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Obstetrics & Gynaecology 1

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Summary

This on-demand teaching session for medical professionals will provide practical tips for navigating clinical presentations to help make diagnoses. Topics discussed include identifying four essential questions to ask women coming in to maternity triage, diagnosing UTI, diseases associated with pregnancy, risk factors and treatment plans for VTE, and diagnosing placenta praevia. Through interactive discussions and topic-based challenges designed to keep participants engaged, the session will offer valuable information applicable to clinical practice.

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Learning objectives

Learning Objectives:

  1. Describe four essential questions that should be asked when assessing a patient for a maternity triage.

  2. Identify risk factors for developing VTE in pregnant women.

  3. Explain the use of walking saturations for detecting VTE in pregnant women.

  4. Describe the best diagnostic test for venous sinus thrombosis in pregnancy.

  5. Analyze how the placenta position can affect the likelihood of a patient presenting with PV bleeding.

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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Is we're going to go through some clinical presentations um that are found in your um in your specification. And um the way I'm going to try to bring these in is kind of in a sort of practical setting. So, um it's gonna be quite case based divided electorate to four sections. Um So you'll start off as an F Y two in Austin Gynie and you'll eventually progress to an S T T. Um And then the last section is just purely MCQ US and we can go through together, going to try and keep it relatively interactive. So, um probably the easiest way of doing this is in the chat. So, um I'll ask some questions and like, no answer is stupid. No answer is silly. Just go for it, just type it in the chat and I can see the chat on my phone. So, um as we go, I'll ask and you just feel free to write the answers in the chat, um might keep you concentrating because it's quite a long lecture as well. Um So we're gonna start off, like I said with you being the Fy two. So you're covering Maternity Triage for those of you that have done yours and Gynie placements. I think that's probably most of you at this point. Um, you are women don't have to come via their GP, they can just present to maternity triage. Um, and they can come with anything. They can have even seen a lady saying can cut my toenails. So we won't be going through that today, don't worry. Um, so your first case is a lady who's 40 years old and she's gnarly Paris and she's 28 weeks and four days and she's coming complete complaining of feeling generally. Well for a couple of days. Now, the first question I'm going to ask is so I think maybe someone needs to mute there, Mike. Yeah, hopefully you guys can hear me. Okay. Um The first thing I want to ask you is what four questions should you ask every single patient that's coming to triage? Go for it right in the chat. You don't? All right. All four. But what's something that you should ask every single woman coming to triage? So in your Rosky, what are you going to make sure you've covered as well as obviously asking about presenting complaint, pain? Okay. Yeah. Uh Yes. So any abdominal pain, perfect vaginal bleeding, fetal movements. PV. Being perfect yet movements. Uh Perfect discharge. Yeah, I mean, not really. I would say if you have to just ask four essential questions. Yeah. Rupture of membranes. Exactly. So these are the four things that you need to ask everyone is your baby moving. Do you have any bleeding? Do you have any abdominal pain and any gush of fluid from the vagina? Like your water's might have gone? Perfect. And then obviously you're also going to ask them all about their presenting complaint, history of presenting complaint or your standard history as well. So this woman mentions that she's had some back pains and last week she had a little bit of pain, passing urine, which has got better. Sorry, I don't know if I've just lost you that. There we go. Um And she mentioned that her midwife appointment, somebody sent off her urine but didn't give her any antibiotics and she's not really sure why that's her observations and that's how urine dip. What, which of those investigations makes you the most worried? Which of those are you going to note the BP? The your analysis, the your analysis is abnormal but out of the observations. Temperature. Yeah, perfect. It'll be a bit unwell but the temperature of 38.8 gives you a clear diagnosis that this woman uh is. Yeah, somebody has, somebody said it. She's shocking. Yeah, a little bit. She wouldn't say I would say possibly she's not in septic shock, but she might be heading that way. But we're thinking that this woman has probably got urinary sepsis. So, um obviously we know sepsis is really common. I'm sure you guys know all about sepsis and that you've had it drummed into you from like every specialty that you do. But the interesting thing about pregnancy and being postpartum as well is that these symptoms can be masked and actually, it's a state as we know of relative immunocompromised. So sometimes people can decompensate quicker because they're pregnant and because they're postpartum. So in your standard women that you're gonna see in triage, your most likely sources are a uti um and interestingly, UTIs present differently in pregnancy. So they don't always present with your standard symptoms. Um And you can obviously get pyla nephritis as a result of that. Then obviously, you've got to think about the womb. You've got to think about the membranes, chorioamnionitis or postpartum endometritis very, very common. And then my mastitis as well, particularly if someone's breastfeeding, I'm sure you know all these investigations already FBC use Annie's etcetera. You're going to do a full work up. You're obviously, if the patient is pregnant, going to do A C T G and you're going to do the sepsis six. Are you bored of the sepsis? Six? Do you know it completely off by heart? Can somebody just take one for the team and write the sepsis six? So I know that you know it and we can move on. Uh huh. Does anybody know it? Sepsis six? Yes. Thank you so much. I know, you know it amazing. But yeah, like I said, low threshold to admit these patients and give them IV antibiotics because they can become very unwell next patient. Amazing. You're still in triage, you're still the fy two. You've got this time of 42 year old woman who's had three babies before this is her fourth pregnancy. She's 33 weeks and six days. She's overweight, not quite obese, but she's attending triage with sudden onset shortness of breath and palpitations. We also the four questions and there's nothing to worry about that. Those are her observations. Can anybody think what I might be trying to get out with this case? What do you think this could be so VTE fantastic yet, PAPP. Amazing. Love it guys. So, yeah, she's got a few risk factors, hasn't she? She's had three babies before. So every pregnancy you have your risk of VTE goes up. She's got a B M I of 29 which means she probably doesn't meet the criteria to take prophylactic and knocks apar in delta Pa run or whatever they use in the trust low molecular weight heparin. Um So she probably hasn't been taking anything prophylactically. She's also 42. So age is a risk factor. Um So yeah, obviously VT encompasses this whole troop basically any kind of clot. But the what the, the three that you will see in pregnancy most commonly are DVT pe and a central venous sinus thrombosis which would obviously present with a headache. Um In pregnancy, you've got a huge risk compared to just being a normal woman that isn't pregnant, walking around and actually postpartum, you've got a hugely increased risk too. Um, it occurs in one in 1000 pregnancy. So, if you think of how many women are going to see in triage, you will probably see uh VTE at some point in your year. Robson Gynie if that's what you decide to do. Um, and in developed countries, it's a leading cause of maternal mortality probably because we've got an older population and a high, highly obese population as well. So I've given you some risk factors. Can you give me any risk factors for VTE I've given you some clues already. There was obviously clues in the stem of the question. Um And you probably know some more so feel free to write some risk factors in the chat surgery. Fantastic and being immobile yet perfect. Previously t amazing. I love whoever said that. So in often Gynie, if you're stuck for time and someone asked you for some risk factors, you can always say previous this. So for example, a risk factor effect topic, previous ectopic. Um So I gave you one for free there. Cancer. Yeah. Fantastic. Cardiovascular disease on the pill. So if you were on the pill prior to pregnancy, that's not going to increase your risk during pregnancy. It increases your risk relative to not taking the pill while you're taking it. Um But being pregnant is way more of an increased risk than being on the pill or ever or ever having had the pill. Uh So these are your risk factors. So previous BTR first degree relative being over 35 high parity. So even having an instrumentals delivery like a forceps or a vantas increases your risk, postpartum hemorrhage increases your risk as well. Um And yet, obviously, you guys already said malignancy which is fantastic smoking IVF and then obviously those medical conditions like hypertension, preeclampsia and infection as well. So, yeah, well done. I think you guys got most of those. So what are you gonna do with this woman? You're going to send her for what we call walking saturations. So you're gonna put the SATS monitor on check what her saturations are at rest, get her to walk up and down and check the saturations again. And that's where we can see that actually on exertion, the saturations dropping and that's quite a high um indicator of somebody possibly having a P. You're gonna do an E C G. Obviously, the most likely uh E C G result is a sinus tachycardia. Um But always important to do particularly someone's kind of chest pain, shortness of breath. Um And then we have this option of giving her A C T P A or um an MRV, if we're thinking of venous sinus thrombosis, the best um The best investigation for that is a, an M R venogram. Um There's obviously the other option of doing a VQ scan. So, um, different trust you, different things. CT pa are much easier to get hold of. Um, but VQ scans probably happened about once a week. Um So yeah, it just depends on the hospital that you're in and also depends on the women's preferences. Um And yeah, as you know, treatment will be a low molecular heparin which they'll continue to take throughout the pregnancy and then at least three months postpartum and then you'll send them to hematology for a full work up. Obviously, hematology, the investigations that hematology will do can be very, can be very skewed by pregnancy. So it's important to wait until they're fully post partum before you actually test them to see if they have any background mutations or anything like that. Um, so this is a CT PA and you can see lots of ps here actually on the scam. So you can just see the darker where the arrow is pointing, the little darker areas that's a clock in where there shouldn't be one fine. You're still in triage. You haven't left triage for anyone who's done. Often. Guide me, you will understand the situation. Um, so you've now got a 28 year old woman who has had one previous Cesarean section and she's attending triage at 30 weeks with PV bleeding. Well, you ask her the four questions. She's got normal movements, no abdominal pain and she's got a small amount of bright red PV, bleeding, no shrimp. Interestingly, her normally scan, the placenta was low and she's got a follow up scan booked for 32 weeks. So these are her observations, respiratory rate, 20 or looking quite normal heart rate is kind of borderline and there's a little bit of blood in the urine. What are you going to ask extra in this history? So, because she's got bleeding, you're going to ask about her previous smear test or any previous cervical history. Could this bleeding be coming from the cervix? So, has she had, for example, or previous, let's um uh or has she had any treatment to her cervix at all? Is this bleeding provoked? So how she had sex basically in the last kind of 24 48 hours. Um And then you're going to ask about risk factors for abruption. So that would include smoking drugs, especially cocaine. And then because she's bleeding, you want to make sure that you've got a valid group and safer and that, you know, her visa status, obviously, she will need anti D if um if she's bled at all and she's 33 weeks. So, and there's a few, there's a few, a few different conditions that can cause bleeding. So we're going to talk first of all, about percent previa, which is apparently responsible for around 50% of antepartum hemorrhage, placenta, previa