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All right evening everybody. Um, can I just get somebody to pop into the chat if they, if they can hear me or not? Ok. Or give me some indication with her? Hi, everybody, I can see we've got some more people filtering in. Now. Um, can somebody just give me a thumbs up in the chat or some sort of indication if you are able to hear me or not? Thank you. I see somebody's giving me a thumbs up to that message. So I assume that means we're good to go. Um, if anybody can't hear me, um, just let me know, uh, we'll give her another couple of minutes just for people to start filtering in and then we'll kick off if that's all right. Ok. I can see we still got some people, um, trickling in here. Um, boy, people should be joining in the next couple of minutes. So the next issue is, can everybody actually see my slides up on the screen if somebody is able to give a thumbs up in the chat, if you can, if you can see them? Ok. Oh, great. Thank you very much. So, slides are working audio. Is working. We're off to a good start. Ok, perfect. I'll give it another two minutes and then we'll start the presentation. Mm. Ok. Ok. Let's see. We've got another couple of people trickling in there. Um, ok, I think we'll make a start at this stage. Um, and if anybody else, uh, trickles in from now, uh, then they're still very welcome. Ok, everybody go. Good evening. Thank you all very much for coming. Um I hope the weather is better where you all are than it is here in Belfast. We are currently getting covered in snow. So my name is Hannah K. I am currently an F one doctor working in the mater hospital in Belfast. I have a particular interest in obs and G, it's what I'm hoping to specialize in. Um And I'm here tonight to give you a rundown of antenatal care in preparation for what I assume will be most of your final year medical exams. We might have some third or fourth years here as well if they're particularly keen. If so, you're very welcome, but it is mostly finals focused presentation. So let's make sure my s Yeah. Uh So if, if has that slide moved on. Ok, for everybody. Um I'm seeing slide on learning objectives if that's what you're all saying. Yeah, good. OK. So slides are moving. OK. So just a brief overview of what I'm aiming to cover tonight. So I'm gonna give you the run a rundown of what is considered routine antenatal care here in the UK. So what we offer to every single single pregnant person, um who presents to maternity services. I will talk about the management of some chronic conditions in pregnancy that's gonna include diabetes and epilepsy as well as a couple of other um, less common ones. Uh I'm gonna talk about a bit about gestational diabetes, gestational hypertension, preeclampsia and the management of those. I'm gonna talk about how to manage a, a baby with breech presentation in the antenatal period and the management of rhesus disease. Obviously, there are a few topics uh relating to antenatal care that we can't cover in this presentation unfortunately, due to a limited time. But um I hope you do find the, the selection useful for your finals. Um Both written and OSC. So women or anyone who gets pregnant in the UK can um can either self refer to midwifery services or can be referred by their GP in the spelling confirmation of a positive pregnancy test. Their initial contact with maternity services will usually be at the booking appointment. And ideally, we want this to occur around 10 weeks gestation prior to this. Um Any problems relating to the pregnancy would be referred to the early pregnancy problems clinic. Um That would be things like um bleeding early in pregnancy, um suspected miscarriage ectopic pregnancies, things like that. They and they will all be covered in, in a, in a separate talk later in this series. Um but for most women who have an a, a normal pregnancy with no issues that this will be their first contact with maternity services. The booking appointment is a, is quite a long, quite extensive appointment. Um If you haven't had the chance to sit in on one of the, of these appointments over the course of your, your studies, uh it's really, it's really a useful thing to see. It gives you a really good overview of everything that we look for. Um in order to guide what we need, what what we need to do to manage this pregnancy level of care level of monitoring uh to, to allow us to assess her risk factors for various things. So we can put in in place prophylaxis. So what will happen at this, at this booking appointment? Um It usually takes at least an hour if not more. So the pregnant person will be seen by either a midwife or consultant obstetrician or both. Um at this appointment, then we will review the person's medical surgical and obstetric history. So we're looking for any, any medical conditions that might significantly impact the pregnancy that might lead us to um to monitor the person more closely, to monitor the baby more closely, um any medications that we might have to alter change. Um We're looking at surgical history to determine, you know, um the level of risk that might occur in, in terms of, if we need to consider a cesarean delivery and then we're looking at obstetric history. Has, has this person been pregnant before? What was the outcome of that? Were there any complications that we need to be worried about this time around? Is there anything else there that puts them at higher risk for complications in this, in this pregnancy? Uh And all of this information, we use that to guide to, to, to um to guide us in what and what risk category this person falls into. Um So can they safely be um allowed to go to midwifery led care where they will probably never see an actual doctor for the rest of their pregnancy if everything goes well or does this need to, does this person need to come under shared care with an ob with an obstetric consultant? Um that would be for slightly higher risk pregnancies where um we're, we're worried that things might not go 100% to plan. We also look at the social history. Um social history is very important in pregnancy because there are a lot of things there that can influence um the level of risk for the woman, the level of risk for the baby, uh and their engagement in services. And obviously, there are things that we can do to optimize those. So obviously, we want to know if the woman is a current or previous smoker. Um not 1st, 1st and foremost, so that we can encourage them to stop if they haven't so that we can offer support in doing that. And also so that we know if the woman continues to smoke during pregnancy, that would put them at higher risk of things like preeclampsia, placental dysfunction. And so we would want to monitor that pregnancy a little bit more closely and they would probably come under shared care. Um We want to know what alcohol use. Does a woman have um significant struggles with alcohol with, with alcohol or substance use that we can put support in place for throughout the pregnancy. Um And again, it might lead us to monitor the pregnancy a little bit more closely monitor the fetal wellbeing. Um We obviously want to check in in regards to mental health. Um Does she have any mental health history that would obviously put her at higher risk of struggling ment struggling with her mental health? Um Both before during pregnancy and after delivery. Uh If that's the case, then again, we can put supports in place, we can put safeguards in place. Um Additionally, if she's on any medication for her mental health such as an SSRI um or um for women with bipolar disorder, things like lithium, those obviously have to be looked at during pregnancy. Uh And we also want to check in with all with every, every pregnant person if everything is nice and safe in the home, that there are no issues regarding things like domestic abuse, domestic violence um that we need to be concerned about in terms of uh examination, then we want to look at the height and the weight to enable us to calculate a BMI. So a raised BMI