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Hello and welcome to Medal Education. My name is Sue and I just wanted to say it's great to have you. If you're joining us from Sudan, we are delighted you could make it. Medal education was both because of you reaching out and doctor Meram chatting with us about the troubles in Sudan. We called on both Mare's network of social media and our media network to ask for speakers and we are not left disappointed. We have lots of incredible speakers lined up for your medal. And if you follow us, you'll be the first to hear about the new um events on the platform. I do have one small ask before I introduce David. I er I do not have a medical background. So I'm relying on you to ask questions in the chat for David to answer at the end of his talk. At the end of this event, you will get a feedback form emailed to you and you will have an attendance certificate on your medal um profile. Ok. So without further ado, I'm going to introduce you to David. David is our first speaker. Uh He's now retired but he hasn't stopped working He previously worked at Bristol Medical School, the University of Bristol. David's research was in educational assessment, higher education and gynecology. His energies are presently focused on teaching undergraduate medicine and postgraduate gynecology in developing countries. So absolutely perfect for us on this platform um as well as facilitating access to plab in his own country. His research focus is presently directed towards the understanding of differential assessment attainment in different ethnic undergraduate groups. Wow, that's a mouthful. And now David over to you. OK, thank you very much. So, thank you, Sue and welcome. Um This is indeed my first session. So please forgive me if there are any glitches. Um I'm encouraging you to ask questions. Uh It may be that in the questions that you ask, I may not be able to answer them fully and my plan would be as I generally do would be to say that. So if I don't answer them fully today, I will do that in my next session. I think I'm speaking next on this platform in two weeks, time on the eighth of September. So bear that in mind if something crops up that I can't deal with, I'm very happy to admit that I don't know and therefore, and to go from there. So let's get going. So please put your questions in the in the chat box on the right hand side and we will deal with them as we come by them afterwards. So, um and uh hopefully, now you can see all my screen. Um So what you should be seeing hopefully is Obstetrics and Gynecology series one. And today's talk is about miscarriage. Um And uh so this is a very practical issue in obstetrics and gynecology. Something which happens to many women, about one in five pregnancies will end in miscarriage. And for most women, um that will be a one off event for them. Um for some women, it will be a more than once event. But for most women, this is a one off event, but very disturbing nonetheless. So, uh in the learning objectives, I was given by med all to tackle today. Uh This is what they wanted me to cover. So we're going to speak about each of these five things, some in more detail than others. But to try to give a broad rounded impression about the management of miscarriage, some of the challenges and so on. At the end, I'm going to have um five questions and I'm going to no sorry, three questions which are best of five in their structure and we will deal with the answers as well. Uh But I'd like you to all just for self satisfaction, for your own sake to put your, your first choice answer in the chat for each of the questions. So you could write question one ABC D or E. Um uh and then when you hear the answer, you can just reflect back on why you got it right? Or if you didn't get it right, why you didn't get it right? And where was your thinking going a bit off perhaps. So we're going to deal, first of all with clinical assessment and diagnosis. Um So with this, uh I think sometimes people uh doctors trainees, particularly young clinicians um often start to ask questions of the patient when they come in with some vaginal bleeding and the source of that bleeding is obviously vaginal, but the nature of it may not be clear. And I think what's important. First of all, before you start going into the history is to make sure the patient is going to be still alive at the end of your history taking. So in that, as you're introducing yourself and so on, you should quickly check the patient's pulse. Now, that might sound like teaching you the most simple of things. But if the patient's pulse is 60 or 70 steady and strong, they're probably in reasonably good health, you should check their BP if it hasn't already been checked. And if it's relatively normal at uh 1 20/70 millimeters of mercury, that's quite good if their respiratory rate is normal and they're not gasping for breath or short of breath. And if they have no evidence of shock, if they're not pale, if their lips aren't uh blue, uh if they're, if they seem well perfused, if they're not sweaty, then it's probably ok to continue with your clinical assessment. On the other hand, if their pulse is 90 or 100 and 30 their BP is 60/30 they're breathing quickly and are distressed and they're sweaty and their palms are sweaty and uh, the creases of their skin look pale, then they're probably hemodynamically not stable. Their, their BP systems are not stable and you need to start resuscitation before you start finding out more details. So you need to get up a drip, get them, uh get some fluids going in to begin to rehydrate them. Think about taking blood for hemoglobin and full blood count. Think about taking blood for cross matching for blood replacement, which is if they're exhibiting any of those symptoms is quite likely to be necessary. So, therefore on now to the history. So women who are pregnant women who are pregnant will have a, a history uh that should fit with that, probably not necessarily, but it should fit. So they should be able to tell you that perhaps they've had morning sickness, they've had some nausea in the morning or sometimes it's not morning, it's all day long. They may have had some vomiting in association with that. They, they may also have noticed symptoms of urinary frequency and particularly in women who are pregnant, they find themselves getting up at night to go to the toilet a lot more and they may also have had bowel symptoms like constipation. So, those are kind of general, uh, pregnancy symptoms. Women who have been pregnant before will often recognize their symptoms much more quickly because of course, they've had them before. Um, and, and therefore they'll be much more aware that they might be pregnant. So then you want to find out things, like, have they done the pregnancy