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Good morning, everyone and Happy Friday to you all. Um Today we have David talking about antepartum hemorrhage. Um Firstly, I just want to say as always pop your questions in the chat, we wanna hear from you. We've got some polls at the end um that we want you to respond to and also your feedback form will be sent to you via email. We would really, really, really love for you all to fill that out. It's and a and er give David some good responses. Don't be kind to him. If he's, if he's not covering stuff, you want, let him know if there's something you think he can do better let him know because David David's committed to some other talks with us. So we really want you to get all that you want from his talks. You know, these talks are for you and David is just giving them to you. So we really want you to, to give him some real good feedback and please do fill out the feedback again, just to say thank you to him. You know, feedback is a way of appreciating David. So if you could fill out the feedback form when you get it. Um And then your attendance certificate will be on your medal account. But as I said, pop your questions in the chat and we'll get, we'll get through them either during or after David's talk. Ok. I'm going to hand you straight over to David. Thank you, David. Thank you, Sue. Thanks very much. Good morning, everybody. Uh welcome. Um And uh I'm going to talk to you this morning about antepartum hemorrhage, antepartum hemorrhage. Uh And we are going to consider these uh objectives to try to cover in the course of the next hour or so. So we're going to think about how to diagnose the underlying cause of antepartum hemorrhage and do so quickly. We're going to think about how to put in place um ways of managing the situation that are sensible and evidence based. I want to, to think about the people that we will need to work with uh in the hospital that we will be. And this is very much hospital based because um antepartum hemorrhage isn't something that can be managed really as an outpatient. Um But people that we will need to work with the teams of individuals we need to work with and then also how we handle that with the patient. And then more often with their families because very often the patient is so ill because of the condition that you'll need to talk about. Uh their husband, their partner, their mother their father, their brothers and sisters, whatever. And then, uh, to think about how you can look back at what you've done. Uh, and think about what did we do? Well, what did we do badly and so on. So that's the plan for the morning. That's what we're going to cover. Um, so thinking about, uh, I'm going to shorten antepartum hemorrhage to aph, if that's ok. Um, uh, because it's simpler to write and shorter and to think about uh what antepar hemorrhages and it, it, it boils down to it that it's uh any bleeding that comes from the vagina after 24 weeks of pregnancy, up until that time, bleeding from the vagina would be described as a miscarriage or a threatened miscarriage or whatever. But once you go beyond that point and you're then dealing with a fetus with a baby who could survive, then you talk about antepartum hemorrhage. And so why is this happening? Why does bleeding happen? So, in the diagram, what I've done is to look at some very nice cartoons of babies sitting in the uterus and you can see the arrows that I've drawn to the various places. So the sources of the bleeding could be coming from the placenta, whether it's sighted like it is in the left hand picture as I look at it uh up in the top of the uterus or on the right hand picture, whether it's sighted right down to the very bottom of the uterus and indeed overlying the opening to the cervix. And then finally, whether it's coming from the vagina, which is also a possibility or the cervix. So to be aware of those, so here's the case, uh, a story really. Uh So a woman comes to see you in hospital and she presents with a small amount of blood tricking through the vagina enough to soak through her, out her clothes and her inner clothes. Uh she smokes, um, smokes 15 cigarettes a day. She's got no pain. She's 32 weeks pregnant fetus is moving normally and well, and you examine her abdomen, you find that it's soft, the fetus is well grown and it's breech. So the question is to think about is what's the most likely cause of the bleeding? And here, the things to be aware of are her age is not that important in this situation. Um, um, she's had a fair amount of bleeding enough to soak through her underwear and her outer clothes. So that's quite a bit of bleeding. That's probably 500 mils or more. Smoking is a risk factor for placenta previa. So the placenta coming as it is in this picture, on the right hand side, sitting down uh over the overlying the Cervi to the canal. So, um she's got no pain, which is important. So the pain, the bleeding is painless and she's 32 weeks pregnant. The fetus seems well, it's moving normally and the abdomen. When you examine the uterus is soft, the baby is well grown and it's breech. So what's the most likely cause of bleeding with all of those things? Well, the things that would suggest to me that I would draw from her story is that she's had vagina. Yes. Can you see the, um, answers? We have an answer in the chat. Uh I can't see them. No. But, but then, uh, so can you read out the answers? Yeah, we've got Rink. Who says Placenta Previa Major? Yeah. Would that be right? I've only got the one answer. That's correct. So, yeah, so, so this is, so this is, this was not a test question. This is more of a discussion case, but that's fine. Thank you for contributing. So I think this is a major degree of placenta previa also. And the reason I think that is because the bleeding is painless. The abdomen is soft. Interestingly, the baby is breech. And so, and that means that there isn't enough room for the baby to turn around and get it head, get its head into the pelvis because there's something in the pelvis already. So the most likely cause is placenta previa, painless soft abdomen, a breech presentation and a healthy