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So print could feel free to, to start whenever you're ready. Ok, great. Um So good evening everyone. I'm Priyanka. I'm one of the ST 10 N G doctors working in North Middlesex in North Central London. So I'll be doing a fine, I'll be uh doing a presentation today, sort of, it's, it's all MCQ based. So we'll be starting off with MCQ and then we'll sort of go, go through the theory sort of behind it. Um As you know, already there's loads to cover knobs and Chinese. So I've kind of just chosen some of the key topics that sort of tend to come up. Obviously that I wouldn't, there's no way I'll be able to cover um everything instead of like an hour and an hour and a half, an hour to an hour and a half. Um Yeah. So, um it should be an interactive session. Please feel free to ask questions as we go along, just put it in the chat and someone from the team will let me know um if there's any questions and stuff that come up. Um And we're gonna do the post for the MCQ questions just so it's sort of, um, so we can see what people are answering and stuff. Um. Ok, great. So, if I can figure out how to change slides. Um, yeah, so the first topic that we're covering is, so we'll go to the obstetrics part first and then we can see how we're doing for time, have like a five minute break or something and then do the kindly bit. Uh, so we're going to start off with antepartum hemorrhage and we'll go through bleeding less than 24 weeks and then bleeding over 24 weeks, your differential diagnosis is going to change depending on how far along you are in the pregnancy. And that's just something to keep in mind when you're sort of either taking a history from someone who's bleeding in pregnancy or sort of obviously doing an antique. You question because you're differentials are going to be different depending on how far along they are. Okay. So this is your first question? Um You've got a 25 year old woman at 25 weeks, gestation presenting with constant lower abdominal pain. She's got small amount amount of vaginal bleeding on examination. About pressure is 90/60. What is the most likely diagnosis? Mhm. I'm sorry, I've managed to lose my screen there. Let me just get it back to here. It is okay. So we've got, so most people have said c which is where is my screen? Sorry guys, I'm just having a bit of. Oh, perfect. Good. So most people are set c which is placental abruption and that is the correct answer. Uh So if someone want to put in the chat, why they picked placental abruption, what in the question made them think this could be an abruption. Yeah, hypertension. Second trimester. Good. Um And she's got constant lower abdominal pain as well. So I know that obviously this, this, this does not, uh this is not a blanket rule and it's not something you would sort of would follow sort of in real life. But you just have to think in your, in your exam questions, you sort of get the most classical scenario, right? So this is what so typically an abruption would present with painful bleeding and often actually, the the bleeding is out is not as much as the pain is. The pain is a lot more than the bleeding. You might just have like a very little bleeding because what you can have is a concealed abruption where they're sort of abrupt ing sort of at the back, which is why they're not getting as much bleeding essentially, whereas the placenta previa would present differently. And we could we go through in the next few slides, how that would present. So next question, you have got a young woman at 30 weeks gestation who presents with pain, less bright red vagina bleeding. She reports to previous episodes of similar kind of painless bleeding, but she feels like this episode is much more severe at 30 weeks. Uh Such an examination finds a Catholic presenting part with Catholic presentation with a high presenting part. Uterus is nontender cervical office closed and cervix appears normal. So what do we think this is? Okay? Good. So, more syphilis, I placenta. Well, everyone has that placenta previa, which is the correct answer. Great. Next one. So you've got someone who's bleeding a bit earlier on in pregnancy. So last period was around eight weeks ago, 19 year old, two day history of central lower abdominal pain, one day, history of vaginal bleeding. Um and she I have to, I should mention on the she is she's got a positive pregnancy test on examination. Her cervix is tender to touch. What do we think this is okay? I'll wait for a few more people to answer. Okay. So it looks like we've just split between A and B okay. Fine. So the answer here is actually a topic pregnancy. I mean, it is difficult cause it could still be a threatened miscarriage. The thing is we don't know where the pregnancy is just from the information that you have. You can't tell. Does she have a pregnancy inside the uterus? Is it an intrau trying pregnancy or is it a a topic pregnancy? So in this case, when without a scan, any woman with abdominal pain, positive pregnancy test, I mean, you guys have probably had this drilled in, you as we did when we were, uh we were only as teachers and also in that school as well is an ectopic until proven otherwise, because you don't have a scan that says that she's got an intrauterine pregnancy. She can't be by definition of threatened MS catch cause for that you need to have an intrauterine pregnancy confirmed. So in this case, it would be an ectopic pregnancy. Okay. So we've got one more 25 year old. She's 10 weeks pregnant, she's complaining of abdominal pain, um and heavy vaginal bleeding. Observations are normal. She's a fibril Aartsen scan. A fetal heart rate is present and the uterus is the size expected on examination as cervical os is closed. So what do we think the answer is for this one? So slightly different, also bleeding early on in pregnancy. Okay. So got a few answers trickling in. Okay. So everyone has said Bethan miscarriage, which is the correct diagnosis here and we'll go through some of the other sort of types um of miscarriage, what we need, what, what we call incomplete, inevitable uh missed miscarriage to all the different kind of classifications of miscarriage. So we'll go through that. There's a, there's a useful table that um that kind of explains the differences between them. Ok. So that was sort of four MCQ that kind of tells you about the different how your diagnoses are basically different, depending on the gestation and how these uh these basically present and how they might be tested in an MCQ setting. Does anyone have any questions before we start kind of going through them in a little bit more detail? Okay. Um, yeah, I'll just keep an eye on the chat anyway. So just pop any questions that you have in there and I'll try and answer them as we go along. So, bleeding less than 24 weeks, um, what are differentials, I'll just go through them because you've sort of gone through them already in the MCQ option. So make sure it's not an ectopic pregnancy. I mean, obviously a lot earlier on than 24 weeks, uh quite early on, make sure you, you definitely know that there's a pregnancy inside the uterus. Uh It could be a miscarriage, it could be a molar pregnancy as well because molar pregnancy can, can give you bleeding quite early on in pregnancy. What are some of the other findings that you might see in a molar pregnancy when you're examining someone? So, on clinical examination. And it's a, it's a, it's a MCQ favorite. They do like asking about molar pregnancies. What would you find when you were examining someone, let's say with the molar pregnancy or what kind of things can they present with? Apart from vaginal bleeding? Yeah, exactly. So, um, size greater than expected, so large for dates. Great. That's definitely something. Anything else? Hi, prem, assist. Lovely. Yeah, that's, that's something else as well. And the reason why is because of molar pregnancies, you've got high levels of circulating vita hate CD. And it's not that, that's, that's got TSH, uh, like activity and that's what kind of gives you the high premise that's thinking behind it. Um, um, sorry know, the beta HCG levels itself gives you the high premises, but you have to test for T S, you have to test for the thyroid function test in high premises because of the beta HCG levels having like TSH like activity. Basically, the beta HCG is what kind of gives you the high premises? And that's much higher in a molar pregnancy, essentially good. But also think about other Gynie causes. Well, that's why it's really important to do a speculum exam in these patient's because you want to see, do they have an Entropian