test? Uh, and if so was it positive, when was their last period? Um, And, and that's a difficult question because often people pay little or no attention to when their last period was if they, if their lives are busy or for whatever reason, if their lives are disordered, perhaps because they are refugees or um moving from one house to another, that the importance of when their last period was often slips and they may not remember exactly when it was, they may think it was two months ago or last week or whatever. And, and you want to know obviously when it was, you want to know how much bleeding they had? So, was it a normal amount of bleeding if they can remember for them? Was the, was the amount of bleeding uh normal or lighter than usual? Was there much pain with it? Was it the normal amount of pain? And the reason you ask those questions is because if they are pregnant and if they have uh bleeding at the time of the implantation of the uh early embryo into the endometrium, you can often get that, that what's called loosely implantation bleeding, which might happen 3 to 4 weeks after the last period, the amount of bleeding will be very slight, there'll probably be no pain with it. So if their last bleeding episode was much less than normal and pain less compared to the normal heavy or pain, full periods or bleeding, then that's a signal to you to think maybe that wasn't their normal period and the timing of the pain is also important. So does did the pain come at the time of the period when the bleeding was there or did it come afterwards? Because afterwards should make you suspect that maybe it wasn't a period, maybe it was something else and we will in fact deal with that something else in the next session in two weeks time, which will be ectopic pregnancy, pregnancy is not in the right place. So, moving on from uh the assessment and diagnosis to think about examination and I, I think I have stressed the importance of looking at the vital signs. Uh so airways breathing circulation, abc, the vital signs, as I said on the first slide, these are so important to be aware of. So important to pay attention to and not to lose sight of when you're taking a long complex history because actually, it's much more important that you make sure the patient is going to survive this episode, then you get your diagnosis. Absolutely right. So you may feel their abdomen, there may be a mass. Um and the presence of that mass may be consistent with the amount of um, amenorrhea or absence of periods. I should try not to use complex words. So if somebody is eight weeks pregnant, you wouldn't normally expect to feel anything in their abdomen. The the the uterus won't have come above the pubic symphysis, it won't be palpable. And if at eight weeks you feel a mass that's above the pubic symphysis, then think about two things, think about their bladder is full, get them to empty it if they can. And then think about the fact that their uterus is bigger for some reason. And there may be reasons for that why it's bigger. So one obvious reason which uh depending on the population that you live in may be more or less obvious. But sometimes women have uterine fibroids, they have masses of muscle in their uterus, which makes the uterus bigger. And when they get pregnant, you can then feel it much more quickly above the pubic symphysis and the other one to think about. Um And this will depend to some extent on the geographical area of the world that you're living in and working in because there are racial differences, but that's the the a molar pregnancy. So molar pregnancies are abnormal pregnancies often with no fetus in the uterus. And in those situations, the the pregnancy will be much larger than normal pregnancy symptoms will also be much more evident. The woman will be much more likely to have vomiting, um much more likely to have nausea. Uh her symptoms of nocturia and constipation may be more evident as well. And then the last thing important to do on spec on general examination is to do a vaginal examination. And for this, it's you can do it with your fingers as a normal vaginal examination. But actually, the use of a speculum and particularly the use of a Costco's bivalve speculum is much more helpful than just doing a vaginal digital examination. Because when you look at the at the cervix, particularly with the Costco's bivalve bivalve speculum, what you are looking for is to see what's happening with the cervix. So, first of all, is this blood coming through the cervix. Therefore, it's coming from the uterus and you can be, you can assume that it's something going on up there, probably a miscarriage. Um and is the cervical opening, the os, the opening into the cervix, is that open or shut? Um If it's open, then the diagnosis is relatively straightforward because almost certainly this woman is having or has had or is in the process of having a miscarriage. And you, you don't need to worry about other causes of vaginal bleeding and pain in pregnancy to a very large extent, particularly if when you do a specimen examination, you see some tissue sitting in the os, sitting in the cervical opening. What you should do with that at that time immediately is to get an instrument, perhaps like a sponge forceps or the like and try to grab that tissue and pull it out. That may cause some pain. But it's really important to pull that out because the, the effect of that tissue is more than just uh the source of bleeding because it's distending the cervix and it's opening, it will cause a uh up through, up to the brain and back down to the vagus nerves, it will cause a uh a vagal fainting effect, which will cause the patient to lose consciousness and faint and drop their BP. So you do really want to move that tissue, remove that tissue out of the cervical opening. And obviously, you'd keep it for histology if that's going to be possible. And the amount of bleeding is also important to see. So when you put the speculum in, if the vagina is filled with a well formed blood clot, then you know that the woman's had a substantial amount of bleeding, at least probably 500 mils if not more. And if the blood is not clotting, and if it's just running out, that's a worse sign because she may well become be in the, in the faces of becoming less able to clot her blood. And therefore, she will definitely need blood products, things like platelets and maybe other factors that might promote blood clotting Um So those are the really big important things to do with examination. So with regard to some of the terms that people use to describe these uh various conditions. So a threatened miscarriage. So if you describe somebody as having a threatened miscarriage, what you are saying is that she's pregnant, she s having vaginal bleeding, she's less than 24 weeks, uh by