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Ok. Can you hear me still and see my slides? Ok. Hi everyone. Um, so I'm Ruth and one of the F ones. Um, I'm gonna be the teaching today on OBS and Gyn could someone just put in the chat if they can hear me and see my slides? Um, and I'm with C who do you want to introduce yourself? Cat? Yeah. Hi Yvonne. I was actually here for the last um, teaching session but my wifi was utterly terrible. So, um, you guys didn't get to see my face, lucky you. Um, so, so yeah, I'm, my internet is fine today, so I've just come and say hello and I'm gonna be, er, Manning the Q and A chat. So, um, I can see no one yet just put, if they can hear or see us, I'm gonna assume that we can, but could we just get someone to say they can hear and see us? That would be great. Um, and what I'm trying. So, yeah, I'm um like, yeah, thank you, Harriet. So, um, I'm an F two in Princess of Wales in Bridgend at the moment doing respiratory. Um, and I will let Ruth take away but please put any questions in the chat and Ruth isn't doing an amazing job of teaching us all about. And Gyne I've seen the slides and they're pretty awesome. So good to go. OK, Fab and also Sarah is here but her wifi is a little bit um on and off so she might be replying in the chat as well. Um OK, so S and Gyne taking, so let me just go to my slide. Can you see them moving? Yeah, we can. So OK, fab. Um So I'm just gonna go over a quick recap of the standard history taking and then I've got two Gyne cases to go over and then two obstetric cases and then I've just listed some other common Obs and Gyne presentations that you might want to revise as well. Um So this is your standard history that you're gonna do in the EG which I'm sure you all know very well by now. So you start your open questions, you use your Socrates if they're in pain or you want to explore their symptoms, you then go on to a systemic review. Move on to a past medical history, surgical history, drug history and allergies, family history, social history, and always remembering your eyes as well. So this doesn't change when you're doing an Obs and Gyne history, but we just have some more specific Obs and Gyne questions that we will include in these histories, which I'm gonna go through today. So the first case that I'm going to go through is you're a medical student on clinical patient in the hospital and you're in a Gynae outpatient department. Charlotte Brown is a 32 year old female who's been referred to by her GP complaining of worsening menstrual pain. So, based on this, does anyone have any differentials that they might be thinking of for a patient with worsening menstrual pain if you have any ideas, just put them in the chat Cath if you let me know if anyone says anything. Yeah, no problem. Can you see the chat ruth? No, I can't. No worries. I will. No, we haven't got any answers yet. I'm sure they'll come flooding in. Um or femur with this thing. We've got uterine fibroids, endometriosis. Those very good ones. Yeah. And those are the two we've got so far. Great. So you just wanna be thinking of different differentials before you go into the station. Um Because this can help you narrow down the questions that you're gonna be asking and just like get you ready for the station ahead of you. Um So is, does anyone have any like questions that they might wanna ask as patient? Anything in specific you'd wanna ask? You put them in the chart and then I can go through some of the key questions to ask. What sort of things would you wanna be asking this patient if she's got worsening menstrual pain? No, just one just popped in. Now. Are they pregnant? When did it start? Uh Yeah, sorry. Does anything make it better? Um, or could they be pregnant? Does she have, does she have regular periods? Family history of cancer, any bloating? Yeah. In fact, they're all really great questions that you're going to be asking. Um, so thank you everyone who put in some answers. So, if you just had another one, that was a very good one up to date with smears, yes, that's a really important as well. Yeah, fab So that's a really, they're all really good, good things that you're gonna be asking all your histories. And I think most of the time if you get a Gyne history, it probably will be seven minutes because there are quite a lot of questions that you're gonna be wanting to ask. Um, so I'll just go through some of the common areas that you want to cover. So, um, you want to ask about their sexual history? So, are they sexually active? Are they using contraception? Um, do they have any pain, um, when sexual intercourse? So this is called Dyea. Um, or if they've got any like postcoital bleeding at all, like someone said in the chat, um, whether they're pregnant, whether they've had any previous pregnancies, any terminations, um, or any miscarriages, this is really important to ask. Um, and in some issues as well, you want to know whether they've been tried to conceive because this can also be important if they're um struggling to conceive. Um As someone else mentioned as well, you want to be asking about their cervical smears, whether these are up to date. Um And then you want to get a bit more history about the um menstrual cycle, like someone said, so how heavy their periods are, how regular they are when their periods started? Um And that sort of thing as well. And also just any other like, hi um Gyne questions. So like if they've got any vaginal um, discharge, um al like along those lines. Um So this is the patient's history. So