would put the woman at higher risk of again, things like preeclampsia, gestational diabetes, um and VT venous thromboembolism. So we might need to consider prophylaxis for things like that if the woman has a particularly raised BMI, especially if there are other risk factors. Um we also look at the BP. So, um even though as I'll talk about um gestational hypertension and preeclampsia can't be diagnosed before 20 weeks. Gestation. We still look at the BP at this booking appointment even though the woman's only at 10 weeks because if that is raised. Um again, it's a risk factor for going on to develop preeclampsia. And we might need to consider starting the woman o on uh antihypertensive medication if she's not already on it to reduce that risk as well as aspirin prophylaxis. Uh we'll also do a urinalysis um to get a baseline. Um we're looking particularly for any protein in the urine and for anything that might indicate indicate infection. So, pregnancy is one of the only times in which we will actually set to actively treat an asymptomatic uh urine dip if it's positive for like bacteria, um leucocytes nitrates. Um pregnancy is one of the only situations in which we would go ahead and treat that even if the woman is not symptomatic at all. Um because there's an increased risk of that infection. If there is one present, spreading upwards and causing a pyelonephritis, which can cause um potential complications for the pregnancy down the line. Um At this point, the woman will then also be risk assessed for V pe venous thromboembolism for gestational diabetes or GBM and for preeclampsia and if necessary, um prophylaxis put in place, she'll ha she'll have bloods taken, she'll have a full blood count taken at that booking appointment to check for anemia. Um and that will also be repeated at the 28 week appointment. Um And there are, there are hemoglobin targets based on gestation. Um If the woman gets below those targets, we might need to uh think about starting some iron supplementation. So in the, in the first trimester, the, the target is 100 and 10 uh in the third trimester that goes down to 100 and five and after delivery under 100. That's the stage at which we would start to consider iron supplementation. Um The woman will then also be screened for some communicable diseases such as HIV hepatitis B and syphilis, as well as for hemoglobinopathy, hemoglobinopathies, apologies, um such as thalassemia and sickle cell disease because obviously, again, those are things that will, that will um influence uh the risk category, the timing and the mode of delivery and um that we might need to consider treatment for during the pregnancy. And then as I said, we take all this information and um it allows us to determine the risk category of the woman, whether she can go to midwifery led care or if it has to be shared care with consultant. So after this booking appointment, then um there are further appointments at 28 34 36 38 and 41 weeks. And as you can see there, those appointments obviously increase in frequency, the closer that we get towards term um for nulli Paris women. So that's women who have never had a baby before. This is their first pregnancy. Uh They will also have appointment, they, they will start their appointments earlier. So at 25 weeks and they will also have them more frequently. Um So they'll have additional appointments at 2531 and 40 weeks at every appointment. Um Whether that be with the midwife or with the obstetrician, these are the things that will be monitored. So we'll look at the BP again to um screen for any signs of developing preeclampsia. Um We'll look at urinalysis again. We're looking for both proteinuria that might also indicate um preeclampsia. Um And we're also looking for signs of infection that we might need to treat. Um We will measure the physio fungal height as a as a, as a minimum, uh that usually starts at about 25 weeks. Um And we'll plot that on a customized growth chart and that just allows us to keep an eye on how the baby's growing to make sure that this isn't a baby that is particularly small or particularly large for their gestational age. Both of those can be a sign of, of potential complications. Uh, we'll again check in on the woman's general health, how she's coping with the pregnancy if there's anything that has changed with her health, any new medications that we need to be aware of, and we'll also check in on how on, on how often and how frequent fetal movements are. They will usually start at about 18 to 22 weeks. Um, most women will start to notice baby moving and obviously, we wanna be alert for any change, any decrease in, in the fetal movement. We will also discuss, uh again, the mental health of the woman check in is she coping well with the pregnancy? Um, we'll, we'll again check in regarding safety in the home in terms of domestic violence. Um, we'll also gra increasingly as we get towards term, we'll also start to talk about birth planning. Um, obviously elective cesarean sections are something that are permitted in the UK. So, um as term approaches, it's always a good idea to check in with the woman regarding what would her ideal birth be. Um Does she want, does she want to be allowed to go into labor naturally? Would she prefer an elective induction or an elective cesarean section. And again, that will all be guided by, by um her wellbeing and the wellbeing of the baby. So uh a note on folic acid then during pregnancy, so folic acid is obviously recommended for all women planning pregnancy. And I say planning pregnancy because we want to start folic acid prior to conception. Ok. Um By the time most women realize that they are pregnant, um the most of the benefit the time frame in which folic acid is going to benefit the developing fetus has already passed. So, w any woman who's actively planning a pregnancy should be encouraged to supplement with folic acid. And we want to continue that folic acid until the pregnancy has reached 12 weeks of gestation. For most women, not folic acid will be at a dose of 400 mcg per day. However, there are some women who are at higher risk of um neural tube defects, um which is the aim of taking folic acid. We want to decrease the rate of neural tube defects. Um Women who will be in this high risk category will be women with um significant obesity. Uh women who are diabetic women with epilepsy, particularly those who are on um anti-seizure medications, um where there is a family history of neural tube defects in either partners. That would be things like spina bifida, spina bifida, um and cepal hydrocephalus. Um Any history of any of those things would put the pregnancy at a higher risk of a neural tube defect. Um and if there's any heg hemoglobinopathy or hemoglobinopathy traits, so, such as sickle cell disease or thalassemia, all of those um would put the pregnancy at higher risk of developing a neural tube defect. And so we want an increased dose of folic acid in those scenarios. Um So that would be at a dose of five mgs every day. So important scans then during the pregnancy. So scans are probably the things during pregnancy that um the pregnant, the expectant couple will be most, most anxious about and most excited for. Um it's really their only opportunity to see their developing baby um to bond with them prior to delivery. They also allow, they're also very important for us as medical professionals. They are, they give us a really good idea of how the how the pregnancy is progressing allow us to monitor for any potential complications. Um So the two routine scans that every pregnancy will receive are first of all the dating scan. So the dating scan will take place usually at the booking appointment. If the booking appointment isn't, isn't too early in the pregnancy, do do that. Um It should take place between 11 and 14 weeks of gestation and this scan has a couple of function, first functions. First of all, it allows us to determine the gestational age and estimated due date. And we do that using crown rump length at this gestation. Um