can be categorized as a minor or major. And then Southern categorize the grade one or grade two. So grade one will be anything that's close to in the lower segment but not actually reaching the OS. So about two centimeters away from the US. You would say that's grade 1% previa grade two is where it's close to the office or reaching the OS when I said also mean the survival loss obviously. Um and but it's not covering grade three is where it's partially covering the OS and grade four is where it's completely covering. So what happens is these are often diagnosed at 20 weeks on the anomaly scan. And most hospitals will have a policy where they book them for a follow up scan at 32 weeks. By this time, most of the placenta's will have moved. So they will usually have resolved and they will no longer have placenta previa and they can go on and have a vaginal birth. However, if it's still lower 32 weeks, they can have another one at 36 weeks. If it's still low at term, then we recommend elective section. Um So uh the, what you're going to do with this woman is you're probably going to admit her for 24 hours. If there was reduced movements or there was an abnormal CTG or you had any concerns about the woman, then you would give her steroids and you would consider early delivery abruption is another cause of uh bleeding, 20% is concealed. So, actually, 20% of abruption won't present with bleeding. Now, obviously, the, the reason that the placenta bleeds is because it's low and actually, it's probably because that it's not quite an adherent where it's reaching the os. Whereas this is actually bleeding because the placenta is shearing away from the uterus. So usually you present with pain because the blood is in between the placenta and the uterus. It causes irritation of the uterus. So these women will come in usually with really bad pain and they'll have a tense what we call woody uterus. So when you press the uterus, they will be very sore. They may also have reduced movement because if you think this is the blood that would be getting to the baby. So this, this may actually cause compromise to the baby. And usually we need a very urgent delivery. Sometimes the blood and the irritation of the uterus causes contractions and actually, it can cause labor. So sometimes these people can present in labor and actually abruption can also happen in labor. Um It's important to check the baby with the CTG an ultrasound. But ultimately, if you suspect a big abruption, you should do a category one Cesarean section. The last condition is a lot more rare. So it's a lot less likely that you will see this particularly in triage. Usually this is diagnosed on a scan. Um and it's, it's not something that you would diagnose an acute presentation, but it's good to know about as a cause of bleeding. This is visa previous where the vessels right in the membranes. So it can be from a bilobed or a sucked into it. Low placenta. So obviously, the ideal placenta is just one big blob if the percent is actually split into two blobs with just the membrane in between sometimes vessels running those and obviously, they're exposed and they're very sensitive and very uh yeah, very um sensitive to anything that could cause any trauma they can bleed. This is really, really rare because obviously, even having a bi lo placenta is rare. Um but having the vessels running in it is, yeah, we thought to be about one in 3000. Obviously, if you're bleeding from the cord, you're bleeding straight from the baby. And this is like this, you know, it's an equivalent of an aortic dissection in an adult human, isn't it? So, um it can cause a significant amount of vita mortalities. Very sad. Um So risk factors for this or a low lying percenter because obviously, then this cord can be near the US multiple pregnancy and IVF as well. So you finished triage well done. I don't know if you want to have a quick break or we can, if anyone wants to ask any questions from that section before we move on to the next bit, I will just give you a few seconds if you want to write any questions in the chat management of these previous. Yeah, very good question. So, when it's diagnosed, it's like I said, it's usually diagnosed on a scan and usually what the management is, is admit. Don't even let the woman, oh, someone wants to spend again. Yeah. Sure. 100%. Let me see if I can just go back back to the slide. So basically a usual placenta is one round kind of blob of tissue with a central cord attached to the baby. Sometimes we can get these kind of abnormalities of a placenta. Sometimes it doesn't affect anything at all, having these abnormalities, but sometimes just the way that that percent to happens to develop is that it's in two lobes or sometimes even three lobes. Sometimes it's two instead of just being one large blob, it's too large blobs, almost like 50% of 50%. Sometimes it's like a tiny mini placenta on the fungus of the uterus and bigger center on the side. I mean, you can see all kinds of weird and wonderful things and sometimes the cord doesn't develop properly. So sometimes rather having three vessels in the chords, only got two vessels. Um and these are all kind of, I guess uh anatomical variations that we note, they don't necessarily cause problems. But there's something that we note if there's two lobes of a placenta. So you can see like on this picture, be there's placenta on like both sides of the uterus and then there's a membrane that's covering between the two and the vessels going to the cord are in that membrane. Or if just the the vessels before the cord gets enveloped in the membrane are exposed and near the cervix of in a low lying placenta like in picture a um if you bleed from that, that's all the blood that the baby's getting. So this is like the baby's lifeline. So it's rare that this anatomical variations even happen. But if they do happen, they can cause significant fetal mortality. Um So, yeah, hopefully that answers the question for the person who's like, can you explain it again for the person who said, what's the management? Um It would be delivery, but obviously you want to balance risk and benefit in terms of, you don't really want to deliver a baby at 24 weeks. So, um once this is diagnosed, usually we admit the patient, we keep them on a really, really strict. Um It's really hard for these patients actually because we kind of ask them not to really move around, not to leave the hospital were like constantly trying to check if the baby's fine, constantly checking for bleeding. But we usually make some kind of plan to deliver them a very early stage, probably around 34 weeks. Um But obviously, if there's any signs of fetal compromise or any signs of bleeding straight to a Cesarean section. Uh So hopefully that answers the question for the management and uh what is the four questions to ask? The four questions to ask? Are, is your baby moving? Do you have any abdominal pain? Do you have any bleeding? And do you have any signs like your water's have gone? And then of course, also go into presenting complaint, history, presenting complaint why they've actually come to triage. Usually it will be one of those four reasons that they have come to triage, but often it's other things. But yeah, I would ask that to everybody because you never know. Hopefully that answers that question, everybody happy. Yeah. Amazing. Okay. Should we move on? So you are now upgraded. You're the ST one um and you're covering labor ward at night. You're hoping for a nice quiet night. You just want to do your own portfolio but obviously not. Um the emergency buzzer goes off. Number one. It's the lady in room four. Her first pregnancy, she's 39 weeks and two days and she is a diabetic. She's having an induction I O L for diabetes on insulin and her B M my 35. You can already probably guess what this is going to be. You enter the room and you see the patient in the thought a me the baby's head out, you see a contraction and you see her pushing the head, the head is turtle necking and receding. Can you please write in the chat? What is this emergency? Amazing. Amazing shoulder dystocia. Perfect. So the definition of shoulder dystocia, really important. It's a bony impaction, okay. So it's the anterior shoulder of the baby, which is a bone against the pubic arch, which is a bone. So risk matches the shoulder social, obviously all nose, previous shoulder dystocia, having an assisted delivery and basically everything that was in the stem of that question. So, uh here we go, I'm having an induction um being a diabetic and a high be in line. So those are your main risk factors. Now, these, this is the management. The most important thing. First of all is that you call for help. Even if you're a senior midwife or consultant, you're going to need more people because the first thing you're going to do is something called mcroberts, which is where, first of all, if the patient's in lithotomy, you need to re straighten the legs and then push them right back and the art with the medical student. Exactly. That's where you're going to try and push the legs right back. And, and that hopefully opens that pelvic outlet and allows that shoulder to deliver. You're going to need to do an episiotomy not to relieve the bony impaction because obviously you're cutting tissue, um soft tissue, but to give you more space to do the maneuvers, um super pubic pressure, ideally behind the back of the baby's shoulder. So if it's the baby's left shoulder, you want to be on the right side, the left side of patient and if it's the other way, so basically you want to push the baby forwards from the shoulder from behind. Um And then would screws manoeuvre is basically where you try to twist the baby. So you're trying to bring that shoulder that's stuck for words, and you're trying to push the posterior shoulder back, then you're going to try the opposite. If that doesn't work, then you going to try to deliver the posterior arm because if you deliver the posterior arm, you change that angle. And if you imagine you're doing this, uh I don't, if you can see me hopefully continues, then we'll see me on the camera, but you're going to try to deliver that posterior arm and just dislodge that anterior shoulder. If none of those work, you're going to do it all again. But this time you're gonna change the position of the woman and then these are horrible things to talk about. But collider to me is where you break the brave bees, clavicle symphysiotomy is where you try to cut through. This emphasis pubis of the of the woman. And Zaven Ellie is where you push the baby back in and you go for a Caesarean section in a situation like this. Do you go straight to mcroberts or applies to put pressure first? You should do mcroberts first, most or a lot of shoulder associate will resolve with them at Robert's so definitely, always do mcroberts first and sometimes we kind of do what we call a Prophylactic mcroberts. When we've done a forceps, it's a big baby. The mom's got diabetes we think, right. We really need to be ready to put these legs back. So this is a picture of shoulder dystocia where you can see and you can see that break your plexus. So, um, it's a different quotes from different papers, but we think about 11 in 1000 babies that have a brachial plexus injury where there's lasting damage. So it's a, it's a low risk of this happening. I mean, this is in all shoulder dystocia is okay. So this is not in all women but in all shoulder. So she is um so we think that the risk of a break your plexus injury in the shoulder. So she is about 1%. Um and it's about one in 1000 where they have some kind of lasting damage. The baby is delivered with Matt Roberts. Amazing what emergency is going to happen next. I'm sure you know anyone who's been on Labor Ward, you've definitely seen at least one of these PPH. Fantastic. So, um definition of PPH is uh depends on who you ask. Really, it depends on your hospital actually when you're supposed to put up the buzzer. But technically, more than 500 mils, sometimes the quotas, more than a liter and more than 1.5 liters, we call a major obstetric hemorrhage. Um And obviously if it's at the time of delivery, technically, within the 1st 24 hours, we call it primary. If it's somebody who's coming back two weeks later, um, or even four weeks later, we call it a secondary. PPH. Now we always talk about these forties, please tell me you guys know the forties. Any of them is fine. What are the forties? Amazing tone, trauma, tissue thrombin and UV Marina, you've even said them in the right order, which is amazing. Um So yeah, perfect tone is the most likely reason. Um She's this woman had an induction. She's probably been in labor for a long time. She might have been on Oxytocin. All of these are risk factors for having an atonic uterus and al after delivery. You've probably given her an episiotomy because you've tried to make more space than this baby to come out. You've probably done some maneuvers, you might even cause the survival tear. This woman is definitely going to have a pph issue is obviously where there's any kind of retained placenta or anything