that they have like a polyp or something? Um And also just ask them about sexual history and take swabs and stuff as well if they've got any abnormal vaginal discharge. Because all of those other things that you would see in a non pregnant person could also be found um in pregnancy as well and things like ectopia and stuff because the circulating hormones are greater in pregnancy, you're more likely to get an ectropion as well. Ectropion would typically present with postcoital bleeding, but you can also just have kind of irregular bleeding as well with an ectropion. Um, fine, what is the, what does that show So the ultrasound scan at the top, uh, that, that has a name. Does anyone know what that's called? Yeah. I mean, it's, it's called, I mean, if I'm not mistaken, it's called like a snowstorm sign, which is seen with like a molar pregnancy. Basically, it's sort of like the abnormal kind of presentation and the abnormal kind of sack itself. Um, so that's why you've seen like a molar pregnancy. Uh, does anyone know what that pouch is called? And what does that actually show, what is that free fluid that you're seeing when, when might you see that? Mhm. So that's called the Morrison's pouch. And if you're seeing free fluid in the abdomen, so whenever they do a fast can in any, they kind of check for fluid basically in various pouches, various kind of areas inside the peritoneum, basically. And that you would be concerned about a ruptured ectopic if you did see free fluid under the liver. Okay. Um Next one. So ectopic pregnancy, what is the most common site where you'd find the neck topic? Pregnancy? Obviously on here, you can see the tubal ectopics are the most common. But where within the tube are you most likely to find the neck topic, pregnancy, ampulla. Lovely, good. Um So as you can see on here, so you can obviously get topics wherever. Uh but the most common 95% is in the tube and the most common area within the tube is the ampulla. Perfect. And this is a laproscopic, it's an image you see at laproscopy. And on here, you can see that there's an ectopic on this side and that's the free flow that I've just explained already. So it's basically, whereas, you know, an embryo implants outside the uterine cavity, the impala is the most common side risk factors, previous ectopics damage the tubes. So asking about P I D, the ST eyes, previous surgery, if someone's had a salpingectomy, uh it's more likely that they're going to have an ectopic also, if they've had sterilization as well, we always inform are women that if they've been sterilized and they happen to have a positive pregnancy, does they have to go and get a scan early on because it's more likely to be an ectopic pregnancy. Also, obviously, if you have a topic before there's an increased chance of you having any topic again, I think it's up to 10% if I'm not mistaken is what we cancel women. Um Are you s and copied? So obviously, are coils are very, very good at preventing a pregnancy. But if you do end up becoming pregnant with a coil in situ are more like you have an ectopic, not that you can't have an intrauterine pregnancy with a coil because that's also something that we see. Um But yeah, but you just have to make sure that they don't have an ectopic if they've got a coil in situ and I've mentioned this already always do a pregnancy test, especially if they're presenting with abdominal pain, that sort of stuff. Um Symptoms of erupted ectopic social acttive pain, Singapore episodes, but that's only seen in less than 25% of people might be hemodynamically unstable. But again, young fit women will come, will compensate for quite a long time before they actually become unstable. They might be parasitic as well. You would see fluid in the pouch of Douglas on ultrasound scan. Also, you can also see fluid in like the Morrison's pouch and stuff as well. Uh And just to just to remind her that um if a woman is rhesus negative, um you have to give her anti D if you're doing surgical management for the ectopic because that's sort of like it counts as sensitizing about. That's just something to keep in mind. Um So management options for an ectopic pregnancy, we've already mentioned Salpingectomy, which is basically we just remove the ectopic or salpingectomy, which is why we remove the entire tube. We usually recommend to do a salpingectomy, but obviously the other tube is damaged and we can do what we call a salpingectomy as well. Um So what are the other management options for an ectopic apart from surgical? But the truck said, yeah. Um That's definitely something that we uh that we give. Yeah, some units don't actually like giving up the truck said, but at North, maybe we do give we do see a lot of women who actually end up having that. The truck said yes, anything else? So with anything you've got, obviously you've got your conservative medical surgical, so you can just watch and wait as well, which is something that you know, some women decide to have, especially they're happy to come back for follow up. So it's really important that you uh pick the right set of clinical findings and also pick the right patient as well. Cause some patient just would not be suitable for uh conservative management. I would not be suitable for methotrexate, for example, you have to go for surgical. Um So this is just a table that kind of tells you. Um So expecting to just wait and watch you basically just monitor over 40 hours recheck, the beta HCG um medical, you've got methotrexate, which is a single dose, but you might need to give further doses depending on the beta HCG level. So patient follow up is quite important for expecting and for medical. And obviously you've got surgical, which is a lap salpingectomy or Salpingectomy depending on the size, depending on whether it's ruptured if they're symptomatic. So if they've got significant pain and also if it's a live ectopic, so if you're able to see a heartbeat inside the ectopic, it's more likely to rupture. So you're, you would sort of go straight for surgical basically over the other two and for the, depending on the beta HCG levels as well. Okay, fine. So moving on to miscarriage. So definition is basically spontaneous loss of pregnancy before 20. For the current miscarriages, a loss of three or more consecutive pregnancies. It affects around 1% of couples and majority of miscarriages do happen sort of before 12 weeks. So it's quite rare to kind of have it um over 12 weeks and the rate does increase, the maternal age will go to the different types of the classifications of miscarriages causes. So isolated chromosome abnormalities actually account for over 60% of miscarriages. And this is just more when we see women in the early pregnancy unit. So just things like exercise, intercourse, stress and emotional trauma, those things are not cause miscarriages, nothing that they could have done to stop them from miscarrying and even just doing a scan is not really going to stop you from miscarrying. It's more just to see how things are going basically, unfortunately. Um So types of miscarriage. So you've got threatened, inevitable in complete, complete and miss those are kind of like the ways that we classify a miscarriage essentially. Um And the way that I sort of remembered it was the the to the inevitable and incomplete. Both the ones beginning with I are the ones where the office is open and it kind of makes sense if you actually think about what it is. So it threatened is basically where nothing's happened yet. Um You just had a bit of vaginal bleeding, but you're also still closed. You haven't really passed any products. Nothing's kind of happened. It's just threatened and 25% going to miss guy, but 75% and kind of continue their pregnancies as normal. Um, inevitable is basically what you do. The office is open. You do have heavy bleeding and miscarriages. About two a come in complete is what you've already passed. Some fatal products already complete is where everything is passed. So the Oscars basically closed and the bleeding is almost stopped. The uterus is no longer enlarged, basically. And the mist is something that we see sometimes in early pregnancy where let's say someone has gone down for their dating scan at our answer of 10 weeks and then they have noticed there's no fetal heartbeat. So they don't actually have any symptoms, no pain, no bleeding, but it just an incidental. Sadly, the futures is just died in neutral and that's diagnosed an ultrasound scan, that's a missed miscarriage. So they're all the different ways that you can classify miscarriages. So, investigation and management for miscarriage. So investigations, you