later on. Um we can use things like head circumference, abdominal circumference and femur length. But at this early stage, the fetus is not developed enough to allow us to do those things. So we use crown rump length to um to determine the age and also to get an estimated fetal weight. The dating scan also allows us to confirm whether this is a singleton pregnancy or a multiple pregnancies with twins, triplets or higher order than that. Um And finally, it allows us to measure the nuchal translucency and that's as part of antenatal screening for Down Syndrome, which I'm going to talk about shortly. Then we have at 18 to 21 weeks. What is commonly referred to as at least here in Northern Ireland, the big scan or the fetal anomaly scan. So as I said, this should take place at around 20 weeks, gestation 18 to 21. And it is a comprehensive assessment of the, the fetal anatomy. So, we're looking for things like neural tube defects, spina bifida. Um and cephal hydrocephalus. We're looking for things like congenital, diaphragmatic hernias, gastroschisis, exomphalos, congenital heart diseases, um skeletal dysplasias and cleft lips among a multitude of other conditions. It also allows us to check for placental positioning. So if the placenta is particularly low lying, um then that's obviously something that will need to be monitored going through the pregnancy to make sure that it rises to the appropriate position and if not, we may, there are some precautions that we may need to take during delivery um up to and including the recommendation for a Cesarean section. But again, that will all be covered in a separate lecture later in this series. So I said I would talk a little bit about um antenatal screening for Trisomy 21 also known as Down Syndrome. So this should be offered to every pregnant couple in the UK. Um They have the absolute right to decline that screening should they wish? But if it, if it is something they want, then it is something that we can go ahead and offer. Um There's a couple of different options for um for screening for trisomy. 21. And which one we go for all depends on the gestation of the pregnancy. So, between 11 and 14 weeks, uh we can perform what's called a combined test as first line. Um And the combined test is um a combination of maternal blood tests and an ultrasound scan. Usually um this ultrasound scan will be the dating scan that we use. Uh And we're looking for increased nuchal translucency on that ultrasound scan. Um higher nu nu translucency. So, the nuchal translucency, you're measuring the fat pad at the back of the fetus's neck. Um and the more translucent it is that gives an increased risk of the of the fetus having Down Syndrome. And then things that we're looking for in fetal blood in I'm sorry, in the maternal blood tests would be increased levels of beta HCG or the pregnancy hormone and reduced levels of pregnancy associated plasma protein or Papa. Um And uh combining all these three factors together, we can estimate the risk of the fetus having Down syndrome if we get a little bit later on in the pregnancy and the woman um maybe initially decided that she didn't want screening, but now I would like would like it or if she's booking late. Um Then between 14 and 20 weeks, we can offer what is called the triple test. Um The triple test only involves maternal blood tests. There is no scanning involved. Um And we measure three things. We measure again, the beta HCG, we measure alpha fetoprotein which um some of you might know is a tumor marker for things like hepatocellular carcinoma or testicular cancer. Uh But in pregnancy, we use it as part of the triple test um and estriol levels. Um and an increase in HCG combined with low A FP and low estriol, all indicate an increased risk of that fetus having uh having Down Syndrome. So what do we do in these scenarios? So these screen tests uh allow us to provide the woman with a risk category. So we either categorize them as higher risk of Down Syndrome or lower risk of Down Syndrome if the woman is put in the high, if the, if the woman's test results, um indicate that she's in that higher risk category. So that there is a greater than one in f one in 150 chance of her fetus having Down Syndrome based on those results. Then we offer further testing. And again, what we offer is based on gestation. So uh uh any earlier in pregnancy. So before 15 weeks gestation, we offer C VS or chro chorionic villus sampling. Um And basically what this involves is a biopsy of the placental tissue that's done under ultrasound. Um Any any, any later than 15 weeks, so greater than 15 weeks in pregnancy. Um then we would, we would not offer that. We would offer instead amniocentesis. Uh and that involves again, ultrasound, guided aspiration of the amniotic fluid. Now, these tests are, are um they're very good tests. They'll, they'll allow us to send samples of these tissues for karyotyping. And they will give us a definitive answer as to whether or not this this fetus has down syndrome or not. However, they, they do involve risks. Um They, there is increased risk of infection of um of rupture of the amniotic sac uh of preterm labor. So that has to be the woman's decision as to whether or not she wants these tests. And again, she has every right to decline them. Um There is the other option for follow up of these tests is noninvasive testing, which just involves prenatal, just involves maternal blood tests. But unfortunately, that's not currently offered in the UK under the NHS. Women should still be informed about it though because it is an option. Um, if they want to go privately for that. Um, obviously it's much less, much, much lower risk than the other two procedures. Unfortunately, the reason the NHS doesn't offer it is as with most things, it's purely an, an issue of funding. It's quite, they're quite expensive tests. So that's why, um, it has to be done privately. If that's the, if that's the route the woman chooses to go down. So, vaccinations, then are another part. Uh another important part of antenatal care. And these are going to protect both the woman and her and her developing fetus as well and the n which will become the newborn baby when it's born. So it offers um protection in all of those situations. So we divide these into two categories. So there's the vaccines that we want the woman to have had preconceptually. Um One of the most important ones is her mmr vaccine. Um So if we have a woman who is planning a pregnancy and she has never had an mmr and she is um negative for rubella antigens. So she's never been uh or sorry antibodies. She is, she, she's never um she's never been infected with rubella before. Um Then that would put, put her baby at increased risk of congenital rubella syndrome. If she should con con uh if she should come in contact with that infection while she's pregnant. So, ideally, um we would want to offer her the mmr vaccine prior to conception. Similarly, with the uh the varicella vaccine. So if we have a woman who is planning a pregnancy, she has never had, there's no history of chicken pox infection and she has certain risk factors. So those would be she has occupational exposure to um to chicken pox, which would be all of us as healthcare professionals or she's the household contact of an immunocompromised person. Uh Then we would offer a, a vaccine prior to conception, but only if she has those two risk factors that I've mentioned. Um it's not routinely offered to every woman planning a pregnancy and it also shouldn't be offered if there is a confirmed history of chicken pox infection. Um The Hepatitis B vaccine should also be offered to women prior to conception if they fall into certain risk groups. So that would be women who are IV drug users um uh who have chronic liver or renal disease or who um have frequent changes in sexual partners or who are in regular contact with someone with an active Hepatitis B infection. Um The important thing to note though is that these are all live vaccines. So we don't actually offer