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Um a ba basically, we are actually talking about obstetrics. Um And it's more towards the finals. We're um, gonna talk through some questions. Although I know that obstetrics is like a really, really big large topic, but I've basically tried to break it down through, um, you know, the first trimester, second trimester, third trimester. Um, and hopefully we're gonna, we're gonna go through it in a, in a good pace. Um We've got d throughout the whole session. So, yeah, so this is the first ba I'm just gonna give um a few seconds for you to actually answer this question and then we'll go through it and you can use a chat to actually answer any questions or any discussions and have a look at the chat as well the whole time. So, yeah. Ok. Hopefully that's enough time for everyone to answer. Um, just looking at the chart if there's anything there t um, yeah, someone has answered T as well. Um And yes, that's the correct answer. Um, as you may know, of course, like nausea and um, vomiting breast tenderness and these are the really common symptoms experienced in women um, in early pregnancy and these are very, uh normal physiological changes of pregnancy. Um, so sometimes, even if, if you wouldn't know that this, this patient is pregnant and if you see the patient in A&E who has been complaining of these symptoms, it's important to do a pregnancy test. Um, since, you know, you, uh, for somebody who's weight who is, um, an age who will childbearing bearing, it's really important to know what the last menstrual period is. Um as well as um if they have any abdominal pain, et cetera because of things like that, you'd actually think about ectopic pregnancies. Um But these are really common changes in um pregnancy and these are more because of the hormonal fluctuations that we get in pregnancy. Um And obviously, they don't, they don't usually require any um treatment unless the, the nausea and vomiting become very aggressive. Um In that case, hyperemesis of gravid is one of the um diagnosis that we think about. Um does anybody know what the definition of hyperemesis is? If any, if anybody wanna tell me on the chart, what the definition of hyperemesis grader is or how we thought you would diagnose it. So, for hyperemesis, gravidarum, um it's a diagnosis ba based on the weight of the, of the patient. So, if a patient actually has lost more than 5% of their prepregnancy weight, then you would uh diagnose hyperemesis gradia. Also, you should obviously try and get um uh diagnose um try to get how many times they're vomiting in pregnancy. Um But of course, these are normal, the, the normal um things that you can hear physiological changes, nausea, vomiting, breast redness, so the normal physiological changes. Ok. Uh So we'll move on to the next SBA and again, I'm just gonna give you about 30 seconds to think about the answer. Ok. Does anyone want to put that on the chart as to what they think the answer is for this question? Ok. So um this is a 33 year old lady. Um We know that um on the 25th of April, she had a positive pregnancy test um to basically find the estimated date of delivery. There are some few um rules that we can use to get the estimated date of date of delivery. Um There's one called the nasal rule. Um and it's basically calculated by first, you add a year and seven days to the, to the date of the last menstrual period. So that's why it's really important to ask the last menstrual period and then of then count um backwards 33 calendar days. So for that patient, the her last menstrual period was on the 10th of April. So you add a year and seven days the date and then that's gonna be 17th of April and then you can come back three times a month from that date. Um So this is one of the rules that's available for some people um for to actually determine um the um estimated date of delivery. But of course, um it's important to know a detailed men history because um this, this rule can apply to, um can, wouldn't apply to people who got a complex, so don't have a regular cycle and who, who have used um hormonal contraceptives and the like. Um So, of course, it's important, it's very, very important to mention to a patient that is an estimated date of delivery. Ok. Um Any questions for this? Any questions? OK. Um I assume there's no move on to the next question then. OK. Any suggestions in the chat at all? C Yeah. Um That is the right answer um for women who are pregnant, um calcium channel blockers and Ramipril are ace inhibitors. Um So Ramipril is one of the ace uh the um ace inhibitors and any calcium channel blockers. These are all very teratogenic. So it's really important that um if any patients uh actually got um hypertension before pregnancy, um let you switch them to labetalol um beta blocker which is safe in pregnancy. So the rest of them um you wouldn't obviously stop and want your BP because that's gonna increase the BP. Um even further. Um we know in pregnancy that in the in the first trimester, BP would reduce. But then in the second trimester, you can actually get um pregnancy induced hypertension, but those who are not hypertensive before pregnancy. So, um you wouldn't completely stop Ramipril because that's, that would be dangerous for the patient. Um Then we would switch them to labetalol and um monitor the BP whenever they come for any checks later on. Ok. Um So the differences between preexisting and pregnancy induced hypertension as well as preeclampsia and we'll talk a little about preeclampsia later on