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OK, I will continue then. Um and then hopefully this won't be a problem next time I'll get it sorted out whatever it was. Um But yeah, I'll just get cracking then. Um So postpartum hemorrhage. So the definition, by definition, if someone has five, more than 500 mL of blood coming out from their genital genital tract. So that's uh vaginal delivery or anything. Um And they have 500 mL, then that's what postpartum hemorrhage is. But then that can further be divided into primary and secondary depending on when the bleeding occurs. So, and what you do need to know is the four Ts which are the four causes of postpartum hemorrhage and they include tone. So uterine at and what this basically means is that normally physiologically when a mother is uh has just given birth, her body will contract, the uterus will contract to try and prevent blood loss. But sometimes what happens is that because of um how distressful the uh sit the delivery was, et cetera, et cetera reasons. The uterus doesn't contract and when it doesn't contract the blood still, uh you still get blood coming out and then that can cause a postpartum hemorrhage. And that's one of the most likely cause 90% of the time. That is what the problem is, but also trauma. Um again, if uh the, the delivery something happens and you get a perineal tear that can also cause a lot of bleeding. Again, retained placenta is a big cause of bleeding as well. And thrombin. So, having sort of blood bleeding disorders such as um thrombophilia, et cetera, low platelet levels, et cetera. That can also um cause it. So what you guys need to know is that if it's more than 500 mL and it's uh the genital tract, then it's postpartum hemorrhage. And it's classified as primary if the bleeding occurs within 24 hours of delivery. And it's secondary if it's um after 24 hours, but before 12 weeks and the main cause of primary um postpartum, he is uterine at and then secondary um is infection. So that's endometritis, which is inflammation of the endometrium itself from the pregnancy from the delivery or retained placental tissue. But that is less likely the case because um uh in in C sections, because if you've ever seen ac section before, what they do is that they take the baby out and then this, the surgeon would put their hand inside the uterus and put their ar uh use their hands to try and feel all the inside of the uterus to make sure that there's, there isn't any remnant of the placenta being left behind, but that's not uh possible uh with normal vaginal delivery. So instead, what they do is that when the placenta comes out, they inspect the placenta and make sure that there's no sort of like um areas missing, et cetera. But still sometimes uh you know, even doing that, um there are some placenta remaining and that can cause the secondary uh PPH. Um and then in terms of management. So with PPH management, it is really important to remember um specifically for primary PPH. So the medical treatment that we like to give is IV Cytin, which is also known, known as Oxytocin or Ergometrine. And the way they work um is they induce sort of smooth muscle contraction, UTR contraction. Uh again, which is the most common cause of uh primary PPH, which is uterine A and, and so that can help with the uterine contraction and prevent uh PPH. Again, ergometrine works a lot more faster and is a lot more powerful than Oxytocin. But Oxytocin also does a really good job and it really does depend on the case, but normally you can use either one. Um And then if medical treatment doesn't work and you need something a bit more stronger, um because 90% of the primary is due to uterine, there is something called an IU uh balloon tamponade and it works, it does wonders. I've seen it um being used and you essentially you insert it up into the uterus and you blow it up. And what that does is it, it tries to compress in all the bleeding vessel. Um, and try, it doesn't cause uterine contraction, but it tries to, um, it, uh, it tries to prevent the blood vessels bleeding by blowing it up so much that it's compressing on the vessels. Um, and then that really helps with preventing blood loss. But again, um, there are some scenarios where just because of the sheer amount of blood that's coming out, nothing seems to be working. Then unfortunately, a hysterectomy, um, has to be done in order to save the mother's life. So that's basically PPH in a nutshell. Um, I'm just gonna quickly check the charts. Um, and hopefully, uh, what is it called? If it's bleeding after 12 weeks? Uh, then I don't think it's not, yeah, it's probably not related to pregnancy. It could be something else. Um, but essentially PPH is because 12 weeks would be around, uh, three months after pregnancy. So the bleed, I, if there was bleeding, it would have occurred by then due to the pregnant due to any postpartum problem. So if it's after 12 weeks, then it's probably something else that we're looking at. Um, instead of it being pregnancy related. Um, but that being said they will probably, um, I can't say anything on the top of my head but like, uh, it's very unlikely that it's going to be pregnancy related just because it's around three months after the pregnancy and if there was going to be any bleeding, it would have been, it would have been done at that point. Um, for example, a placental tissue that whatever happens, it would have been done within the 1st 