definition, although probably less than 20 weeks. Um but the fetus is probably still alive and it may all settle down a delayed miscarriage or a missed miscarriage means that the pregnancy has come to an end. The woman hasn't experienced the bleeding or pain associated with it coming to an end because that hasn't started yet. But she might have noticed that her symptoms like uh sickness or like vomiting have disappeared and she may tell you I stopped feeling sick about 10 days ago and perhaps that's when the pregnancy stopped because those symptoms of sickness are very much associated with the presence of HCG human chorionic gonadotropin. So those, those symptoms are related to that. So if the, if the levels of HCG drop, then she's going to feel less like she's pregnant. If you do, if you do an ultrasound scan, what you may find is there may well, just be, excuse me, there may well, just be uh an enlarged uterus with an amorphous mass in the uterus, which is probably some uh placental tissue and blood. You may find a gestational sac which uh is evidence of a pregnancy and there may be a fetus within it, uh which may measure the size, which may measure in size equivalent to what her number of weeks of pregnancy is. Um But the the great likelihood is that that fetus will not have a fetal heart. So you will not know anything about the state of the fetus uh except that it's died. Um And then the final one to think about is what's called an inevitable miscarriage. So that means that no matter what you do, this woman is going to go and lose her baby. So even if you scan her and there's a fetus and there could still be a fetal heart. But this is the situation where if the opening to the cervix uh has actually, if the cervical oss has opened and admits a finger or admits a forceps, a tissue forceps, then there's, there's no likelihood that the pregnancy is not going to be saved. The pregnancy is almost certainly going to be lost because already tissue has passed through the cervix and caused pain. Uh And there's no bleeding in association with that. Ok. So there are other terms which are less important. These are key terms because if you're in the hospital and you're phoning somebody else, perhaps in the lab about blood or you're phoning your boss at home about the woman's condition. These are key definitions to have to be able to explain shortly and accurately what's wrong with the woman. So if you say to your boss, this woman has got an inevitable miscarriage that conveys a picture, a clinical picture to that person, which is different than if you say this woman has a threatened miscarriage because the risks and so on are so different. Septic miscarriage simply means that you've gone through a miscarriage, the tissue has become infected and now the woman's got an infection in her uterus following on from that. Um But these are the important terms. So with regard to miscarriage, um so that you're aware, so these are not necessarily things to share with patients, but they're important to have in your mind that about one third of women who are pregnant will have some small amount of bleeding in early pregnancy. And of the women who come with a threatened miscarriage, probably at least half of them are going to continue with their pregnancy and go to a successful pregnancy at the end. And then finally, as I said, at the very beginning, about 1/5 of pregnancies end in miscarriages. And that's clinically diagnosed pregnancies that generally means at least a positive pregnancy test. Um And I've had situations in the past where women have come to me and said I've had at least five miscarriages and then you go through their history and you ask them about the amount of time between the periods that were missed and you find it was three or four weeks. And did you have a positive test? No, but I felt pregnant. Um, so a, a historical diagnosis of pregnancy doesn't have the same strength or weight in terms of saying whether somebody's been pregnant or not and miscarried as does um, a positive pregnancy test, which are very sensitive or better still a blood test showing the presence of HCG. There are very few things in the body that show HCG. Apart from a pregnancy, there are some but most things uh if you have got HCG in your blood, you're pregnant. So with regard to investigations and how do you then carry out the management of this woman sitting in front of you or lying in front of you depending on her state. So if you are privileged enough to have a place where there's an early pregnancy assessment unit, then that's how this should happen. But those are increasingly common in Western countries. Uh They require resource, they require the presence of, for example, an ultrasound machine to be present there all the time. They require backup facilities from the laboratory. Uh And therefore the the amount of support required is greater. Um and they require somebody present most of the day and maybe sometimes into the night. Um somebody with the skills and ability to diagnose a pregnancy and to see whether that pregnancy is continuing or not. Um So ultrasounds a very important part of that. I've highlighted that uh and ultrasounds, one of the key things in terms of making the diagnosis. Um and that's quite important. So if you find, if you do an ultrasound scan and you find that there's a pregnancy sac and that there is a uh fetus which is the same size as her period of missed dates. So if it says if she's six weeks since her last period, and there's a fetus which measures equivalent six weeks, which is about one centimeter. And if there's a flicker of a fecal heart and that, then it's unlikely that she's going to miscarry. So, as well as ultrasound, you will want to measure her HCG levels. Um and as I said, is rarely found, apart from uh pregnancy, you want to measure a specific portion of the HTG molecule. So there are two portions, one of them is alpha, one side arm of HTG and the other one is beta and that beta one is very specific for pregnancy. Um So it's possible to confuse the in terms of why a HCG level might be suggestive a pregnancy, but the woman not be pregnant is that if you don't specifically go for that, that section of the HCG molecule in your test, most tests do look for that specifically. But if you don't, what you may end up finding is that you're measuring, for instance, levels of luteinizing hormone at mid cycle when the woman is just about to ovulate because bits of LH and bits of heg are completely identical. And therefore, if you're not careful to look for the very specific bits of HG, you may miss them and think it's something else. And the value of measuring that hormone is that, uh, if it's not there or less than a very small level, then whatever the ultrasound scan shows, she's probably not got a pregnancy that's going