um progesterone inject implants, ius and injections, um it's seven days. So for the next seven days after starting either of these methods, you would need to use additional contraception right. Um So let's move on to cop. Uh So combined oral contraceptives are usually started within the first five days of the are, are usually started. And if it started in the first five days of the cycle, there is no need for additional contraception. But if it is started at any other time, we would need to provide um additional contraception for the next seven days. Um uh the cop pill should be taken at the same time every day. Um It was earlier, it was taken for 21 days and then stopped for seven days. But uh recently, there's a change in the, in 2019 which says that uh there is no additional benefit to take this pill free uh period. So then you can just continue taking uh CP pills uh back to back. So either take 321 day, back to back to back to back before having a 4 to 7 day break or never have a period is also fine. So intercourse during the pill free period is usually safe if the next pack is started um on time, right? Um So uh in combined oral contraceptive pills, um if two or more pills are missed, um right, if two or more pills are missed. So if one pill is missed, you don't need to do anything. What you do is the next day, you immediately start the um immediately take the missed pill and the pill that you're supposed to take at the same time. Um So emergency contraception is not required. So, um, yeah, so that's here. So if one pill is missed in a week, you just take the missed pill as soon as possible and continue taking the remaining pills at the same time. Um No additional contraception is required. Um It at any time if, um, if any time over the week api is, is the same. Um, if two or more pills are missed, um if it's missed in the first week, um then we would, ok, we would, if, if you miss two pills in the first week, then we would uh need emergency contraception for the next one week. Um and just take the next pill immediately and continue on. So take the most recent pill as soon as possible and continue the remaining pills at the same time. Um If two, more than one pill is missed, that's two or more um missed in week two or three. So then emergency contraception uh is not required, but you need to take the most recent pill as soon as possible and continue taking the remaining pills at the same time. Um Yeah, so if more than seven consecutive pills are missed, then you do need emergency contraception for the next seven days. And uh you would start it as a new cycle, you would start the new pill. So manage just a new start contraception. So again, you would have uh additional contraception for the next seven days. Um Also, if you had unprotected intercourse at any time, you would need to do an immediate pregnancy test and start the new packet. So it would just be like you're starting over your cop, right? So, progesterone only pills. Um So again, progesterone only pills, if they are delayed for less than three years, then you don't need any action. You just continue as normal. If you've forgotten it for three years, if you've forgotten it for more than uh three years, then you would need uh to take some action. So it depends on what poop you're using. So only in the situation of desogestrel, if you're uh if you've forgotten it for 12 hours, less than 12 hours, then it's OK. You just need to continue the same pill as normal. And if it's more than 12 hours again, you would need to take the action. So the action that needs to be taken is you need to take the missed pill as soon as possible and uh take the next pill at the usual time whenever that is and continue the rest of the pack. Uh But you would need to have extra precautions, uh extra contraceptive methods for the next 48 hours. So these are just modes of action for different contraceptives. Um So most of the contraceptives work by inhibiting ovulation. The difference is in the progestone only pulse which works the primary mode of action is by thickening the cervical mucus. Um and IUCD, which is the copper IUD um usually decreases the sperm mortality and survival. And that's the main action to prevent uh pregnancy. And in ius, the primary prevention is by preventing endometrial proliferation. And it also thickens cervical mucus um for everything else, uh it inhibits ovulation. So cop de Detrol only pill, um injectable contraceptive, um implantable contraceptive all inhibits ovulation as the primary mode of action, right? So, um if you don't mind, we're just gonna take a five minute break and we'll come back if that's all right. Oh So we're just gonna take five minutes and I'll come back in five, right? Um Let's start again. I'm just gonna share my screen, right? Um I hope you can see my slide. Uh just confirm. OK. Right. OK. Um So we're moving on to the obstetric parts of uh this presentation. Um So let's start with hypertension in pregnancy. Um I hope you guys can hear me and see the light, right? Um So hypertension in pregnancy. So, um these can be of four types. It can either be chronic hypertension, gestational hypertension can present as preeclampsia, um or preeclampsia plus which is severe