just have to do an ultrasound scan basically. And sometimes people get this diagnosis of, um, kind of, uh, let's say the pregnancy of uncertain viability depending on the measurements and stuff. They're, they're sort of certain measurements that they have to see. They look at the Crown Drum plant, they look at the gestational sac length and stuff as well. So sometimes if they're not sure they might rescanned them basically there a week or two weeks later, they early pregnancy units are very kind of strict criteria about when they bring people in. So they kind of just follow those pathways and follow those guidelines. And you want to do FBC, obviously, because you want to see what the hemoglobin depending on how much they're bleeding. You want the research status as well and you want to do a group and save and serum HCG levels as well. If, if kind of relevant, not so much in a miscarriage, you don't really tend to do HCG levels. But if it's pregnancy of uncertain viability, if you're not really sure, then you might kind of do it. Uh So when do we admit obviously, any suspicion of ectopic mean, depending we don't, we, we actually do not admit every ectopic pregnancy, you can manage ectopic pregnancies as an outpatient. But obviously, if you have ruptured ectopic of the woman's unstable, quite symptomatic, then you would kind of admit her septic miscarriage. Um If they're having quite heavy bleeding, low hemoglobin, those kind of things and you might think about admitting them resuscitation. So we would always do a speculum. If you can see any products at the US, then you basically just remove it because what you can get a cervical shock, which is kind of like just having the product sitting inside the OS can give you quite severe pain, bleeding and it can make them quite hypotensive as well. Um, so obviously they're septic, the new septic serena, the antibiotics. And if they have, if they're bleeding after 12 weeks or if they've been treated medically or surgically and the recess negative, then you might have to give them anti D So you do have a question. How do you recognize a threatened miscarriage? So, it's basically someone who let's say they come, they, they've come in with some abdominal pain, some bleeding. Um you scan them, they've got a viable until you try and pregnancy. Uh the office is closed basically. So what I mean, you just say that's a threatened miscarriages, nothing else that you would do. Basically just ask them to monitor, you can send them home and then just see, obviously they've got any further. Absolutely. Than we can scan them again. That's basically all you would do for them. But that's kind of like how you diagnose a threatened miscarriage. Nothing's really happened yet. The office is still closed. It's just monitoring. Um Okay, fine. So that's basically how you kind of investigating how you essentially manage miscarriage. And again, with miscarriage as well, you've got same as a topic, you've got expected medical and surgical. So expected management is you kind of, if they've already started miscarrying, let's say you can just say that, you know, you can go home, we expect you to start bleeding, sort of like, anywhere between, like, uh, I mean, they've already started breathing. They might be building up to two weeks after you just ask them to basically come back. They do a pregnancy test in two weeks time, 2 to 3 weeks time and that's still positive and they do, then they will do a scan. Basically expected management. You don't really do anything, no medications, no surgery, just follow them up medical management. You give them miSOPROStol, which is a Prostaglandin analog. And what that does is it basically causes the uterus to start to contract. And if someone had a missed miscarriage, let's say they haven't had any bleeding, what you can do is just give them miSOPROStol in the vagina, you can also give it buckley as well. But often we sort of give it vaginal e and then they go home, they are expected to start leading sort of the next day or so. And then we again, we bring them back in sort of like three weeks time just to make sure that they don't have any retain products, they're not still bleeding, that sort of stuff. And the surgical management, uh is basically, you can do it under two, you can do two methods for surgical management. You can either put them to sleep and we do what we call a suction curettage, which is basically where there's a long thin plastic tube which has got suction and you essentially just empty the uterine cavity under ultrasound guidance or you can do a manual vacuum aspiration, which is kind of a similar concept, but they do it under local anesthesia. You don't need to be put to sleep for that. Um Yeah, so essentially that's kind of an there are obviously different cutoffs. So when you would use each of the different methods, I don't really think you guys need to know that um necessarily, but for surgical management, it's important to know that it's obviously someone septic and they're quite unstable and you might want to go for surgical management and just extra points for urinary pregnancy just after three weeks and indications for surgi surgical management, as I mentioned, women's choice, heavy bleeding signs of infection. So just because this was something this is uh this is used to confuse me before when I was sort of like revising for exams and stuff. So the drugs that I use in miscarriage, ectopic and terminations. So I would just remember the termination of pregnancy is to for terminations. So it's two things that used for termination of pregnancy, which kind of makes sense because you want to first give them something to soften their cervix. So that's Mifepristone is what you give and then you have the miSOPROStol is on which is what causes you try and contractions and expels the pregnancy tissue. And if you press stone is an anti progesterone and then you can for miscarriage, you just give them Misoprostal. So Miss Mizzou. Um And in fact, topic is the weird one that you give methotrexate. Um So, so determination, you use two drugs miscarriage, you just use the miSOPROStol because kind of they've already started miscarrying, so to speak and then methotrexate for the ectopic. So what are your differentials for antepartum? So, first of all, any questions for with that? Okay. Um So what are differentials for an antepartum hemorrhage? Over 24 weeks? We've kind of went, we went through some of them already required miscarriages three times a more. Yes. So three or more subsequent pregnancy losses. Center previa. Yep. Exactly. Abruption. So as miscarriage usually pain is speeding. No, that's no, actually, miscarriage can be uh usually quite painful. Actually, women are in a lot of pain because they can feel that you just kind of contracting and trying to get rid of the pregnancy tissue. So it's usually quite painful. But if you've got a missed miscarriage, then you wouldn't, you might not have any pain, you might not have any bleeding. I hope that answered the question. So, differentials are present a previa, placental abruption. Less common things are visa previa, which is basically where the vessels are running quite close to the os on uterine rupture as well, which is much less common. That can also give you antepartum hemorrhage. So placenta previa, we'll just quickly kind of run through this. So it's basically the placenta implants in the lower segment of the uterus, risk factors, anything if you've had it before in pregnancy are more likely to have it again. So previous placenta, previa high parity, age twins and previous cesarean section as well. Um How does it present? So it could be an incidental finding on an ultrasound scan, painless vaginal bleeding, usually in MCQ but not so much in real life, abnormal lie a breech presentation as well. Um And as you can see, you can either have normal that, that, that shows you a normal placenta than the other one shows you a marginal placenta. And you've got a complete placenta Previa. It's also graded from grade one to grade four. Grade four is when it completely covers. The often the other ones are basically varying distances away from the US and the complicate, they are, they're more likely to bleed and placenta accreta as well, which is basically you've got present uh Previa, you've got placenta accreta and you've got placenta accreta as well, which is basically varying levels as to how. So if they start to invade the myometrium, for example, that's accreta you can have per critters, which is where it invades all the way through. Um and just something to kind of keep in mind. So unless the placenta