to succeed. So the likelihood of having a high level of HCG and, and a scan that shows no fetal heart or the likelihood of having. So that's unlikely and it's unlikely to have a fetus with a fetal heart and a very low level of HCG. Um and the situations where you might find that will be we will deal with in two weeks time when you're thinking about a pregnancy outside the uterus. And therefore you need to think maybe there's an ectopic pregnancy and the other things to think about and to be aware of are so that you're looking at one pregnancy sac and you don't see a heartbeat in that fetus, don't forget to look for another pregnancy sac. Uh because it may be that there are two pregnancies, a twin pregnancy going on and one of them is continuing and one of them has died. That's a possibility and that woman will have bleeding and she may have a bit of, she may have some pain as the blood goes through her cervix, but be aware of those possibilities for the reasons why you might have a HCG level that's consistent with the time of pregnancy, but not see a fetal heart. You also want to check for her blood group or a bo blood group and for her rhesus status. And the importance of checking for her rhesus status is that if you have the facility to give her NTD, then you should do that. If she's had significant bleeding because you want to protect her from the future of having uh rhesus isoimmunization and causing a cross reaction to in a future pregnancy where her antibodies will attack the cells in the fetus if it's uh rhesus positive and the woman is rhesus negative. I hope that makes sense. And if it doesn't, we can go back over to the questions if you ask me. So when you're checking for her blood group and her rhesus group, you also want to think about, will she need blood herself? So you'll check a full blood count, look for hemoglobin uh and the other markers of blood loss. So the mean cell volume, mean cell hemoglobin uh is her blood loss, um consistent with an acute hemorrhage with acute bleeding or is it iron deficient or some other form of blood loss, you'll want to group and save her for blood and consider that if you think it's going to be necessary if she's had a lot of bleeding or if she's shocked or hypotensive and then you will probably admit her to hospital if her bleeding is significant and there are any of those signs of significant bleeding going on. And if particularly if you think she needs further surgical management, she will even at that stage, she will need some degree of reassurance and explanation of what's going on. Um And one of the things that women will often remember and recall after they've had a miscarriage is how well they were not medically treated, but how well they were psychologically treated. So if you, if you treat them as you'd like your sister treated or your mother treated, if you treat them well, explain to them what's going on. In words, they can understand and that applies no matter what country you're working in. So people's ability to uh take into account the concepts that you're portraying to them in terms of pregnancy and blood loss and the meaning of it. It's important to get that across. In words, the woman and maybe her husband or partner can understand. So those, that element of psychological support is really critical. So ultrasound is a useful thing to use if you've got it. And if, if all is going well in the pregnancy, you should expect to be able to see a, well, what I've written here in the text is called a viable fetus. In other words, that means a fetus that's alive with a heartbeat. Um And you should expect to see that in a transabdominal scan from 6.5 weeks onwards from the last period. Um Most of us now favor doing transvaginal scanning. There may be strong uh faith or cultural reasons why a woman mightn't want that or why your partner might want not want it for her. The, the big advantage of it is, is it's so accurate, so much more precise. So you can see that at 5.5 weeks pregnant, you should be able to see a fetus with a heartbeat transvaginally. It will take you a whole week more to know transabdominally. Partly because the gap between the gestational sac in the uterus is this much as in, you know, 10, 15 centimeters from the surface of the abdomen to the gestational sac on transabdominal scanning. Whereas it's 45 centimeters perhaps from the top of the vagina to the gestational sac trans vagina. So you're so much closer and you don't have such an amount of tissue in between to distort and reduce the quality of the ultrasound scan. I think that, you know, it's the diagnosis of the pregnancy can be made using transvaginal scan only. So that if you see a healthy ongoing pregnancy, then it's probably likely that everything's ok. Don't forget the things that I said that if you see if you see a pregnancy sac that got nothing in it or a fetus that doesn't have a heartbeat and yet the HG levels are high and there's only been a small amount of bleeding. Look elsewhere in the uterus for another pregnancy because that's a strong possibility in those situations at 5.5 to 6 weeks, the length of the fetus should be seven millimeters or more. Um And it could well be up to one centimeter or 10 millimeters. Uh The accuracy of the machine will give it in millimeters. And that's a more precise way of talking about crown rump length uh than talking about it in centimeters. Generally, people tend to use millimeters as a, as a means of describing it. So you might say 16 millimeters, as opposed to 1.6 centimeters. It doesn't really make a difference as long as you're clear about what it is you're talking about. And if you're again phoning your boss at home, you need to be sure that if you're saying that it's 16, some things that they understand that it's 16 millimeters and not 16 centimeters because 16 centimeters is like a 20 week baby as opposed to 16 millimeters, which is a six or seven or eight week baby. That word CRL, crown rump length describes the length of the fetus from the top of the head to the distinguishable end of the fetus which we call the rump, which is the bottom. Um And that's useful in the early stages of pregnancy because effectively from five weeks to about eight or nine weeks, the fetus is a long structure and only after that does it start to curve? So you're, you're measuring accurately its length by measuring top to bottom all through that time. And then beyond that, it becomes less accurate, less certain as to what you're dealing with. And you move away from using the crown to the rump length to using the measurement in its head of from one side of the head to the other, which is called biparietal diameter. Biparietal diameter is accurate from 12 weeks. So there's a kind of a window between 10 and 12 weeks where crown room length is no longer accurate