12 weeks, uh, postpartum rather than after 12 weeks. Um, so, yeah. Um, and then the two last slides are pretty easy. Uh, there's not much to go into it. Um uh This one, this one actually came up in our exams. So peripheral infection, this is essentially when you get an infection. So an infection is what, uh a temperature, which is more than 38 degrees in the 1st 14 days of delivery. And most of the time it's endometritis which is inflammation of the endometrium or sometimes it's the u uh it's a normal uti and so again, if it's an infection of the, and uh it's an, if it's an infection, you give them IV antibiotics. Um And then you would continue that until they have been afib for around 24 hours. So that's all you basically have to know if a pregnant woman has just given birth, she's seven days in and then she notices a temperature. Um then think about pal infection. The management is IV antibiotics. Um, sepsis is pretty much the same, uh whether it's a non pregnant person or a pregnant person. However, the the causes are different. So the clinical features are the same, you will still do sepsis six. But the most common causes in a pregnant person developing sepsis is normally due to uh amnionitis and uti. Um And then so yeah, so those are the two that, that's the main thing that you need to know for sepsis in pregnancy. Um is the the two causes because they are different from a a no a normal person developing sepsis, but the clinical features are the same as a normal sepsis. So, fever, tachycardia, rest rate, et cetera. Sometimes if you have the chorioam, you also have the symptoms associated with it. So that includes um abdominal pain and uterine tenderness. Um and then last of all, but not least uh preterm, um prelabor of membranes, rupture of the membranes. So this is where you, your water breaks a little bit earlier. Um and you don't really need to know about the complications, but it's nice to have a little bit of an idea about what can go wrong if this happens. Um And so most of the time for females, you can get inflammation of the amniotic fluid. Um and the chio uh which we call chorioamnionitis and then for the fetus itself, um because the because the water has broke, which protects them, it can cause prematurity. So they may be, they may have to be delivered much more earlier than expected. But also because the amniotic fluid uh helped protect them, they can also, it increases their chances of developing infection, but also because they're premature, uh that can also increase the risk of um infection. And then you also have pulmonary hyperplasia. But again, as mentioned, we give corticosteroids for this very reason that it helps to um uh aid in fetal maturity. So it tries to uh reduce the risk of pulmonary hyperplasia and infection of the lungs, etcetera. Um And in terms of investigations, if a woman breaks her water, um what you would do is actually you would do a speculum and you would actually see the posterior side and you would see if there's any pooling of the amniotic fluid in the posterior vaginal va. And if there is, if there is a pooling of the amniotic fluid there, which means that the amniotic fluid has ruptured and it's collected in this posterior vault, then you would do, um then that would confirm your diagnosis of a um preterm prelabor rupture of the membranes. Um And also, again, same thing, don't do a digital examination because you're putting a foreign finger, even if it's sterile with gloves, et cetera, it can, it can uh increase the risk of infection, not only to the mother, uh but also to the baby as well. And um in terms of management, uh again, you would admit them, you want to observe them, make sure that the mother is hemodynamically stable that the baby is doing well. Um And make sure that um you give the mother oral erythromycin and this, you give them so that it can prevent, uh, the risk of them getting an infection. And even if they do, then this can help them and you would give them for 10 days straight. This is really important to remember that if a mother's water break early, um, and they get prom, you give them oral Erythromycin for 10 days. That's something that you should know. Um, if it's the only thing that you know about from, that's the one thing that you need to know. And then again, uh because the mother's water has broken, there's a risk of infection to the baby. The baby is premature itself because it's ruptured earlier. Then you wanna give them antenatal steroids because you want to mature their lungs as soon as possible so that they're not. So they don't develop stuff like pulmonary hyperplasia and they get infection of their lungs, et cetera and have to live in an incubator um after the delivery. So, yeah, and then they also have the risk of respiratory distress syndrome. So that's why we want to give them the corticosteroids. Um And uh that should be uh all the topics. Yes. So that's all the topics that I have for today. Um uh Could you please go the one slide previous? What do you mean by that? Um The Purpur infection? Uh Yes, I will be sending out the slides. Um Once if you, I'm going to give my email because I don't understand how this fee uh this, I'm just gonna type it now. Uh if you guys just email me, but the feedback should have your email address on it so I can send it to the send it then um previous to the hemorrhage slide. Um So that's the dental abruption. Uh Do you have any questions related to