that's not allowing that uterus to contract. Um And it's very rare to have clotting abnormalities and usually know about those in advance. So, uh yeah, just to give you some kind of percent. These are the ones that we quote sometimes obviously it's mixed picture. Um But yeah, most likely reason is tone. So, uh these are the risk factors for tone, like I said, having a big baby, having previous BPH, um and having twins, anything that's kind of stretch that uterus. So the uterus is a muscle, it can be stretched and it can become floppy, it can become tired, it doesn't want to contract back down. Um So there's a kind of all the risk factors that lead to the uterus being essentially stretched or floppy trauma, like we said, obviously, tears can also be a C section and then, um these are the kind of clotting abnormalities that you might see. So, um hopefully we'll know the management very well. Most important thing to always say in your or ski is first what I would call for help. Then I'm going to assess the patient in an 80 E manner. So obviously, you're going to start with airway check that the woman's talking to you. You're going to put her on a 15 liters non rebreather because this is an emergency situation. You're going to make sure that you cite too wide, bought Kanye Lee and that you're going to use those to send off blood, most importantly, group and save and a cross match. You can also use that to take a V B G which will give you an accurate hemoglobin reading at the time of the PPH. And you're going to put in a catheter bag where you can check an accurate urine output. So you're going to put on what we call a your amit. Er And then obviously examine, establish the cause if needed, take her to theater. So this is how we treat tone. First of all, conservative management, which doesn't look very conservative on the photo, does it? Um, so you're going to try to help that uterus contract back down medical management. These are the medications that we give. It would again depend on the hospital which order you give them in. But, um, Syntocinon is most commonly what we give. So the same thing that we use in labor just in a different concentration and the idea is just to try and get that uterus really to, to, um, shrink down ergometric in. We use, we give it I am. We don't use ergometrine when somebody has a history of BP issues because it can interfere and it can, it can make those worse. Carboprost is also called hemabate and that's also given I am and that we don't use in people with asthma because it can make the asthma worse miSOPROStol. We give pr um, can also give it PV, but it's probably just going to come out if she's bleeding. Um, and miSOPROStol can also raise your temperature and because obviously it's a prostaglandin can also cause you to have diarrhea and irritation if it's given pr if none of those work, you're gonna go to theater for an eu a which means examination under anesthetic. So that can be with a spinal. Um, but if needed, it can be under a G A as well. And that gives you a little bit more leeway to really press on that uterus and really try and contract it down. You can also do you try and packing so you can put a pack into the vagina, which again, just allows you to put more pressure on the uterus and allow it to clamp down. If you want to try and compress those vessels from the inside out. we'll use something called a Bakri balloon, which is plastic and it just goes inside the uterus, we inflate it with water and that allows the vessels that are bleeding on the inside of the uterus to be tamponade it from the inside out. If those are working, you might have to open the patient and you might have to put compression sutures, be lynch, uh the most famous sutures which are kind of like braces for the uterus. So you would literally put the stitch through the lower segment out the other side all the way around and try and use that stitch to really help the uterus to contract. Um If you're still bleeding and you still got a problem, you can do things like interventional radiology. So you try an artery embolization. Um And obviously our last life saving resort is a hysterectomy emergency bars. A two, you've just sorted her out. She didn't need a hysterectomy. Thank goodness. Um But the buzzer goes off again and you rush into birth center uh room eight and you see a woman on the floor on all fours, which is very typical birth center, not so typical for labor would. Um, and the midwife is delivering, but the presenting part appears to be buttocks. This is called undiagnosed breach. Obviously, it's a, it kind of is a funny term because it's diagnosed at the time. But obviously, what it means is that it wasn't diagnosed before. Can anyone tell me any risk factors in the chat for having a breech baby or having undiagnosed breach? I've just seen somebody said, when do you, do you try and rub after cannula or before? So, um in reality, it's going to all be happening at once. The way that you would say it if you were saying it in our ski is in a two e manner. So you would probably say in see that you would do the cannulas and then when you move onto the, you would move on to examination compression, etcetera, etcetera, small uterus pelvis, interesting previous beach. Amazing Laura. Well done. Um So not attending scans. Yes. Um But, but that's just, that's a risk factor for it not being diagnosed. Um rather than having a breech baby. Um Yeah, see your point. Um It's not on my list but that's fine fibroids. Yes, because it can cause the way that the baby's lying can't. So for example, if you have a very big fibroid in the lower segment than the head can't fit and maybe we'll just try and fit itself around the other way. Um Having a small uterus or pelvis. Not really. Actually, it's interesting because we used to have this thing called cephalopelvic disproportion where we used to say this woman is too small for this baby. Um, and people used to measure on scans and things like that, but these days we say that's just not a thing and actually we don't know which babies are gonna fit until they fit. Um So yeah, interesting polyhydramnios. Amazing. Yes, that's a good one anymore. Any more diabetes because it causes probably abdominus but not on itself. Not by itself. Macrosomia. Yeah, more the opposite. I think you guys have done well. So um these are the risk factors, the previous breach, obviously going into labor, preterm means that your baby might still be breech and it just hasn't turned yet. So that's a that is a risk factor having lots of babies. So I guess the person who said muscle laxity, you are correct in a way because the more babies you have them or your uterus is stretched and therefore it can cause the baby to have loads of space to move around in and therefore be breached, having multiple pregnancy, having too much water, not enough water. You try an abnormality, things like five boys and presenter Previa and then any kind of fetal abnormalities, particularly of the head because obviously it the baby's head needs to be the biggest heaviest part that's going down into the pelvis. Um I would, so if someone's just asked a question, would Oxytocin be a continuous infusion or a single bolus? Uh I'm guessing you mean for the PPH. So in labor, it's a, it's an infusion and um when it's a PPH, it is still an infusion but it's much shorter. Um So yeah, we don't give it as like a one off injection. If that makes sense, it is still an infusion. Hopefully that answered your question. Okay. So these are risk factors for breach. These are your types of breach. So, um you can have a Frank Breech, you can have a complete breach and you can have a footling breech and these are sometimes called extended and flex, which gives you a clue as to what the legs are doing. So, uh Frank Breech is the most common kind. That's where buttocks are coming down first. This is the kind that's actually most easy to deliver vaginal e um flexed or complete is where the obviously the hips are flexed. So you're, you're getting um So you're getting kind of feet and buttocks at the same time. It's almost like the babysitting clock, cross leg. It like it is in the photo and footling breech is where the foot, sometimes 1 ft or sometimes both foot, both feet are going out at the same time. Um This is another way to describe it. You can see that. So um 4% of babies will be breached at term, but 20% at 28 weeks because obviously the baby starts off breach and then as it gets towards term, it turns to be head down. Now, this is obviously the reason that having a preterm birth is that you're more likely to have a breech baby. If the baby is still breech at 36 weeks, then we offer something called PCV. So what might happen is say, for example, the woman goes to her midwife appointment at 30 weeks or yeah, let's say 30 weeks and she feels well, actually, this baby still feels breach, that's fine. We'll see it again in a few weeks and then if 34 weeks, she's thinking, I think this baby feels breach. I can feel ahead right up under the ribs. She's going to refer the woman for a scan. If the baby is still is breached on the scan and breach at 36 weeks, we offer this external Catholic version. So we're trying to turn the baby to head down from the outside. Now, we quote women that this works 50% of the time. It depends on who does it. Um So obviously with more experience, more likely to work, but obviously, it depends on the reason why this this woman is breach or it depends on why this baby isn't head down. We think that probably works 50% of the time but out of the times it works, it probably goes back to being breached 50% of the time. And actually even doing the procedure gives you a one in 200 risk of emergency Cesarean section. Um, if the woman doesn't want any CV, you can offer her an elective section and this is a very common reason to have an elective section. Um, but some trust will allow her to try for a vaginal breech. And obviously, this would depend on her risk factors. So, if she's had lots of vaginal deliveries before, you're more likely to say yes, if she's never had a vaginal delivery before or um she's got a big fibroid in the way or yeah, other reasons you're gonna take it on a case by case basis and actually, it's very trust dependent. So I don't know if anyone's been to West mid, but um they are very, very keen or breech birth, whereas other, other trust don't really support it. So the baby is delivered and she's fine and then the buzzer goes off again. Obviously, you're, you're asked to do an A R M this time for room three. Uh she's 33 years old. It's her, she's had four babies before her fifth baby. She's got polyhydramnios. You get consent, you examine for the cervix. It's once you sent me to some very stretchy, you ruptured membranes and you feel a rubbery string in the cervix. Can you write in the chat. What uh what emergency is this and how stressed are you? Cord prolapsed? Amazing. Amazing. Perfect. So the definition is descent of the umbilical cord through the cervix. So either this can be alongside or past the presenting part in the presence of ruptured membranes. Can anyone right in the chat? Any risk factors for called prolapse? Uh your mm hmm. Good one. So you have as part of the definition, the membranes have to be ruptured. I wouldn't really say that that's a risk factor. The center previa. Yep, because the cord is low and everything slightly abnormal. Okay. I'll give you that polyhydramnios. Yes, that's a good one. That was in my, in my question. Multiparty. Yeah, maybe not sure. I'll tell you something. Essentially what you want is for the head to be at the cervix, right? So if the, if there's anything abnormal about the way the baby is lying or about the water around the baby, then you're going to have a higher chance that that cord can come past the baby's head and go through the cervix. So obviously breach the baby changing around and being unstable lie and keeps moving a bleak is where the head is like towards the pelvis, but towards one side, transverse lies lots of babies transverse. Anything that's causing that baby to be a slightly different shape to normal. So any kind of congenital abnormalities, having too much water, having any CV, like we just talked about um if the baby is very small, then that head sometimes isn't quite enough to kind of block the way and the cord more likely to come down. Um And yet, obviously, we just talked about, you need to have your membranes rupture, so you need to have an A R M or if you've shrunk, it can just happen at home. Um But having that, that presenting part being high and un engaged, as opposed to the member is breaking on their own, I suppose gives you a slightly higher risk of that happening. Um And prematurity obviously more like to have smaller baby, again, again, again, babies less like to be engaged, etcetera. So, um what are you going to do? First of all, you are going to call for help, you're gonna relieve the pressure on the court's so you don't try to touch the cord that's really important. You try to relieve the pressure that, that baby's head. If, if it's Catholic is putting on the Cortisone, what that, what you