and and the head circum the head diameter is not yet accurate enough to be able to say how many weeks people are. So if you know from an early scan, you can say yes, it's consistent with what it should be. But, but doing a scan at 11 weeks to try to get the dates right, might be better off waiting two weeks or measuring it now and then coming back in two weeks to be to be certain. Um and if you see an empty gestational sac, so a sac with clear fluid in it and no fetus and the sac measures 25 millimeters or more, then it's exceedingly unlikely that pregnancy is going to continue. That is probably a miscarriage that has stopped a missed miscarriage, the ones I described earlier inevitable because the pregnancy, there's no sign of a fetus and it has probably died. So, measuring HCG uh is of value, particularly if your scan results are not helpful. If your scan results don't give you a clear picture uh of a fetus in the uterus with the fetal heart. Um So it's perhaps useful, then it's particularly useful if you're trying to make sure that the woman doesn't have a pregnancy outside her uterus. A question just to think about is what's the likelihood of having a twin pregnancy, one in the uterus and one in the fallopian tube? Think about that for a moment. I think about what the possibility of that might be. So the likelihood of having a twin pregnancy, if you remember, maybe from undergraduate days is about one in 80 and the likelihood of having an ectopic pregnancy uh is about mm one and 50 roughly. So roughly one or 2% of pregnancies end up as ectopic pregnancies depending on the population. So if you said 1% so one in 100 as the ectopic pregnancy and the likelihood of twins being one in 80 you multiply 80 by 100 which will give you 8000. So the likelihood of having a population of a woman with an ectopic pregnancy and and an intrauterine pregnancy at the same time is one in 8000. Um Most of the hospitals that I've ever worked in in my life have um dealt with 87 or 8 to 10,000 deliveries a year. So, in any of those hospitals, you might expect to see one uh twin ectopic pregnancy in a year as it were. So it's very rare. Um, and it's very unlikely that if you find an intrauterine pregnancy, that you're also going to find an extrauterine one and vice versa, but it does happen, but it is very rare with HCG levels. What you'd expect is that if you've got a healthy pregnancy and you measure a level today and it's 500 say, and then the pregnancy is healthy and you measure it again today is Friday and you measure it again. On Sunday, you'd expect today's level to have increased by two or so, actually, 66% to be precise. But it should, the level on Sunday should be 800 900 perhaps if it's a healthy pregnancy. And similarly, if you measure a level today and it's 500 on Sunday, it's 300 then it's exceedingly likely that that pregnancy is going to come to an end, it's going to fail. And one last thing, thing at the bottom of the slide is that if you have a blood HG level of say 2000, depending on how accurate your measurements are. Uh but if the HG level is 2000 international units per per liter, then you really should see a heartbeat because that level of eg means there is somewhere there is a healthy pregnancy and if you don't see one in the uterus it's got to be somewhere else. And uh that's very important. So if, if your level is above that, then you've got to say to yourself, this woman is pregnant, but I don't see it. So it must be somewhere else. And this is, there's, there's a bit of overlap here, obviously with ectopic pregnancies and I want labor, I want labor this so much in two weeks time when we come to deal with that. So here are the management options for dealing with an ectopic pregnancy. So if the woman comes in and she has a small amount of bleeding and no pain and her BP and pulse are normal and she appears to be having only a threatened miscarriage. Then the sensible thing to do is to do nothing. Um And the medical word, medical word for doing nothing is expectant management. So that would be the thing to do if she's BP is stable, if she has no temperature and things are otherwise uncomplicated, if she um has clearly uh the baby, if the baby is dead or if the cervical os is open and tissue has come through it. But you know, on ultrasound that there's still tissue within the uterus, then you can use medical management. And that means so that does involve the use of miSOPROStol. So, miSOPROStol is a drug which is not available everywhere because because of its nature and because people recognize that it can be used for other things besides um dealing with miscarriage. So I'm going to come back to that just in a moment. Um And you can use miSOPROStol orally or you can use it uh vaginally either way is effective and one way is not more effective than the other. Um So, uh and then if you haven't got access to that or you don't, the woman doesn't want to use it, perhaps you, you would then suggest a surgical approach. So you might be, if you might have the equipment to do the manual aspiration and clinic without using a general anesthetic, I personally would, would not want that to be done to my wife or my sister because it's quite a shocking procedure. It's quite distressing and, and you might not uh would not enjoy it. And I would prefer to have it done under G A under general anesthesia because it's much more tolerable and there's quite a risk of having problems of um uh vasovagal attack when you go through the cervix. Uh because of the nature of uh the cervical dilatation that happens. So I would prefer to have a general anesthesia and be able to control that effect. But it may be that uh that's not the way that's going to work. And it may be that uh you go for the first option simply because that may be all you've got available here. Um And generally speaking, I think that you should consider um sending the tissue that you removed for histological examination to confirm that it was a pregnancy, to confirm that it's normal, particularly from the point of view of confirming that it is not a molar pregnancy. So, if you, if you were to live in, I think in Japan or China, they have a much higher. If I'm right on remembering they have got a much higher level of molar pregnancies than people do in Western Europe. I hope I've got that right. Um And I don't in your area, if you know that the likelihood of molar pregnancy is one in 10,000, then you're going to send a lot of histological tissue to the lab for no reason. And you may, you may want to make um a hospital policy decision about whether you should do that or not, but that would not be a, that would not be an individual decision to take. I would not take that the decision myself. I think I would sit with all my fellow doctors and say, you know, if we miss one in 