she's come in with constant abdominal pain, um associated with menstruation. So this chronic dysmenorrhea, she's also got pain and defecation. She's got a regular period. Um But they're very heavy. Um, can't use tampons as they're too painful. Um She doesn't have any spotting in between her periods and she's currently sexually active with a long term male partner. Um, but she does get pain during sexual intercourse. Um She's not on any contraception and she's been trying to get pregnant for the last two years. Um So this is a sub infertility. Um and she previously was on the combined or oral contraceptive pill, but the pain has got worse since coming off the pill. Um She's not had any previous pregnancies, miscarriages or terminations and she is up to date with her sub smears um on further questioning she doesn't have any other symptoms to note. Um, her main concern is that her periods are really bad and they're becoming unbearable. She doesn't have any past medical history. She's taking Ibuprofen and paracetamol for the pain. Um, but no allergies. Her mother had breast cancer at 55 but she's now in remission. Um And again, it's important to ask about the social history and the ice. Um, she's working in retail, but she's having to take 2 to 3 days off a week due to the pain and her boss is getting frustrated with her. Um So based on that history, does anyone know what your top would be in this case? What do you think is going on with this patient? Any answers? K what would you be giving your differentials to the exam? And I can go back, I think a few people have written endometriosis. Ok. Fab Yes. So that is the correct um differential. So, endometriosis. Um So this is when um areas of, of the uterus um kind of implant outside of the uterus and causing severe pain. Um and just going back to um her presentation. So, some of the common symptoms of endometriosis, um if you get um pain and sexual intercourse, you can also have pain and defecation. Um She may be often patients have difficulty conceiving. Um And the combined oral contraceptive pill is one of the management options for um endometriosis. So often if they come off the pill, they may, um, the pain may have worsened. So, does anyone know any investigations that you'd want to do for this patient? Um, or any investigations for endometriosis? If you put them in the chart, any ideas? Let me have a look. No. Ok, I'll do some investigations. Um, so just remember your B boxes. So, um, you'd want to do your bedside, um, investigation. So, um, you do want to do a full abdominal examination, including possibly apr exam as well. She's got pain and defecation. You'd also want to do a speculum and bimanual exam if it's not too painful. Um And then your other vital signs urinalysis. Um You'd want to check if she was pregnant and get a vaginal swab. Um You'd also want to get some um blood to look, just look, look for a baseline if any signs of infection or anemia, if she's got heavy bleeding. Um And you also want to look for coagulation screen if, as she is having heavy bleeding in terms of imaging, you'd want to get a transvaginal ultrasound. Um And you can also consider pelvic MRI S in endometriosis. Um And then in terms of special tests, the gold standard um diagnosis of endometriosis is a diagnostic laparoscopy. Um And then moving on to the management of endometriosis. Does anyone know any management options? I've already mentioned one. Oh, I've just seen the um investigations in the chart. Yeah, they're all correct. Like you said full history and exam, ultrasound observations. Great. Someone's had surgery for the management. Yeah, that's one, any other options you can use in endometriosis? So, our mind that dropped down over the roof. So we've got, um, ultrasound pelvis and obs for the investigations for surgery, laparoscopy slash hysterectomy, um, combined oral contraceptive pill as well. Yeah, fab. So they're all really good management options. So, when you're doing your ki and presenting it, remember to use your conservative medical management to help you remember everything when you're going through it. So in terms of conservative management, you'd want to give the patient information about the condition. You would want to refer them to a gynecologist. Um You might consider a fertility referral in this case as, as patients trying to conceive. Um and you'd also give them lifestyle advice. So weight loss, reduce of alcohol, um smoking, et cetera and then in terms of medical management, so you'd want to give them some analgesia for the pain. So the first line in endometriosis is nsaids, um you can also try mefenamic acid. Um And if they are using nsaids, long term, you might want to consider using a PPI um to cover them. Um You can also use transam acid for menorrhagia. So they're heavy bleeding and they take this when they're menstruating. Um and then hormonal contraception, like lots of you have said is the combined oral contraceptive pill. But again, this can get difficult if the patient is trying to conceive. Um, other options also can include, um, the GNR H. Um, so these a agonists, um, again, they're contraindicated, they're trying to conceive. Um, and you might consider IVF they're trying to conceive. And then like lots of, you said surgery is also an option for endometriosis. Um, so you can have a therapeutic laparoscopy, um, to excise some of the endometriosis and it's often used if patients are trying to conceive. Um, and you don't want to use the hormonal um options and you can also consider a