in the lecture as well. But it's really important to know the differences between these because these are very common questions that come in um exams. So, pre preexisting hypertension, somebody who, who has got a history of hypertension before pregnancy um or a BP, more than 100 and 40/90 before 20 weeks of gestation is the diagnosis basically of, of pre existing hypertension. Um But for pregnancy induced hypertension, it's usually after 20 weeks and it's um but then you don't have any proteinuria or edema. Um If you get these symptoms, then it will be um classified as preeclampsia. Um That's also again, if, if it supposed to be um beyond 20 weeks, um It's a diagnosis of preeclampsia. Um So it's really important to know the differences between these because they do come out quite often actually. Ok. So again, we'll move on to the next S VA. Um Let me give a minute. It is more of like a very straightforward question and it's just to consolidate what we learned earlier uh because of how common these questions come up um any suggestions um at all, which is basically just to consolidate um what we've learned. So the answer for this question is or um so the patient does have hypertension because the BP is 15, 5/90. So it's more than 140 over the 80 what it is. Um So that's the reason why we need to um still treat this patient. So we, we, we give this patient or, and that's a first line guidance uh guidelines according to nice. OK. Um So we move on to the next one. OK. Um A I II got a suggestion about with the ba A. Um So for this is a 36 year old who is the GP um from this pregnancy and she has basically used for her depression. Um So sertraline is um an antidepressant. We, we may know what all it is necessary. It's the first line for depression and it is uh it is um OK, to use it in pregnancy. There are no major complications that have been um that have been documented so far or has been discussed so far. Um Therefore, so stopping sertraline would actually cause her depression to go worse. Um And that's why we didn't actually stop the sertraline um because it doesn't, it doesn't cause any congenital heart diseases or it's not not known to cause any asd or low birth weight or anything. So, for the correct answer for this is the you continue sertraline for this patient. Um because there hasn't been any, any documentations regarding any um complications because it's safe to use in pregnancy. Ok. Any questions for this for this FDA no questions. I assume we move on to the next one. Any suggestions so far? C Yeah, that is correct answer. Um It is c um So postpartum hemorrhage is one of the most common complications that happen post uh um after delivery basically. Um And that's why it's really important to, to know what happens, what, what the, what you can do for this patient. Um If some of the patient comes in with, with a patient actually has postpartum hemorrhage for any emerg emergency, of course, is to do an ABC and see whether the airway is compromised, then the breathing circulation, et cetera. Um And then something that's specific to postpartum hemorrhage is that we do have uh some mechanical approaches. We have some medical approaches. Um And IV Oxytocin is one of the first things that you do. You give IV Oxytocin. Um because the all the rest of them have Carbot, um I am Carbot, IUD Carbot, these are the ones that um would be later stages, um intra and again, that's also a very late stage that you would do. Um So I'm just gonna move on to explaining a bit more about this. Um I'm not sure whether you've heard of this uh injury from balloon tamponade. Uh tamponade. But it's one of those things that happens, what you do in a very later stage to actually stop the bleeding from happening. Um It's a small device that you, you ba basically in the uterus and try and um put pressure to reduce the amount of bleeding that happens. Um But before that I mentioned, like earlier, you would do the ABC approach and then you would locate the uterus from the fundus to stop to stimulate contractions. Um But, and then you try the medical approaches, like I mentioned earlier, I Oxytocin uh as well. Unless obviously, if the patient has a history of asthma, then you wouldn't. Um But my, um yeah, um uh there's also like some people does do still use um Texa in, in PPH. It is, it's really what you need to do um with these sort of patients is obviously look at the local guidelines as well because um every, every guidelines locally might defer slightly different to the other um, trusts basically. Ok. Ok. That's the next question I'm gonna, I'm gonna give him the next. OK. Questions at all. Ok. Um So the correct answer for this question is Aspirin. Um Aspirin, Aspirin is one of those medications that is contra to the device, breastfeeding. There are different ones for pregnancy and different ones for breastfeeding. The ones for breastfeeding are quite specific, the ones that need to be avoided as, you know, antibiotics for such as Ciprofloxacin Tetracycline, sulfonamides, um, for psychiatric drugs, lithium benzos, um, aspirin needs to be. And these are all, these will all passed through the membrane and, um, from the mother to the baby, that's why you have to be really careful. And the car methotrexate and cytotoxic drugs and the, um, these, these drugs are, um, you know, it's just, I think one of the most important thing is just to memorize them, uh, for the exams because there isn't any specific way I remember. I'm afraid to actually remember them. Um, but yeah, they will cross through from