them um during pregnancy, they can only be given preconceptually and the woman should be advised to actually avoid becoming pregnant for at least a month after each of these vaccines. So, although they are an important part of preconception care, um once that once conception has occurred and the woman is pregnant, it's too late for any of these to be given. Unfortunately, then there's a set of vaccines that we give routinely during pregnancy. So the first would be whooping cough, um pertussis and that's given routinely at 16 weeks gestation then as of September this year. So this is quite a new development. Um We now offer all women an R SV vaccine at 28 weeks pregnant. Uh and that will protect both her and her newborn baby from um R SV infection. Any of you who have been on your pediatric placement, know what a horrible infection that can be for young babies. Uh And then all pregnant women should also be offered the seasonal flu vaccine if their pregnancy occurs um at the time of year when those are offered. Uh and as I said, all live vaccinations should be avoided during pregnancy. So, next bit, I'm gonna talk a little bit about is diabetes during pregnancy. So about one in 20 pregnancies are affected by diabetes. So it's quite a common thing that um that maternity services have to deal with. The majority of these are gonna be gestational diabetes. Um and that's as a result of increased ins insulins or sorry, decreased insulin sensitivity during pregnancy. And that's mostly related to hormonal fluctuations. Women who do who are ee either have preexisting diabetes or who develop gestational diabetes. They're at an increased risk during, um both during pregnancy and during labor and delivery, increased risk of things like preeclampsia, um and stillbirth and then during labor, um, there's increased risk of shoulder dystocia largely due to macro macrosomia. And then after birth, there is the risk of neonatal hypoglycemia, which has seen a lot of babies end up in the neonatal icu. These risks can be reduced but they cannot be completely eliminated. And that's why it's so important that these women are provided with good quality education counseling on the importance of good glycemic control during pregnancy. So, ideally a woman who has preexisting diabetes, her pregnancy will be preplanned and that would, that will enable us to opt to optimize everything so that she can have the most successful pregnancy possible. So we wanna um we want the glycemic control to be as good as possible and we want to um optimize any complications that she might have from those diabetes. So the first thing we want to do is we want to, we want to check the HBA1C and we're aiming for a HBA1C of less than 48 millimoles per liter and that would indicate good glycemic control and reducing the risk of, of complications during pregnancy. We want to encourage the woman to lose weight if her BMI is greater than 27. Um As I've mentioned before, she'll need an increased dose of folic acid from the moment she starts planning that pregnancy up until 12 weeks of gestation and then she'll also need an up to date renal and retinal assessment um, to assess for any complications of diabetes. Um, part of that preconception counseling should also involve a medication review. So a pregnant woman with diabetes, her diabetes must be managed exclusively on Metformin and insulin. Ok. All other, um, oral hypoglycemic agents are, are not, are not safe to use during pregnancy. And then you also wanna look at any medications that she might be on for the, for the complications of um, of diabetes. So things like ace inhibitors and Arbs that they might be on for hypertension, um statins that they might be on for, um, for high cholesterol, all of those have to stop during pregnancy and immediately, then all of these women automatically fall into the high risk pregnancy category. And so they cannot go to just to midwifery led care. It has to be shared care under, under an obstetric consultant. Um, and contact should be made at least every 1 to 2 weeks. We're aiming to maximize glycemic control and you can see the targets. Um, over on the left hand side here on this little table, we're aiming for a fasting glucose above five point or above 5.3. Um, and a one hour post meal glucose of less than 7.8. And we always want that blood sugar to be greater than four we want to minimize the amount of, of hypos that these women are experiencing, they should be encouraged to monitor their blood glucose at least 2 to 4 times a day. Um So that's prior to every meal and before bed, if they're not already on a continuous glucose monitor, which most diabetics are at this stage, particularly type one diabetics. Um As the technology is evolving and becoming um more accessible, that's becoming much more common. But if they don't already have one, if a woman with type one diabetes becomes pregnant, she should absolutely be offered that or a woman with type two diabetes who has particularly unstable blood gluc blood glucoses. Um They should all be offered continuous glucose monitoring with things like the, the freestyle libre or the Dexcom. Uh It's important to note that during pregnancy, the woman might have a decreased awareness of any hypoglycemic episodes during pregnancy. So, um hence why increased monitoring of the blood glucose is, is important uh anti, then they should have a retinal assessment at their 28 week appointment. Um They should also be offered one booking. If their, if their previous one was greater than three week, three months ago, they'll need um ultrasound monitoring for, for um fetal growth every four weeks. Once they reach 28 weeks, gestation up until 36 weeks and then from 38 weeks on, they're going to need a weekly assessment of fetal monitoring. So that's gonna involve ultrasound scans for an estimated fetal weight to track fetal growth, um, umbilical artery Doppler amniotic fluid indexes. And, um, and uh, CTG that all has to occur weekly once they hit 38 weeks. So a little bit about gestational diabetes then, um, so you can see here, we've got a list of risk factors and potential features that you might see in these women. So the risk factors would include um, gestational diabetes in a previous pregnancy. Uh A woman who is obese with a BMI of greater than 30 a woman who's had a previous macrosomic baby weighing um greater than 4.5 kg. Uh a first degree relative with diabetes or women from uh certain ethnic background. So women who are black, Middle Eastern or South Asian, those the these all are um higher risk populations for gestational diabetes. All of these women um fall into any of these categories, even 11 risk factor should be offered an oral glucose tolerance test uh between 24 and 48 weeks or sorry, 24 and 28 weeks. Um So this test basically involves they come in fasting, they have their blood glucose tested initially. They will um they will then be given a, what I'm told is not a particularly nice tasting drink. Um quite a sugary drink containing 75 g of glucose, they'll drink that and then um two hours later, they will have their blood glucose tested again to see how it responds. Um And to remember the, the um the cutoffs for diagnosis of gestational dia diabetes go back to your step on, you know, 5678. So, uh fast if fasting glucose is greater than 5.6 or if the glucose is greater than 7.82 hours after that drink, then we can make the diagnosis of gestational diabetes. Um Some features that you might see in these women is uh a fetus that is large for gestational age. Um You might see polyhydramnios or an increased um volume of amniotic fluid um or a significant glucosuria. So what we class as a significant glucosuria would be um testing of one plus on the urinalysis on two occasions or one incidence of um a testing of two plus. Uh if it's just a one off of one plus or a trace of glucose, that, that's not clinically significant. Um that can be a normal finding during pregnancy, a transient glucosuria. Um But if it's persistent or if it's more significant, uh that woman