well grown fetus. Here's a different case. Um A 30 year old woman comes with a small amount of bleeding enough to begin to soak through her clothes. She's got pain in her tummy pain in her abdomen, 32 weeks pregnant, the fetus hasn't moved since this morning, you examine her abdomen, it's firm and irritable and the fetus is small and head first. So I think in this situation compared to the last one, the things that are different are the pain. The fetus hasn't moved and it's small and it's head first and the feet, the abdomen is irritable. It, it tends to when, when you touch it. So I'm going to have to answer this. Yeah. Uh So this is a, this is an abruption of the placenta. And I would say that because of the pain, the irritability of the uterus when you touch it and the firmness of it and the fact that the baby is small and it hasn't moved since the morning. So you need to make sure that it's still alive or not. And there's a question about that here. So I think that's probably the situation there. This is quite different from the other one so that there's that pain absence and presence, there's the size of the fetus, the head presentation, the breech presentation. Um and the uh the, the firmness or irritability of the uterus. So how do you judge the severity? Um So here are some kind of rules or thumb to think about what is major and minor bleeding. So, these are what I would suggest. Um So, and I've made these up, these are not from a textbook, but so in terms of a situation where the woman walks into you, she's not short of breath or distressed. Her clothes are clean, they're not blood stained and she can answer your questions sensibly and without difficulty. And on, when you examine her, you might see that there's some blood spotting in her underwear or in sanitary protection. And there might have been a bit of blood loss, less than 50 mils, perhaps she's normotensive. Her BP is normal. The pulse is normal. That's a small amount of bleeding. That's a minor hemorrhage. On the other hand, uh, if she comes in on a wheelchair or a stretcher and the blood is through her clothes and on her hands and particularly on her feet. Um When you examine her, there's a steady trickle of blood through the vulva. There are several towels soaked through with blood and she may be hypotensive. She may have a rapid pulse. That's a major degree of bleeding. And I put down, don't panic, don't run around like a headless chicken. If you ever seen a headless chicken, I haven't, but I understand they run around a lot. Um But do ring alarm bells in your head to say this is a major bleed and tell your colleagues around you that this is a major bleed and make sure they understand that because it's critically important that you communicate with your colleagues who are right there, whatever other doctors or nurses. So they can think OK, we need to get into action here. We need to do stuff. OK? We can, you can ask me a question about any of these as we in the questions set at the end. So um the the major causes of ante Parker hemorrhage then are, are so intrauterine causes so stuff from within the uterus. So obviously, one of those is going to be placenta. Previa, previa is a um a word which means coming before. Um And so placenta previa means the placenta is coming before the baby. It's in the way of the baby abruption is another cause of, we've just seen that in our two stories. So abruption and this means uh it means the the tearing away the ripping away of the placenta from the uterine wall. Um and that gives rise to bleeding. And then finally, don't forget that sometimes the bleeding that somebody presents with is because they've ruptured their membranes and they've had a show that pass of bloody cervical mucus that represents the onset of labor. So, as well as intrauterine causes of antepartum hemorrhage, there are outside the uterus causes extrauterine. So one, a common cause of extrauterine bleeding is what's called a cervical ectropion. This is a condition which is completely normal and physiological in pregnancy and it occurs because the the lining of the cervix. So you will, you should remember from your undergraduate time that the cervix uh has got an outer surface to it, which is smooth. Um and is uh columnar. No, is is uh flattened surfaces of, I forget the name squamous. That's the word squamous in its lining. And then inside the cervix, the lining is columnar and much more risen off the surface. And when you've got lots of estrogen, that inner lining tends to protrude out to the outer side. So that you get to see this rather red appearance around the opening to the to the cervical canal, the cervical os, the opening to the cervix. And you can then and so at intercourse, for example, then it's quite easy for that to be, to be damaged and cause some small amount of bleeding. That's not unusual. Um The other big cause of bleeding from the re causes, however, is much rarer and much more serious and that's cervical cancer. Now, you might think that never happens in pregnancy, but it does. Um And disturbingly, it does. I remember I worked in one hospital in Dublin many years ago now, but in the space of one year, in a year where about 10,000 women were delivered in the hospital. So that was the volume of women coming through. Um There were two women who presented with antepartum hemorrhage at 30 or 32 weeks who, when they were examined vaginally with a speculum were found to have cervical cancers. So you, you could expect to see a cervical cancer probably um in any hospital who's delivering that number of women, you might expect to see that happen once a year or once every two years uh as a normal thing. And the important learning point from that, however, to take away is that if a woman presents with antepartum hemorrhage, and you don't think it's due to placenta previa and it's not due to abruption. You must do a speculum examination to examine the cervix. So the bleeding could be due to an ectropion which is normal or to a cervical cancer, which clearly is not normal. The two look different. Um and if you are uncertain, you can do a biopsy which will bleed obviously, but you can