the mother to the baby and that's why it's important to not give these medications. Ok. Any questions about this SDA, ok. We move on to the next question. Ok. B yeah. Uh, that's the right all done. So, yeah, this is a 27 year old woman in her 36th week of pregnancy and the first child. That's, that's important information about a brief presentation and explain the second as why. Um, but the most suitable thing is to refer for external Catholic version because, um, it's, it's a procedure and I think you may be aware of, of what we, we do by, by excellent version. But essentially it's just to tell the baby. Um, and they, you know, there are some, some sort of, um, you need to be a certain grade for you to be able to, you know, do this, but it's basically turning the, the baby um into the correct position, head down. Um And it's recommended that those who are near term 36 weeks or more, um unless there are any contraindications, then, then you would basically refer, refer them for that. Um And for Cesarean section or providing reassurance at this point of stage, it wouldn't be, you know, suitable um providing reassurance that maybe 33 weeks would be the appropriate thing because you can, you can, the baby can still um spontaneously get back to position. Um But yeah, so for somebody who's or if you, if you had a BB breach presentation, um less than 36 weeks, you know, like I mentioned earlier, many fetuses will return spontaneously. Um But if there's still a breach at 36 weeks, then version is, is um the recommendation by mice. Um If a early paras woman comes, then it's 36 weeks. If it's a multipara women, then it's 37 weeks. So it should be tried. Um If, if after this, then if, if the baby is still reach, then um you need to basically do a planned Cesarean section for this patient or a vaginal delivery. Um but making the decision about regarding the infection or delivery um if these are recommendations, so this one of the women should be informed that plan section carries a reduced prenatal mortality and early neonatal mobility for for babies with a brief presentation attend compared with the planned vaginal birth. So this will be a decision between the obstetrician as well as the patient. Um But yeah, this is what this is the recommendations for brief presentations. Have you got any questions regarding this at all? No questions in the chat. I wanna move on to the next question. Any suggestions so far? Ok. Yes. Then for this, what would you and basically do the liver function tests for this patient? And the, the reason for that is um we would want to like um exclude obstetric cholestasis for this. If a patient comes in with severe itching at 34 weeks, gestation and um they have itching all over the body, uh rashes and if, if the patient has no rashes at all, um then, then you think of obstetric uh um obstetric cholestasis, this increases the risk of freedom labor. That's why it's really important. And patients who have got obstetric cholestasis would be induced at 37 weeks. Um So you, you basically wanna wanna do that at that time. Um Uric acid levels would not be um the ones that are raised at this point of time. It'd be the bile acids and that's why you would check the liver function tests. Um But it's one of the, these are one of the emergencies that you should, you should be ringing alarm bells whenever you see somebody who's got itching all over the body. OK? I just talked about this. Ok. Um The next SBA I'm just gonna give it another minute again. Any suggestions for this d yeah, previous cesarean infections? And is there um Do you mind just telling us in the chart as to why you think the answer is? Yeah. Yeah. Adhesions. That's that. So placenta Previa is when um the placenta is low lying and uh um it can, it, it's the different stages of placenta Previa where it's stage 123 and uh that according to the grade as to how close it is to the cervix. Um And if there's any adhesions that's present from the previous um Cesarean sections that does increase the risk of placenta previa because um then the placenta will attach to um the wrong places. And um according to if they had the Cesarean section earlier, um and other other risk factors having as you and surgeries, multi priorities. So having multiple pregnancies, these are all um risk factors for placenta pre um and obesity is also one of the one of the risk factors to cause placenta previa. OK. Is SBA I've just seen that that um placental abruption is one of the options that's been told. So we report a 26 year old pregnant woman presided in the emergency room at 3034 weeks. Gestation with sudden on very severe abdominal pain, general bleeding. She has a history of multiple severe infections and uh BP on the examination is really low. Heart rate is very high fetal heart rate monitoring show signs of fetal distress. This is a very, very common um exam question that comes up and the most likely diagnosis is the abruption. Um These are one, these are not very common, they run in, in di and obstetrics, but when it does happen and then it's like a medical emergency and needs to be um approached immediately. If you are the F one there, you need to call the registrar or the consultant immediately. Um because this can escalate very, very quickly. Um The patient for ectopic pregnancies, of course, that's a very, very young. Um It's in the very early stages and rupture does not present like this, although the patient will be very unwell at that time and their BP would also be very low. Um And then placenta previa, we mentioned