preeclampsia. Um So, chronic hypertension is seen in patients. Uh that good, right? OK. You can still see me, right. Uh Yeah. OK. Sorry. That's fine, right. Um So what uh to diagnose chronic hypertension, we would have uh two measurements that are uh measured at least four hours apart. Um And it's diagnosed before 20 weeks of di uh gestation. So everything else does gestational hypertension, uh preeclampsia and severe preeclampsia would be diagnosed after 20 weeks of uh 20 weeks of gestation. Uh So it is diagnosed during pregnancy and it persists 12 weeks, postpartum as well. So, gestational hypertension is seen after 20 weeks of gestation and uh systolic BP is more than 140 or and diastolic BP is more than 90. Uh Again, we would suggest that we uh take two measurements at least four hours apart. Um And in gestational hypertension, there are no features of proteinuria or organ injury, which is how we know it's not preeclampsia. So, in preeclampsia, um again, uh it's diagnosed after 20 weeks of gestation, uh systolic BP is more than 140 diastolic BP, more than 90 on two different occasions. Again, four hours apart. Um or if the systolic BP is more than 160 diastolic is more than 100 and 10, then you would immediately diagnose it as uh preeclampsia if there's uh high BP as well as proteinuria. So, preeclampsia is diagnosed if there's hypertension as well as proteinuria or um organ. So, proteinuria is seen with uh more than 300 mg in a 24 hour urine um or the uh protein. Um I'm sorry, I uh Right. Ok. Or the urine protein creatinine ratio is more than 0.3 or protein is uh two plus on the urine dipstick. Um if there's no proteinuria, but there's hypertension as well as organ injury. Again, we will diagnose it as preeclampsia. So, organ injury would be um either platelets of less than 100 which shows thrombocytopenia. Um raised liver enzymes which can be uh which causes liver damage, which uh which shows liver damage. Uh severe right upper quadrant pain or renal insufficiency with the creatinine that's risen. Um any pulmonary edema or cerebral or visual dis. So basically, any organ injury is seen with hypertension, then we would again diagnose with preeclampsia. Um So severe preeclampsia is seen if the systolic BP is more than 160 diastolic BP is more than 100 and 10. Um again, taken twice, four hours apart, um or evidence of any uh end organ injury. Um Eclampsia is basically, if seizure, if a patient with preeclampsia presents with seizures, then we would call it eclampsia. Um a complication of preeclampsia. Eclampsia is hellp syndrome uh which uh we diagnose. So it's so this is a Pneumonic I where my right. So he is pneumo Pneumonic to see what are uh what are the conditions seen with He syndrome. So, hemolysis is seen they can be elevated liver enzymes. So, hemolyzes hemolyses elevated liver enzymes. So, el um low platelets. So LP and uh it's associated with preeclampsia or eclampsia. So, in all uh in any hypertension in pregnancy, whether you have been diagnosed with hypertension before pregnancy during pregnancy, um we need to change the antihypertensives. So, the only hypertensives that are given in pregnancy are either labetalol or Nifedipine. Um So for most patients, the first line treatment is labetalol unless there are severe asthma features. In which case, Nifedipine is given. Right. Um Right. So if the these, this is how you manage the whole situation. So if the BP is 1 40 90 to 1 59 1 90 so that's essentially below 1 61 1110, which would so more than 1 61 10 would be severe hypertension. If it's less than 1 61 10 and has hypertension, it would be um non severe hypertension. So what we do is if there are any clinical concerns, we admit to hospital, but if there are no clinical concerns and no high risks of adverse effects, adverse events, then we start the patient on labetalol or Nifedipine. Um if the patient is, has a BP of more than 1 61 10, we always admit the patient. Um Yeah, so we treat so both patients, we give pharmacological treatment. If the patient has eclampsia, the management for eclampsia would be um that if the patient presents with seizures with hypertension, then IV magnesium sulfate is given as a treatment. So, in both these conditions, the aim is to reduce the BP below 1 35 85 with either medical management, with uh with medical management and sometimes admission. So the BP needs to be monitored at this point. So at least every 48 hours, you need to monitor the BP. Um And if the patient has a BP of it has a BP of more than 1 61 10. the BP is monitored every 15 to 30 minutes. Um And uh so dipstick protein again, we see if the patient has protein to see if it, if the patient has preeclampsia or eclampsia. Um So we do repeat the uh protein. Uh we do repeat the dipstick only if indicated, like for example, if new symptoms or signs develop. Um Yeah, and we need to do the full blood count as well too. Uh We need to do other blood tests as well, like full blood count, liver test and renal function test to see. Um um So this is done twice a week in case of in the first situation. But if the BP is more than 1 61 10, we do it three times a week to make sure that the patient doesn't have any end organ damage. Um So, indications for