do a biopsy which will confirm the normality or abnormality of the tissue. So this is a diagram uh about the causes of death. Now, these are causes of death uh over a three year period in, in the UK. And the reason I put it up here is so you can see how, what the, what the rate or, or how much of a problem bleeding, antepartum hemorrhage is to deaths in pregnancy. So, on the left hand side, it says the rate per 100,000 maternity or women being pregnant and hemorrhage uh and bleeding is one, is a, is a cause of one death per 100,000 women. Um And when you consider that in the UK, the number of women dying in pregnancy in every three years is about, it's about 10 per 100,000. It's contributing to roughly 10% of the deaths in women. And so you need to keep that in your mind when you're thinking about women who come in with antepartum hemorrhage, that they, they represent a fairly high risk group of people who are likely to uh bleed a lot and be at risk of dying and therefore need a lot of health care and intervention. I hope I'm kind of not laboring that too much. But it is important to make the point that um that bleeding in pregnancy is not a benign condition. So I want to think now a little bit about how to consider how best to manage the situation if somebody presents with bleeding and what the best evidence for that is. So the sorts of things you should be thinking about uh are first of all to try to establish um the before we kind of go on to those more detailed things to think about. So the first thing to do when the woman comes in is to decide is this bleeding minor are major and clearly those two differences will uh will mean an awful lot in terms of what you're going to do to um initiate uh management. So if she comes in, in a wheelchair or a trolley and is bleeding a lot, then you're going to want to get access to her intravenous vessels. You're going to want to do that with not small tiny needles and cannula to do it with a big needle, maybe a size 16 or something because you're probably going to need that. Don't be putting in something that's a size 22 gauge because that when her veins collapse, that will not be big enough to get the blood in that you might want to get her other replacement fluids. So that's the first thing to do is to decide which of those she falls into. If she falls into the major category, then you've got to get her resuscitated first and foremost, get her BP up, get her pulse back to normal and then decide what's wrong with her. Um Before you go on any further and in the case of it being minor, then it's sensible to think about something. So you, you would, if she's rhesus negative, you want to see whether or not she's had any bleeding from the placenta into her blood system using a hard test. Um And that will gauge whether she needs NTD or not. If she's rhesus positive, she doesn't need any. And if she's rhesus negative, she may need some because the baby might well be rhesus positive. You then want to try to diagnose what the problem is. Uh And it's the big things to be concerned about are either placenta previa or abruption. Those are the two major causes. Ultrasound is helpful in telling you whether she's got placenta previa or not. But abruption is more of a clinical diagnosis than an ultrasound one. And uh smart people on ultrasound think that they can diagnose uh an abruption by seeing blood between the uterus and the placenta. Uh I, I think that's true if they're really good, but mostly the average person like me would not be able to diagnose that. And you shouldn't rely on ultrasound to tell you that it is or isn't an abruption. You really do that by the symptoms of pain and tenseness of the uterus and so on. If the baby is alive and well, then you will want to start monitoring it. Uh because if that changes, if it's uh heart rate becomes uh more abnormal, you may then want to speed up delivery and, and move on towards that. Um And if they are bleeding at the time and it's fresh bleeding or they've had bleeding in the past, you probably want to put a scalp electrode onto the baby and not just do external monitoring because you'll want to be more certain of what's going on with the baby than just using external monitoring because that can, can be confusing. Um That word should say pregnancy, not pregnant, sorry. Um Silly mistake. Um OK. And then uh so if she comes in with a minor bleed, uh and she stops bleeding and she doesn't have placenta previa. Um she can go home providing, of course, that home is not uh 50 miles away or, or, or up a mountain road, um, that would take her an hour to get into hospital from or whatever. Um And if she lives near the hospital, then she can go home if she lives very far away. Or if there's no transport to get her back into hospital, should she start to bleed again? Then maybe you advise her to stay in hospital and that's often something women struggle with. If they have smaller Children, they may not want to do that because who's going to look after the Children at home. But that's often a tough call if they have more than spotting. And if they have ongoing bleeding, they should not uh leave the hospital until at least the bleeding has stopped and settled for a few days. And uh if they've had any bleeding from uh an abruption, uh and then that settles, which is unlikely or if they've had bleeding for which you cannot find the cause, then they should um be considered to be much more at risk in this pregnancy should be looked after by a senior doctor. They should have ultrasound scans, check for fetal growth and you would measure the head circumference and the abdominal circumference probably best to do that. Uh Then if the baby is, if the baby has died, which will happen in probably about at least one third of cases with an abruption and almost never in placenta previa. But if the baby has died, then you don't want to uh do a cesarean section and vaginal birth, vaginal delivery is the best way to deliver this baby. Providing the mother is well enough to tolerate that. But you don't want to put a scar on her uterus for the sake of a dead baby if you can avoid that if the baby is alive, but uh is