want to do is elevate the presenting part. Um And then you, you actually you, if the baby is um if the baby is having a brownie Kardian, if the baby is compromised, you are going to climb on that bed and you're going to go like this with the woman to theater until the Cesarean section is done. Um And you're going to try and get the women in a position that relieve that pressure on the cord. Um, would you retro feel the bladder, do you mean push the head up a little bit? Yes. So, essentially what you're trying to do is where the cord is coming down into the cervix. You're just trying to push that head off the cord. So you might be trying to push the head kind of anteriorly. You might be trying to push it towards the mom's head, but essentially you just want to make sure that that cord isn't being squashed so that the blood can actually get to the baby. Yeah. Did someone have a question? Sorry. Oh, good. Would you retro fill the bladder? No, I don't know if people do that. Is it the same if it's breach? Yes. So you would try to push in that case, it would be the bump that's coming down or the feet, etcetera, etcetera. And you would try to push those off the cord. Um And if the baby is compromised, then you want to really rush to theater. If the baby is not compromised, you still need to do a Cesarean section, but you don't need to go in a tearing hurry. Uh Just a bit of one. Um So after that emergency Cesarean section, you asked to review room one labor ward is continuing. Um This time it's a 35 year old. So would she have rupture of membranes with the cord prolapse? Yes, because if the membranes are intact, that cord isn't going to be able to come out. So that's why I'll just quickly go back. Sorry. That's why it's part of the definition in the President's of ruptured membranes. Does that make sense? Hopefully that makes sense? Cause the, if the baby's enclosing it's nice little balloon, the cord will just be tucked up. Yeah. Perfect. Okay. Cool. So, um moving on to the next case. So yeah, it's a woman who has had one previous Cesarean section and it was an emergency Cesarean section for fetal distress two years ago. She's 35 years old. She's having an induction of labor for reduced fetal movements at term. I've kind of put all these acronyms in there just to remind you of what they all are because this is what you might see in the notes. It's good just to um put you in a, in a real life scenario. So she was last examined one hour ago and she was four centimeters. She was contracting well, 3 to 4 and 10 and she has an epidural in situ, but she's feeling uncomfortable. So I don't know if anybody can get at what I'm trying to get at here. But what do you think you might be worried about? She's, I mean, you can sometimes have an epidural that's not really working well, can't you? But it's a bit unusual that she's feeling uncomfortable with an epidural and she's had a previous emergency section. The baby's not moving well, that's why she's having induction hyper stimulation is a good answer. Um, so it could be hyper stimulation. Yes. But she's contracting 3 to 4 and 10, which is normal. So, I don't think it's quite that anyone got any other guesses, fetal hypoxia. It can be if the CT is abnormal, yet concealed abruption. Amazing. What can anyone say? What do you think might be the golden question to ask? It would be very impressed if somebody gets this, I'll give you a few seconds and then if not, I'll give you a clue. Do you want the clue? Shall I give you the clue? So, it's to do is to do with her contractions. So you're going to ask a specific question about her pain and about her contractions to ring any bells. If not, do the contractions relax. Fantastic. Pay them to contractions. Amazing. Amazing, good job guys. Yes. Do they go away? Amazing. All the answers are suddenly flooding in. Perfect. So essentially, if somebody is having an abruption, they're kind of usually having one big contraction. They can be in labor as well, but usually in between the contractions, the pain should go away and you know, it should get better. If you're having an abruption, you have that sustained pain in between contractions so well done. So, um uh I'm sorry, we're going to talk about uterine rupture as well, which is basically that, that because this woman had, when I was saying abruption sorry, I mean, you tried rupture, I'm sorry. That's confusing you. But this woman's had a previous emergency section. So she is having where that scar is opening. You can, you can bleed into there. You can also have a placenta previa. This is going to really confuse you now. So you can have a placenta previa in that scar. You can have an abruption in that scar and this could be a concealed abruption. But another really a common emergency presentation or not common, but a common question that you want to ask and you want to rule out is, is this woman who is in labor and she's having an induction. Has she got a rupture of that scar? So, um this can, this can present in a very similar way to that stem. So this can present as uh pain, feeling uncomfortable, constant pain. It can also present as fetal distress because the baby can actually be in the abdomen. Um It can come all the way through that scar, which is terrifying. You're we quote the risk of a uterine rupture to be one in 200 but obviously, with an induction, this is far more. So, um it can actually go up to 23 times. And remember in this stem, this woman was having an induction. So it can manifest as fetal distress, spots of pain. And you can sometimes lose the ability to monitor the contractions because actually the womb itself is not contracting. Well, um So this is the important thing too. Ask her, how are the contractions? How is the pain in between contractions? Are you feeling them? And obviously the management is a cesarean or basically a laparotomy, you need to open the abdomen and you might see this. So you might see the amniotic sac staring you in the face as you go into the sheath. This is absolutely terrifying. Um And you can see that's the uterus there and you can see the rupture. Um Finally you manage to sit down, you go back to the labeled room, you sit down in the handover room and the midwife and charge ask you if you remind reviewing room to who's just been brought over from the antenatal ward. She was admitted earlier on in the day with protein in the urine for induction. Okay. So here we go. Everybody knows what this is gonna be, I'm sure. So she's 40 years old is her first pregnancy to 38 weeks and it's an IVF pregnancy was incidentally found to have three plus of protein. The urine at the midwife check it was quite normal, the BP on admission, slightly high. Uh There's in the systolic wolf. See, you know, it's not 100 and 20 but it's not really, really high. And on the Antenatal ward, um it's gone up slightly. We've sent off a year in PCR and we've sent off PT bloods. So, what are we thinking that this is gonna be preeclampsia. So, the definition of preeclampsia is a BP that high or above and protein urea and buy protein urea. We mean a formal PCR of over 30 or a BP over that amount and protein urea with any of these symptoms. So, headache, visual disturbance, right, upper quadrant pain, uh papilledema, obviously, clinical practice, we don't check for that as often as we probably should any kind of hyperreflexia. So um any kind of three beats of cloners or if you're examining her, what if normal BP but protein urea. So if the BP is completely normal, but there's protein urea, that's not preeclampsia, it might develop into preeclampsia. But at that stage from just answering the question on the chat, someone's asked what if the BP is normal? But there is protein urea that is not preeclampsia, but it may develop into preeclampsia. But at that stage, it's called gestational protein urea. Uh Yes. So we're saying the, yeah, these are the other, the other kind of signs and symptoms of PT can anyone put any risk factors in the chat for preeclampsia for? Uh so someone's put gestational hypertension. Yeah. Three miles, three times the Amazing. Yes. Um diabetes. Yes. Um Do you treat gestation protein or just mindset? So usually we just monitor, we're going to, we're going to have a high suspicion that this patient might actually develop preeclampsia. Um If they remain with normal BP and no symptoms and just protein urea, depending on the hospital. Some people think that they should be delivered at different times. So some people recommend 38 weeks, 39 weeks term. Yeah, by time, I mean, 40 weeks. So, um, yeah, that's usually what we do is we just monitor, we'd obviously check for, you know, any kind of other thing going on. So we'd also do like renal function tests and you know, we'd investigate the patient properly. We might even do an arts. Sounds like kidneys. If we have time, if it's diagnosed just before delivery, then we wouldn't. But yeah, and obviously we just check that it goes away as well. Uh Renal D Yes. Very good. Increased B M I smoking, amazing, increased maternal age, over 40. Amazing, very good. So previous PT always got to say that one first pregnancy and then interestingly, um so being very young or being very old. Um so first pregnancy and then if you have a big into pregnancy interval. So if you have your first baby and then you wait 10 years before you have your second one, it's almost like as if the body is surprised by this pregnancy experience, it reacts differently. Um I'm changing having in pregnancy with a new partner, you can almost treat that like a first pregnancy because it's almost like we don't know how the genes of this placenta are affecting this woman and her physiology So, uh yeah, obviously any kind of pre existing hypertension renal disease or diabetes, autoimmune conditions, family history, uh multiple pregnancies always double trouble. It's almost increases your risk of everything. Uh and obesity as well. I think you guys actually got most of those so well done. So, um this is just a nice little picture. I don't know if you want to take a screenshot or save it. It's just quite a nice way to remember everything about preeclampsia. So, um obviously, it's characterized by high BP and then kind of signs of damage to either the liver or the kidneys. So you're going to see that in the form of dry, arranged LFTs. Um So you might see raised A L T in pregnancy. Um You might also see a raised creatinine, all these are kind of all signs of quite bad PT and in the FBC, you're looking for the platelets. So those are the kind of three tests that you're usually looking at. A LP is always raised in pregnancy. A LP should be normal in pregnancy. Um And then obviously, you going to see the BP going up. You might see the women getting swelling, to be honest, actually, loads of women have swelling in pregnancy, particularly towards the end, there's not very specific sign. Um But in preeclampsia, when people suddenly get preeclampsia, they often get swelling in their face in other places that it's not typical to get in pregnancy A LP. Yeah. So A L P is always increased in pregnancy and it's normal to have a high A LP in pregnancy. A L T should not be raised in pregnancy. It should be normal. But one of the reasons it can go up is severe P E T. Hopefully you guys heard that? Okay. I don't know how good my internet is, to be honest. Hopefully you're hearing everything. All right. Okay. So A S T is different A S T. So I'm talking about A L T A S T is a different liver function test. Low platelets doesn't mean it's help syndrome, not PT. So help syndrome and PT overlap your is very unlikely to have help syndrome without PT, but it's very common to have PT and not have help syndrome. Help syndrome is much more rare. So uh it helps syndrome. You're going to see the breakdown of red blood cells. So you're gonna see L D H goes up and you might also have really deranged liver tests. Can you summarize what you said about A LP? Yeah. So A L P always increased in pregnancy, not worried about it. I don't even look at it when I look at the LFTs A L T should be normal in severe preeclampsia. The three blood tests that you're looking at our platelets, which can go down in pregnancy A L T which can go up in pregnancy and creatinine which can go up in pregnancy. Is that all good? Everybody happy any more questions about this. So if you diagnose preeclampsia, let's say, okay, let's say the woman's got a raise BP and protein, the urine and she's an antenatal patient, the baby's fine. Her BP is not that high. You're gonna treat her with the kind of a conservative style management. As in, you're going to watch how she goes. You're not going to deliver the baby now. So you're gonna make sure you check her BP at least twice a week. If it gets worse, you'll increase that to every other day or every day. Ideally, you give the woman a home BP machine and you're gonna make sure you're also checking that, that the baby is fine every now and then. So you might do that like a twice weekly CTG or you might even do every day if you're really concerned about this patient. If you're doing everyday CGs, you're probably going to get to the point we're going