10,000 moles, but if we spend 10 lbs or $10 on each sample, that's going to be, you know, 88,000 multiply it by 10, that's $80,000 a year. Uh For one last case, is that worth it? Um It's, you know, that's a difficult challenging question to go for. So Mr pros uh is a, a drug which stimulates the contractions of the uterus. And because it's sometimes used in terminations of pregnancy, you may find in your individual countries that it's not licensed for use and that you may not be able to use it. So that's the expectant, the medical and the surgical management. And again, just to remind you about the problems of major hemorrhage. So if the woman's bleeding heavily, look in the vagina, look at the cervical os, check that there are no products in the Os. And if there are remove them and then empty these uterus surgically as soon as you can and give her some sort of drug that's going to make the uterus contract. I've worked in England for many years of my life and I, I encountered great resistance from my anesthetic colleagues who didn't want to give the woman Ergometrine, which is the drug I put down on the screen here. Uh I think ergometrine is the best drug for this purpose because it contracts the uterus, not just once, but it will keep it contracted for up to an hour and that will stop the bleeding and save the woman's life. They will want to give her a drug like cytosol which makes the uterus contract. Yes, but CEO makes it contract and then relax and then contract. So it's not as good as stopping the bleeding as ergometrine is, that would be my favorite drug if I had a choice. So, coming on to think about some of the more uh the other learning objectives that made all set for us in this lecture. So, counseling and emotional support is critically important for women who have a miscarriage. No matter if it's their first pregnancy, their third pregnancy, their fifth pregnancy, it doesn't matter, it doesn't matter if the pregnancy was wanted or not. It doesn't matter if it was expected or not, they will still feel it has a major blow. Friends of mine who have had miscarriages will talk about that experience as if it was the worst thing in their life and they've had other worse things. But they talk about is the worst thing in the life because because it hits them right at the core of being a woman. You know, having a child, having a baby is part of what women can do. Men can't do it. Women can and having a baby is something that women think they should be able to do without difficulty without any problems. And if they are embarking in a pregnancy and then they get pregnant and it starts and it's growing and then all of a sudden it's gone, they really struggle with that for obvious reasons. They really find that a blow to their personality, to their, to their being a woman. And they would ask lots of questions about why did it happen. Um They would ask questions about what did I do to make this happen? Uh Should I have taken those tablets from my doctor, all sorts of questions like that, which you may ask, you may get asked and you may not know the answer. And if you don't know the answer, don't give them a rubbish answer. Don't, don't try to waffle or give them a lie. Say, I don't know. But I'll find out, can you wait here while I go and ask somebody and, and come back and tell them far more important than tell them to tell them a lie or whatever. Um, so these are the kind of questions, you know, what did I do to make it happen? Is it likely to happen again? Can you do any tests to make sure it's not going to happen again? Um, and for most people on their first pregnancy loss like this, it would probably be inappropriate to do tests because the likelihood of finding a significant problem is very small. Uh, in the country I work in, in England. Um, we would normally start to investigate multiple pregnancy loss after the third loss and would want to be a confirmed loss with either ultrasound evidence or a positive test or some proof that she was pregnant. Um, because the costs because the investigations, because the likelihood of finding a problem before that is very small, the investigations generally are quite expensive to do and therefore you end up spending, um, 2000 lbs, $2500 on investigations which may not reveal any problem as time has gone on, the likelihood of finding a diagnosis and having appropriate tests has improved and that has changed a little bit, but that's not really the subject of our lecture today. So I'm not going to cover that for now. So now I've got, um I've got some questions to think about. So these are, so I, I was asked to think about decision making in complex scenarios. So the first one of these is a woman presents with eight weeks amenorrhea and that means she's had, it's been eight weeks since her last period. And she says to you, the doctor, she no longer felt pregnant two weeks ago and her pregnancy test is now negative. How would you manage her? So I hope that you picked up enough from what I've said earlier that this is going to suggest to you that probably this woman has started a pregnancy, the pregnancy progressed, but then it came to an end. So she stopped feeling pregnant and her pregnancy test is negative. So the the pregnancy test measures urinary HCG and the absence of symptoms of nausea and maybe vomiting are related to blood levels of. So if those have fallen, she's now probably has a missed miscarriage. And how would you manage her? So it depends on her situation where she lives, how far away from the hospital she is. So, uh and where I live, if she lives a mile from the hospital and if she's healthy and well, and, er, is sensible, you might say to her, well, you've got one or two options, at least to manage this, you can either wait for it to come by itself and it probably will, uh, you probably will miscarry or you can have it managed medically or surgically as we talked about before. It's possible that if she manages without intervention, that the pregnancy tissue will get reabsorbed and she may not even have a period or bleeding. And you could review the situation in two weeks time by doing a further scan and maybe doing a pregnancy or doing a HCG level. And you might then find there's nothing left in the uterus. You might find that her HCG levels are now very low and then it's very likely that she's not going to bleed at all. So those will be the ways you might manage that. The next scenario is a woman had a miscarriage two weeks ago and then she still kept bleeding and a preto test is still positive. How would you manage her? So here, there are lots of possibilities in terms of what the diagnosis might be and you need to be aware of that. Um And think about the fact that there might have been a twin pregnancy, think about an ectopic pregnancy, all those possibilities. The