in trouble as you might diagnose perhaps by an acute problem of the heart rate, slowing down or a slightly less acute but more still still a problem. If you found for instance, that the baby's weight wasn't growing, that would be a fairly slow problem to develop because it would take a week or two to work that out. Or if the baby had stopped moving or if it had stopped producing like war and the the woman on ultrasound is found to have very small amounts of amniotic fluid in the, in the uterus. All those things indicate compromise of the fetus compromised, meaning the baby is sick, there's something wrong. And so then a cesarean section would be the appropriate method of delivery with, with resuscitation of the mother. Should that be required? I realize that there's a lot of stuff I'm throwing at you here and feel free to come back with questions at the end. If things that I'm saying are uh confusing or have uh don't make sense. So uh just going on. So if they've had a bleed, if they've had a hemorrhage antepartum hemorrhage. And it's evident that the mother or the baby are in trouble. They're showing signs either the mother, uh, you can't resuscitate her, you can't bring her BP back up. You can't bring her pulse down to normal or the baby is showing signs of distress, then they need to be delivered immediately. And maybe by vaginal delivery if she's going into labor or maybe by Cesarean section, simply because that's quicker, but it's much more of a trauma for the mother. And you may have to balance the fact that um if the baby is, uh you may have to balance the mother's health against the baby's health um in this situation and whether or not it's better to have a live baby and a dead mother or a dead baby and a live mother. Uh That sounds, you know me saying it, that, that sounds like it's terribly, uh callous and harsh, but sometimes you have to do that. Um And you would do that after discussion, maybe with the relatives who are there, the husband, the mother, uh whoever's with her, uh to see what they would prefer to do. Um uh because the patient may not be well enough to discuss it with if they've had, uh if they've had a bleed that you don't find the cause for uh it's not placenta previa, the, the, the placenta up in the right place out of the way and it's not apparently an abruption clinically but she's had a definite bleed and you don't know what the cause of it is. Um Then, and the baby and the mother seem fine, then it's difficult to know what the right time to deliver that baby is. And probably, uh the best thing to do is to allow her to go into labor by herself. Uh, if she was, uh, if she was willing, uh, and, uh, and if her cervix was favorably developed for uh delivery, uh and you examine her and the cervical Os is open, you could consider inducing labor at a wrong term. Um By which time, hopefully, she will not have any problems and should labor smoothly. But you could also consider letting her go and deliver by herself. Uh when, when nature as aware will allow it to happen with regard to how you manage uh the delivery. Um If you were um putting her for a Cesarean section, then you will want to give her some anesthesia and a spinal is probably the best option. And I've seen in my time in Africa working in Somaliland, I have seen some incredibly slick and fast inductions of spinal anesthesia by, by an east of this who are very skilled and have done this almost for all their deliveries and they're very good at doing it. So I think that that's probably the first option because it's the least disruptive for the mother. If on the other hand, the mother of the baby are uh unwell and I use that word compromised and I've used that before and I mean, the same things by it now, um then you might put her to sleep because it is slightly faster from the point of view of operating to be able to have the woman asleep. Um And ideally you should have the most, um the most senior anesthetic person in the hospital should be around uh to be able to take control of whatever um, abnormal problems might happen during the delivery. From the point of view of anesthesia, in terms of um blood, uh blood pressure, uh tachycardia and so on, in terms of dealing with all of those things, you should expect her because she's had an antepartum hemorrhage, excuse me. Yeah, sorry, you should expect that because she's had an antepartum hemorrhage because she's had bleeding beforehand. You should expect to have bleed after delivery. That's kind of, it's, it's almost like one and one equals two in terms of mathematics. So, if you have a woman who's had, who's pregnant and has had an antepartum hemorrhage, she's almost certainly going to have a postpartum hemorrhage. Um And so you should plan, uh that's the subject of a whole different lecture. But right in this context, you should plan to give her a drug which will make the uterus contract quickly after the baby is born. And that would be using a drug called a drug like um SNRI Cyn mene is a combination of uh Oxytocin, which is what is given to induce labor and it is a drug which uh causes um contractions and relaxation of the uterus. Uh And the other part of Syn Merin is ergometrine, which is a drug which causes a very firm, continuous contraction of the uterus. And really, that's what you want in this situation is to contract the uterus completely and allow it to start to shut off the blood supply to the placental bed and prevent a further loss of any blood. You, you need to think about um all the staff areas that you're going to have to interact with. Uh during this time. You, you might be fortunate enough to work in a hospital where they have uh a serious hemorrhage protocol. Um That's probably not likely uh in the hospitals that I worked in most recently. Uh What that meant that you phoned up somebody and said we have a serious hemorrhage and that means that somebody will get blood from the blood bank and somebody will get other stuff and whatever, but you may have to do it yourself. Uh And, and think about who you're going to need. So you're going to need to alert everybody on that list below it. So you need to warn the delivery suite