hysterectomy if it is severe and all um other options have been exhausted or it's the patient's wishes. Ok. So is there any questions about that case before I move on to the next one? We haven't had any questions, but I've just added to the chat, um, that it's a really good um, point to say patient information is really good and patient education is really good for any condition actually. And with endometriosis, you can, um, pain is the main symptom as heavy bleeding. But pain is the thing that should lead you towards endometriosis. And a specific thing for endometriosis as well is pain during sexual intercourse and pain on opening your bowels as well. So those key sort of um buzzwords that like, yeah. Yeah. No, exactly fab. Ok. I'll move on to the next case. Um So the next case, um you're in a GP practice and Jean Smith is a 63 year old female who presents with urinary symptoms. So, what sort of differentials would you be thinking about before you go into this station? If a 63 year old female comes in with urinary symptoms? Any ideas? Pop them in the chart? Yeah. Yeah, I've seen some people have said uti, great. So, yeah. So you want to thinking about UTI, so you're gonna move on to your gyne questions that we've already talked about. So it's the same for all your gyne um history taking that you do. So you wanna ask about the sexual history, any pregnancy terminations, um whether they could be pregnant at all? Ask about the cervical smear and also ask about the um menstruating. There's also one other thing you want to ask in this patient that you wouldn't have asked to the previous patient um as she's older, does anyone know what sort of questions you're gonna be asking an older lady and a Gyne history about? Yeah, menopause. Yeah, fab. So you wanna be asking about the menopausal symptoms in um older people? Um So you wanna ask about when the menopause started if they've had any um postmenopausal bleeding and if they've had any um like H RT at all. So, um this patient's come in with a sudden need to pass urine. Um It's gradually got worse over the last three months. Um And she's not been able to make it to the toilet on a couple of occasions, um, no increased frequency, but I'm passing normal amounts of urine and there's no symptoms when she's coughing or sneezing. She doesn't have any symptoms of dysuria and no vaginal discharge. How she does have vaginal dryness and itching. Um, there's no abdominal pain and no dragging sensation or bulge. She was menopausal 10 years ago and hasn't had any HRT otherwise, her menstrual history is normal. She's not currently sexually active and she's had previously three Children um by vaginal delivery with no complications. She had one previous termination in the past. In terms of her past medical history, she's got asthma hypertension anxiety. She had an appendicectomy as a child. Um She's on Salbutamol and amLODIPine. No family history of note. And again, the importance of asking social history. So she lives with her husband, um drinks a glass of wine a night and drinks four coffees a day and it's having a big effect on her quality of life. She's taking time off work due to embarrassment, not been going out and it's affecting her mental health. So, based on what I just told you and this history, what does anyone think of some differentials now that we've had this, we've asked these questions. So we've got urge incontinence so far, atrophy, vaginal atrophy. Um Yeah, urge incontinence and vaginal atrophy are the two ones and prolapse as well. Fab Yeah, they're all really great differentials. So in this case, um this patient does have um urge incontinence. So there's two different types of um urinary incontinence, urge and stress incontinence, which I will go into a bit more detail in a couple of slides. Um But urge incontinence is when you get an increased, like a sudden urge to pass urine. Um whereas the stress is when you um like cough or sneeze and you pass urine. Um and like someone else has correctly said that also is um vaginal atrophy. So this is when you get um dryness and like itching of the um vagina and it's caused you to low estrogen often in menopausal. Um women. Um and vaginal atrophy can contribute to urinary incontinence. So that's why it's important in this case. Um And um someone else did mention vaginal prolapse. That's a really good thing to think about as well. Um And it's a good differential and you want to be asking about whether they've got any like dragging sensations or any bulges as this can lead you towards that as a differential as well. Um So does anyone know any investigations that you'd want to do for um urinary incontinence or vaginal atrophy, remembering your B boxes. So we go after exam U and MC Ns um the gile swab. Yeah, fab they're all really good investigations. So I'll just go through them now. Um So like you said, urine dip the urine MC Ns because you want to exclude any infection cause a lot of, you said uti at the beginning. So this is a really important differential to exclude. Um you also might want to do some bloods just to get a baseline check for infection. Might also want to do a HBA1C and glucose to check for diabetes because you can often um have symptom you like urinary frequency and diabetes. Um You might want to do a vaginal swab, like you said, maybe a specular and bimanual examination as well. In terms of imaging, you can do a post void bladder scan. Um and then your special tests. Um If anyone presents with um urine incontinence, you want to do a bladder diary for three