Previa has been excluded on scan, never kind of perform Avian woman. A ph just because it's, you're, you're likely to kind of precipitate even more building, that's just what they kind of. Um that's just where the teaching is. Um, okay. And how do we manage it? Basically, if you find earlier on in pregnancy usually just rescanned them at 32 weeks, you admit them if they're, there's any bleeding and you just observe them for 24 hours, basically, see if there's any more bleeding episodes and just make sure that they are stable. If you're under 34 weeks, you give them steroids. Do you guys know why we give steroids? Is it for the mom or for the big? All right. Yeah, exactly. So, it's long, mature maturity of the baby? Exactly. Um, and usually you would do an elective cesarean section for these women in 39 weeks. You don't really want them to go all the way to, like, 40 weeks and go into labor and stuff. Um, okay. Yeah. So rescanned them, admit of any bleeding steroids and elective C S at 39 weeks. Uh, um, and the question spoke about presenting part at the beginning. Um, what, which question do you mean? Brandon? Ah, do you mean the MCQ question about the placenta Previa? Ah, the one right at the stop. Uh, let me check. Uh, can I just go on to the, uh, uh, I think, I think this might be quicker, uh, too high presenting part. I think I just meant that the head was high. Oh, yeah. So that's such an examination. Is this the question that you meant? Um, so Catholic presentation? With the high presenting part, just means that the head is basically floating high up in the pelvis. That's all it means. Uh, since before present, uh since both present, earlier than 24 weeks, how do you differentiate between a miscarriage and topic pregnancy? So essentially for, um, you need to have a scan that confirms an intrauterine pregnancy. Essentially for it to be a miscarriage, you'd be able to need to be able to see a gestational suck. Whereas in a topic, pregnancy, obviously you've seen an Excel mass and that's how you differentiate it. But in a question, it would be difficult to differentiate if you didn't have an ultrasound scan. Um Okay. So let me go back to slide show. I hope that answered the question for that. One, two. Um Okay. So placental abruption, we've kind of mentioned this already. So it's basically where all our part of the placenta basically separates before delivery of the fetus. Risk factors. Are, are you g are preeclampsia, hypertension, maternal smoking, previous abruption. Cocaine use is also something else that they kind of bring up in MCQ questions that's also linked to placental abruption. I'm not really sure what the mechanism is, but I know that there's a link. How does it present? So constant pain, plus minus bleeding, I said plus minus because as you can see the second photo, if you've got a concealed abruption, you might not really have as much bleeding and usually kind of. They say that you've got a woody hard tender uterus and complications could be kind of poor urine output, renal failure. And obviously, the mom can be quite unstable as well. And also the baby as well in, in a percentile abruption. Uh usually the CTG trace does not look very good. There might be decelerations, they might be kind of other um signs that show that the baby is kind of struggling. So usually you would admit in resuscitative severe abruption and you basically to deliver ASAP, there's any signs of fetal distress on the CTG. So just quickly going through differences between previa and an abruption. So in an abruption, the shock is uh kind of greater than the amount of external blood loss that you see because there might not be a lot of blood loss, often severe pain, constant with exacerbations, building may be absent or dark. You get a tender hard uterus. The fetal lies usually normal, but there is a fetal distress, placenta, previa shock is equivalent to the external blood loss. Pain is uncommon. You get occasional contractions that bleeding is red. It's perfused and they might have a history of previous smaller kind of A P H S or antepartum hemorrhage. It's rare to have a tender uterus at the center previa and they often have like an abnormal i high head. Uh and fetal heart rate is usually normal with previa. Okay, great. So we'll go through a postpartum hemorrhage quickly. So 36 year old woman suffers from major PPH after delivering twins, etcetera consultant examines her suspects you trying to eat need to be the cause protocol for major PPH is initiated. Um They try by manual eutron compression that fails to control the hemorrhage, which drug is an appropriate next step in the management of you try an 18. So it's the first kind of pharmacological therapy or non pharmacological therapy. What would you do next? We've got one response so far, wait for a few more and then we'll carry on. Um Okay. So most people have said B which is correct. So IV Oxytocin is the first line that you give is the first you teutonic that you give. And after that, it very much kind of depends. So you can give, we give I am carboprost. Um It, our trust you can give rectal miso as well and balloon tamponade would be afterwards after you've tried all the pharmacological management. Um So going through PPH. So you think of the forties, tone tissue trauma from it? So tone is you trying to eat me? So this lady had delivered twins. So a lot of things that might put you at increased risk of having an atonic uterus afterwards. And twins is one of them because your uterus is quite distended during the pregnancy because it's kind of carried to fetuses, right? That's less likely to kind of come back and contract that that was her risk factor but also parity that if someone is like para five, para six, they're more likely to have a PPH. Um So how do we define it? Blood loss of over 500 miles after a vaginal delivery, over one liter after cesarean section. Risk factors are maternal, maternal. So high B M I Pani Asian ethnicity as well age over 40 you try and overdistension, which is what I mentioned just now. So if you have polyhydramnios as well, which is increase in fluid around the baby, multiple pregnancies, the twin pregnancy, for example, macrosomia, so a big baby as well. Um then think about labor. So if they've been induced, if they've got prolonged labor, they're more likely to have a PPH as well because if you try an attorney and any placental problems of previous abruption and previous PPH. So tone and trauma. So usually for a three, you do by manual compression, that's just a photo of that. You can give drugs. So, oxytocin, ergometrine, carboprost, Misoprostal surgical measures. So you can obviously put in sutures, you can do balloon tamponade or um kind of life saving measures. You can do a cesarean hysterectomy as well, uh trauma. So obviously want to repair any tears that you find, you just have to do a repair. If it's a rupture that you might have to do a laparotomy and a repair uh tissue. So you want to basically check is the placenta complete. Is there anything else? Is there any retained products? Basically, you have to do manual removal of placenta. There's anything else remaining, you give them prophylactic antibiotics and theater, you would use the risk of any postpartum infection. And also because you're kind of going in and you're doing a lot of like manual, manual removal itself increases the risk of getting infection. And thrombin is the least common. The most common cause of P PH is just tone. And I think probably after that might be like tissue trauma from been is the least common. So you want to just correct any coagulation abnormalities of blood products basically. And then discuss with hematology for the weird and wonderful things. Okay. So we'll do some MCQ looking at complications that might arise in labor. Uh So next one, so you're a junior doctor on labor board called by the midwife to delivery in which the baby's head's delivered, but the shoulders are not delivering with normal sort of downward traction. Um Which of these is your first step in the management of this condition? Is it a Cesarean sections in physiognomy? Peas, Iata me asking the moms to hyperflex her legs and apply superpubic pressure or is it would screw maneuver? And if anyone can also put in the chat, what this maneuver is called? Yeah. Perfect. Good mcroberts manoeuvre. So the correct answer is deep. Um And what is the, what is this emergency actually called shoulder dissociate? Perfect. Um So shoulder, dystocia is basically where it's a bony problem. So your anterior shoulder becomes impacted behind the maternal pubic synthesis. Um, the biggest risk factor is G D