earlier, um is painless vaginal bleeding, bleeding and ruptured of your ovarian cyst. It's not something that you can completely removed or if, unless if we knew that the patient does have an ovarian cyst, that it is one of the differentials that you could have. Um but again, sudden onset, very severe abdominal pain, uh would be sort of, you know, you can feel that the uterus is very woody as well. Um This is a suggestive of uterine rupture. Um So other risks associated with this is, you know, having previous uterine surgery including cesarean section also increases the risk of placental abruption. Um It can present with these sort of signs of shock and fetal dis uh distress as well. Ok. Sorry and a suggestion so far. Sorry about that. Um Someone's answered a pulmonary embolism. Um which is, yeah, the correct answer. Common things are common. Um If a patient's pregnant doesn't mean that they can't, they can't actually get the common medical emergencies. Um So the patient with the patient having a BP, no, uh sort of hypotensive uh tachycardic oxygen saturation is low. Um pulmonary embolisms is one of those common con uh common conditions that can happen in the third trimester pregnancies. Um So it's a potentially life threatening emergency. Um It's really important to diagnose this immediately and then um to start thinking of management is you think of different medications. So for um thin blood thinning medications, for somebody who's pregnant, you'd start thinking of therapeutic um delta or the, it really depends on the, on the trust that you are working in. Um, you would think of an treatment dose um for my trust, that's what we use. So it's a different sort of thing. So you can look, you can, you can look up the guidelines in your trust and um prescribe accordingly. But yeah, um well done on that. The next question. Any suggestions in the chat? Ok. Ok. So we've got a 32 year old pregnant woman. So sorry, we've got a 32 weeks gestation, pregnant woman. Um So she basically is feeling a bit dizzy and lightheaded when she was lying on her back, she reports improvement in symptoms when she turns to the left side. So this is a classical uh presentation for a compression syndrome. Um This is some uh usually this happens in the third trimester again. Um So the patient who basically comes in complaining of um feelings, like basically lying down um makes it completely on their back, makes them more uncomfortable. And therefore, um you need to ask them to lie on the left side. And that, that's one of the main treatments basically for this. Um But what happens usually is uh the due to the, you know, the size of the baby, you that compresses the inferior vena cover and the abdominal aorta um when they lie completely flat. So if you think about it, um he's got a very heavy weight that's compressing the, the IVC as well as the abdominal aorta and that reduces the venous return as well from, from down to up. And um that reduces the colic output, which can lead to all these symptoms that the patient is experiencing the lightheadedness um on when lying in the back. Ok. So, and the last question for the day today is this for S SBA 14. Um le OK. OK. So we've got a 30 year old woman who presents uh labor and delivery unit with persistent vaso bleeding after delivering her baby. Um She, she gave birth vaginally. Um um 30 years ago, by examination, the uterus is largely than expected for the postpartum period. And the most likely diagnosis for this is retained placenta. Um So if you, so what happens usually is a after you deliver the baby, then you have to the delivery of the placenta and that sometimes takes some time um according to the priority of the patient or if they've got any of the complications ongoing. Um But one of the most common things that can happen after postpartum is having retained placenta. Um So, if you don't, uh if your contents are not expelled within 30 minutes after delivery, that can, that can be a risk factor. Um And that can also lead to postpartum hemorrhage. Um So it's really important for the uterus to contract um after delivery. And if that doesn't happen, if they basically have any issues in the past, if they've got um A and A which is the tone, the, the ba the ter is not contracting properly or they've got um any other hematological issues. Um That, that's another risk factor um for um postpartum hemorrhage. And one of the things that was the most common thing is retained placenta. Um So, having like a soft boggy uterus is quite important after um and placental abruption may present with vaginal bleeding, but I obviously have different clinical features in the third trimester of pregnancy. Um It is, it is quite, it's, it's obviously something that you think about is a differential diagnosis. Um But because um the patient, the patient's urosis is large than expected from the postpartum period. Um and she was already given birth, it's less likely that it's a uterine doctor. Ok. Has anyone got any questions or anything else? We'll be here for the next sort of five minutes if anyone has got any questions p that, that's the end of today's presentation. Thanks very much for attending though and hopefully you've got something out of the session today. Um I do apologize for the technical issues in the beginning and please feed, do all the feedback forms just so that we can keep improving the series that we have started. Ok. Um Thanks very much for everyone for attending and hopefully we'll see you in the next session that's gonna be next week. Ok. See you.