delivery and preeclampsia. So the patient, if a patient presents um at 37 weeks of gestation, uh or more, we can immediately deliver the patient if the patient presents at less than 36 weeks of gestation, then we uh consider delivering the uh child uh the fetus only if there's an inability to control the maternal pressure despite uh three or more causes of antihypertensives. If the maternal pulse oximeter is less than 90%. Uh and if there's a progressive deterioration, if in liver function, renal function, um hemolyzes a platelet count. So basically, if this hellp syndrome uh and there's ongoing neurological features and the there's a reversed and diastolic flow in the umbilical artery Doppler or a non reassuring cardio cardiotocography or uh stillbirth. So, in these situations, even if the uh gestation is less than that seven weeks, we would consider uh delivering the child. Um So basically, if, if there's any uh risk to mother or baby, we would have to tell you. So, moving on. So, diabetes in pregnancy. So, um so that's the next complication sometimes seen in pregnancy. Uh So the this these are the complications that diabetes in pregnancy can cause. Um So maternal circulation. So when the patient has diabetes, the mother has diabetes, um the lipids and amino acids from the maternal circulation can enter the fetal circulation. And this causes um various complications in during childbirth or for the child like macrosomia can be seen because of increased growth. Um They can also be traumatic birth or shoulder dysplasia or perineal tear. So, in all these situations, c section would be considered because uh of increased growth of the fetus. Another complication is that glucose can again enter the fetal circulation as well. Um This can cause hyperinsulinemia, which can cause hypoglycemia. And uh the surfactant in the lungs can decrease, which can uh cause respiration distress syndrome. So, patients with diabetes have a higher risk of uh respiratory distress syndrome, right. Um there's also increased oxygen consumption which can cause polycythemia or hyperbilirubinemia. So, how do we manage GDM? Um So um we do a screening test. So, um oral glucose tolerance test is done at 24 to 28 weeks. Um And if there's a previous gestational diabetes, we screen uh earlier. But if uh if without any chest cancer diabetes in previous pregnancies, then we screen at 24 to 4824 to 28 weeks. Um If the fasting glucose is more than 5.6 or the two hour glucose is two hour glucose is more than 7.8 then the patient has uh gestational diabetes mellitis. So if the fasting glucose is less than seven, we can initially try it with diet and exercise. Uh if the target is not. So we try that and exercise for uh 1 to 2 weeks. And if the target is not met, then we add Metformin. Uh So if the, if Metformin also does not meet the targets uh in the next two weeks, then we add insulin as well. So if the patient has a fasting glucose of more than seven, then we immediately start with insulin, uh, pregnant women with gestational diabetes mellitis, um should basically maintain their blood sugar levels below the target levels, which is for fasting 5.3. Uh post prandial one R, it should be less than 7.8 and to us should be less than 6.4. So these are the targets that the uh mother is given for her BMS, right. Um I think, I think you guys can just go through this. I'm just gonna quickly go through this. These are just the antenatal booking tests. Uh when the when the mother goes, whe when the visits are for in any pregnancy. But uh I think this is more of just learning it. So at 8 to 12 weeks is the initial booking visit. Um So bloods and urines are blood and urine is taken for all of these. So basically, um vital screen is done. Hemoglobin of these are tested, resat is tested FBC blood group is done. Urine culture is also done because um to see if the patient has any uti uh the any asymptomatic uti because if you remember like in pregnancy, we do treat asymptomatic uti. So at 10 to 13 plus six week, uh is the early scan to confirm the dates and to exclude the chance of multiple pregnancies. 11 to 13 plus six weeks, we do the Down Syndrome screening test including the nucal scan. At 16 weeks. You do the anomaly test and we do a hemoglobin test as well. So if the hemoglobin is less than 11, then we consider iron. Um we also do a urine dipstick and check the BP. Um At 18 to 20 to 6 week, we do the A scan. Oh, sorry. I think I mentioned it wrong. So at 16 weeks, you basically give the information on the Annaly scan and you test for it, he test the hemoglobin level and consider iron as well. So 18 to 20 plus six week is when you do the aly scan. Um at 25 weeks, again, it's a routine check, you do a urine dipstick, um check the uh uh symphisis fundal height to check if it's appropriate. Again, 28 weeks is the next routine check. Uh This is also the second screen for anemia and atypical red cell allo antibodies. So, if HP is less than 10.5 again, you consider right. So the HP target at 16 weeks is 11 and 28 weeks is 10.5. This is because of the um physiological uh anemia that can happen in pregnancy. Um at 13, 1, 31 weeks. Again, um there's 31 weeks check only if it is a primary gravida. That's, it's