days, doing normal activities um to get them to monitor um when they're um having these episodes and how much they're um drinking during the day. Um So this is just a quick recap on urge versus stress incontinence. So, urge incontinence is an involuntary leakage accompanied by or immediately preceded by a sudden compelling desire to pass urine which is difficult to defer and this is due to the overactivity of the detrusor muscle, which is the muscle that surrounds the bladder. Whereas stress incontinence is the involuntary leakage on effort or exertion or on sneezing or coughing and is due to a rise in intraabdominal pressure and we can damage urinary sphincter. So the muscle which prevents urination. Um So it's really important that you can um differentiate between these two types of incontinence and when you're taking your gyne histories. It's really important you ask questions to show the examiner that you know, the difference between these and that you're um thinking about the measure of differentials and that's just a little image of them. OK. So moving on to the management of urinary incontinence, does anyone know um some management options for urge and stress bearing in mind? Um The management options are different for both of them. Any ideas? I know some of you won't have done S and G yet. Um So we've got pelvic floor exercises for the stress. Yeah, perfect. Uh Blood training, oxybutynin and uh Mary Ba Yeah, perfect. They're really good management options. So, in terms of urge incontinence, so, um you again, you want to go through your conservative medical and surgical options. So conservative, you want to tell the patient to reduce the alcohol and caffeine intake because this can worsen incontinence. Um And then for urge incontinence, you want to do a six week bladder retraining course. Um And medical management includes antimuscarinics like some of you have said oxybutynin and Mira one. Um And you also want to remember to treat any associated conditions. So, in this patient, you would want to give intravaginal estrogen therapy to treat the vaginal atrophy. So when you're doing your is try and remember anything else that's associated with it or worsening it. And then in terms of stress incontinence. Um So again, remember your conservative management also in stress, you might want to advise to lose weight. Um And then the mainstay management is three months of supervised pelvic floor muscle retraining. Um You'd also want to refer them to a gynecologist um for surgical intervention as this is first line. Um But if the patient declines medi um surgical management or they're not suitable for surgery, then you would treat them medically with DULoxetine. But this is second line. Have um any questions on that case or anything you want to add Kath or Sarah. Nope, no questions and nothing really to add. I think you've covered everything. Yeah. Ok. So moving on to the um obstetric cases now. Um so the first case is um you're on placement in an obstetric assessment unit. Katie Brown is a 27 year old pregnant female presenting with abdominal pain. So, what are your differentials before you go into the station? Bearing in mind? There's probably quite a lot of different things. This could be any ideas, put them in the chart. So we've got pregnancy ectopic miscarriage one to see. Remember it could be anything. Yeah. Obstetrics. She could have pancreatitis. She could have uti there we are um Citi Yeah, fab. So yeah, they're all really good differentials and I think it's quite hard as well in this one to think of them because you want to know where, how many weeks pregnant she is. And once you know that you can narrow down your um differentials Um but yeah, like I always remember your um like medical courses of abdominal pain, um as well cause like it could be anything as well as well as all the obstetric conditions. Um So what sort of questions would you want to be asking this patient? Any i any sort of questions or obstetric focused that you're gonna be asking in this history? What do you wanna know about this patient's obstetric history? So, last menstrual period, how many weeks pregnant, uh, on any new medications? Yeah. Yeah, they were really good suggestions. So, yeah, I'd say the first thing you want to ask in an obstetric history taking is how many weeks pregnant they are because like I said, this can really help narrow down your differentials because if they're in the first trimester and early on, it might be more likely to be miscarriage, um, like topic pregnancies. Whereas if they're, they're like 3536 weeks pregnant, then you might be thinking of other differentials. Um, like preeclampsia and that sort of thing. Um, the other thing you want to ask about is how many scans they've had. Um, so usually in pregnancy, if it's an uncomplicated pregnancy, um, patients will have two scans. So they'll have the 12 week dating scan and then a 20 week, um, screening scan for like any abnormalities. Um, and this can give you a really good idea of whether there's any complications going on so far because if they say they've had more than two, then you start to think, oh, why they had more scans, um, whether it's a multiple pregnancy or whether there's been any complications at all. Um And then a really important question to ask, um, in obstetric history is especially if they're over, about 20 weeks is about fetal movements. Um So always remember to ask this and whether this has changed the pattern at all. Um You then want to ask some questions about any symptoms um that you