should also be offered a glucose tolerance test. Um managing gestational diabetes largely the same as the management of um preexisting diabetes. So, if her initial fasting glucose at that glucose tolerance test is less than seven, she can attempt to control that gestational diabetes just with just uh through dietary measures, we monitor that over the course of two weeks. And if the, the um blood glucoses are still not at the targets that we discussed previously. Um She should be offered Metformin. And again, that should be for a trial period of two weeks. Uh following that, if the, if the blood glucoses are still uncontrolled, um she should be offered insulin, then if the fasting glucose, then on the, on the glucose tolerance test is greater than seven or if there are um features of macrosomia or polyhydramnios. So that indicates a more significant um gestational diabetes and that woman should be started on insulin straight away. Um Obviously, with the addition of dietary measures and then Metformin if needed. If the, if the um blood glucose levels are still raised on the insulin, some considerations then during labor and delivery. So, uh women with diabetes, whether gestational or preexisting, um delivery should be something that's discussed with them a little bit earlier than some women. Um The timing and the mode of the delivery are both things that are going to need to be considered. So, for women with preexisting type one or type two diabetes, we would, we would recommend um slightly earlier delivery between 37 a week, 37 weeks and 38 plus six. And that can be through um induction of labor or elective cesarean section. Women with gestational diabetes, we can let them go a little bit longer, but we don't recommend that they go before 40 plus six weeks. Uh And again, that's because women with uh that women who are diabetic, they're at increased risk of placental dysfunction, fetal growth restriction. And then conversely also at increased risk of having a baby that is macrosomic that is large for gestational age, which it can increase the risk of complications during labor. They should be encouraged to deliver in hospital uh with access to a neonatal unit. Um And that's largely because, as I said, the babies of these women are at increased risk of neonatal hypoglycemia. And so they may well need monitored for that in the neonatal unit. And so that should be something that's easily accessible at the time of delivery while these women are laboring and they're gonna need hourly glucose monitoring. Um And we want to keep that glucose between four and seven to achieve this there, they may well need um IV dextrose or IV insulin to keep this within range, some considerations after delivery. Then, so for baby, as I said, they're at increased risk of neonatal hypoglycemia. So we want to prevent that as much as possible by feeding the baby as soon as the woman is physically able to after birth. Um If that's not going to be for a prolonged period of time, then um formula supplementation should be encouraged until the woman's able to breastfeed. If that's what she desires to do, we should check the blood glucose at least twice following delivery at two hours and at four hours of life. And that baby should be monitored in the hospital for at least the 1st 24 hours of life for the mother. Then um insulin requirements, particularly for women who have preexisting diabetes, they very often rise during pregnancy. As I said, um pregnancy decreases insulin sensitivity. So pregnant women often need an increased dose of in or increased doses of insulin after delivery. Then they are at increased risk of hypoglycemia because that insulin sensitivity rises again. So the, so the doses of use of insulin that have them perfectly controlled during pregnancy might be a little bit too much for them. A after after um delivery. So, consideration should be given to reducing those down um oral hypoglycemic agents. Um same during pregnancy, they should be avoided if that woman is breastfeeding. So again, it should be just Metformin and insulin. Uh women who had gestational diabetes, then during their pregnancy, we know that they are at increased risk of both type two diabetes later in life and recurrence of gestational diabetes um in subsequent pregnancies. So we're going to offer them a fasting glucose test between um 6 to 13 weeks after after after delivery. And they should also have a HBA1C checked annually. And again, they'll be offered an oral glucose tolerance test in any subsequent pregnancy. So what about women with wo women with epilepsy then? So epilepsy, a common condition that affect younger people of childbearing age. So we do see quite a few pregnant people coming in with epilepsy. Again, as with diabetes, preconceptual counseling is, is really important. Um, outcomes tend to be better in planned pregnancies. It allows for medications to be adjusted, um, allows for starting preconceptual folic acid and safety advice to be given to those wo women as well as advice on the potential complications during pregnancy. Um, conversely to that, then the difficulty with that is that some medications used for epilepsy such as carBAMazepine and phenytoin, they interact with the combined hormonal contraceptive pill, um and actually reduce its efficacy as a contraceptive. So, they are at increased risk of accidental or unplanned pregnancies. And uh as I said previously, all women with epilepsy are gonna need an increased dose of folic acid um, prior to conception up until 12 weeks, um to prevent, to reduce the risk of neural tube defects. Ideally, epilepsy should be well managed before the woman becomes pregnant. Uh And again, that should be on a single agent. The safest ones during pregnancy would be lamoTRIgine and levetiracetam. Um All other ones carry an increased risk of, of congenital malformations. The big culprit that I'm sure you have all help had drilled into you many, many times is valproate and that is absolutely contraindicated in any woman of childbearing age. Um, unless there's absolutely no other um suitable agent. But yeah, as it, but um, ideally that what the um a woman planning a pregnancy should be controlled on just either lamoTRIgine or levetiracetam hormonal fluctuations, lack of sleep. Um Stress are all a normal part of pregnancy. Unfortunately, uh and these things do put the woman at increased risk of seizures during the pregnancy. Um So the seizure threshold can reduce and to control that she may need an increased dose of her, of her epilepsy medication during pregnancy, postnatally. Then um the woman should be giving safety advice for both herself and for the baby. So that would evolve things like um not bathing the baby when she's in the home on her own, in case of in case of a seizure or by that happening, um not carrying the baby at the same time, she's carrying things like a kettle where there's hot liquid involved. All of those would put the risk of would increase the risk of injury to both herself and the baby should the seizure happen. And there have been some really, really tragic cases in the in, in the news of um women with epilepsy killing or seriously injuring their baby um through no fault of their own. It, it's something that's really sad to see. So appropriate safety counseling on that is is needed. And then after delivery, she may need a reduced dose of her, of her seizure medication. Um If it was increased during pregnancy, a couple of other conditions to note, then, oh, sorry, we're going back. Um hypothyroidism then. So any woman with hypothyroidism um should have an increased dose of levothyroxine it's usually increased by 25 to 50 mcg and we titrate that based on TSH levels, which should be monitored regular, regularly during pregnancy. Um, and the reason for this is that undertreated or untreated hypothyroidism, uh, puts the woman and her fetus in an increased risk of miscarriage of intrauterine growth restriction and of preeclampsia. So, it's important that those TSH levels are, are kept, are kept steady. Um, women