M A preexisting, preexisting diabetes. In the reason is because these um babies usually have a lot of fat. Uh not just a lot of fat, but their, their shoulders are also a lot are quite big, which means they're more likely to get stuck, but they're also just bigger babies as well because of the macrosomia uh maternal complications. So the women are more likely to have PPH third or four degree test, fatal complications include vehicle plexus injury from the traumatic delivery fracture, the clavicle of the humerus, fetal hypoxia as well. And you can get herbs policy, which is basically the weight it'd position. Um which kind of as well. It shows over here um management of shoulder dystocia, as you guys mentioned, obviously, call for help, put out the call. Bell, ask them um to stop pushing. Well, you, you might consider episiotomy can make the maneuver is easier. But the first thing that you need to do is make sure that her put her niece the chest position. And basically what you want to do is you want to hyperflex her legs. And this essentially widen the pelvic outlet. And actually over 90% of shoulder dystocia is actually kind of managed just with the mcroberts maneuver alone. You don't need to do anything more. And yeah, that's actually 90% and it's even higher when you combine it with super pubic pressure, which is what she's doing over here. Um, good. Next one. So you've got a 30 year old woman who's 41 weeks pregnant is being induced in labor ward. She's gone out if she's had an artificial rupture of membranes. The mid wife notices that the umbilical cord is visibly protruding from the vagina she's brought for an emergency cesarean section. What's the correct position for her to be in whilst being prepared for surgery? Mhm. Okay. So great. So the correct answer is e which is on her knees and elbows. Um So the emergency here is called prolapse. What is it? So it's basically the umbilical cord descends through the cervix on or before the presenting part. Why is it a problem? So it's basically, it's linked to high mortality because of other links to risk factors. And essentially what happens is because the cord is sort of exposed to the cold atmosphere, you get arterial vasospasm and that then includes the blood supply to the fetus. You have fetal hypoxia and all the resulting complications from that risk factors are breech presentation is more likely unstable, live. Um And if you have, if you do have unstable lives, then you might consider in patient admission just because of the risk of cod prolapse. Um and, and A RM as well. So if you're artificially breaking the membranes with an omni hook and the baby is presenting parts quite high in the pelvis. There is a risk that because of kind of the waters break all of a sudden that the cords going to then prolapse. These are all the main risk factors and polyhydramnios as well and prematurity. So management of course, prolapse, consider this in anyone with a pathological CTG. Um And if they've got absent membranes and a non reassuring fetal heart rate trace, it's confirmed just by external inspection or by doing a ve um and fetal by the card is you've got a sudden fetal bradycardia, then you want to, you're, you're wondering, could this be a cord prolapsed? Always just examine and check call for help avoid handling the court to reduce vasospasm. And you basically want to manually elevate the presenting part off the court's during the V and you want them to basically be on a knee and elbow position, which is basically that was option E on the MCQ question and considered localized as well just whilst you're kind of uh transferring them to uh for the emergency caesarean section. That's, that's how you usually deliver them basically. Um And this is just basically what you can do is you can um kind of put a catheter in and you can just inflate the bladder essentially just to kind of push the presenting part kind of up a little bit. Um So you can do that if you're in the community for example, you're bringing someone in with a cold prolapse. Um And that's just the need to elbow position. You can either do an exaggerated SIMS or you can do in the in the elbow position. Okay. Uh I think this is the last MCQ for complications in labor. So you've got a 36 year old nulliparous woman admitted in labor, 37 weeks, gestation on examination services, seven centimeters, dilated head is occipital anterior fetal station is minus one and head is to fifth palpable per abdomen. CDG shows late decelerations, fetal heart rate of 100 which continues for 15 minutes. So basically, you've got a bad a cardia. You've got a prolonged fetal bradycardia. How would you manage this situation? Yeah. Okay. So most of you guys have set Cesarean section, which is the correct answer. So in this case, you've got fetal concerned. It's a prolonged by the card. Yes, you would go for a cat one Cesarean section basically. Okay, good. Why can you not do a forceps delivery or I want to silivri in this case, what are some of the prerequisites for you to be able to do a forceps or any kind of instrumentals delivery? No. Okay. So this lady is not fully dilated. Yeah, exactly. Yeah, as Brandon said, so she's not fully dilated. Um The head is 2 50 palpable. So the the station, first of all needs to be at least at spines or below and the woman needs to be fully dilated. So there are certain prerequisites that you need for a instrumentals delivery. So she would not be suitable for an instrument. We'd have to take her for a Cesarean section essentially good. So I've got few questions on conditions in pregnancy. Just a quick question to the organizing team. How much time do I have? Cause I still have the guinea section to go through as well? I wonder if I should kind of start the guinea section now um for running out of time. That's right. We can carry on as normal. We'll release the feedback, the feedback form at eight o'clock. So if people have to leave, they can head off, but we can carry on. Okay. That's normal if that's alright. Fine. Yeah. Yeah, that's absolutely fine. What, what time do we, are we running the session to sort of, are we saying half eight just so I can kind of keep an eye on time? Uh We can pretty good till about 8 15, 8 20. Okay. All right. Um Okay, so what am I doing? Uh Okay, we'll do one of these questions and then we'll move on to the guy need it just so that I can, you guys also have a go at covering some of the guy need sections as well and I'm happy to send these slides over and then you can have a look at the questions that we haven't covered. So there's just so many things to cover that. I've sort of tried to put it all into one presentation. Okay. So, actually, I think we've kind of gone through this already. I'll skip this because I'm sure you guys kind of know about the symptoms and signs of preeclampsia, um, and how we treat it. So, you need to know how we treat preeclampsia and what are some of the criteria for admitting someone? Because that's a common question as well. So what, what's your threshold for admitting someone with preeclampsia? Fine, uh gestational diabetes? I think that's fine as well. Um So we can do this on itching in pregnancy. So women complaints of severe itching at 34 weeks, gestation itching started two weeks previously, preventing her from sleeping. So it's worse at night if she all over her body, especially in her hands and feet. No rashes. Um And she's had this before with her second child. What's the most appropriate actions? What would you guys do? Okay. So I think we've got uh most people have said e which is correct. You basically want to check her LFTs and bile acids because the thing that you want to make sure she doesn't have is O C of such a college basis. But also just remember someone, there's someone, there are some sorry, dermatological causes as well of rashes and pregnancy. So you can have things like a topic eruption and pregnancy, which is an exematous and sort of itchy red rash. You can have polymorphic eruption which is more associated with the third trimester and the lesion's first appear in the abdominal. So try and you just manage that with more liens, topical and oral steroids or you can have kind of blistering lesion's as well, which is pemphigoid gestation itis and that starts kind of periumbilical, then it moves to the trunk, the back buttocks of the arms and you might, you treat that with oral steroids, obviously need to make sure she doesn't have O C first, such a Cali stasis, third trimester, palms and soles was at night. You might have other features as well and raised bile acids over 19. And previously, kind of thinking was that you would