might get in um pregnancy. So if they've had any spotting, any PV bleeding, um if they've got any like headaches or leg swelling, um I like uh ask more questions about the abdominal pain as well and any vaginal like discharge as well. Um You also want to ask about if they've had any previous pregnancies, um any previous miscarriages or terminations. Um And if they have had um previous pregnancies, you want to know whether there's any complications in these pregnancies, how the babies were delivered? So, were they vaginal deliveries or what did they have ac section? And if they had ac section, was there any reason why they had ac section? Wasn't it emergency or was it just routine? And then another important question to ask in obstetric histories is the rhesus status. And then just put these here. You also wanna ask a few of your Gyne questions. So you want to ask about their sexual history. Um if they're, if they're, um, having any pain or, or if that sort of thing and also if their cervical smears are up to date. So this patient, um, is 36 plus three weeks pregnant. She's got a single baby. She's grava one para zero. she's got sudden severe abdominal pain associated with PV, bleeding, but regular fetal movements. She's not got any, um, urinary symptoms and she hasn't lost any clear fluid. She's rhesus negative and currently had two scans with no complications but did have some spotting in early pregnancy. But this was checked and there's been no further issues. This is her first pregnancy. She's not had any previous terminations or miscarriages. She's got no visual changes, headaches, her leg swelling and she's up to date with her sub. In terms of her past medical history, she's got depression anxiety. She takes sertraline, no family history. To note she is a current smoker around a 10 year pack history but hasn't drunk any alcohol. And she currently lives with her partner and feels safe at home. And her main concern is whether the baby's gonna be ok. So what would be your top differentials are in this um presentation? So threatened, miscarriage, placental abruption any more. No more yet. But I'm sure everyone's thinking oh previous or percent previous. Yeah, fab. So this is placenta abruption um as your top differential, but it's really important to mention other things that placenta previa. Um and someone mentioned such a miscarriage. Um I think that would usually be a bit earlier on if there were a few less weeks pregnant. Um, but it's a good thing to be thinking about if they're having bleeding um, in pregnancy. Um I also just wanted to go back to quickly before we move on. Does everyone know what grava one and para zero mean in terms of um pregnancy? So gravel one is just like how many times have been pregnant and then the priority is how many times I've given birth um to a fetus over 24 weeks. Um regardless of whether they were born alive or whether they were still born. Um So if you can include that in your presentation at the end, in your summary, at the end of the excusation, then that looks really good. Um The exam to the examiner looks like, you know what you're talking about. Um So that's really useful to say at the end. Um And again, I just wanted to mention on this one. I've highlighted the feel safe at home. I think this is a really important question to ask in any obstetric history. Um and also in any pediatric history. Um I think it's a really nice question just to say, um, do you feel safe at home? And it gives you an insight into whether it could be any like domestic violence concerns? Um And this again just shows to examine that you are exploring these areas without being too much of an invasive question. So, moving on. Um, does anyone have any investigations that they would want to do for someone with suspected placenta placenta abruption or like placenta previa? We've got ultrasound pelvis. Yeah, that's a good one. Uh, cross match of blood. Yeah, that's good. Yeah, that's really important if they're bleeding and with blood. What do you think of with just giving a tip to everybody if you're thinking of bleeding? Yeah. PBG is a good one. Yeah. What should you check if you've, um, if there's bleeding, um, how can I get more of a tip? It's type of blood type FBC. Yeah. Yeah. Good. Yeah. Hemoglobin. Yeah. Yeah, that's good. Yeah, that's it. Rhesus. That's what I'm going for. Sorry. My tip was a little bit vague. Yeah, fab, so they're all really good ideas. So, um, like I say, when you're doing your investigations, just go through your B boxes. So you're gonna do the general, um, bedside investigations, um, including a speculum examination. Um, you'd also want to do, um, your blood. So, um, like coag screen cross match group and same, like someone said, um, you might do a vaginal swab and also a speculum. Although I think a speculum is contraindicated if you're suspecting placenta Praevia. Um, in terms of imaging, um, you'd want to do possibly a Doppler ultrasound of the fetus to check. There was no concerns with the fetus. Um, and you can do a CTG to check the fetal um tracings. Um And then in terms of the month that you do a transvaginal ultrasound, although this is much more useful for placenta previa rather than placental abruption. Um And then just in terms of special tests. So the K how test is what's used to determine the amount of anti da mother needs um if they are rhesus negative um fine. And then, so now I'm just gonna quickly recap um antepartum hemorrhage. So this is bleeding from or into the genital tract occurring from 24 plus