staff, you need to get hold of the most uh experienced Denise at this, that's around. You need to get in touch with the blood bank and get some blood ready for a transfusion. That might be if you don't know the woman's blood group, um you may just have to use o negative blood. Um You're maybe going to need to have some uh lab support for doing things like uh clotting, uh tests and check for blood loss with hemoglobin and other blood markers and biochemistry. Um And therefore you're going to need to perhaps to, to do those things. And if you are fortunate enough to have a machine for cell saving uh in the hospital, you need to get back to your delivery area because the cell saver will allow you to uh collect blood that the woman is losing uh clean it and then use it back for transfusion. And that might be particularly important if you work in a part of the world, oops if you work in a part of the world, which has got a high hepatitis C uh um infections or other parts of the world, which have HIV infections as a high incidence because then you're avoiding the woman's need for transfusion. In, in my experience, cell SARS are good, but they, they seem to not often give enough blood back for, for you, the doctor to be able to say that's all she needs and to be able to get all the blood that she's lost from that. But nonetheless, if you can, if you can avoid having to give her a transfusion with other people's blood and just use her own. That's clearly a very sensible thing to do. You need to talk to the family and to the patient about what's going on. And I put up here a list of the, of the complications so that you, you're aware of what they are and so that you can translate them clearly and with a degree of empathy to the patients and to their families. So by empathy, I mean, that you don't just blurt these things out and say she's, she's probably going to die. Um, and if she doesn't die, she's going to have all these things. Um, I mean, I think you'll, it's important to say that she's very sick, she's very ill. Uh, she might die. Uh We, we're aware that she's going to lose some blood. Uh, we're aware she might need to be given some blood. We're aware that she might have some problems with her clotting. She's probably going to need to stay in the hospital for a while. This will be for her. This is going to be a very shocking episode. She will have nightmares about this in the weeks and months to come. And if we give her blood and if we have to give her blood, there may be some problems from that. And from the point of view of the baby, the baby's going to be probably if, um, if it's being delivered early, it's going to be small. If she has an abruption that's often associated with poor growth in the fetus, poor growth rates, smaller babies and therefore less healthy babies. And so it's quite likely the baby's going to stay in the hospital for a little bit longer while it learns to feed and puts on weight. And clearly, uh that maybe dying because of prematurity or because of its inability to put on weight is something you need to be very aware of. With placenta previa, the baby tends to be not compromised. The baby will tend to be healthy at birth. And the main problem will be prematurity. If it's going to, if that's when it happens, if it happens early, then the main problem will be prematurity. On the other hand, babies who have, who are born as a result of an abruption of an abruption are much more sick, much more unwell because they've probably already been unwell and distressed by the placenta. Uh and before it tears away from the uterus, it's probably already not functioning well. And so therefore, you need to recognize that the baby will be sicker and maybe in hospital for longer. And there's more risk of dying because of that. So the big risks from placenta previa are to the mother, she will lose blood, it, it will be all her blood that's being lost. Uh And therefore the biggest risk will be to her from abruption. The blood lost is both the baby's blood from the placenta and the mother's blood. And therefore, clearly the risks are to both, uh, both of them because of that. And you need to be able to, to transfer the information about those risks and their magnitude to a very scared mother, uh, to her husband, maybe to her own mother, whoever's with her, who comes in with her in labor, if anybody does and you need to give some idea of the likelihood of a good outcome carefully. Um, don't promise what you can't deliver. Um, and, and if it's, if it's likely that she's at serious risk, you need to say that so that you won't say to them, she'll be fine. And then, uh, six hours later you come back and say she's dead, that will be, that will be wrong to do that because you would have given them false hope. So you don't want to do that, but you also need to give them reasonable hope or sensible hope if you can, when you get to the very end of the management, when you get to the point where it's all over and the mother goes home hopefully and the baby goes home hopefully, then you need to think back about, ok, let's think about how all that went and that might be the next day or the next week whenever, but you need to think back about what, what went well, uh, what, what worked well and all that situation and as well as what went well, what didn't go well, what were the problems? What, what were the falls that developed that we didn't foresee happening? Um, so maybe the blood came from another hospital and it was delayed because there was uh a food market that they had to drive through, which was very slow or whatever. Um, and you think, excuse me? Right. Um, and you think, ok, so how could we improve this the next time? So if you know, always that on Friday mornings, the main part of town is closed off because of a market and the hospital that has the blood is on the other side of that. Then you got to think about some other way of getting the blood uh, from there to you that might mean going a different route through the town, uh, and whatever, but it's important to have sensible things. So, you know, on Mondays or Tuesdays or whenever that happens, you make sure that