it? Um. Ok. I'm gonna send the slide so it should be. Oh OK. OK. That's fine. Um And then someone else said, looking for the amniotic fluid or speculum exam, but can't put a finger in. Yes. So let me just explain that. Let me put this up again. So the speculum, you're not actually putting your finger or anything. It's a very sterile um equipment that you take out from a sterile package and you can insert it in and you can have a look, you don't put your finger using a speculum examination. So in that sense, what you do is that you see if there's fluid, the amniotic, there's, there's basically a collection like a pool collection at the back of your uterus called the Posterior Vault. And that's what I, in fact, if I give you a little bit more information, I don't wanna so make it sound confusing. But with bleeding in the uterus, the problem is with placenta abruption actually, even when you have a placental abruption, you have bleeding occurring. And the thing is we have this collection pool at the back of our uterus. And when the blood pools into that blood is an irritant, it causes, it causes when it collects, it can cause irritation to your endometrium, et cetera. And that's why you have the tender woody uterus sort of sensation when it comes to placenta abruption. Um and it can, and it can cause a lot of pain, et cetera. But with amniotic fluid, you don't have that, but the amniotic fluid will be sitting in the collection. So you can visualize that and then that would give you a diagnosis of um I would give you a diagnosis of prom and then you can, you can think. Ok, fine. So is is there something wrong with the baby? Is there something wrong with the mother if nothing's going on? And if you give the mother, the Erythromycin, so that to make sure that she doesn't get an infection. Um And if you make sure that you um mature the baby's lungs and um as soon as possible, so that they uh so that it reduces the risk of infection, but also you can get them stable enough and that they can, it can grow more so that it's uh so it doesn't, so it's not premature, it's not so premature and then you can do um ac section when required. Um So that's the point with doing ad with doing um a finger examination, a vaginal examination, you have that risk. Um And it's a, it's a higher risk compared to um you know, using a speculum, et cetera. So that's why we do that rather than um a normal vaginal examination. I hope that answered the question. OK. Yeah. So um if you have any other questions, email me, um the feedback should go out if it doesn't go out. Uh oh, I can send the feedback form now. So OK, fine. I've sent the feedback form Now, you guys fill it out and then once I've got, I think there's like 23 people in this chat. Um So once I get a, a good amount, then um I will send out the slides, but the slides are going to be like this for all my obs and gu things. So, um if you find it really useful then just come along. Um I'll try to finish the sessions as quick as possible just because I know that it's the month of Ramadan for some people. So they might be a bit tired when doing this, but hopefully it should be useful. And if you have any questions, let me know and I'm also a medic at ST George's. So, um if you have any other questions regarding Osa etcetera, um just message me and let me know. Um So yeah, I will do more teaching um mostly obs gyne related. Um But if you guys want me to do anything else, I'm more than happy to um I'm currently into So I have quite a free time. Um, I have, I have done a lot of sessions before but I don't know where the recordings are. I just teach them and then I just, like, leave them be. Um, I'll have a look through, I'll ask the people who have done it before and I'll see if I can get the recordings if you guys want any more teaching that I do. Um But again, like if, if you have any questions just, just message me like I don't mind giving my number either. Um So I would give my number and my email address and if you have any questions, I think it is recorded. So with me, I think it's automatically recorded. Um But even if you don't understand anything whilst you're going through the revision, just message me and I'm more than happy to um just voice note it. So don't, don't be afraid to um message me one second. Ok? I'll see you guys if you guys decide to come on Thursday, Thursday one is pretty quick. It's not a lot. Um Yeah, I do have not, I can send them, but Thursday's one's pretty short, the teaching series. So if you want me to teach you guys anything else like anything that you're struggling with? I'm more than happy um for you to message me what topics and then I can do that because the session on Thursday, it will be like around 20 minutes 2030 minutes, post post mental health is pretty quick topic that um so it's going to my sessions are all 630 to 730 just because that's the only free time I can do it. So if you have any other topics like outside of OB and Gynae even that you want me to cover, I am more than happy to on that day but like, yeah, like two or three more topics. Um and I'm more than happy to do that. So yeah. Um Thank you everyone so much for joining. I really appreciate it. And again any questions just message me um fill out the feedback form and then hopefully um I'll see you guys on Thursday. Ok. Ok, perfect. Thank you. Yes. Yes. Dodgy internet. I will get it sorted out by Thursday. Hopefully it won't be a problem. Ok, bye then.