have to induce all these women earlier like at 37 weeks or so. But actually, now the latest guidelines actually said that it very much depends on, on the bile acids. So actually there over 100 of course, you have to deliver them a lot earlier, but they just over 19 and there's no other issues, normal LFTs, no other fetal maternal concerns and you can basically weight. Um and I will kind of move on from that one. That's fine. Um Yeah, this is just a question on hyperemesis, gravidarum and how you manage that. So it's a triad of weight loss, dehydration, electrolyte imbalance and always check the TFTs as well because it can be associated with hyperthyroidism and anyone with hyperemesis, gravidarum. If they haven't had a scan already, they should always do a scan because you want to check, she doesn't have a molar pregnancy, want to check that she has not multiple pregnancy, those kind of things that would increase your risk of having hyperemesis. Uh So management, when do you consider admission if they've got any kind of comorbidities, ketone, urea weight loss, unable to keep down any fluids and failure of oral anti m antiemetics. And you start off with sort of prochlorperazine, cyclizine. Second line is metoclopramide, Ondansetron, Don Paradorn and IV fluids as well. Ted's and no molecular weight heparin. And you want to give them timing and folic acid as well because they're going to be quite malnourished from not being able to eat a day for sort of like days or even weeks, sometimes quite severe hyperemesis. So we'll move on. Um So the next bit is uh Chinese. So we'll go through a few what times? And now it's 7 55. Hopefully we should uh well, I'll aim to kind of wrap up by 8 20. I think that Chinese section is a bit less. And also Gynie people are a little bit more familiar with kind of Gynie pathology and stuff. So we should be able to go through this slightly quicker. So, abnormal vaginal bleeding, apologies for the quite long MCQ stem. So you've got a 41 year old woman, heavy menstrual bleeding that's been worsening over the last 12 months. She also has severe pain which begins a few days before each cycle. Periods are regular. She's had 29 day cycle. She's not been sexually active over the past year. No regular medications you and Abdul exam is unremarkable speculum. She was a normal looking cervix. She requested FBC. What's the most appropriate next step? So, what do you do want to do next with him? Okay. So we've got a few answers. Mhm. Okay, good. So most of you guys have said e which is request the trans vaginal articles can, which is exactly what would be done. So, before you kind of arrange for a coil insertion or a hysteroscope, anything you want to do a trans vaginal scan? Because you want to see, does she have a polyp? Does she have a fibroid? What is that cavity looking like? And can that cavity? Because if that cavity is normal, then you can just give her, you can give her an eye, us, you can give her something else, but you want to know, does she have a normal kind of cavity? Is there anything else going on that could explain the menorrhagia? Good. Uh Next question. So you've got 27 year old, heavy menstrual bleeding. Um She's otherwise asymptomatic. She's no desire to have Children in the near future following a normal examination. How do you manage this case? Let's say she's had a transvaginal ultrasound scan and that's normal. So menorrhagia uh no fertility sort of uh no, no desire to have Children. How would you manage that? So, what's the first line basically? Obviously in real life, you kind of offer them all the options. But okay. So most people have said d which is an eye us. Exactly. So actually, uh a Mirena coil or leave us out, which is also a progesterone coil and ensure you train system basically. Um uh that would be your first line management good. But obviously, if she has fertility needs and she does want to have kids, um then you, you'd be able to give her just tranexamic acid and, and sets, for example, because you can't really give any of the other stuff fine. Um So just these are just just a diagram that shows you some of the, some of the things that could cause menorrhagia. So just think fiber is the most common one. Endometrial polyp. You can't think of the more kind of sinister things like carcinoma, cervical carcinoma, endometrial carcinoma, variant tumor P I D as well can give you kind of heavy bleeding as well less commonly, but it can. And also endocervical polyp is also, it's really important to do a speculum examination. Um So most common causes. Are you trying to fibroids and polyps? You want to do an F B C and transit genital, if you're suspicious for any structural pathology management, basically, they're trying to conceive just Tranexamic acid if they're not trying to conceive, then it's marina and then uh C O C P as a second line and Third Land, you can't give them kind of like I Am Depot or GNRH analogues is of so long acting progesterones surgical management options. So obviously, if you've got uh if you've got a fibroid kind of within sub mucosal fibroids and what you can do what we call a transcervical resection or an ablation as well. You can do a uterine artery embolization. But if someone wants to get pregnant in the future, then this might not necessarily be the best option for them. They might have to do what we call a myomectomy. So we remove the fibroids, obviously, they've completed their family, then you can just do a hysterectomy, uterine artery embolization is in someone that doesn't want to hysterectomy. They also don't want to have kids in the future because they're not really sure how are uterine artery embolization effects facility in the future. So it's not really an option for someone that hasn't completed their family, for example. So, fibroids are different types of fibroids are benign tumor's. Um it can basically just give you heavy bleeding or I can give you pressure symptoms. So, um so it can give you kind of like hydronephrosis and stuff if there's very, very massive fibroids or I can give you difficulties passing urine open in your bowels that Theresa want to give you some fertility as well complications. So you can have Torshin, which is basically the production lated fibroids, the little stock that they have, they can basically taught and that can give you quite a lot of pain. You can get generation and pregnancy, which is basically where these fibroids outgrow their blood supply, which is why you get degeneration, you can get malignancy as well. I think it's not 0.1% of fibroids have a chance of transforming into a sarcoma which is a malignant tumor. Um And then features of malignancy are basically pain, rapid growth, um growth in someone who's post menopausal because basically, you would expect the fibers to shrink post menopause. And if or if they're not responding as well, then you, you kind of worried about malignancy basically. And the best way is you, you do an MRI and then they basically should tell you if it's got any sarcomatous changes and stuff like that, uh management of fibroids. So obviously, with anything, you've got medical, conservative, medical and surgical. So medical marina us, but there is a limited efficacy in women with fibroids. It could just be because of the cavity could be distorted and stuff. GNRH agonist, short term use because they have, they, they have been linked to bone density loss. Uh but you can use add back HRT but the problem with GNRH agonist is fibroids can return to the normal sized. Once treatment is stopped, you can't give them a little Liberace elasticity. I think there was, there's been issues with that recently with regards to um kind of like um effect on the liver and stuff. So they don't really use a Liberace last city anymore, but it was used to kind of shrink fibroids, um surgical management. You can do a hysteroscopy and just kind of remove the fibroid, especially if it's a sub mucosal fibroids, but you can't do a myomectomy as well, which is an open procedure And that's for someone that hasn't completed their family. You cannot tree embolization or hysterectomy or other options as well. Um Fine. So next question. Really, uh postmenopausal bleeding. You've got a 67 year old woman attends your GP complaining of three episodes of P M B. She describes that as pots a spotting. She went through the menopause 10 years ago. She's not had any bleeding since, since then, until this episode. She did take HRT for five years. You perform an abdominal examination which is unremarkable and a vaginal examination which is normal apart from some vaginal dryness. What do you need to do first? Okay, good. Everyone