it goes another way. And the other thing that's worth doing then is having practice runs. Uh, so somebody, you have a practice. So you'll say that next Tuesday morning, we're going to have a practice run at dealing with a woman coming in with severe bleeding and we're going to get things going. We're going to alert people, we're going to prepare them and we're going to see how long it takes, for instance, to get blood from the hospital where it is or we're going to see how long it takes for us to get a hemoglobin level and a full blood count on the woman to see whether she's anemic and how anemic she is. And in those you can see and you can look and see. So are there any steps along there that we could have speed, could have sped up? Could we have taken the blood directly to the laboratory? Uh from the point of view of getting that hemoglobin result quicker? Did it sit at the front desk for an hour until somebody had time to do it? Those are the kind of things you can look at to see. Uh could we have done this better? Ok. So I'm going to stop there, I think, and we're going to switch to some questions. I'm going to press the shops, stop sharing button and go back to sue. I hope. Yes, I'm here. Ok. Uh Thank do that and back there you are. Ok. Perfect. Great. Ok, good morning everybody. Uh Right. So now we've got some questions that sue is going to put in. So this is the first question. So a woman is seen on delivery suite, she's 32 weeks pregnant, uncomplicated so far, generally fit and well, she's got lower abdominal pain which goes down to her, right. Her right loin, she's got some frequency of micturition and dysuria pain with urine for the last two days. Her temperature is 37.8 abdomen is soft tenderness, suprapubically and in the right, right loin, there's protein and white cells in the urine dipstick. What's the most likely diagnosis from those five? So, uh people have said the answer is urinary tract infection and that's exactly right. So, not all pain in pregnancy is due to abruption, it could be due to other things. And the list of things there that you see abruption, pubic symphysis, dysfunction, appendicitis, urinary tract infection and premature labor are all cause of pain in labor in pregnancy rather. But in this case, because of those uh specific details, this is a urinary tract infection. Ok. Let's go on. What's the p uh uh hang on. Can we just go back to, to that question from Riu there? Do you mind? Can we actually let's go on and look at the questions and we'll come back to that then. So uh this is another question uh seen there 37 weeks, normal delivery of a baby at 39 weeks, who was small. This pregnancy maybe small but growing she's taking cocaine presents with severe abdominal pain that came on suddenly one hour ago, constant bleeding, vaginally. Her BP is normal. Uh She's tachycardic CTG is suspicious on palpation. The uterus is firm and tender select the most likely. So, um ok, so somebody has changed their mind very wisely. Um So here you've got a small baby. You've got a, a drug user, abdominal pain for an hour which is constant bleeding, vaginally, normal BP, but tachycardia and uh an abnormal looking CTT G, uh the uterus is firm and tender and all those things should say to you should scream to you abruption. Now, do you see why? So the, the pain? Uh OK, Joshua. Uh can I come back to that? Uh OK. Jo So Josh, you put several questions in there which we'll come back to. Uh can we OK. All really good questions. OK. Uh Can we do question three and then we'll deal with the questions and there's a question between, there's a question typed in between the poll for question one and question two. So let's go on to question three now and then we'll go back to the question. So this one here, a woman is 17, comes into the clinic at 34 weeks. Normally fit and well booking pressure of 100/60 today. She's got headache and nausea. She's got uh hypertension three pluses of protein and from the list of diagnoses. So I don't quite know why this one's in here because uh sue, I'm terribly sorry. I have sent you the wrong question, I think for that or maybe no, I haven't. That's the question I sent you. But this is a question to do with uh hypertension in pregnancy. But anyway, so um uh so I, so here, OK. So um so for those of you who have tried to answer, let me go through and tell you why. I think the answer is whatever it is. So she's 34 weeks. She, this is her, she's 17. It doesn't say whether or not this is her first pregnancy or not. Her BP booking was 100/60 and now it's 1 60/100. So it's significantly elevated over her booking BP. She's got a large amount of protein urea. Um she's got a headache and nausea and from the list of diagnoses, which is the most likely. So this is not a normal pregnancy. Um This is not um eclampsia because she's not fitting. So of the three in her left. Um This is probably not a, so a pheochromocytoma is a uh adrenaline secreting tumor uh which is very rare uh but causes hypertension. Um and she also has proteinuria. So it's unlikely to be a pheochromocytoma. So, we're left between pregnancy induced hypertension and preeclampsia. So she was normotensive at, at booking and she's now hypertensive and the difference between the, the two at booking. And now is that she also now has got proteinuria and some symptoms of headache and nausea. So, I would think this is preeclampsia as most of you said in the answers. Um and it's preeclampsia because of the hypertension, the protein urea, the headache will be due to a degree of raised intracranial pressure, the nausea uh in terms of a pathology is probably most likely caused by distension of the liver capsule that happens because of portal hypertension in women with preeclampsia. So I would think that three is the correct answer here. Preeclampsia. And I note that most of you got this right and thought it was either that or pregnancy induced hypertension. Uh That's not the the pregnancy. Just hypertension is not as correct as preeclampsia. Although you would probably manage the same to begin with by giving her some antihypertensives. Ok. So, so can we now flick back to the space between