to admit her and you might even think about delivery. So, preeclampsia is a reason that we can deliver people early, but we usually try to give them management first. So usually that's Libby to law. Um and then we move on to the other BP medications like Nifedipine. So is the blood vision due to papilledema or neurological problems? Really good question. It could be either so blurred vision is sometimes just because they're tired they're having a headache. It could be because their blood brushes raised. It could be because they've got actual papilledema. It could be anything. Um, it's quite nonspecific really. Actually. Loads of pregnant women and blood vision anyway. Um, why do you only treat severe hypertension? No. Yeah, exactly. So, somebody who had a consistent BP for 100 45/90 yeah, you would probably start them on a low dose of libido low. Um If somebody reaches term. So if somebody reaches kind of, we'll definitely 38 39 weeks with these symptoms, you would just recommend delivery. So if that's like they want to have vaginal birth, it would be an induction. If it's a, they want to have a cesarean, then you would um do a cesarean when you give aspirin. So, aspirin does not treat preeclampsia at all. Aspirin is a preventative medication for preeclampsia. So we give it to women that have risk factors and we give it to them from 12 weeks, usually because that's when we get to see them. So they usually book with the midwife about eight weeks by the time they come to see a doctor or they see a midwife, it's usually about 12 weeks. Um So we start them on a low dose aspirin. Um And that's if they have risk factors. So for example, if they're older, if they have twins, if they are obese, um but once you've got preeclampsia, which is probably due to abnormal placentation, so, abnormal formation of the placenta, then, um, it's kind of too late for the aspirin to do anything really at term with the BP. 145. Would you give all Lobitol? Oh, or expert delivery? You probably do both. So, if somebody, I mean, to be honest, if somebody comes in and they're, let's say, 40 weeks and they've got a BP 140 of 90 and it's not just a one off, it's like you've checked it three times and it is high that there's no point continuing this pregnancy because she will get prolapse it probably. But you just are going to you and the baby is already ready to come out of 40 weeks. So you, you would probably give her labetalol to try and bring that BP down. But you'd also recommend that she stays in and she has an induction, how come aspirin is okay when other NSAID are contraindicated in pregnancy. Um So uh real NSAID is like, for example, Ibuprofen, the reason it's contraindicated in pregnancy is a few reasons. But we think it's because uh to be honest, you could probably have some NSAID in pregnancy, but we're obviously not going to let women have them because we think that it, it causes the doctor's arteriosclerosis to shut. So that's why we don't give it in pregnancy. But aspirin is different. Aspirin. Aspirin is given because we know it's safe in pregnancy because we know that actually we think it affects platelet function. And, um, yeah, it's completely different to N C is like ibuprofen, naproxen, etcetera. Um, does that make sense if they were 34 weeks with BP? Not, would you admit them and then wanted to treat if they were 34 weeks with the BP of exactly 140 over 90 you would probably give them medication to try and bring it down. If everything else was absolutely fine, they can probably go home. Um, and you would just monitor it. Yeah, that's what I would say. If it was much higher than that or, you know, if it, if it wouldn't go down with medication or if that was after you given medication, then probably, yes, you would admit them. You do pre account, you do the whole set what we call PT bloods, etcetera. I'm assuming there's also no protein in the urine. If it was really bad, when will we want to deliver? So you can deliver any time because of preeclampsia because ultimately preeclampsia is a threat to the mom's life if it's really, really bad. So there's even cases in the literature where people have had preeclampsia at like, for example, 22 weeks or, you know, this is horrendously early, but it's, you know, if you really had to, you would still deliver and you would have to unfortunately put the mom's life at that point over the baby's life. Obviously, everything is in one of Citrix is a risk and benefit, isn't it? So you have to think uh for these women, you don't want them to become too ill. But obviously, for the baby, if it's a case of 28 weeks, 29 weeks, 30 weeks at this kind of stage, every day makes a difference for the baby's survival. So, um but obviously if the baby is in an environment where the mom's got a really high BP and her whole organs and systems are failing because of this preeclampsia, that's also not really a good environment for this baby to grow. So you have to weigh up everything you have to do. You know, how is this mom? If she, if she has a BP of 200 over 100 and 50 and she's on the verge of having a seizure, even if she's 26 weeks or she's 25 weeks, it doesn't matter, you would deliver her. So, um on the, on the other hand, if she's like 39 weeks and her blood pressure's like 135 over that, you know, you can think okay. Well, she's so desperate vaginal birth, we can probably allow her to, you know, see if she can have vaginal birth or, you know, everything is a compromise basically, in a discussion with the patient, obviously as well. Um Does that answer your question? Do you always give magnesium sulfate for severe. Yes. Okay. And do you give for preeclampsia with the BP of 100 and 50 and 95? So, magnesium sulfate were given to situations magnesium sulfate. We give for the mum if there is preeclampsia if there is severe preeclampsia. So if we're uh if the mom meets the criteria for severe preeclampsia, which she could do with the BP for 100 and 50 of 95. If she has other features of severe preeclampsia, for exam, for example, like the symptoms or deranged blood tests, hyperreflexia, etcetera, then yes, you would start her on magnesium sulfate and we usually give it as 24 hour infusion. The other situation in obs in guinea where we give magnesium is if the woman is in preterm labor. So if she's going to deliver a baby less than 34 weeks and we want to give it and that's it for a different reason. That's for neuro protection of the baby. Sometimes those two actually coincide because you need to deliver somebody early because she's got preeclampsia. So there's the two times in obscene guinea, we give magnesium sulfate. Hopefully that answers your question any more questions about this before I can. Obviously, we talked about this already. Okay, perfect. So, um like I said, you obviously gonna try to stabilize her. You're going to control BP, prevent seizures. This is in the acute phase um monitoring. So you're gonna do ob obviously, including BP, you want to measure the urine output and you want to do a strict fluid balance because these patient's can become so fluid overloaded. Obviously, this is a blood test. We talked about, check the neurological status, check symptoms and check the baby and make a plan for labor or birth. So even if she's at this point 33 weeks with a slightly raised BP, um you might make a plan to deliver her around 39 weeks and then let's say her BP gets worse. You're gonna change that plan and you're gonna plan to deliver her earlier. When do hydrALAZINE. Yeah. So we can use hydrALAZINE. Usually you will see people deviate from that protocol, but that's kind of the general gist. If you need to give something IV, then you can give libido low IV. You can also give IV hydrology. So it's kind of your second line if you need something IV, if that makes sense, hopefully that will answer your question. Cool. So, and it camps here is obviously when somebody starts having a full blown seizure. So again, you're going to call for help, you're gonna do a double two, double to um you're gonna paint, make sure the airways patent, breathing, going to put the oxygen again, IV access full set of blood. Indeed. You're going to try and control these seizures. So you're gonna give magnesium again. But this time we're going to give a loading dose of 4 g over for five minutes. Um And then you would continue the infusion after that. So that standard infusion that you give for severe preeclampsia, you're gonna give an eclampsia but just after a big bolus. Um and then you can keep giving further bolus is if they have recurrent seizures. Now, just a note of that magnesium toxicity, you might see the patient get a lower respiratory rate with absent reflexes and then you're gonna give your antidote, which is either going to be calcium gluconate or calcium chloride. You're going to look really slick in your rosky. If someone asked you about preeclampsia and you say I would make sure that we're aware where the eclampsia boxes on labor ward because these days, most labor wards kind of have either a trolley or a box or something. They can get that contains these, these drugs because obviously, it's not something you need to use every day. They're not going to be in every labor ward room or easy access in the drug covered. So quite often there's like a postpartum hemorrhage trolley or there's an eclampsia box. Um So yeah, you just look really nice and slick if you say that in your rosky. Amazing. So you've just finished prescribing the labetalol of room to be. Um you can. So if any towing obviously is an anti epileptic. So uh we don't tend to use it. I personally never seen it needed to be given, obviously, if somebody's having like status epilepticus, then you might enter a scenario where you give it. But usually you would give, you would give uh LORazepam if somebody is having a seizure. So that would be the first line anti epileptic that you would use in a kind of pregnancy situation, laboard situation. But obviously this woman doesn't have epilepsy, she has preeclampsia. So the treatment is magnesium. Hopefully that answers your question. Can moderate pro company be managed in the community if they are over 34 weeks. Uh Yeah, it can I mean, I don't know what really mean by moderate preeclampsia. So if someone's got preeclampsia that isn't severe. So let's say they've got the conditions you give me. Yeah. So sorry. Let me just write down the question one at time. Sorry. So the first question can moderate pre cum to be managed in the community if they are over 34 weeks or should you always admit the patient? Well, for a start in medicine being the kind of never state always or never. So yes, definitely you could manage somebody in the community with preeclampsia as long as it's not severe and as long as you have no concerns about them, so it would have to be well controlled on the BP medication. So if you give lobby to low and on labetalol, the BP is normal or less than 1 40/90 then yes, the patient can be managed in the community. Obviously, you want to make sure that they aren't like completely living alone or you know that there's somebody who's going to represent if they get symptoms, that they understand what you're telling them about all the risks, etcetera. Um So yeah, you would kind of again, patient dependent, but yeah, you would make a plan for them. Uh Can you repeat the condition you get magnesium? Yes, definitely. So, um preeclampsia, so severe preeclampsia, we give a magnesium infusion, any clampsia, we give a magnesium bolus and then an infusion and we also use it for preterm delivery if we have time. So obviously, sometimes we don't have time to give it, but even a few minutes of magnesium um for a baby that's less than 34 weeks has been shown to improve the outcome. And that's because it's neuro protective for the baby. So you'd admit them from the clinic to check first if they respond to medications. Is it? Yeah, and then they can be discharged? Yeah. So it depends. So if you do the BP and you find that it's, it's really high, then you would probably admit them for a full work up and the preeclampsia, bloods, etcetera. If it's a little bit high, you would do all of that. But you'd make sure you check it before you go home, but you let the patient go home and yeah, you could just give her the BP medication So Lobitol, oh, it's a little bit slow. Nifedipine tends to work quite quickly but you just, you would give them the blood, the medication and you say come back tomorrow and we'll check your BP tomorrow. Um, or you say, you know, we'll check it in three days, depending on what the BP is and the gestation of the patient. Usually we start off with twice weekly blood pressures. Hopefully that makes sense. Yeah. All good. Ok, guys, the buses going off again, it's a Braddy. I'm sure you've all heard this on Laboard. This is the short hand way of saying Bradycardia, which actually really means a deceleration. Can you write the definition of the deceleration in the chat decrease in the baseline, fetal heart rate of greater than 15 BPM for greater than 15 seconds nailed. It doesn't have to be an abrupt decrease. It's just that you can just say decrease. But