the first pregnancy. So again, it's the routine test, 34 weeks. Again, routine test and also the second dose of anti D prophylaxis can be given at 36 weeks. Uh routine check as well. As we check the presentation. Um So if it, if the patient is uh at in breach or some of the presentation, we would need to offer external cephalic version as well. Um At 38 weeks, again, 38 weeks, 4041 weeks again would be routine care. So at 40 weeks, if the patient is still not delivered, we will need to discuss options of prolonged pregnancy. And at 41 weeks, if the, if the patient has still not gone into uh delivery, then we need to discuss the possibility of induction, right? Moving on, let's talk about antepartum hemorrhage. Um So, antibody he hemorrhage is usually either you either placenta previa or uh abruption, placental abruption. So, first, we'll talk about placental previa. Um So uh placenta previa is a condition where the placenta lies low. Um It usually covers the internal os, which is here. So this is where the normal placenta lies. But then in placenta previa, it would lie in a lower region, um placenta accreta. So these are just some uh different lines of the placenta. So there's something called placenta accreta uh which is here. So it's, it's where the uh where the placenta basically moves further into the myometrium without actually going into the deci placenta increta is where it uh where the placenta, placenta will lie, penetrate deeply into the myometrium and it goes all the way to the cirrhosa which is here. Um And placenta for reta is spend the uh placenta ba where will I basically um penetrates through the entire wall and may also invade other surrounding structures. Strong slide, right? So placenta previous, so placenta Previa um has a grade uh right. So this is how the normal placenta is. This is a low lying placenta. And if it's completely low and it blocks the internal loss, it becomes placenta previa. Uh So grade one is placenta reaches the lower segment but not the internal loss. Uh placenta, grade two is placenta reaches internal loss, but but doesn't cover it completely. So it would be like that placenta covers the internal loss before dilatation, but not when dilated is grade three and four is placenta completely covers it like this. It's completely covering the internal loss. So if the patient has a low lying placenta at a 20 week scan, then we rescan at 32 weeks. So if the placenta is still low lying at 32 weeks, um and it's either grade one or grade two, then we just scan every two weeks. Um Ultrasound is done at 36 to 37 weeks to see what the method of delivery would be. So in placenta Previa, the most commonly we do ac section um elective C section. So uh that's what we, that's the usual management. But if the uh level of placenta previa is grade one, then we can try a vaginal delivery. So if the patient has presented with bleeding, then we need to immediately admit um obviously ABCD to stabilize the patient. Um And if you're not able to stabilize the patient, then we need to do an emergency c section. Uh If the patient is about 37 weeks, again, you can do ac section. Uh placenta abruption is um yeah. So, placenta abruption is when the placenta gets separated from the uterine wall. Um This also leads to maternal hemorrhage, um intrapartum hemorrhage. Um So there are a few associated risk factors. We don't know the exact cause as to why the placenta completely detaches from the uterine wall. Uh The few factors that are associated with this is hypertension, um proteinuric hypertension, that's preeclampsia, cocaine use multiparity, maternal trauma, increasing maternal age. Um So, in this situation, as you can see in this picture, it is detached and this blood pooled around this region. But then because of the attachment at the sides, it wouldn't be significant blood loss. So the shock features like hypertension, tachycardia would be there, but it would be much more unproportional like the shock features would be significant, but there wouldn't be too much of a bleed. Uh The there's pain, the pain is constant. Uh If you palpate, you would see a tense uh tender uterus. Um the presentation would be normal. Uh There's also usually fetal distress as well. Um Yeah. So in, in placental abruption, um you need to immediately deliver the patient. That's the treatment in most cases, unless it's a very mild case of placental lob rupture. In which case you can admit and observe. Um, moving on to the next topic we'll discuss is shoulder dystonia. So, if you remember in diabetes, we had said that, uh, because, um, we had said that diabetes mellitis is a cause of shoulder dystonia because, um, of enlargement of the baby. Um, so shoulder dystonia is when the anterior fetal shoulder of the fetus would impact on the maternal pubic symphysis and it causes uh difficult delivery. Um So, risk factors are like I said, fetal macrosomia diabetes, mellitis, um high maternal BMI uh prolonged labor. All these are are risk factors for shoulder dystonia. Um So, because this is a difficult delivery immediately, you would need to call for senior help. And the initial management for the initial first line management is the mcroberts maneuver. So this is the Macrobids