questions? One and two that you can do that? Yeah, just scroll. That's it. So, um, so Rio, you've said, um, what's the point? What's the role, sorry, a point of care test such as a hemoccult sly and lactate? And, uh, RM. Now RM is an anagram that I'm not familiar with. But thankfully I have, uh, uh, uh, a Google doctor Google will tell me what a role him is and this is a way of, uh, looking at blood clotting, uh, in a more quick way. Uh, so, uh, let's go back to us here. So what's the role of those point of care test? I guess that, um, if, if you've got those at the bedside, if you've got them ready to be used, uh, then, uh, it's much more preferable to do that. Um, I think that one of the things about point of care tests like that at bedside care tests like that is you need to be sure that they're accurate. Generally speaking, in a lab every day, they will run um tests to make sure that the testing conditions are consistent from day to day and that a result done today on a blood test that gives a 14 g per deciliter of hemoglobin will get the same result tomorrow. And point of care tests sometimes don't have that degree of reliability. But if you find out that their hemoglobin is eight on a hemoccult, then it probably won't be hugely wrong. And if you find out that their clotting is normal, again, it probably won't be hugely wrong. So, so they are useful to help direct initial management, but I think you should back them up with having laboratory tests which will be more accurate. I hope that makes sense. Uh So I'm going to come on to Joshua's questions. So Joshua in the first case example mentioned in this lecture Cesarean section, you to manage it. So let me just let me run back to that first case that I did and read it out again for us. Uh So this was a case of a woman, 32 weeks pregnant, no pain, fetus moving, normally, examine her, find it soft and breech presentation and placenta previa. So your question is uh your question Joshua was, is Cesarean section the only way to manage it. So, so first of all, I would think that based on what I've said there and that and that and that story, she doesn't need to be managed immediately. She can wait to 38 weeks or so before she is delivered. And is Cesarean section the only way. Well, it's not. And the reason I would say it's not is because sometimes, um, the sighting of the placenta depending on where it's sited in the lower segment of the uterus. Uh So that's the bit of the uterus that, uh you could reach with your finger. Uh If you had a very long finger or sits behind the bladder at Cesarean section. Uh But sometimes that as the uterus grows and stretches, that placenta will be moved away from the cervical oss and therefore the likelihood of baby being able to go through the cervical Os is more likely. And therefore, Cesarean section is not the only way if the, if the placenta doesn't move and still at 38 weeks is lying right over the Os, then definitely there is no other way but to deliver her by Cesarean section. But no, and she doesn't need to be managed. She doesn't need to be delivered right away. She can be managed expectantly and you can wait till 38 weeks. Uh Your next question was, is vaginal birth a advice and fetal death, complicated symptom. Previous type three and four. So, no, of course, it's not because if the placenta is like, you know, the type three and type four, refer to it being absolutely over the cervical os and therefore, vaginal delivery is not uh possible. But then the chance of fetal death in placenta previa is quite small. And if fetal death happens for some other reason, perhaps it was a very small baby or whatever, uh or abnormal, then you, you would be forced to do a Cesarean section uh because of the placental cycle because to go otherwise would mean that the mother would bleed a lot and might be at risk because of that. There's a question about cytometry and you've got somebody else got a question about Cyn Merin, uh or you say about better than Oxytocin and I got, I'll deal with that both of them. So, SNRI um So is Cyto Merin contraindicated in women with high BP or eclampsia because of the association with Archym Mene? So, uh this is an interesting question. Um It's interesting because uh the Anestis would all say you should never give Syme ergometrine to women with high BP because it makes it go higher and it does. Um uh And that's true. The thing I think is that for most of these women giving them cytometer or ergometrine particularly uh is lifesaving. Um And if they've had a significant bleed before delivery, they're unlikely to be hypertensive and, and if they are anesthetized, they're unlikely to be hypertensive because the anesthetic uh will drop their BP. So, unless her BP levels are in the range of being uh, where the diastolic level is 100 and 10 or 100 and 20. And in which case, raising the BP even more is likely to do the harm then, yes, I wouldn't give it then. But otherwise I think, um, I think we, well, I guess if I ruled the world, which I don't, but if I ruled the world I'd be giving a Merin a lot more. But this is a, I guess this is one of those things. It's a personal view. And I think we are, I think that we are slow about giving Ergometrine because we are being too cautious. And if you want to save the woman's life, you need to balance the risks versus the benefits and in each individual discussion. So you might have a situation today this afternoon somewhere and you'll have to think now, which is the best thing to do here to stop her bleeding or to stop her, putting her BP up a little bit more and generally what's gonna kill her will be the bleeding. Uh So it's kind of hard to, to generalize on that. I think, I think for all those situations, you'd have to think. So, what's, what's the right balance of risks and benefits here? Does that make sense? I hope. Um, and uh, ok, you said why is SNN better than Oxytocin? I didn't get that. Ok, so Oxytocin. Um, so can you see me? Yes, I can see you and can everybody else see me? Yeah. Great. OK. So I'm going to do something with my hands to illustrate the difference. So, um Oxytocin on the uterus causes a contraction