yeah, perfect. That's exactly it. So dropping the baseline of more than 15 for more than 15 seconds and a prolonged deceleration is one that goes on for longer than three minutes. Sometimes this can be because of a change in blood pressure or change of position. So the classic example is after the patient set up for an epidural, the BP drops when they have an epidural and then some the baby just does not like it. So sometimes they just have a prolonged deceleration after that. And So what we usually do is we try to change the positions were trying to encourage blood flow to the baby or we're trying to get the baby off the cord or whatever is kind of causing that. So we try the left lateral usually first because obviously that gets the weight of the uterus off the IVC, increased venous return, ideally increased BP. And then sometimes that can actually be all it takes to get the baseline back up again, we examined because sometimes the reason there's a bradycardia or there's a reason there's a problem, deceleration is because actually the patient has become fully dilated or she's progressed quickly in the labor. So we always examine the women. We examine for two reasons. One because we're trying to see is she fully dilated? What's happening with this baby? Is there a cord prolapse, etcetera, etcetera? But also because if she does, if it doesn't recover, we need to deliver this woman by the quickest or safest route. So if at the time of the prolonged deceleration, she's fully dilated, that's probably going to be an instrumentals delivery. If she isn't fully dilated is going to be by Cesarean section. So, um just a quick note before we finish this section about amniotic fluid embolus, which is a really, really rare complication um of the amniotic fluid entering the maternal circulation, causing maternal collapse and cardiac sometimes cardiac wrestle, often cardiac arrest. Um This is a kind of yeah, it's something you're really not going to see very often, but there's also not very much you can do about it. So, and it's just good to be aware of it. It often presents a kind of anxiety or agitation um and respiratory distress almost a bit like a pea. But uh instead of it being an endless of a clot, it's an embolus of amniotic fluid in the maternal circulation. So the management is supposed to be supportive correctional clotting factors. Um and liaising obviously with I T U. But yeah, it's very uh bad maternal outcome. So amazing. Finished labor ward you got through the night shift, well done. It's good that you've been asking questions as we go actually because probably easier to clear up things um in the moment. So, um if anyone else has any questions now is the moment, otherwise we'll move on to the next section. We're good. Hopefully this is bringing back some nice memories of your office and guiding placement and how much you enjoyed it. Okay. So you've upgraded, you're now the ST too. Uh someone said, oh, could you repeat Braddy cardio versus severe prolonged, right? No, no, no. So um sorry if I said that too quickly. So uh people say it's a Braddy and by Braddy they mean Bradycardia but you Braddy cardio just mean slow heart rate. So technically, if, if the, if the baby's Braddy Kartik, that means something that's been going on for a long time. Technically, when they say it's a Braddy, what they mean is a prolonged deceleration. So, a deceleration is a drop in the baseline by 15 beats for more than 15 seconds. A prolonged deceleration is one that goes on longer than three minutes. Does that make sense? And then as it continues, if it continues six minutes, you should be thinking about delivery. 12 minutes. You need to be in theater. 15 minutes, baby needs to be out. Perfect. Awesome. So, uh yeah, you're, you're now ST to uh did you say a patient with preeclampsia should be on aspirin? Know? So, aspirin, aspirin is a preventative for preeclampsia. So if you diagnose preeclampsia, there's no point putting the patient on aspirin. They need to take it from 12 weeks. Usually we continue it to 36 weeks because we ideally don't want the patient to be on aspirin when they deliver. So hopefully that answers your question. Okay. You've made it your ST to your covering of Zangana at night. Now you're going to be in A and B. So the first patient is 30 years old, eight weeks pregnant. She's prevented with persistent worsening, vomiting, unable to keep fluid down. What investigations are you going to do for this patient? Who has got hyperemesis? Your analysis? Fantastic. Yes, you're gonna check. She's got a UTI she is vomiting. Very good. Uh You're gonna check key tones, assess for dehydration. Fantastic. Use Annie's. I love it. Guys. Perfect, perfect. Uh Amazing. So yeah, you're gonna do your analysis. You are going to send an MSU to exclude a UTI because that can be a reason for vomiting even in the absence of abdominal pain, you're going to do a full set of blood test particularly including using these um and you want to do an ultrasound because you want to look if she, if she got twin, has you got twins And is that why she's vomiting? And also molar pregnancy, which gives you a very high HCG and therefore gives you vomiting. So uh puke score, you can calculate which is basically uh something where if you're forever in that situation, you can just look it up on your phone. Basically. You want to ask for. How long do you uh sorry for what percentage of the day do you feel like vomiting? How many times do you vomit, etcetera, etcetera? Um If it's really bad, you might admit them, you're going to give them some fluid. It's really important to give them some fluid with some potassium in. You want to check the user knees every day and then you can give them a whole host of antiemetics. The only one that we don't give as a kind of first line anti emetic is Ondansetron. And that's because there's a very, very slight increased risk we think of having in the baby or oh uh like sort of oral cleft palate basically like or a pallet abnormalities. So, um it's really, really tiny but it often puts women off taking Ondansetron and it's something that we have to counsel women about. But unfortunately, often on Dansetron is the only anti emetic that she really works for these women. And the risk is so small and it's more important that the woman herself can, for example, take her folic acid and actually eat and actually drink water. Um, so it can often be a difficult balance. But yeah, all the others are absolutely safe in pregnancy. Um And if it's really bad, we can even stop the women on oral steroids. Um Just a little picture just to help you remember that. And Dame Leslie Regan, who was the recent um R C O G Presidente with Kate Milton, who obviously herself suffered from hyperemesis just to kind of help it stick in your head there. Second patient is 34 years old, 10 weeks pregnant, presenting with PV, bleeding. So miscarriage unfortunately, is 20% of pregnancies defined as any pregnancy lost less than 24 weeks. But by far the majority will be less than 12 weeks. Can anybody write in the chat types of miscarriage? Inevitable? Yeah. Yep. Fantastic. Fantastic. Fantastic. So threatened miscarriage is any bleeding, abdominal pain with a closed cervix and on a scan that might correlate to you seeing a sat of fetal pole, fetal heart activity. Complete miscarriage is well, where obviously the whole baby, the whole pregnancy has passed. So at this point, the pain and the bleeding has stopped with a closed cervix and you would see on a scan, an empty uterus in complete miscarriage is where you have pain or bleeding with an open cervix. And that you may see on a scan of gestational sac or endometrial thickness or some kind of pregnancy tissue that's still inside the uterus, an inevitable miscarriages where you can see the whole pregnancy still on the scan or you can see if it's a heart, you can, but the patient has pain and bleeding with an open cervix. We can come back to that if anyone has any questions, management of miscarriage is uh like anything in surgery. Expectant medical surgical, we tend to call uh conservative management in orbs and gain in the in the context of early pregnancy. We tend to say expectant management. Um which just means that we're keeping a close eye on the patient to see what happens. Medical management of miscarriage is firstly Mifepristone and then followed by Misoprostal. Sometimes we give multiple doses of Misoprostal and then surgical manages a surgical management is either an E R P C which is evacuation of retained products of conception, often called now surgical management of miscarriage or S M M and then M V A which is where um it's a similar procedure actually, the patient is awake. So that's manual vacuum aspiration. Okay. You call to Reece us this time there's an 18 year old hemodynamically unstable who's called an ambulance because of abdominal pain on the pregnancy test. It's positive on the urine pregnancy test. And on Far scam, there's a liter of blood in the abdomen. What is this? Come on? Somebody knows it's kind of obvious ectopic. Fantastic, there's blood in the abdomen. So the ectopic is a ruptured ectopic. Fantastic. Ectopic pregnancy occurs in 1% of pregnancy. So it's actually relatively common. Um So uh the definition is that it can be anywhere outside the uterine cavity, but obviously 98% percent of the time this is in the tube. Uh Somebody asked is medical management of miscarriage the same as T O P. Yes, it is. Um But obviously if you're having a medical, if you're having a medical T O P, then yes, it is the same. But the dosage of the miSOPROStol may vary depending on the gestation, the size of the pregnancy, etcetera, etcetera. Um Surgical management is also very similar. The only difference is obviously if it's a late terminations in. Um yeah, which is kind of a bit sad and not so nice to get into. But if it is a late terminations in, then um it's not going to come out as easily. So you uh first of all need to stop the fetal heart. So they give potassium for that and then um remove the baby, what it's not going to come out just with the suction. So, um, yeah, it's a bit more of a complicated and bigger procedure if that makes sense. Hopefully that answered your question. Uh So in the meantime, if you want to write the risk factors for ectopic pregnancy in the chat B I D? Fantastic. So, yeah, previous P I D, uh, previous ectopic. Fantastic. I D IVF. Yep. Amazing. Uh, so endometriosis and fibroids. I don't think it's actually a hugely significant risk factor. Definitely wouldn't put that as the first ones. Um, tubal surgery. Yes, definitely. Um, these are all good. So I would say that the most important ones to say would be previous ectopic. The coil, I would say P I D, all of these should come at the top and then you can say things like uh endometriosis. And you can also say, uh IVF or a history of infertility. Now, the reason that the infertility is a, is a risk factor is probably because it's linked to P I D. So, if you've had previous P I D, you may have a history of infertility and therefore your tubes maybe blocked endometriosis can cause block tubes. But in practice, you're not going to see that very often at all. So the most important ones to say, I would say a previous ectopic, um, and a coil and previous surgery. How much does coil increase the risk by? I'm really sorry. I don't know the answer to that. But the reason that the coil is a risk factor is that it stops any pregnancy from implanting in the uterus itself. So, is in the body of the uterus. And that's why if there is a pregnancy, it might be slightly more likely to implant in the tube. So, I don't know. That's a very good question, which I'm definitely going to try and find the answer to architecture but exactly how much the coil increases risk. But I'm not sure. Um It's more like if there's a pregnancy happen in. Yeah, yeah, that's kind of what I was saying, but it's still possible to be pregnant with the coil. Um and it to be in the uterus. So, um yeah, either of those as possible, but yeah, most important ones to say our previous ectopic um and history of P I D. So investigations, obviously you're going to diagnose it on an ultrasound. Um You're obviously going to measure beta HCG and depending on the hospital, depending on the protocol, you may measure progesterone as well. So, um management again is gonna be expectant medical or surgical. So if this is an ectopic where we think actually this pregnancy is failing, the HCG is falling, it's not a high number to begin with. The patient's asymptomatic stable, the patient lives nearby. She sensible. She understand what you're saying. Then you can manage them expectantly medical management. We use methotrexate. It gets very confusing in these scenarios because there's so many drugs that begin with M, so in a miscarriage, the drugs are Mifepristone and methotrexate. So, eh, my miscarriage there, the M I drugs in an ectopic pregnancy with an E, we're gonna use methotrexate. Hopefully that helps a little bit. Methotrexate is actually kind of like a chemotherapy agent. So, it's pretty horrible drug to take and you need to have your LFTs