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Hello, everyone and welcome to our medical education event. David and I were having our old chat backstage talking about Northern Ireland, the island of Ireland because he lived there and I live here currently. Um Anyway, we are gonna talk about preeclampsia and hypertension in pregnancy today or rather David is, and you're gonna ask lots of questions. Do put your questions in the chat on the right hand side and David will answer those questions at the end, but he may be asking questions throughout. So please put them in your answers in there in the chat and I'll read them out to David. OK? As always at the end of the event, you're gonna have your feedback form. So in an hour's time, there will be a feedback form in your inbox. Complete it. Please. David may just do some more sessions in the new year for us. Pardon? Cos he's enjoying it so much. Oh, yeah, I love to spend my Friday mornings up the attic where it's the warmest room in the house at the moment. So let's give lots of feedback of topics that we would love for him to cover and then maybe we can make him commit to another five or six sessions next year. How's that, David over to you? Thanks very much, so, so, good morning, everyone and welcome from wherever you are joining us. Uh It's a real pleasure to have you. Um And I hope you are safe and well, wherever you are uh this morning in, in my series of talks on various aspects of obstetrics and gynecology, we're going to be talking about BP problems in pregnancy um and dealing specifically with conditions like eclampsia, preeclampsia, hypertension and pregnancy and all of those things. Um You, you uh this talk will be recorded, isn't that right? Sue. Oh yes, talks recorded, the talk will be recorded. So there's a link at the bottom of the first slide for nice.org dot UK. Um So that is the most up to date um uh English advice on the management of hypertension in pregnancy and all of its complexity. Um Much of what I've talked about today comes from that as well as partly that and partly my own experience and uh trying to ensure that what I'm saying to you is up to date and relevant and correct. Um So with regard to terminology, um there are a couple of terms on the first slide here which are worth just paying some attention to. So, first of all, um what is hypertension in pregnancy? So, uh if so it's the standard definition of hypertension that most people go by is a BP of 1 40/90. And if that's present at booking when the woman books or before 20 weeks, or if she's already taking some sort of antihypertensive medication like labetalol or methyldopa or some other medicine, she is categorized as being hypertension as having hypertension in pregnancy. Eclampsia is a relatively rare condition, uh where you have a convulsive er, episode, er, associated with preeclampsia. That sounds like a rather odd definition. Um But you, first of all have to have preeclampsia before you can have eclampsia. And eclampsia is the presence of, of fits convulsions in association with it. I think acampsia comes from the, from the Greek language. Um and I think it means uh lightning and the, the meaning of, of it being that eclampsia strikes like lightning um and comes completely out of the blue as it were. Now, that's, that's actually not true. It might have been true when people were talking about eclampsia 100 204 100 years ago when they might have given it that term. But nowadays, we recognize that there are symptoms and signs associated with preeclampsia and the more severe they are, the more likely you are to get eclampsia. So it's no longer lightning out of the blue. It's uh I would say maybe more it's lightning. Uh And you didn't take care to get under the cover of the house because you could see it coming and you haven't taken the appropriate steps to manage it perhaps. So, preeclampsia is something we're going to talk about a lot more because it's much more likely to be seen. And that's new hypertension, new high BP after 20 weeks and in association with one of the following things. So you might have proteinuria, which you would measure on a dipstick, measuring for protein. You might have some maternal organ dysfunction. Generally that organ is going to be one of two or maybe three. So one of two would be either the liver. So you might get disordered liver function uh or the kidneys. So the kidneys might not be working correctly. You might have raised creatinine levels in the blood perhaps. And then the third organ which can be affected is the brain and that would be um uh shown less by blood tests, more by clinical signs like confusion. Um uh things like papilledema on examination, um things like uh slurred speech um and so on. And the third thing that uh is associated with hypertension uh and to make preeclampsia is evidence of uteral placental dysfunction in English. That means that there are some signs that the placenta and uterus are not working correctly together. Now, an an obvious um sign of that, I think the most obvious sign would be that the baby either slows in its growth or its growth stops. Um Those are the most obvious signs that somebody might pick up on clinical examination, you may find other more complex evidence of that if you were able to do ultrasounds and look at blood flow in the umbilicus or other arteries of importance, the the ones that are, are relevant are things like various blood blood vessels in the brain and so on, which are able to demonstrate abnormal flow and therefore the evidence of uteroplacental dysfunction. So we're going to go on from that, that was a long talk on that very first slide. So to in today's lecture, what I want to cover what I've been asked to cover by sue and her colleagues is that you should be able to assess and recognize how bad preeclampsia might be in an individual patient that having recognized it, you'll then be able to put together a plan for that individual person which uh will help you to manage their preeclampsia. You, you need to be able to communicate those risks uh and the implications of the condition to uh to women, to