maneuver where the maternal hips are flexed and abducted. You bring the mother's tight towards the abdomen, you rotate and deliver the anterior shoulder. Um So, potential complications of shoulder dystonia are postpartum hemorrhage, peralte because of the difficult delivery. Um in fetus, it can cause brachial plexus injury, um or neonatal death, right. Um So, prerupture. Uh So let's talk about the rupture of membranes, pre rupture of membranes. Uh So the complications of prom are uh fetal can be prematurity infection, pulmonary hyperplasia. In maternal, it can cause chorioamni again an infection. Um So, something to remember if there's a, a premature rupture of membranes is that uh speculum examination should uh can be done, but you should always avoid digital examination because it increases the chance of infection. Um So, if there's no pooling of fluid, you can send out a placental alpha microlobin one protein or an uh insulin like growth factor binding protein. One. Um an ultrasound can also be done which would show um oligo hydro because of the rupture. Um So how do you manage this? Um The first thing that you need to do is uh give oral Erythromycin uh for 10 days. Um Antenatal corticosteroids should also be administered to prevent respiratory distress syndrome and we aim for delivery at 34 weeks um coming to the pregnancies. Bye. Right. Um So, if a mother is rhesus negative and the child is rhesus positive, this is something that would um immediately uh cause um which would require uh rhesus and uh which would require an TD to be given to the mother um to prevent further uh complications and further uh pregnancies. Um So, what we do is like we discussed earlier, we test for um antibodies um at booking. Um And if the mother is non sensitized, said that is the mother is um rhesus negative, uh then we give an TD to Rh negative mothers at 28 and 34 weeks. So this can be given as a single dose at 28 or we can give it as two doses as 28 and 34 weeks. Um, so an TD is basically, can only, can be given if the mother is non sensitized. So if sensitizes it's, it's prophylaxis. So if the uh child's Rh positive blood has already been in contact with the mother's blood, then the mother is sensitized and once that has happened, it's irreversible. Um So other situations in which anti d immunoglobulin is given is uh anti immunoglobin is given within 72 hours. Um Right. Um I'm just gonna take a two minute break. I'm really sorry. Anyway. Uh Right. So anti immunoglobulin should be slide. So, anti immunoglobulin should be immediately given within 72 hours if there's a delivery of a or positive infant, if there's any termination of pregnancy, if there's a miscarriage, um if gestation is more than 12 weeks um in any ectopic pregnancy, in cases of external cephalic worse, antepartum hemorrhage, if you've done any amniocentesis, chorion sampling or blood fetal blood sampling or if there's any abdominal trauma. So, basically, if there's any chance of the Rh positive blood of the fetus, um being mixed with the mother and uh in being mixed with the Rh negative blood of the mother, then we need to give anti D immunoglobulin within 70 to us. Um Right. Um Right. So the problem with this is so if the baby is Rh positive and the mother is Rh negative in the first pregnancy, it does not usually cause many complications. Um but in subsequent pregnancies, it's uh very and subsequent pregnancies because the mother has um already uh been sensitized because of the first pregnancy. Um in for in future pregnancies, it can really cause um fetal uh death and fetal risk, increase the fetal risk. So that's why um Rh negative and desensitization is very important and to prevent the risk to the child in further pregnancies. Right. Um Right. So this is how we do it. So in the first trimester, that's in the booking test, we check for the rish antibodies and the we basically test for the Rh uh status of the mother. So if the mother is Rh negative and there's no anti D antibodies and the child is Rh positive or it's unknown, then at 28 weeks, you would give the first dose of the immunoglobulin, the anti D uh which is um either it can be given at 300 mg uh at 28 weeks. So 120 MGI uh IM or IV uh 300 mcg uh uh or 120. So if 120 is given at 34 weeks, you would need to give an additional dose. So if 300 is the dose that's given, then it does not require an additional dose um of uh anti an anti prophy axis. Um So, postpartum, what we do is we uh we take the newborn co blood for screening um So, if the infant is Rh negative, then we don't need to do anything if the infant is Rh positive again, uh within 72 hours of delivery, um, you would need to give, um, the anti D prophylaxis. Um, we also need to assess for, um, right. Um Not 100% sure what that is. I'm sorry about that. It's not my presentation. Right. Let's just go to the next topic. Um, so the next topic is postpartum hemorrhage, right? Uh postpartum hemorrhage um is one of the most common uh or uh is postpartum hemorrhage is the most common form of major or hemorrhage. Um So this is defined by loss of 500 mL or more blood from the genital tract within 24 hours of the birth of the baby. PPH can either be minor or major. So minor. PPH is, if