checks and you can't get pregnant for three months. It's not, it's not actually a very nice thing to have surgical management. We try to do a salpingectomy which is removal of the whole tube. But if the other tube is damaged, we try to preserve the tube and do a salpingostomy if we possibly can. Um, you finished the emergency laparotomy for the ectopic and then a and he call you and they tell you you have two more patient's to see. Uh, it's a 15 year old girl with severe colicky left eye, let false of pain. Her pregnancy test is negative. She's got raised inflammatory markers and she's vomiting. What do you think? And which emergency do you think this might be? Fortune. Amazing. I love it. I love it. It's actually really annoying because quite often people don't have a high suspicion of Tor Shin in young patient's. But obviously for this 15 year old girl losing her ovary is a huge deal. So really important if you have an A and E job where you have a peed job, always in your mind, if you think it could be taller shin, even if the I'm gonna regret saying this now. But you can always ask, you can always ask for advice if you think that the patient is how it is. Um talking, you can always ask for Gynie and you can always do inflammatory markers as well. So technically, the management should be to go to theater. But in practice, what often happens is people do an ultrasound and that's because they want to rule out things like an ovarian cyst or I mean, actually an ovarian cyst can even cause torsion in the first place. Um But people want to, you know, people want to be sure, sure before they take a young patient theater, technically, really, the management should be straight to theater. And if there's an ovarian cyst that's causing this torsion, you remove the cyst. If the ovary is completely dead, really, you should still leave it and see whether it revascularize is after you dete ort it. But if you really think that this is going to cause the patient to become septic later, and this ovary is completely beyond salvage, bit on salvaging, then you would do an oophorectomy. Um Finally, we're going to talk about bath linens just briefly, which is something that you will often see in a and e it's not necessarily going to cause the patient to become very unwell, but it's just something to be aware of. So the bath linens duct is in the lower third of the labia majora and it can often become infected or blocked and then infected. Um And it then becomes what's called a Bartholin's abscess. So, um this is a bit of a confusing picture because it's kind of sideways, but it's basically at the bottom opposite the vaginal opening. Um And the way that we manage these is first if you try antibiotics or something broad spectrum like co amoxiclav, you, we then you something called a word catheter, which is kind of actually like a bladder catheter, but only four centimeters long, make a small cut on the abscess after putting some local anesthetic, of course, put in the catheter, inflate the balloon and it allows the past drain out and that can sometimes stay in for a few weeks actually. Um And then the only kind of cure because often these can keep coming back is um incision and drainage or incision and marsupialization. That's where we try to open the, the abscess, let the past drain out and then we try to stitch it open so that it can't reform. So that is it for the Andy section. Does anybody have any questions before we move on to the M C Q s? Everyone happy. Should we do some M C Q s? Yeah. Hopefully you can still hear me. Okay. Can someone just put in the chat if you can hear me? Yeah. Okay. Cool. So I've had internet I/O all day in this room. So perfect. Perfect. So um first question 20 year old with previous PT undergoes induction of labor for raise BP. The baby is delivered by Cesarean section, which uterotonic should be avoided. A car. Pitocin be syntocinon. See Misoprostal d ergometrine or E carboprost. Oh, we're sorry. I didn't tell you how to do this. I was gonna say write it down. Don't, you don't have the right. Okay. Okay. You were all written in the chat and you will get the correct one. It's okay. Veteran. Just so that people can take time to think of it themselves. Maybe don't write the answers in the chat for. This may be just everybody just have a guess on paper um or just in your head just so you know what you would say. Um And then I'll tell you the answers just so it gives everybody a chance to like really think about it before they see the answer in the chat. Is that okay? I think that's probably fair. It's for everybody. Okay. Yes. So the answer the Endometrin. So Ergometrine, we avoid with raise BP and heart and carboprost we avoid with asthma. Carboprost also called him a date. So you were listening but all you know it from before, either way, well done. Um Okay, which of these accurately describes the breech presentation of a foetus where the hips are extended and the knees are extended. Is it footling Frank extended, complete or flexed. So, don't write it in the chat. Just have a think what you would put. He's okay. Don't worry, he's fine. So if the hips are extended and the knees are extended, then the first thing that's going to come out is gonna be the foot. Yeah. Okay. Cool. So next one first whittling, sorry is filling. So the next 1 28 year old gravity for power three, that's how you say that. By the way, I know some people say G three piece, you can say that if you want to. But technically it's gravity for power three. So three previous Cesarean sections comes to triage with sudden onset, severe constant abdominal pain at 35 weeks. She's a smoker on examination. She's severely tender with a tense uterus, tachycardic, know PV, bleeding and the C T G shows borderline variability, but otherwise it's okay. What is the correct management? Would you continue the CTG for 30 minutes? Would you start her with an induction of labor using Oxytocin? Would you do nothing? Would you do an emergency Cesarean or would you admit with a plan to deliver once she's 37 weeks? Because hopefully everyone had time to think about it and everybody's got an answer that they would put. Um, so I think the answer should be emergency Cesarean section. I know that she's kind of okay and the baby seems kind of okay, but she's got this really if you're thinking it's an abruption you have to deliver. And actually, although the CTG shows borderline variability is otherwise normal. Borderline variability shows that this baby is probably not actually happy. Um And if you continue the CTG, it would get worse and the patient would get worse. So actually the answer is emergency Cesarean section. Hopefully that will make sense. She's got. So she's a smoker. She's tender, she's tacky card ick. Um, so yeah, she's huffing an abruption question for a 33 year old underwent Cesarean section after failed induction for prolonged Schrum. She comes in day five, post partum in the race temperature. You diagnose her with sepsis. Now, this is annoying question. I'm sorry about this, but you do get annoying questions in your exams. Which of these is the most urgent management option? Is it a trans vaginal ultrasound? A catheter for urine output? Is it to start IV cataracts and neutralize or IV fluids or a chest X ray? What do you think? Do you know what I hate when you, you think you know the answer? You read the first sentence you like yes, sepsis. It's infection and then they're like you diagnose her sepsis anyway. So hopefully you all know that the most urgent thing to give is antibiotics. So you are actually going to do a lot of the other things, but the most urgent thing to do is the antibiotics. Um There's obviously a lot of evidence, I'm sure you know this, I'm sure you're sick of hearing about this. But there's a lot of evidence that if you give antibiotics within the first hour of presentation, it has a hugely significant impact on the clinical outcome. So the most important thing in this scenario is see antibiotics, a broad spectrum, by the way, broad spectrum antibiotics. So question 5 34 year old gravity to power. 11 previous Cesarean section concentrated, worried about her. A normally scan, the placenta is low and partially covering the off. Are those always the antibiotics? You give good question. So uh most of the time, yes, obviously, uh imperial hospitals or like Northwest London, usually the protocol is going to be to give. Uh so you wouldn't give Tassan straightaway. You would start with Kevin Mezzo. IV Keffer met some trust will have a different policy and I'll start with IV Co Amoxiclav. Usually if that doesn't work after a few days, we switched the patient to Callison, but you wouldn't start with Alison. Hopefully that answers your question. So yeah, so this question, one previous Cesarean section comes to try. I was worried about how normally scan the present is low and covering the cost. What is the correct management? Is it to book an elective Cesarean for 40 weeks? Because she's gonna Eucerin book it for 39 weeks. Is it to repeat the scan at 32 weeks? Repeat the scan at 28 weeks or book the repeat scan immediately. Hopefully you're all listening and my internet didn't cut out earlier and you know that the answer is book the repeat scan. See for 32 weeks. Okay. Your final, your medical questions can be you very soon watching a normal vaginal delivery in the birth center, the head is delivered and after the next two contractions, there's no restitution. What is the most appropriate immediate management? A mcroberts bees. A benelli see would screws the woods screw to or e call for help. Okay. For this one, you can write it in the chat. Please tell me, you know. Okay. Okay. Someone's for a E Yes. Cool for help. He's not one of the thing mcroberts on your own. Yeah, I know. You know, the answer is mcroberts again, that was like an annoying question. If call for help wasn't there mcroberts would be the answer. Oh, yeah. Yeah. She's got it. She's got it. Okay. Perfect. So, um, next question, you're fine. All your medicals. You're watching a normal vaginal delivery after calling for help, what is the most appropriate? And now you all know the answer. It should be a mcroberts. Yeah. Perfect. Amazing. Amazing. Amazing. Okay. Sticking on the shoulder dissociate theme which of these statements is false. Shoulder dystocia occurs in not 0.7% of vaginal deliveries. Shoulders associate is associated with instrumentals, deliveries. Beetle size is a good predictor of shoulder dystocia. Half of shoulder dystocia occurs in babies weighing less than 4 kg. Uh, infants of diabetic mothers have a 2 to 4 fold increase risk of shoulder dystocia compared to babies and normal waves point and non diabetic mothers tongue twister. Uh, give you a second just to have a read and have a think, maybe, don't like this one in the chat. Just have to think about it. What would you put if this was your real question in your exam? Okay. So the answer is actually c which is weird because you would think that actually fetal size, if there's a big baby, it's more likely to get stuck. Really? Interestingly, it doesn't predict shoulder dystocia very well at all. Diabetic babies or babies of diabetic mothers are more likely to have shoulder dystocia. But that's because these babies have a bigger torso or a bigger abdominal circumference in relation to the head. So these babies are kind of like little rugby player babies. They've got big shoulders, little tubby bellies and that's why they can have shoulder dystocia when I, that's the diabetic babies, but a baby just being big in general does not, um, does not give rise to, um, shoulder dystocia. So you can have a big baby as long as the head is bigger than the body. This baby is going to come out without shoulder dystocia. What about b shoulder associate is associated? It's true. So shoulder associate is associated with instrumentals deliveries. I hope that answers your question. That's one of the risk factors. So, having a forceps or having Avantis is a risk factor for surely the social. Um, and yeah. So, yes, boss. I know they always get me as well. You read it and you're like, oh, yeah, it's that one. Uh, yeah. So all the other statements are true. Okay. So half a shoulder dissociate does occur and babies wearing less than 4 kg, that big sentence about diabetes is true. Um, And yet it's roughly 1% delivery is not 10.7 depends on what paper you read. Um And it is associated with instrumentals deliveries. So uh next question, you review a lady in a knees, 12 weeks pregnant, she had a dating scan four days ago confirming a viable into trying pregnancy at 11 plus three. She has two, attended A and E with bright red PV, bleeding, cramping, abdominal pain past lots of blood in the toilet. And now the symptoms have settled on examination. She's got mild abdominal pain and the cervix is closed. Bedside scamble bills are mostly empty uterus. What is the diagnosis? So give you a few seconds to think about it. What you would put in your exam. Okay. So she's past lots of blood and now the symptoms settled, the cervix is closed. She had a dating scan four days ago confirming a viable into trying