weeks of pregnancy and prior to the birth of the baby. So, there's three main antepartum hemorrhages that you want to be aware of. So, the placental abruption which we've talked about. So this is painful PV bleeding. Um on examination, it often said that they have a hard woody uterus uterus and this is defined as separation of the placenta from the uterus wall. Um Placenta Praevia, which I've also talked to about. So this would usually have painless PV bleeding and a non 10 uterus. And this is when the placenta lies over the subcourse. And then the third one, which I think is also important to be aware of is vasa Praevia. So this is when you get painless dark red vaginal bleeding. Um as it's the fetal blood, um you also get fetal distress. So this may present as fetal bradycardia or tachycardia and it's often described as a vous umbilical cord. Um and this is when the fetal vessels travel across the cervic walls. So these are the three main ones that I would be aware of in your iscu. So, moving on to the management, does anyone know some management options for placental abruption? What would you do for this patient? So you've got at the urgency section. Yeah. Emergency section. Yeah. So far. Fluids. Yeah. Recess. Yeah. Yeah, fab. So when you're presenting this to the examiner, remember to go through it systemically um in a systematic approach. So you're gonna sort of get a two approach, you're gonna get your seniors involved straight away. So you wanna get the obstetrics team and the pediatrics team. In this case, you would put out a major hemorrhage protocol because they're likely gonna be bleeding um significantly. You'd want to get the patient lying in the left lateral position and get two wide ball cannulas in. You then want to resuscitate the patient with either IV fluids or blood depending on what's available. Um It's also important to consider um steroids for the mother. And if the fetus less than 37 weeks as this helps the lungs develop of the baby, um you'd also consider anti D if the patient is be is negative. Um and then you would have very close monitoring of the mother and um fetus and if there is fetal distress, then you would want to do an emergency C section. Sorry, I just, just to reassure people as well that you absolutely would never ever, ever be expected to, to manage this patient on your own. Um And, and one thing as well is that when you're in the exam in the scheme, remember that you're 1/4 year medical student. So when you introduce yourself, it's probably been told us already. When you introduce yourself, you're gonna be 1/4 year medical student, not an F one or an F two. But what they want to see from you guys is that you are safe. So if you had this patient and you didn't mention get senior support, that's a big red red flag because that insinuates that you'll be dealing with this patient on your own. You may have some absolutely brilliant nurses there but you have to say seek senior support. You basically, if you think right, start with A to e seek senior support, they will just give you tick tick. So remember that and you don't even need to worry about about the emergency C section. Yes, they would have that. But the main thing that's really, really, really important is that you do at e seek support, a major hemorrhage protocol, that's essentially gonna get you the help that you need, that will eventually lead to an emergency C section. Yeah, and that again, that can be used for any condition that you um acu station. So A to e senior support and and like you said, Ruth White can blah, blah, blah, all that. But that's what you need to remember. Don't worry too much about the intricacies of the, what kind of C section and all this, but just the basics, that's what they, yeah. No, I totally agree with that. C, um, they just wanna know you're safe. Um, and if you can't remember the intricacies of the management, as long as you say, these things that are safe, then that's what they're looking for. Great. So, moving on to the last case now, um so again, you're in the Obstetric Assessment unit, Eloise Parks is a 33 year old pregnant female presenting with reduced fetal movements. So, any differentials for what could be going on with this patient. Um So if she's got reduced fetal movements, probably telling you that she's later on in her pregnancy. Um And this is a really, really common presentation. I don't know if any of you have done your obstetrics placement yet, but when I was on obstetrics, most of the women that were coming in were complaining of reduced fetal movements. So it's a really important one to be aware of. Um I got miscarriage Illegal Hydro. Oh yeah, those two so far. Great. Um So again, um you're just gonna be wanting to ask your Gyne questions that we've talked about already. Um And again, uh sorry, your obstetric questions and also some of your Gyne questions as well. Um and in particular, if they're having reduced fetal movements, you just want to know what the regular pattern is, how long they haven't had the movements for. Um, and any other symptoms that they might be experiencing. So, for this patient, she's 34 plus five weeks pregnant, um, of a single fetus, she's grava two para one. she's not felt the baby move for over 12 hours, which is unusual for her. Um, She's got general fatigue. She's also very itchy, especially on the palms of her hands and soles of her feet and it's particularly worse at night. She doesn't seem to have any rash, just some scratch marks from itching. She's got no other um symptoms to note