their relatives uh to those who come with them, to clinic perhaps. And that's often the biggest challenge because we as as doctors will, will get the the problem, we will understand the implications. But how do you translate that knowledge and anxiety perhaps into a situation where you've got um a woman who may have people that need to be looked after her at home, could be other Children, could be a sick husband, a sick mother, a sick father sick relatives, uh, work to go back to maybe, uh, you know, and, and that's often a challenge. So, uh, in western world, um, women who are working, uh, struggle with the idea, they might have to stop work even if just for a few days because they have committed themselves to doing things. So you need to be able to communicate those risks well to people. And it's no good in just saying you've got preeclampsia, you need to come into the hospital and that's the end of it. So that's not going to work often. You need to be able to do you as listeners need to be able to understand what the right tests are and how to interpret them. And you also need to be able to communicate and work together with other people involved in the care of that woman. So that will again be situations like people like the other nurses or midwives on the um labor ward, maybe where she's being kept because that's the most high care environment in the hospital. You need to be able to communicate with the laboratory about the results you want tests rather than you want done and with people like anesthetist who you might need to recruit uh in, in help, in setting up particular management plans for her. And particularly if you're thinking about doing delivery about whatever they might want in terms of information about delivery. So at the start, please, if there are things that I say. Um, and, uh, and mention that you haven't heard before or you don't understand, please write it in the chat and if it's important enough, sue will stop me. Um, last Friday morning, my, my wife, um, came in at some stage during my talk to you and she said she wrote on a piece of paper and hand it to me and said, talk slowly and I thought I was talking very clearly but clearly she didn't. So even if it's that if, if I'm being indistinct and you can't understand what I'm saying because my language is too complex or whatever, please stop me and give me a chance to catch up. Oh, yeah. So, uh this is lightning striking from the sky and I have written the Greek word for eclampsia there and pointing an hour to it. So that's just for fun really to give the history of that word. Um So, um these are the pointers, the signs, the historical things, the things in a woman's history that is, that should tell you that she amongst others is more at risk of developing preeclampsia. So you can see the list there yourselves on the screen. Um I don't need to read them all. Um So it's clear that some of them are very evident things we would know about. Um, the ones, the particular ones are in a situation where somebody has a preexisting disease like diabetes or some sort of kidney disorder, like a nephropathy of some nature because those are vascular disorders. And if the woman has got those, then that ups her likelihood of developing another vascular disorder such as preeclampsia. If she herself has had preeclampsia before, maybe in her first pregnancy, then it's more likely to occur. Uh It's most common in first pregnancy. But clearly, if you get it in one, then you're more likely to get it in another. There is some evidence of a of racial differences in women between those who do or don't get uh eclampsia or preeclampsia at least. So, uh the, the numbers at the bottom of the slide are from some big American uh study that was done within the last 20 years. And what they found was that uh in women who were uh what we would call white uh in terms of their background, European probably uh their chance of getting preeclampsia generally was 5% if they were of Hispanic origin. And in America, that would mean people mostly from um Mexico uh Honduras, uh Panama, uh the Northern States, um countries of South America, Venezuela and so on. They had a 9% chance and in women whose origins were West African and were then taken 100s of years ago to the Caribbean and then moved to live in the US. Uh Their term there is African American uh and they had an 11% chance. So those women, those black African women of origin had an 11% chance, the highest of all of those, those figures, I think would be certainly true in the UK. We have a very low population of people from the, from the Spanish, um, peninsula from Spain or Portugal. But we have a lot of people from the, from either directly from Africa, from the old British colonies in Africa of Nigeria and so on or people from the Caribbean who have come over here in the 19 fifties to the UK and they tend to have a higher incidence of preeclampsia as well. Um I'm not sure about other races because nobody has looked at it. Um So these are some dates that you can see some data rather from uh some study that was done and presented as part of the data for nice, the National Institute for Clinical Excellence. And it shows you the differences in the frequency of uh dying in pregnancy and it's distressing the differences that exist and they exist. Uh Partly. So if you just look at them, you can see that white women have a chance of dying in pregnancy of seven per 100,000 black women have a chance four times that 32 per 100,000 mixed ethnicity, which means maybe black and white or Indian and white or Indian and black. And Asian women have roughly a 12 or 15% 15 women will die in 100,000 women who are pregnant. Partly that's due to um circumstances of deprivation. So Indian uh and black women in this country, it, it is recognized that they will often live in poor quality housing. Uh They may live with less income in their houses. All those things are true. Um And that's partly why it also maybe relates to their willingness to go to see a white male doctor. Um So still in this country, many of the people involved in primary care doctors who are, who