pregnancy. So we know that this pregnancy was in the uterus. So now there's nothing in the uterus. So this is a complete miscarriage. So the answer's eat, hopefully you all got that right. Um, just going back actually, if she hadn't had a dating scan and she'd had no scan and she was more likely to be eight weeks pregnant, something like that. She hasn't had a scan. Then this would be a pregnancy of unknown location because you scanned her and you can't see anything in the uterus closed. Cervix is always complete. Uh, No, because the clothes service can be a threatened miscarriage. So if you see a closed cervix and the patient's blood bleeding or bled, but there's still pregnancy in the uterus, then it will be a threatened miscarriage. But in this scenario, she's passed it and you know, the uterus is empty. But if she had an empty uterus on scan and um she had never had a scan before, this would be a pregnancy of unknown location. Hopefully you will get that. Does anyone have any questions about that? Hopefully, that makes sense? Awesome. So a 19 year old attends with right left for spain brown PV, bleeding would still be a complete miscarriage in in what scenario? So, so what I'm saying is if let's say we took out this sentence about she had her dating scan four days ago, the difference between a pregnancy oven location and ectopic is um uh so the pregnancy of unknown location is where the patient has a positive pregnancy test that can be in the urine or the blood and you can't see where the pregnancy is on the scan. So that can be for a few reasons. Uh, it can be because she's already passed the pregnancy and there isn't a pregnancy on the scan anymore, but she's still biochemically pregnant because the hormones haven't resolved yet. It can be because, uh, the pregnancy is really early and you just can't see it on the scan but it will develop and in that case, the beta HCG will increase. It can be because you can't see the pregnancy in the uterus because not in the uterus, it could be an ectopic. So pregnancy of unknown location is like a umbrella term for, we don't know where this pregnancy is and it might be an ectopic but it might not be. Hopefully, that makes sense. This question, the reason I wanted are perfect. The reason I just wanted to highlight it is because if there was no scan confirming this was ever an intrauterine pregnancy and all you know is that this woman's got a positive pregnancy test and she's bleeding and you can't see the pregnancy, then this answer would be different. It would be a pregnancy of on in location. But because she's had a scan and you know, the pregnancy was in the uterus, then you know that this is a complete miscarriage. Hopefully, that makes sense. Awesome with ectopics. How does the beta HCG? Uh So B to A C G just measures a point in time in the pregnancy and it kind of correlates to the size of the pregnancy. Sorry, just to go back to this because it will be still that same thing. So it's not like, oh, your beta HCG is this. Therefore, you have an ectopic at all. What we see in an ectopic is we measure BT HDGS every 48 hours. If it's a healthy pregnancy, the beta HCG will double every 48 hours. If it's a miscarriage, the beat 80 G will be falling. If it's an ectopic, the beta HCG will be what we call sub optimally doubling every 48 hours. So usually it's increasing by about two thirds. So not always and you're not going to use two thirds as a marker. But what we see is this, this phrase, the beta HCG is sub optimally doubling. So the pregnancy is growing but it's not growing like a normal pregnancy. Um So it's not like a certain number, the number you do use for the eight Beta HCG to help work out the management. So for example, if it's over 5000, you're definitely not going to manage this patient conservatively. Um If it's over 3000, you probably can measure them conservatively. But if it's over 5000, you're probably going to recommend surgery, but it's not like a certain number on the Beta HCG correlates to a diagnosis. Hopefully, that makes sense from that part. So, um a few more questions guys. So um uh 19 year old tends with right enforce pain, bleeding history of P I D. The pregnancy test is positive there's no pregnancy visible in the uterus. You're like, yes ectopic. And then the question says, where is the room seem most likely to be located? If you were listening to the lecture, you got a 50 50 chance of getting this right? And that's a big clue. Hey, hopefully this is a super easy one. And you all know it's the ampulla of the fallopian tube. So the answer is see, it can be in any of the other places. By the way, they're all options. It can even be on the liver. It could be anywhere. But remember, ectopic just needs outside the womb. The most likely location, 98% of the time is in the tube and it's usually in the ampulla question 11 4 to a lady with severe PT starting magnesium. After the loading dose, she becomes flushed and hot oxygen saturations, drop espiritu, it's only eight reflexes are absent. What is the correct management? Give you a few minutes to have a little think about that. Hopefully you all recognize this is magnesium toxicity. And the answer is to give by the calcium. Okay. Next question, 36 year old attends with high premises at seven weeks pregnant. She's had some IV fluid, she feels better and she wants to go home. Which of the following should be rearranged. She can't go home. You've got to admit her or do you want to do thyroid function tests? And early outpatient ultrasound. Do you want to do an urgent impatient scam? Maybe she can just see the G P later to start antiemetics or do you want to do an MRI head to rule out prolactinoma? Have a little think about that one. Okay. So the answer is b you always want to check thyroid function tests at least at some point in a patient with hyperemesis. Um and she does need a scan, she needs an early scan compared to she's not going to leave until 12 weeks like everybody else. Um but she can go home and she can have it as an outpatient. So that's why you wouldn't do it as an inpatient. Um It's probably nicer to give you antiemetics yourself rather than leaving her to see the G P. She doesn't need to be admitted because she feels better and she's fine. Um And you wouldn't need to rule out a prolactin in her because that is super rare. Um And most likely she's probably just got hyperemesis. So hopefully you all got that right. Um So question 13 uh if you mention, but why do we monitor TFT five parameters? So um probably I didn't mention. So thank you for highlighting it. So sorry. So thyroid function tests because actually one of the reasons you can have high premises is because you can actually have hyperthyroidism. Um, so sometimes you can have a weird hyperthyroidism that's almost caused by the HCG itself and it can resolve. Um, but actually it's really important to check thyroid anywhere in case the patient has grave's disease. And actually that's why the vomiting. Hopefully that makes sense. Um, so we always just do them once. It's not, it's very rarely abnormal, but it's just something you should take that box. She should always check using knees and things like that at the time when the patient comes in beat HCG mimics TSH. Yeah. Do you remember they kind of all got the really similar hormones and they've got their alpha and they're beat a sub units. So they are structurally very similar hypo. Uh Question 12 is different. Hyperemesis. Gravidarum. No, no same thing. Hyperemesis is just a short way of saying hi premise of gravity are. So gravidarum just means in pregnancy and hyperemesis just means extra vomiting. Uh So question 13, 36 year old history of infertility, diagnosed ectopic pregnancy. Uh She has a previous ectopic which was treated with self inject A me. Her beta HCG is 1500 she's stable with no symptoms. Which management option would you encourage her towards? Again, it's a difficult question actually and it's probably patient dependent, but there's an answer that obviously trying to get out of the question. So hopefully you all in your head thought hang on a sec. So her beat HCG is not super high. It's only 1500 she's stable. She's got no symptoms and she's already lost her previous tube. So hopefully you put all of that together and you thought, let's try medical management, which is the right answer for this question. And the answer is B methotrexate because remember the ectopic is treated with methotrexate. Um You could also do a self inject me with a plan for IVF in the future. But obviously, for this patient, you're gonna try, she's going to want to try and keep her tube if she possibly can. A 36. Your depends with her first presentation of a bath linens, she's been given co amoxiclav by your colleague a week ago. The bath lenses two centimeters today and it was three centimeters when it was examined by your colleague. A week ago. Her BM is 45 she's a smoker with asthma. What would be the next most appropriate management? Would you then try a week of amoxicillin? Maybe a week of metroNIDAZOLE? Would you try to insert a word catheter under local anesthetic? A word catheter under German anesthetic or would you recommend she has surgery marsupialization? Okay. So, um I'll let you have to think about that. Somebody asked the question is less than 1500 a hard and fast rule, for example, if she was 1600. So no. Um that's obviously in relation to the previous question about ectopic. Uh Yeah, sorry. Here we go. Um So I can come back to it at the end. But um in the talk on the slide about ectopic management, you can only meet the criteria for expectant management. Um If the beat HCG is less than 3000, every hospital and every trust will have their own policy as to the level of the cut off of beta HCG that they except for each management option, which is probably partly just dependent on the uh the emergency pregnancy unit. Um the early pregnancy unit kind of bored of how they make their decisions and also that specific lab and how that they correlate that HCG result. So, um essentially more than 5000 I would have in your head surgical, less than 3000 could meet the criteria for expectant. But obviously in your, it depends on symptoms, how stable the patient is. Um Yeah, etcetera. So no, there isn't a hard and fast rule. Um For this question that involves 1500 but each hospital, each trust will have their own policies. Um And generally less than 3000 could consider expectant. Generally more than 5000. You probably should think about surgery. Um But again, very patient and hospital dependent, they're not hard and fast walk back to the bath linens. What are we going to do? Hopefully, you can get at what I was trying to highlight, which is that this patient is an anesthetic nightmare with a B M I 45 a smoker with asthma, you are going to try to avoid G A if at all possible. Um And obviously she's come back because the Co Amox Clav she feels hasn't really worked, but actually is improving with the antibiotics. So I would say the answer here. Amoxicillin is not going to do anything if she's already had co Amoxiclav, that's obviously stronger. Um You could give her Motrin is all that could be an option. But I think the best option here is to do the word catheter under local anesthetic. So, um I would say the answer is c for this question, final question four minutes ago. This has been a very long lecture. Thank you for bearing with. Um So last question, which of these is not a risk factor for venous thromboembolism. I will let you have a think about that. Hopefully, you will know this probably trying to, I think is Caesarean section a risk factor because I don't think I actually said it. Although we did say surgery, did we say surgery? Multiple pregnancy? Hopefully, you all know that the answer is e because factor eight deficiency is hemophilia. So is the opposite problem. You're going to have bleeding problems and instead you're gonna have a risk factor for postpartum hemorrhage and major obstetric hemorrhage. So, um that's my email address. I think that used to be the feedback QR code, but I think now you actually have to do the feedback. Um in the in the link that was sent in the chat. Um But if you have any questions, feel free to write them in the chat, I am going to attempt to stop sharing my screen. Let's end this show. If anybody wants me to go back to a particular slide, actually, you can tell me and I will go back. Um Let's have a look. Where is the feedback link? I don't know. Yeah, just before, just before you end off. Yeah, thanks. Thanks a lot. Laura. I'm gonna put the feedback link in the chat. Um I put it in just now and um if there's any questions, uh feel free to ask now, I'm going to also put in a QR code, share it on the screen for everybody. But just before I stop the recording, thank you so much, Laura. I thought this, this lecture was really, really, really helpful today and sort of consolidating the knowledge, applying it to cases and then the questions at the end, we're really good. I thought the good, good level. It's quite long. It's hard for you guys to concentrate for two hours. It's hard for me to talk to our house up. But yeah.