no PV, bleeding, no headaches, visual changes, no dysdera. She's had two scans and no complications. So far she's had one previous pregnancy seven years ago, which was an emergency c section due to failure to progress and she did develop postnatal depression. She's up to date with cervical smear and she's research positive. She's got a past medical history of anxiety and depression takes citalopram. She's also taking folic acid up to 12 weeks and she's not currently taking aspirin. She's got no family history to know and does not know in the family that's had preeclampsia. She lives with her partner and her child who's seven years old. She feels safe at home and she's not drunk any alcohol or smoked and she's an exsmoker. Her main concern is that the baby's died and is it all related to this itching? Um, so any differentials for this patient? This is a bit more of a tricky case. I think. So. Any ideas of what might be going on? The big clue here is that she's itchy. Yes, that is the big clue. That's the thing, the thing, you know why she mentioned that that's random. But they wouldn't give you just random information. Yeah. I think that's a really important point. Actually, everything in the is, is usually very relevant. Yeah. So we got, yep, cholestasis of pregnancy, some liver problem. Yep. Good cholestasis, fatty liver disease. Um Great. Yeah. So the um top differential would be um obstetric cholestasis of pregnancy. Um and also some other differentials in terms of the liver and pregnancy. I've just put some here. So it could be viral, hepatitis, acute fatty liver of pregnancy, hellp syndrome, autoimmune liver disease, drug induced liver disease. Um and polymorphic eruption of pregnancy. Although if they had this, they would have a rash. Um And before we move on, I just wanted to go back quickly to this slide. Um So I'm sure you all know why they take folic acid um is to prevent neural tube defects. So it's always good to ask us in your histories um whether they've been taking that and it just looks good to the examiner if you ask that. Um But does anyone know the relevant of the relevance of asking about whether a patient's been taking aspirin you have of aspirin in pregnancy. Any ideas? We've not got any other? 00, someone's put protective, but is there any reason why uh we've got preeclampsia? Yeah. So it is, it is protective for preeclampsia. So if patients are high risk of preeclampsia or they've had previous preeclampsia, patients will take aspirin from 12 weeks until um they give birth. So that again, if, if it's a preeclampsia history, you want to be asking about that. Um I don't actually know what makes them high risk, but there's a, there's like a, a performer of who's high risk. So you can have a look at that. I think it's to do with like previous high BP failure who had it. Um I think maybe certain of this is more likely but yeah, I think they're the usual ones. Um But it looks really good if you ask in the history if they've been taking aspirin because it makes the examiner think that you've been thinking about preeclampsia as a differential and as a completely and utterly side note. Sorry, I wrote to go um Aspirin, you're not meant to give to Children. Um Anyone know why please put it in the chat now. Um So you're not meant to Children under, I think it's six off the top of my head. I don't know. Don't quote me, but yet good. Exactly. Ray syndrome. That's why you don't give aspirin. However, there is one exception where you can give it. Uh What is that? This is very neat. I've never met anyone with this condition but it, yeah, we are Kawasaki just for your progress test questions, guys, you can give aspirin for Kawasaki, but that's the only reason you could give it to Children. You should not be giving it to Children otherwise. Right. Sorry. Ruth. That's very much. That's apes tangent. That's OK. OK. So just a little outline of obstetric cholestasis. Um So this also known as intrahepatic cholestasis of pregnancy. Um It's characterized by reduced outflow of bile acids from the liver and it commonly resolves after delivery of the baby. It is a relatively common complication of pregnancy and occurs in around 1% of pregnant women. It usually develops later in pregnancy. So, after 28 weeks, um and the build up of the bile acids in the blood is what causes the classic symptoms of itching. And the relevant of this in this case is it is associated with an increased risk of stillbirth. So, um patients may present with reduced fetal movements and it's important to remember that um it does have an increased risk of stillbirth. So, does anyone have any ideas of what investigations you'd want to do for this patient? Oh, for obstetric cholestasis. So we've got bilateral levels, uh immediate abdominal ultrasound. Yeah, they're both great, great things that you're gonna be doing. Um So again, just go through your B boxes. So, one of the, one of the most important things you want to do for anyone that presents with, um, reduced fetal movements is you want to check the, um, fetal heartbeat straight away. So you probably do a Doppler to assess this or do a CTG as well. Um, and you want to reassure the mother, um, and check that the fetus isn't in any distress. Um, also want to just do your usual bedside investigations, want to get your baseline blood and in this, it's really important to get your LFT S and your bile sorts. Um I think they're the main ones and they just put here that um, your A L TA LP and bile salts will all be elevated in obstetric cholestasis. So, in