with rheumatoid arthritis, then their symptoms often actually improve during pregnancy. Uh and they, a lot of them can safely come uncomfortably, come off their medication. Uh Unfortunately, that's not the case for all women. Uh They do still require some, some management for that during pregnancy. If that is the case, then the one that is absolutely contraindicated as uh I'm sure again, you will have drill in you is methotrexate. So methotrexate is a folic acid blocker. Um So that would put the, the, the pregnancy and um a significantly increased risk of neural tube defects if that were to continue other um dmards such as hydroxychloroquine sulfaSALAzine um are all considered safe during pregnancy as are steroids. So, hypertension then during pregnancy um can be split into essentially three different categories. So there's chronic hypertension. So that's a, that was, that's raised BP that exists prior to 20 weeks, gestation. And again, that's why we monitor the BP even going all the way back to the booking appointment. Um Gestational hypertension then is a new raised BP. So greater than 100 and 40 systolic or um at greater than 20 weeks, gestation with no evidence of proteinuria or of end organ damage. Um And I'll come on to that later. What that end organ damage can look like severe hypertension, then can be classified as a systolic BP of over 160 or a diastolic of over 100 and 10. And that's relevant to all three categories here that I'm gonna talk about the final category we preeclampsia. So, preeclampsia is a new high BP at greater than 20 weeks gestation. But this time, there is evidence of significant proteinuria of one plus or more or of maternal and organ damage or of uteral placental dysfunction. So that can look a bit, look, look like things like um uh intrauterine growth restriction. A fetus that's small for gestational age, um placental abruption, all things like that can occur during preeclampsia. So, um all women, as I said at that booking appointment are risk assessed for preeclampsia and we can see some of those risk factor here. Factors here. So, preexisting hypertension, um previous gestational hypertension, certain autoimmune conditions such as lupus diabetes or chronic kidney disease are all considered high risk of preeclampsia. And then um a woman who's slightly older. So at age greater than 40 a woman with BM I of greater than 35 who were there a and a woman where there's greater than 10 years between her, between pregnancies, a multiple pregnancies. So, twins triplets, et cetera. Um a woman in her first pregnancy or a woman with this with a family history of preeclampsia, they're all considered at moderate risk of preeclampsia. So, while we're, when we're taking the history at the booking appointment, we look out for all of these things and if the woman has one high risk factor or two or more moderate risk factors, um she should be offered aspirin prophylaxis um to reduce the risk of preeclampsia that should be taken from 12 weeks, gestation until after delivery. So it continues throughout the whole pregnancy, how to manage women with chronic hypertension, then during pregnancy. So again, as with all um preexisting conditions, we want to go into the pregnancy with that as well controlled as possible. So we're aiming for a systolic BP of less than 100 and 35 and a diastolic pressure of less than 90. Um as I said, she should be offered aspirin prophylaxis from 12 weeks until delivery. And then if that BP needs to be controlled on controlled, controlled using medications, that's something that needs to be reviewed during pregnancy because there are uh there are a lot of antihypertensives that aren't, aren't safe to use. So during pregnancy, the first line would be labetalol for raised BP. If that's not enough, then we can say or or if labetalol is contraindicated with that. So for example, if the woman has a history of significant of, of severe asthma, uh then we would go to Nifedipine. Uh and then methyldopa would be third line. Um Again, medications like ace inhibitors, Arbs, none of those are safe to use during pregnancy. And then um the important thing to note is that all of these women need to come under consultant lead care. Um So they're not safe to go under um midwifery lead and they'll need a regular monitoring of their BP and urinalysis. Um so that BP needs to be monitored, um that BP will need to be monitored at least 48 hourly. So, preeclampsia then is an, as I said, is a new raised BP greater than 20 weeks gestation this time with evidence of end organ damage. So, if a woman is um diagnosed with preeclampsia, we've got a list of signs and symptoms. Um to, to look out for that might indicate that might lead you to that diagnosis. So any pregnant woman complaining of a headache, dizziness, um blurry vision or any sort of visual disturbances or significant edema um should all be assessed for preeclampsia. So, at uh on the same day, so they'll need the BP checked, they'll all need a urinalysis. Um And the important thing to note is that when we say edema, um we're looking particularly at non dependent edema. So, um dependent edema, which is um edema related to, to just, um, gravity, uh that's largely seen in the feet or sometimes in, in the hands. Uh, if a woman's been on her feet all day, that can be, that can be, again a normal part of pregnancy, unfortunately, um, but if it's significant edema or if it's uh in a part of the body where you wouldn't really expect. So, for example, you might see some preeclamptic women with um, particularly puffy faces, um especially around the eyes that should lead you to, to uh lead you to um assess that woman quite thoroughly for preeclampsia. Other signs that you might look out for on examination would be things like papilledema or hyperreflexia. Uh So increased deep tendon reflexes. Uh and that's as a consequence of increased uh nervous system excitability and preeclampsia. So, again, if the diagnosis of preeclampsia is made similarly to chronic hypertension, she's gonna need frequent monitoring of that BP. How often that's done is gonna depend on the severity of the preeclampsia, but at an absolute minimum, it should be every 48 hours. She's also going to need regular assessments of fetal wellbeing. Um So we track the growth of the fetus. We assess the ctg the umbilical artery Doppler and the amniotic level of amniotic fluid or the amniotic fluid index. Uh And again, that happens at least every two weeks. Um if not more often, uh how often will just depend on on how well that fetus is coping in that environment. Woman's gonna need weekly blood tests to assess for end organ damage. So those blood tests should involve kidney function, liver function, um coagulation screen. Uh And we're, we're so we're looking for things like kidney damage, um liver failure, um hemolysis, which we need regular FBC S, um thrombocytopenia. Um All things that would indicate increasing severity of preeclampsia. We're also going to need to monitor the fluid balance of preeclamptic women. Um A lot of these women will need to be put on a fluid restriction, um particularly ones that are um do become quite edematous, quite swollen. Um And it's important to counsel the women that um preeclampsia, it does increase the risk of um of a growth, restricted baby um of stillbirth and of complication complications with the placenta such as placenta, placental abruption and she should be taught um to monitor the um fetal movements. Uh um and also educate her on like the signs and symptoms of a placental abruption. So she can seek um medical attention if needed management of preeclampsia. Then with medications for the BP is exactly the same as we've gone as we've mentioned before. So, um labetalol first line, followed by nifedipine and then methyldopa. So if the woman then presents with severe preeclampsia, so a BP of greater than 100 and 60 systolic or a diastolic of greater than 100 and 10, then we should really consider hospital admission for that. Um During that admission, we can obviously