is a trans vaginal scan, which is exactly what you need to do because you need to see how thick is the endometrium in this lady because that will then help guide you as to what you would do next. Because if she's got an endometrial thickness of less than four in someone who's post menopausal, that's very, very good at ruling out a malignancy. It's got a very high um sensitivity, sensitivity because it's good at ruling it out. Um If obviously the endometrium is thickened, then what you would do next is you do a hysteroscopy and a biopsy basically. So common causes of post menopausal bleeding, think endometrial, either hyperplasia or cancer could be from the vagina could be from the cervix. It could be cervical cancer could be ovarian cancer as well and other causes are H I T H R T sorry and Volvo and vaginal cancer, post menopausal bleeding guidelines. So over 55 year old with post menopausal bleeding, you want to do an ultrasound scan as a two week, wait, a normal endometrial thickness is less than full. And the way to diagnose it is you basically to do a hysteroscopy and a biopsy or you can do a propelled biopsy as well. And you need to investigate women on HRT. You present with post menopause ability to rule out cancer. And often these women, it might just be a case of actually changing the dose of the eastern and progesterone that they're on. So you might have to tweak that a little bit, but you only do that once you have ruled out any kind of suspicion of malignancy. So management of other court's, if they've got vaginal atrophy, then you can just give them tropical Eastern's, you can ask them to use lubricants. HRT. The patient is on HRT. As I said, you can just change their preparations of HRT. And if they've got endometrial hyperplasia, you can just do like a DNC to remove excess tissue or you can just kind of monitor them and see. Um, so endometrial cancer risk factors are age, obesity, early menarche and late menopause if you've never had any pregnancies before PCOS as well. And if you're on estrogen only, HRT, if you've got a uterus, you have to be on combined estrogen and progesterone. Because if you've got unopposed estrogen, that's more likely to cause endometrial hyperplasia and malignancy as well. Protective factors. R C O C P and smoking. Um Treatment options are. So if you've got localized disease and you can just do a th which is a total abdominal hysterectomy and a bilateral salpingo oophorectomy. You remove all the tubes and the ovaries as well. Obviously, if you've got more kind of uh extra, you try and disease, then you might have to do radiotherapy and stuff as well. Um Fine, let me see. Can okay for time. Okay. So pelvic pain. So you've got 33 year old woman investigated for infertility, lapa, laparoscopy is normal, but H S G shows blocked fallopian tubes bilaterally. So what do we think the diagnosis is in this case? Just from what you know already? Okay. So I think, yeah, so blocked fallopian tubes bilaterally. Okay. Yeah. So most people have said d which is pelvic inflammatory disease good. Um So quickly just touching pelvic inflammatory disease. So it's a sending infection from the cervix, which basically then causes infection, inflammation in the pelvic female pelvic organs. You can have a frozen pelvis, which is basically where you've got lots of adhesions. You can have a swollen blocked fallopian tube as well. Uh um Risk factors are having previous ST especially they have not been treated a recent new sexual partner, multiple partners on prep sexual intercourse and a history of P I D as well. Uh Most commonly, actually, it's polymicrobial. So you treat it with something that's broad spectrum. Uh and chlamydia and gonorrhea only comprise around 40% of P I D. So basically, the pathophysiology is you get this inflammation which then causes scarring adhesions and you can get partial or total obstruction of fallopian tubes, which is what, which is what causes the infertility. Uh P I D management is energetics antibiotics and it just depends on whether it's mild or severe as to the choice of antibiotics that you use. And if there's no significant improvement that you might consider a laproscopy, basically, if it's an abscess that you can do an ultrasound guided drainage or you can do a laproscopy and then treatment of sexual partner as well. Complications of P I D. So, there's a pneumonic called I face P I D. Um So you can basically infertility fits you Curtis syndrome, which is the adhesions between the liver and the anterior abdominal wall. You can get abscess, you can get chronic pelvic pain, ectopic pregnancy, peritonitis, testing obstruction, or you can get disseminated infections as well. This is much less common these days because we're quite good at kind of treating it earlier on. And we've, we've got sort of broad spectrum antibiotics to get the infection under control. Okay. So, next one, you've got 29 year old nulliparous female, um, working menstrual pain, no relief from NSAID. She's sexually active and reports pain during intercourse. She's got pain during intercourse, pain on passing urine. Um And she's got this uterus economic modularity and tenderness. She's been trying to conceive for the past two years and she's failed. So, what's the most common diagnosis here? What's the most likely to be sorry? Yeah. So I think a few. So the correct answer is endometriosis, correct. Um So, endometriosis just think of. First, we'll go through differentials for dysmenorrhea. So, primary dysmenorrhea is quite common. It coincides with the start of menstruation. It responds quite well too and sets in C O C P. Secondary dysmenorrhea. The history is that the pain basically starts a few days before and its relieved by the onset of menstruation. Um You get things like deep disparity union, menorrhagia and irregular menstruation is common. So, um the common kind of differentials for secondly, dysmenorrhea, you think endometriosis, adenomyomatosis, fibroids P I D, query ovarian tumors, but less commonly. Um And adenomyosis is basically presence of the endometrial tissue within the myeloma tree and you would see this um either an ultrasound scan or an MRI. MRI is the gold standard, but you can't see it on ultrasound scan as well. I don't know my osis. But obviously, endometriosis, you might not see it on an ultrasound scan. You might see things like an endometrio MMA but you wouldn't see like your deposits and stuff on um on an ultrasound scan. You can't sometimes see it in an MRI scan. Okay. So, endometriosis is basically presence of endometrial tissue outside of the cavity. You've got the four dees dysmenorrhea, painful periods, disparity, uni a pain during sex, dyschezia, pain on opening your bowels and dysuria pain and passing your. So those are the kind of things just remember pain with endometriosis. Um Do you on examination? You might see fixed retroverted uterus because of all the adhesions and stuff, they might have pelvic tenderness as well. Um Ultrasound scan. Um Is your primary investigation? But lap is gold standard. We've got a question. So, can you differentiate? I don't know, my ex is an endowment choices based on clinical features. No, probably not to be honest. And often you might actually have both present in the same patient side by side. Um So yeah, so you wouldn't actually be able to different sheet. That's a good question actually. Uh management and complications. So often you can just give them something to suppress their menstrual cycles of things like C O C P Marina GNRH analog to induce menopause and add back estrogen. So usually most common you can try see, oh CPR marina pain relief surgery, you can do laproscopy but a it might not treat all of their symptoms, be it can go back as well. And actually you might need to like what are endometriosis specialist? Always says when he councils in a patient's is that it is not just a single procedure, they do it in stages, especially for severe endometriosis, you kind of go in, you see what you're dealing with, you see what, how everything looks and then you might have to do multiple laproscopy, laproscopic surgeries and in the factory cases and sort of like like last case scenarios, you might have to do it total abdominal hysterectomy and kind of BSO as well. Complications of endometriosis, ovarian failure, pushing especially if you remove the ovaries, formation of adhesions, infertility as well. Good. So, um how are we doing for time? Okay. So we can go through some of this. So just quickly going through vaginal discharge of the common causes of vaginal discharge. It could just be physiological candidate, trichomonas, vaginalis