a um station for an SQ, they might give you some liver function, um, test results. Um And if these are all abnormal, then you would be thinking about obstetric cholestasis. And then lastly, does anyone know any management options for obstetric cholestasis? How would you want to manage this patient? We've got someone saying delivery. Yeah. So you would consider um delivery of the baby. Uh I'm not even gonna tempt to say that, but II know what it is, but I can't say it is. I don't think I can say that one. Yeah, fab. So again, like we said earlier, go through your usual steps. So you want to do an ad approach, inform your senior, um confirm the fetal heartbeat initially and confirm that the baby's not distressed. Um You'd want to monitor this um patient um closely as well for 48 hours. And then the medical management on is this uh medication that I also can't say very well, your sux acid. Um and the management of the um itching, you'd also want to manage that. So you can use antihistamines like pyriton um and calamine lotion as well. Um You want to do regular monitoring of LFT S up until delivery and most of the time obstetric cholestasis, you wouldn't do an emergency C section unless the baby was distressed. But because of the increased risk of stillbirth, you would want to book them for AC three C section at 35 to 36 weeks. Gestation um due to this risk of increase um due to this risk of stillbirth. Um And like I said, you'd consider um steroids if they're less than 37 weeks. Um And you can also consider Vitamin K in certain situations as well fab So any questions on that case, if not, I've just put some um or any questions at all from the, from the chat, put them in the chart. If you have any questions about anything we've done today. Um I've just made a list of some other gyne conditions to revise. So, um PCOS STIs S and pelvic inflammatory disease, you'd also want to look at miscarriage, vaginal prolapse, um and your gyne cancers and then some other obstetric conditions to revise in your own time to preeclampsia. That's a really important one to look over um preterm, premature rupture of membranes, chorioamnio itis, gestational diabetes, hyperemesis, gravidarum, and your postpartum hemorrhages and also like um cat earlier. Don't forget the, the other medical things that could be going on in gyne obstetric cases. So, uti S appendicitis, um these sort of things as well. So that's the end. Um Thank you for listening. Um Before you go, could you fill in the feedback as well as sort out as well? Brilliant, brilliant, brilliant talk as well. Ruth Thank you for that. I feel like I've learned loads as well. Um The other thing I wanted to mention is um and this is very easy to get caught out by, this is any female of childbearing age ever. Um That's with an abdo pain, just always get a pregnancy test because it could be that they've come with an, they've got abdominal pain and I think, oh gosh, ok. This is our surgical station, right? What's the surgical history? Have they got hernias? Have they got previous surgical um problems that they've been blah, blah and actually they could be having ectopic, but they won't actually say that they're pregnant. So you need to say, is there any chance you could be pregnant? And then, then the actor I go. Oh, actually, yes. So it may not be, it, it may be seen as a surgical station, but actually when you uncover it, it's a, um it's a Gyne um history. The other thing I wanted to mention is the way that I used to remember this. Um I know it's a bit crude and II apologize for this, but it's, it's a way of um it's, it's easy way to remember. So the four Bs, all right. So with any g near any obstetrics history, think of the four bs blood brush babies and bang. So blood to do with periods. Um painful, heavy, regular, irregular um any spotting in between menopause, all that brush is for cervical smear. So when you do a cervical smear, um you literally brush the cervix. So brush is to ask about your cervical smear babies is oh, sorry di into that. Um Babies is if they've got any Children, have they ever had any pre they had, ever had any pregnancies? Um Remember to ask just because they've just because they've maybe had two Children, maybe they've had 10 miscarriages. We don't know. So remember to ask how many times they been pregnant and the last one, I apologize. This is crude, but hopefully you remember it is bang for sexual history. So ask how many sexual partners do they have? Sometimes maybe they are, they have um a sexual partner of the same sex. So never ever, ever assume. Um I definitely think Cardiff could throw that in and, and just to um get you thinking. So blood brush babies and bang again. Sorry, I know it's crude, but that's how I used to remember. Always ask those questions. It's really important. Yeah, I agree with that. Ok. Thank you for that little pneumonic. Great. I think that's everything and if there's not any questions then feel free to go and if you could fill in the feedback before you go, that would be really helpful. Yeah, please do the feedback form. Guys co um, we'll put a lot of effort into that and it's something that can, it's something that you guys can do for us as well. We've given up on Monday evenings for you. So you can do a little two minute, not even two minutes, 30 seconds feedback form. Thanks everyone. We'll see you next week. I think next week is pediatrics, history taking and you know all about Kawasaki and you can give us cool. All right, great. Well done guys. Take care. Thanks. Bye.