it's 500 to 1000 mL, major is more than 1000 mL major can be further subdivided into moderate and severe. So moderate would be 1000 to 2000 severe would be more than 2000. Uh Secondary PPH is if uh so primary PPH is within 24 hours of the birth. Uh secondary PPH is between 24 hours to 12 weeks postnatally. Um So, uh how do you manage? PPH, right. How do you manage? PPH. So uh prophylactic rons should be routinely offered in the management of the stage, third stage of labor. Um In all women. So that's one of the ways to prevent BBS from happening uh for women without risk factors of PPH delivering vaginally. Oxytocin is the uh agent of choice. So, Oxytocin is given um in the third stage of labor for prophylaxis uh for women delivering by C section. Uh again, oxytocin is given, but um Oxytocin 10 IU is given by IM injection in uh vaginal delivery for C section five IU by slow IV injection is given for C section. Um Right. So, ergometrin oxytocin um may be used in the absence of hypertension in women. So, if there is no hypertension, this can also be used to reduce the risk of minor PPH. Right. Um So another thing that can be done is intravenous. Tranexamic acid can be given in addition to Oxytocin to reduce the blood loss in patients with increased risk of increased risk of PPS and C section. Right. Um So, active management has showed a reduction of average risk of maternal primary hemorrhage at the time of birth. Um Right. Let's just go to the next slide. I think it's a little bit better to explain how BPM is managed. Um So if the patient has a major retic hemorrhage, that's a blood loss of greater than 1000 mL, then immediately we should obviously call for help, get the uh senior obstetricians or the an and the anesthetist and alert hematologist because possibly you would require a blood transfusion and alert the consultant as well. So again, the first thing is resuscitation as with all patients, you go via ABC, make sure that um oxygen is fitted in fluid balance is corrected. Um If there's arrange for bloods in case blood transfusion is required and make sure to keep the patient warm. Um So we monitor the patient um because it's a serious risk for uh going into shock. So we monitor the patients via um usually ABCD protocol. Take the bloods, um take all the bloods, cross match the bloods for transfusion, get an ECG done. Uh put in an oxy meter, uh catheterize the patient if required um and put in the IV to or uh two wide IV bore canal. So in medical management of the patient that has a great major, which has a major uh PPM, what we first do is we do drop the uterine fundus. Um The second thing is we need to make sure the bladder is empty. So we catheterize um Oxytocin can be given, this can be repeated um slow IV. Oxytocin is given. The other medical management is um ergometrin Oxytocin infusion, carboprost or miSOPROStol tranexamic acid can also be considered. Um if the medical management does not work, we will need to take the patient to theaters um and for examination under anesthesia. So in the theaters, what we can do the, the surgical management of PM is that in T not can be inserted um uh or internal iliac ligation or hysterectomy is also um an option. You try not embolization can also be done, right? So this is the last topic for the day. So we're talking about perineal test. Um So perineal tear is usually seen in vaginal delivery of uh vaginal delivery of fetuses. So, it's most commonly seen in a primary gravida. Uh There are four degrees to the perineal test. It can be a first degree tear, a second degree tear, third or fourth decade. Um So first test basically involves the skin. Uh for first test, you don't really need to do anything. You don't uh need to suture it or do an epi you can just uh it'll just heal on its own because it's just the skin. Second degree tear is involving the perineal muscles. So in this and ectomy needs to be uh in second degree test, you would need to uh suture the uh you would need to suture the perineal muscles. This can be done. It's not necessary that you need to take the patient to theater. Um On the other hand, for third degree test and fourth degree test, theater management is required. Um So if any perineal tears happen, omy is an option. Uh So third degree tear is basically when there's anal sphincter involvement, uh partially and fourth degree tear is when there's a complete tear of the anal sphincter, right? That's the end. Let me just stop check. Right. I'm so sorry guys. This is very last minute. So I haven't had like too much time to prepare. I'm sorry for the, um, I've, I've done the best I could, uh, with the limited time, like we were only told yesterday that, um, the person was unfortunately sick. So we've just had a last-minute session. Um, hope the rest of the day goes. Well, um, I'm just going to, we're just gonna go on a break now. It's still 215. So anyone has any questions, please do ask and I'll try to answer it as best as I can. So we'll, we'll try and get someone for OBGYN to cover it in a little more detail. Um, I don't know if it will be possible or the person that was supposed to pre present, we try and get them to cover another session. Right. We're just gonna go on a break now.