monitor her, her BP, her wellbeing and the wellbeing of her baby much more closely. We can also use IV medications if needed in order to control that BP, if it's particularly difficult to control on oral medications. So things like IV, labetalol or IV hydrALAZINE can all be used if that BP just won't stay down despite optimum medical management. Uh, a severely preeclamptic woman is also going to need magnesium sulfate. Uh And that is prophylaxis for eclampsia. Uh and that magnesium sulfate is given as a loading dose of 4 g followed by an IV infusion if we're considering them preterm delivery for these women, um then steroids should be given to a fetal lung development. Now, I've put this little picture of a seesaw at the side. Um and that's just to represent the balancing act that we're trying, we're trying to deal with here. So our aim is to get um as close to term as possible. So when we deliver this baby is gonna deter is gonna be determined by both the, the wellbeing of, of the mother and of the fetus. Um we have and the balancing act is really between the potential complications of allowing that pregnancy to continue. Um as the severity of preeclampsia increases and the potential complications of an early delivery. So we're trying to really weigh up the risks and benefits when we're considering an early delivery. Um Obviously, as we get closer to term, our threshold for delivering would, would, would decrease uh if there's any signs of either maternal or fetal distress, then uh that would um that would indicate an, an urgent delivery. Uh whether that be through induction of labor or emergency cesarean section. The important thing to note is that if this woman does deliver vaginally, then um ergometrine has to be avoided in the third stage of labor. It's contraindicated in women with hypertension. Um So when you're in the third stage of labor, delivering the placenta, um you wa you want to go with other medications. So just a quick note on, on magnesium sulfate, which I mentioned briefly there. So as I say, it's given in, it's given to women with severe preeclampsia or um or those who go on in to develop eclampsia and it's ACN S depressant. So, in preeclampsia and eclampsia, there is increased C ns excitability, which is why um women with eclampsia will often have seizures. Um So this helps to counteract that. Um it's not perfect though there is a significant risk of toxicity. Uh And so we want to monitor that woman very closely when, when that's being given. And we're looking for things like um reduced, reduced or absent, deep tendon reflexes. Um We want to look out for pulmonary edema. So any signs of um respiratory distress and she also might need cardiac monitoring for any arrhythmias if there are any signs of um of magnesium toxicity. Then um we would be given calcium gluconate as the anti antidote to that. Um And that absolutely has to be readily available. If you have any woman receiving magnesium sulfate on the ward. Um after delivery, then so the delivery of the placenta is essentially the cure for preeclampsia and eclampsia. But um some women can still then have ongoing issues after delivery. So, within the 1st 24 hours after delivery, there's still a significant risk of seizures, especially if the, if the that woman had severe preeclampsia. And for that reason, if she was started on magnesium sulfate before delivery, that should continue for 24 hours after delivery. Um The BP should still be monitored closely after delivery um to ensure that it goes down and if it doesn't, then she's gonna need ongoing treatment for h for high BP, what we use actually changes after delivery. So Enalapril, whereas that would have been contraindicated before delivery is now actually our first line in, in um a woman who's just delivered and is and is hypertensive. It is safe to use if breastfeeding. Um If that's not enough, then uh next line would be again, Nifedipine. And we want to aim for a BP of uh under 100 and 35 systolic medications then can be stopped or reduced as deemed appropriate. If that BP falls is consistently below 100 and 30/80. So, um next part of the talk is about just about reis incompatibility. So, um as I said at the, at the booking appointment, all women should have um uh a, a group and hold done of a group in the group and screen to determine whether to determine their blood type. Uh And when within that, we'll obviously get whether that woman is rhesus positive or rhesus negative. So for all women who, who that test comes back to indicate that thesis negative, they will need routine anti d prophylaxis. Um During that pregnancy, there's two options for that. It can either be given as 1500 units at 28 weeks, gestation for a single dose treatment or it can be given as two doses of 500 units um at 28 and 34 weeks. And the reason that we're doing that is to prevent maternal sensitive sensitization to rhesus antigen. So if the, if her, if her fetus is rhesus positive and some of that blood leaks into the maternal circulation, her immune system will become sensitized to that, that process is irreversible once it's happened. Um So prophylaxis, stopping that from happening in the first place is the most important thing. If that woman does become sensitized to the rhesus antigen, then um if she subsequently has a second rhesus positive baby, that would be that baby would be at risk of what we call hemolytic disease of the newborn. Um which can cause fetal anemia, eye drops, uh and intrauterine death. So it's really something that i it's so it's, it's, you can't, you can't emphasize how important it is to prevent that sensitization from happening in the first place. So routine MDD prophylaxis given then to every woman um either as a one dose course or as two separate doses, additional doses then may be needed depending on the events of the pregnancy. So, if there are any sensitive, potentially sensitizing events during pregnancy, then she'll need additional anti D prophylaxis. So, sensitizing events would be um would be things that would would cause increased um fetal maternal hemorrhage. So, crossing of the fetal blood into the maternal circulation. So, examples of that are going to be um a miscarriage or an ectopic pregnancy, uh an antepartum hemorrhage, any significant abdominal trauma, uh invasive procedures such as amniocentesis or chorionic villus sampling um to um to screen for Down syndrome. Um external cephalic version, if the baby is breech and act the actual process of labor and delivery itself. So after birth, if the baby is found to be um rhesus positive, then an additional dose of anti D will be needed. Um the dose of anti D at that stage again, depends on the gestation. So, if that sensit sensitizing event takes place at less than 20 weeks of gestation, um then it should be given as 250 units if later on in pregnancy at 20 weeks gestation or more, uh it should be given as 500 units, slightly higher dose. Um Again, a greater than um oh, sorry, I see that question. Um A ph, so a ph that would be antepartum hemorrhage. So any um any bleeding prior to delivery? So, if that woman has a sensitizing event, uh a greater than 20 weeks gestation, then um you want to run a Kleihauer test. So, a Kleihauer test uh developed uh and determines the degree of any fetal maternal hemorrhage. So how much of that fetal blood has entered the maternal circulation? And essentially how that works is um you take a sample of the maternal blood. Um and fetal hemoglobin is uh is more resistant to acidic conditions than, than, than normal hemoglobin, the hemoglobin that we have in our blood. So, during a try hard test in the lab, they will apply a sample of acid to that blood sample. Uh and that will essentially destroy any maternal hemoglobin in that sample and leave only any fetal hemoglobin that will remain. Uh And that gives us an idea of how much if any fetal blood crossed into the maternal circulation. If there were, if it was estimated to be greater than four mils of fetal maternal hemorrhage, uh then an additional dose