final one on the page is that she's had a miscarriage two weeks ago, continued to bleed her pregnancy test is negative and she feels unwell and shibby. So that probably means that she is uh having an infection most likely in her uterus. And so she's probably got a septic miscarriage needs antibiotics perhaps intravenously depending on how unwell she is uh for several days with IV fluids uh because she may not be able to take in any fluid food or fluid orally. OK. So in terms of people you're going to be collaborating with, you should be working with an ultrasonographer, maybe with theater staff, with gynecology, nurses, with the blood bank. If you want to have blood transfused for transfusion with the biochemistry staff, if you want levels of HCG done, these are all I think these are fairly straightforward, but it's important to remember that. And then for with regard to the patient, they're going to want to ask you questions like how long am I going to bleed for? What to do if I don't stop bleeding? When can I get pregnant again? Now, that's an interesting question. So when can they get pregnant again? And I think a sensible question is once you bleed next, you are probably at risk getting pregnant. If you want to get pregnant, that's fine. Go ahead. If you don't want to get pregnant, you should start using some form of contraception or whatever you might be using from that time on. And how likely is it to happen again? So this is an interesting question. So this is a slide which is not mine. Uh, but it shows what the risks of a further miscarriage are depending on how many you've had. So, if you had no miscarriages before your likelihood of a further one is 10% not much different to the normal, a little bit higher. Um, if you have had one, then your likelihood of a further one is about 16%. If you've had two, it's 24% or so. If you've had three miscarriages already, your likelihood of a further miscarriage is 43% almost half the people in that situation will have another miscarriage in their next pregnancy. That's why that group are worth investigating because they have a much higher likelihood of something wrong with giving them a miscarriage. Remember that there are other things that might be, uh, it could be pregnancy related or coincidental to the pregnancy but still gynecological um like bleeding from a cervical malignancy, um, rupture of a corpus to hem causing pain, an ovarian cyst accident, causing pain and so on. And then things has nothing to do with pregnancy causing pain like appendicitis, very much the same area where you might have an opic pregnancy or renal colic or cholecystitis, maybe not quite in the same site but be aware of it. Ok. Now, these are quickly we're going to go through these because we're running a little bit out of time. But I want you now in your chat boxes to write in what you think the answer is here. So a 28 year old woman presents to the early pregnancy clinic. She's seven weeks pregnant by her dates. She says that she's had lower abdominal pain, worse on the right side and she's had some minimal brown discharge vaginally. So not red bleeding in the past when she was 18, she was treated for chlamydia. So there are five options there. I want you to write in your uh chat box. What do you think the most likely option is do that? No. And now we're going to move on to the next one. So if you haven't done it, then it's too late option. This is question two. So a 25 year old woman comes into the accident in the emergency department with heavy vaginal bleeding and a positive test. She's been passing clots with some lower abdominal cramping like pain, no relevant past history. Her pulse and BP are normal on speculum examination. She has moderate vaginal bleeding. There's a small amount of tissue protruding through the os, the scan shows she's got retained products of conception. What is her diagnosis? There are five options. I 10 form mole, a molar pregnancy, complete, miscarriage, missed miscarriage, threatened, miscarriage or incomplete. One of those five is the right answer as to what the diagnosis is. Write in the box. What do you think the right diagnosis is? So, do that. Now, if you think you know, and then we move on to the final one. So an 18 year old woman is referred to the early pregnancy clinic with bleeding at eight weeks, she's had nausea and vomiting, which are consistent with pregnancy. She's otherwise fit and well, her scan shows an enlarged uterus at 12 weeks with a heterogenous mass within which are grapelike structures. What's the diagnosis? So, we've only, we've only touched on this. We haven't specifically dealt with it, but from what, you know, one of the answers is right, the others are all wrong. So, does she have a high deformed mole? Does she have a missed miscarriage? Does she have a complete miscarriage? Does she have an ectopic pregnancy or does she have a threatened miscarriage? So right now in the box on the side, what you think the answer is to question 33123 or four, sorry, 1234 or five has been the right answer. Ok. Uh So I'm going to finish there. I'm going to come back to the uh stop sharing and hopefully now, yes, I can see sue. Uh and, and we've got answers in the chat. Ok. So, um can you? Ok. That's ok. I can tell you I can. Yeah, brilliant. So it looks like most of them for question one have answered. Answer number four. Ok. So question four. So question one was you spotted the uh pain, the small amount of bleeding and the chlamydia, ectopic pregnancy is the right answer. Correct. So well done. Those of you said four, I won't name you, but you know who you are? Good question number two. So this was the one, this was the one who came in heavy bleeding clots, BP, normal tissue in the cervix products of conception of the uterus. The answer here is incomplete. Number five and many fives. Excellent, great. I, you know, this is very reassuring to me. You've been listening and I, I'm feeling quite excited about that and then this last one, so we didn't touch on this, but I did mention it a few times and hopefully you'll be able to exclude uh it from all the others because you know what all the others are. So the answer here is how the form mole and, and those grape like structures are key to making that diagnosis. So on question three, um uh people said uh one which I think is the answer. Yeah. So 31, those of you have said one is correct. Well done. That's really good. So I've come to the end of what I wanted to say. Um And now it's time for you guys to pick me up on stuff that I might have said that's confusing or you didn't understand or I made a mess of it or whatever. I mean, you know, I can make messes. Um So please feel free to ask questions. I'm sorry, I went a little bit over time. I got so excited with my topic. That's always a danger