like this. But then it relaxes and, and that's what it does. If you give it to induced labor, it contracts and then it relaxes, which is a good idea because then otherwise the woman would be having contractions all the time. But that's its nature. It does not give you a tense, tight uterus, no matter how much which you give within five minutes, it will be relaxed. Ergo me. On the other hand, if you give it to a uterus, if you give it in labor, it just goes like this and it contracts and you wouldn't want to do that in labor cause you would then kill the baby. But after labor, after the baby is delivered and as the placenta, as the baby, the placenta is starting to bleed, that is exactly what you want to do. You want to have a close, tight, see the tightness, the whiteness of my fingers cause all the blood has been squeezed out of them. Uh And, and remember that in the, in the uterus, there's a criss cross of blood vessels all like this. And as the uterus then contracts, it closes them all off and it's, it's really effective in doing that. Ok? Uh We're inclusive, they can be done as well. Yeah, that's great. Thank you. Yes, for the rote. Good. Mohammad says Snn and Oxytocin are both lifesaving. Yes, they are. But you just need to be aware of the difference of them. Um Mohammed, you've said, but I must, I must order Argon more to reduce the bleeding. Well, I hope that what I've said gives you the, the fact that it's not like it's not simple. It's not, you don't, you know, in every case you don't give ergometrine because you might want to think. Oh, actually she, even though she's bleeding, she's actually very hypertensive because she's got preeclampsia and I don't want to trigger her BP going higher. I it's unlikely that that's going to be the case because she's probably going to be quite hypotensive and therefore bring your BP up might not be a bad thing. But I think you, you, you don't, you shouldn't, you shouldn't just assume that for all situations you give that, but rather recognize that for some situations you will give that and for others you may have to tailor it and only give something else. Does that make sense? Oh, lot of really good questions there guys. Thank you. Uh Anything else? I'm happy to wait for a moment while I'm talking. Um Just to say to you that um I'm going to be away for several weeks um and won't, won't have access to uh my computer. Uh So I won't see you again for quite some time. Soon and I have just discussed, uh my next talk to you, which will be on December the first Friday morning all being well. Um, and uh good. There's more questions I'll deal with those and that talk is probably going to be on um, preeclampsia and pregnancy, pregnancy induced hypertension. Uh which, which I put a question in on today by accident and despite that you all knew it, which is really good. Um So maybe I don't need to bother to give the lecture, but I will anyway. OK. Um Now um Mohammed Joshua, so that means Ergometrine must not be given until after the second stage. Yes, absolutely. And, and don't forget, sometimes a baby comes out, don't forget sometimes as in one, in 80 times, there's another baby there. So don't forget that there could be a twin pregnancy and you wouldn't want to give her a check to make sure that there's nothing else in the uterus like a baby. Um Muhammad says, OK, I get it. Thank you. That was awesome. Oh, thank you Lilian. Uh Rona, thank you for, OK, thank you very much guys. I I appreciate that gratitude. It's lovely to see you. Does anyone else have any other questions? Because we're not gonna have David for a little while now by the sounds of things. So any other questions will be great. Great session. Thank you, Mo So your feedback form will be in your inbox like I said, please do fill it out. Um Yes and also be mean if you want to, you can say what you think I prefer to say, be constructively critical. So I want what I want to know is, am I doing stuff? Do I talk too quickly? Can you understand what I'm saying? Um I have a, I've lived in England for 30 years but before that I lived in Ireland and I was born there. Uh Sue lived in England and now she lives in Ireland so she understands the challenges. Uh But I know that I speak quite quickly at times. So it's just, you know, so is that a problem? Uh Do I get too excited? I know I do. But uh even talking about antepartum hemorrhage is quite exciting. Um But it's just so I'm aware that sometimes my, my passion uh overtakes my delivery. Um So please be uh critical and, and I don't care what you say about what my talks. If they're great, that's fine. But if there's something I can do better uh in terms of slide quality or time taking over them and whatever. So I appreciated that. Um uh Who was it? Uh Ola Moa, you said that you didn't get the point about, I said about sent me and I, and I'm really glad you picked me up and that made me go back to it. So if there's stuff, I, I say that uh you didn't get, you know, you have you have the luxury of getting me to go back and therefore, and make use of it. OK, perfect. And also if, if, if you feel that you would like it more interactive, so maybe, um maybe you want to come on to the stage and actually ask the questions verbally instead of typing them out, we can, we can do that, we can invite you to the stage and you can ask the questions if that makes it more interactive or if you like er, typing your questions in the chat, let us know how you want to learn best. Um And what would help you learn best? Ok. Um You can pop that in David's feedback or if it's just generic uh things about metal education and how you feel you would like to learn best, just send me an email or send an email to support at meal and we can look into that because like I said, all these me education events are for you to get the most out of what our speaker is saying. We want, this is for you. We're hosting these. So please do, let us know. Um, so I think we can say goodbye. Can we David? We're gonna say goodbye and we will see you at the next event which is on tomorrow about cardiology and David will hopefully see you again in December. Ok. Take care, see you soon.