of anti D prophylaxis is required on top of what would have already been been given at the sensitizing event. And anti D prophylaxis should be given um within 72 hours of any, any sensitizing event. So finally, then I'll come on to Breech presentation. So, Breech presentation is, um any presentation that is not cephalic. So not he, it's, it's not head down where the, um, where the presenting part isn't the fetal head. Um There's three different types. So we call, we can have a complete or flexed breach in which one or both of the fetal knees are, are flexed up towards the abdomen. We can have a fling breech or an in also known as an incomplete breech. And that's where the presenting part is, is one or both of the feet. Um And then the final type would be a frank or extended breech and that's where both of the fetus's hips are flexed and both of the knees are extended. Uh This type of breech presentation is particularly significant clinically because these babies are at higher risk of, of um developmental hip dysplasia. So they'll need screen for that after birth. So how do we ma what are the risk factors then for uh for a breach presentation? So they can be divided into maternal fetal and placental. So, on the maternal side, if um if a woman is multi power, so she's had lots of pregnancies previously. Um If she has uh a history of fibroids, if she's had a previous breech pregnancy, or if there's any abnormalities of malaria duct um on the fetal side of things, then uh a preterm baby. Uh, a preterm baby is obviously smaller. There's more room in, there's more room in the uterus for them to turn around. So they are more likely to be in breech presentation. Uh, a macrosomic baby is also, um, slightly more likely to be breach or if it's multiple, if it's a multiple pregnancy, there's a good chance that, uh, at least one of the, one of the babies will be breach, um, placental factors. Then um uh if there's a place at the pre pregnant um present, then that baby is more likely to be a breach. Uh And if there's any abnormality of the volume of uh amniotic fluid, so both polyhydramnios and oligohydramnios. Now, the significance of a breach presentation will very much depend on gestation. So at less than 36 weeks gestation, uh it's not really clinically significant unless we're planning um early delivery. Um As I said before, term, babies are smaller, they have more room to turn, they can get themselves into a whole host of different positions, but they will often turn spontaneously to a cyph presentation um as they get closer to term, if that doesn't happen if we reach 3637 weeks and that baby is still breech. Uh then we can offer the woman an external cephalic version which I'll talk about a little bit more in the women or a little bit more in a moment. Sorry. Um That's offered at 36 weeks for women who are in their first pregnancy, um, 37 weeks in subsequent pregnancy. Um, if that CV, if that external clic version fails, elective cesarean section is usually recommended. Um, and that's because if you're attempting a vaginal breech delivery, there is, there's a significantly increased risk of, um, fetal entrapments where the body delivers, but the head doesn't and subsequent risk of, of that baby as fixating and passing away during delivery. If you're gonna, if, if a vaginal breach delivery is gonna be attempted, that absolutely has to involve um some very, very senior obstetric and midwifery staff who are trained, who are knowledgeable about these things who have experienced it before. It has to involve access to an emergency theater with anesthetists in case something goes wrong and it has to involve access to a specialized pediatric team and a neonatal unit. So what does E CV involve then? So E CV is essentially um an attempt to turn the baby into a cephalic presentation. So, head down um by manipulating the the the pregnant person's abdomen, uh and it's done usually under ultrasound guidance. Again, if you get the chance to see this during your placement, it it's really worthwhile going to see. I got to see a couple during my obs and gynae placement. Um So the process of that all what will happen is the woman she'll come in for an appointment. Um and she'll receive a period of CTD monitoring, right? Before. Um just to check that everything's ok with, with the fetus, she then be given um tocolysis with terbutaline before. Um so tocolysis, that's just um a medication given to relax the uterine muscles to make that manipulation as easy as possible. Uh Then the obstetrician will apply pressure to the abdomen in an attempt to turn the baby around. Um head down. It can be quite painful for, for women. Um And they'll usually need some form of analgesia whether it be um like it usually things like ox or gas and air, it should be provided. Um A CVS got about a 50% success rate. So not great. Uh That success rate is higher in um women who've been pregnant before. So multiparous women and that's just because their uterine muscles are a little bit more um uh more accommodating. They've been stretched previously, they're more used to being manipulated. So that's easier to do. Um The success rate is lower in women in their first pregnancy because um because of that and then as I said before, if that woman, woman is uh rhesus negative, she will need anti D and aha test after any attempt at CV. And that's whether that attempt was uh was successful or not. Just no need it regardless important to note the contraindications of E to A CV. Then so any um antepartum hemorrhage, any, any suspicion of ruptured membranes. Um If the woman's had a previous C section and that's because the, the muscles of the uterus are not as intact as they normally would be, they've been previously separated, then they're not gonna be as strong. Um Any significant structural abnormality of the uterus would be a contra contraindication to EC vs. So that would be things like women with um with large, large hemorrhoids or a bicornate or heart shaped uterus, a multiple pregnancies. So twins, them, twins, triplets, anything like that cannot have E CV. Uh or if there's any suspicion on CTG monitoring that uh all is all isn't perfectly well with the fetus. So, any abnormalities of the CTG um would be a contraindication to, to, to CV. And then following the CV, um the woman will again receive a period of CTD monitoring just to ensure that um that the process didn't upset the baby. Any, didn't distress the baby at all. And then provided it was if it was successful, she, she is good to go on her way and await spontaneous labor. Um And hopefully a successful vaginal delivery. If it was unsuccessful, then as with previously, the options are an elective Cesarean section or uh a vaginal breech delivery if that's the route that the woman wants to go around. So that's, that's the end of the presentation. I hope I've, I've given you a fairly good overview of um the, the basics of antenatal care here in the UK. Uh If anyone has any questions, feel free to pop them into the chat now. And if not, I hope, I hope, as I said, I hope it's been useful. Um, and I wish you the best of luck with the finals. Uh, and I do hope you will join me and my, uh, my cohost Joel. She is one of the other mind, the bleep s and lead. She'll be hosting our, our next, our next section, our, our next lecture, which we should be advertised. If it's not already advertised, it'll be up soon. Um We'll be alternating, so she'll do the next one. I'll be doing the one after that and I really hope you all join us for those. Alright. Um Feedback link, there is a feedback link. Uh I'll just pop it into the chat mark. Everyone is able to see that uh any feedback would be much appreciated by the way. Um If you just want to let me know anything that you think should be covered in subsequent in, in future uh lectures, anything you think that we've missed or anything that you think could have run better would be great to know about. All right guys have a lovely night, everyone. Um all the best and I hope to see you all again soon.