PV. These are the most common ones less commonly. Obviously, you've got gonorrhea, chlamydia, ectropion in foreign body and always think could this be cervical cancer? Uh So non sexually transmitted ST ice, you've got BV, which is basically uh loss of the lactobacilli in an increase in the anaerobic and BV, associated bacteria inside the vagina. You've got something called um cells criteria, which is all of these things. Basically thin white discharge clue cells when you look under the microscope and vaginal ph over 4.5 and you treat that with oral metroNIDAZOLE. Can the diocese spit more straightforward. It's your white discharge. You get itching, you cheated with clotrimazole, pessary or oral fluconazole. Do you guys know what you use in pregnancy for Candida? Anyone know? So you can't use fluconazole and pregnancy. So you give them clotrimazole pessary. Yeah, exactly because fluconazole is contraindicated in pregnancy. Um So I might just go, might just skip this slides, just going through chlamydia and gonorrhea, trichomonas, herpes and syphilis. I've got a useful slide here. So when you guys get the side, you can just have a look through and it basically just tells you what the clinical features are and how you would treat it fine. And these are just some questions that you can go through. Uh fine. Let's do this. I think after this is only one, there's only two more Ancic you questions and then we can finish. So you've got a 27 year old woman with A B M I of 18 referred to fertility clinic after failing to become pregnant after two years of trying with her partner, male factor infertility has been ruled out and you expect the patient's low B M I may mean that she's not ovulating. So which hormone do you measure on day, 21? So let's say she's got a 28 day cycle. Which hormone do you measure a day 21 to test for ovulation? Okay. So, uh most of you guys have said B which is the correct answer. So it's just progesterone and the reason why I said 28 days. So basically, it's essentially if you've got 35 day cycle and you measure it seven days before your menstruation, basically. Um So the answer is progesterone. So it's day 21 someone who's got 28 day cycles good. Um Fine. So fertility, basically, there's five basic factors to examine. Are they actually ovulating? Is there anything wrong with the uterus? So any fibroids and you transept them anything wrong with the tubes? So, is there P I D which is why you do the HST to basically check and that's basically where we inject the dye and check the patency of the tubes. You want to look for the diet kind of spilling out of the tubes or is it mail factor as well? Uh Peritoneal factor is endometriosis and unexplained. Actually seen up to 30%. These are the kind of things that you have to think about ovulation, uterus tubes. Male factor, peritoneal factor and unexplained. And these are all some of the investigations that you would do in a fertility clinic to assess for fertility. Okay. So, next one, I think this is the penultimate one you guys will be happy to know. So 63 year old Nulla Paris lady presents to her GP with symptoms of abdominal bloating and diarrhea. She's called family history of I B S. Uh examination, abdomen, soft, nontender. She's got a palpable pelvic mass. Which one of the following is the most suitable next step come. Uh ok. Got a few responses. I'll just wait for a few more. Okay, great. So it looks like most people have said B which is the correct answer. So you measure see a 1 25 and refer her urgently to gain good uh very in cancer. So just remember in someone who's over the age of 60 any kind of new onset abdominal symptoms, you kind of want to think could this be ovarian cancer? Just because it presents quite insidiously and usually by the time you have symptoms, it's quite late. So actually, it's quite uh it does have a high morbidity and mortality. Actually risk factors, the braca one and two, both of which increase the risk of ovarian cancer braca one more so than braca too early menarche, key, late menopause and Nahla parity as well has very, very clinical features I B S like investigation, see 1 25 but just know that it can be raised in menstruation, benign ovarian cysts and endometriosis, trans vaginal ultrasound scan and it spreads directly. So um the blood supply to the ovary comes directly from the IOTA which is why the lymphatic spread is para iota. That's the way that I remember. Um and it spreads kind of directly within the pelvis and the abdomen. And then later on, it's kind of uh it spreads to the lymph nodes as well. So, periaortic lymph nodes and blood borne malignant features on imaging is if you've got rapid growth, societies advanced age, if you've got in assist, if you've got bilateral solid kind of components and increased vascularity as well, all of those things are malignant features of assist, which means which increase your suspicion of it being cancer and management is basically surgery and chemotherapy. So, cervical screening, so essentially with cervical screening, the thing that you guys need to remember is you've got this high risk HPV, which is basically used as a triage because if you're negative for high risk HPV, then you just returned to normal record. And that's three yearly if you're between the ages of 25 50 and it's five yearly for between 50 to 64. And then you only go for cytology if you've got high risk HPV. And it's actually a cytology is normal and HPV is negative, basically return to normal recall. If your HPV positive and your psychology is normal, then you want to repeat your smear in 12 months. And if you've got to, sorry if your HPV is positive and you've got it. You've done, you've done a smear that smear was, the psychology was normal, then you're still HPV positive. You basically would do a colposcopy essentially, if you've got two of them, which are still kind of positive. If you've got borderline or low grade cytology and your HPV is negative, just return back to normal. Recall. If your HPV is positive with borderline or low grade cytology would go for, go for a colposcopy. And this is a bit more straightforward because anything high graded, basically negotiate for colposcopy. Um If it's an inadequate sample, you can just repeat the smear in three months. And if it's still an inadequate, if you've got to inadequate samples, you basically again, uh go for colposcopy. Uh This is just something that you guys will have to kind of learn in your own time, but this is just a useful table to kind of think what happens in this case. So you can you or you can just draw like a flow diagram as well. That's a good way of remembering it. Um And on colposcopy, you can get different diagnosis. You can have CIN 12 or three, CIN one, you usually observe CIN two or three, usually treat that with less and treatment for c again, if you have been treated, you usually do a test of cure smear test in six months time, suppose any kind of treatment. So you've got 27 year old woman who attends Colposcopy as she noted moderate dyskaryosis on her recent cervical smear on colposcopy. She has acetowhite changes and you do a punch biopsy followed by treatment which is the cold coagulation histology of the biopsy show CIN two. When would she next be offered her cervical screening? This is your last question? Mhm So the correct answer is see, so six months. So if you kind of go back um she's had treatment for her C I N which is why you would do a follow up test of cure smear in six months. Um Good. Um Does anyone have any questions? Sorry that I think that was quite fast at certain points, but you guys can go back and hopefully that was sort of revision and it wasn't too much of like new content. So you guys were able to keep up, but of course, I'm happy to send the slide so you guys can have a look through some of the tables and stuff. Um Any questions uh Frank. Thank you so much for that. That's okay. I was absolutely fantastic. We'll get you get the slides across to us and then kind of send them out to everyone who attended. Amazing. Yeah, afterwards to arrange that. Thank you guys all for attending as well. We've sent the feedback form in the chat. Um So do you please fill that out? It really helps us and just in terms of future events, we've got Psychiatry on Wednesday at 6 30. So I hope to see you all there. Thanks again because that was really no worries. Thank you and that's just some useful resources that you guys have probably come across already. Um Yeah. Thank you. Thanks everyone. Thanks for participating as well. It definitely makes a difference and asking all the questions and stuff. Thank you. Thanks guys.