with me. It was great. David. It was really, really good. I really liked that. The fact that I think sometimes things can be so clinical and you really touched on the emotional side and I'm a mum of three. Um, and I think being in tune with what a woman is gonna feel is really, really good. Um, I just think that's really helpful and you really, you really, you really got it really well, you know that they will ask, what did I do wrong? What can I do in the future? And so with that in mind, is there any, is there any way to ST like, I don't know, I'm not medical, I've admitted to this. Is there any way to like stop a miscarriage? Is there any research happening for women who would be prone to miscarriages that they can actually stop it? Um So that's a long answer. Sorry. No, no. Well, no, it's a good answer because it may well. So actually there's one question that come up, somebody's view. Ok. So somebody's asked, can you repeat the questions and answers, please? Do you mean, so do you mean the ones on the slides? I'll do that at the end if that's what you meant? And rle you said the role of vaginal progesterone and repeated miscarriages, please? Ok. So, so Sue's question and Rink, right. I'll come back to them. Um, al although actually, so in my PDF that I sent you, can you send that to everybody? The PDF that I, yeah, I can add it as catch up. I can do that. Absolutely fine. So those are at the end of the PDF file that I sent to sue and you'll get them there and I will make sure that she sends you the correct answers as well. Will that be ok? You're saying? Yes, thank you. So, Sue's question and Rink, who's questions have a degree of overlap. So, um I specifically didn't deal with recurrent miscarriages in my talk because that's, that's another talk in terms of content and volume. But uh you asked, is there anything you can do to stop it soon? So, with regard to, if somebody starts to bleed and somebody starts to have pain, my understanding is you can't stop that. There's nothing you can do to prevent that happening. And, and that's probably because uh in these situations, um whatever has triggered the miscarriage to begin has already happened and the bleeding and the pain are down the line. Um And therefore, it's not possible to hold that back and stop it. Uh Rio says the role of vaginal progesterone and repeated miscarriages. I would refer you to my paper on this topic which uh I did with two colleagues, Moammar Hussein and um a, a fellow Sudanese doctor um uh called uh uh Ha Sam and mono and I did some work on our recurrent miscarriage clinic and several years ago and we looked at the role of vaginal progesterone. And in our view, um vaginal progesterone is worth using in recurrent miscarriages if and only if you measure the woman's progesterone every week from when she thinks she's pregnant and then once progesterone levels start to rise, that's good. And if at any stage between then and 12 weeks, dip or not even dip, just stay the same every week, they should be going up by about 10 or 15%. So any week that it doesn't go up, then we would start vaginal progesterone, uh daily, 400 mgs of vaginal progesterone. We use a drug called Cyclo. Um And we use that twice a day, morning and evening and in our view, that reduced the likelihood of another 4th, 5th or sixth miscarriage. You, you may be aware of the big study that uh a coumarin did in England, which was a multicenter study where he also said that vaginal progesterone in various forms was useful. I I we, they didn't measure progesterone levels. We did. And that's obviously more intensive for the mother, for the woman, but the care that you're giving her. Uh So uh is that one of mine you picked out? Yeah, it's, I think it's the right one. You said it was Saal and Hakeem and Moammar Hussein. Yeah. So that's the one all my secrets are being shown out here. But we uh so we, we felt that, you know, the, the addition of doing weekly progesterone levels, it's a pain the woman has to come into the hospital to have them done. Uh But what what also happens is that the reassurance she gets from that she meets with the nurses, they chat about her symptoms and the whole positive. Um So other people showed once that the thing that stopped people getting recurrent miscarriages the most was tender loving care as it were attention. Um follow up interest and you might think that's not science but that in, in, in, in this study that they looked at this is quite an old study. I don't, I don't know if I can find the reference to it. But, but that was certainly the one that they found the, the key factor in making a difference of whether the pregnancy continued or not was interest care input from the clinicians, the nurses, the doctors. So there you go. Anything else? Otherwise we're approaching our time when I turn into a pumpkin, you need another coffee. Does anyone else have any questions? If you pop them in the chat, if not, what we can do is um as David said, he's got another event in two weeks time, I'll put the link on the chat for you to sign up and what we can do in the feedback form that you'll get. There's a bit at the end. So if you have any questions that David hasn't answered, we can, you can actually pop a question, the feedback form and I can pass all these on to David and he can get them next time. And I guess also I'd be really interested, you know. So from your names, it's clear that there's a multicultural audience listening to this and it's, it's so, I, um in my experience I've taught in uh physically, I've been to Samari Land and taught there and I've been to in Europe, I've been to Albania. Uh those are very different countries. Uh One of them uh is European, but it's not in the sense of it's Eastern European and it's just recently been uh freed up from communism. Soma land is a country that's been uh through lots of, of bad things. So I think I, I'd love to hear how relevant you thought what I said was to you and thank you for the comments about it being informative and interesting. That's, that's, that's great. I like that. Um So we should stop. So we bring this to an end su and I'll communicate with you. Um You can stay on the call. So I'm going to close this. Our next event is tomorrow morning, there is one on oncological emergencies. Um If you follow medal on, if you follow me education on medal, you'll get notified of upcoming events. We have David's event in two weeks time and then he's gonna do a couple more with us too. So if you've got anything you want to pass on to David, you can pop that in the feedback form and I'll make sure he gets that feedback form. Ok. So it was lovely to have everyone join us today. Um Hopefully we'll see you tomorrow and we'll see you in two weeks time for David and for now, uh have a lovely day and um, enjoy your weekend.