are the first port of call, we would call them general practitioners. They are still probably about 50% white, 50% sorry, 50% male, 50% female. Although the racial grouping is much more diverse than it used to be. Um And in terms of hospital doctors, uh when, when I left my hospital, uh when I stopped working, we had 22 doctors who were senior doctors like me and of those 22 there were six men and when I left, there were five. So the rest of them were women. Uh and they were of uh Indian uh uh white uh some African uh extractions. So that balance is changing. But still people are reluctant to go to see doctors that they may not feel comfortable with from the point of view of being belong to a different social class or ethnic group. So here's a, here's a question for us to think about. So this is a woman uh who gets pregnant she's 34. Um She uh has a positive test at seven weeks since her last period. This is her first pregnancy three years ago. Her GP found that she had essential hypertension and he put her on Ramipril. Ramipril is an ace inhibitor. Um uh she's on five mgs a day. Her BP is well controlled and she gets referred to the hospital for antenatal care. So Ramipril is an angiotensin converting enzyme that's spelled incorrectly. I spotted inhibitor and should be stopped at once because the mother has conceived because once she's conceived because they are teratogenic. So she will need a different anti hypertensive which is safer in pregnancy. Uh So she would need something like methyldopa, which is very safe, very old fashioned, um but very reliable and very trustworthy in terms of its risk profile, uh or other newer drugs like labetalol or nifedipine. And then also because she's a woman with hypertension that's preexisting her pregnancy. She's, she's therefore in a higher risk group. Um because of that, she's at more at risk of preeclampsia later in her pregnancy. Uh and she should then from 12 weeks on start to take aspirin in a dose of 100 and 50 mgs a day. Now, I've used uh an old terminology over here um and you'll, you'll need to forgive me for that. But, so this word here are these three letters P et. Um So that's an old terminology for um uh preeclampsia preeclamptic toxemia. Um And people will, people will still uh write that they will still uh say it and use it. Oops. Sorry, I've just flipped out of that accidentally but it's, it's, that's so that's when I use that. That was wrong to use. You say just preeclampsia is there because there's no, there's no element of toxicity or anything like that in preeclampsia in preeclampsia. So that's how you should manage her because of her past history and because the drug she's on is not safe to take in pregnancy because it's, it causes abnormalities in babies. Can I ask a question, David? You can come back and get back to the aspirin. It's only because when I was pregnant, um we were told not to take aspirin. Yeah. And it was, so, what's the, has that all changed now or? So you, you shouldn't take aspirin if you're a normal person? Ok. And I presume, so you're normal. Um No. So, uh yes. Well, it has changed specifically in this area because um Aspirin as a drug does lots of things. Uh It's often people will take it as a pain relieving, pain relieving drug and so on. So it has pain relieving effects, it reduces temperatures. Um But one of its other effects is that in blood cells, it makes your platelets, which are the things that cause you to clot, it makes them less sticky. Um So they lose their ability to stick together. Um And in so people, there was a big study done by some guys where they looked at the effect of aspirin in the reduction of the frequency of preeclampsia. And they found that this dose of aspirin was the best in terms of safety profile and effectiveness in reducing preeclampsia. So it's a very good question to ask because it's counterintuitive to use it otherwise in pregnancy. But in this situation, because of the well defined recognized risks of it, but also the well defined benefits at this dose is what you would reduce, providing somebody fits the category of having a risk. So if we just flick back to here. So this woman has um a previous history. Where is the list here? Uh pre uh blah, blah, blah, blah, blah. Oh Yeah, long term hypertension. So she's had long term high BP before becoming pregnant. She's there for much more at risk of preeclampsia. If she had any of these factors here. Um uh Being having gestational hypertension, thrombophilia or past history, you would put her on uh on this aspirin because that would be effective for her to reduce her chances of preeclampsia. Thank you. Perfect. Thank you. You get full mass for being awake. Oh yeah. OK. So um this is uh this slide is intended to show how eclampsia the fits the convulsions are likely to present. And what you can see, I hope is that a small proportion of them maybe even less than a quarter of them present during delivery. About a third will present before delivery and almost half of them present after delivery. This is a real, this is a real issue because um we tend to think that the time coming up to delivery and the delivery time itself is the most risk. So the baby will be born, be all wrapped up, put to the mother's breast. Uh They'll check her tummy, make sure that the uterus is contracted, there isn't much bleeding, uh bring her a cup of tea, go off to get a cup of tea herself and then she has a fit because that's the most likely time for her to have a fit of all the times more than half, almost half the fits that will occur happen after the baby is born, usually within the 1st 24 hours when all the dramatic changes in blood, uh indices are are evolving as the pregnancy levels decrease. But it's really important not to ignore her just because the baby's born and now she's fine because actually the a can fit can happen even then. So BP in pregnancy can be preexisting um can be there beforehand. So the case that we looked at was a woman who'd had high BP for three years. Uh So it could be preexisting and known about and therefore on medication and maybe well controlled or maybe not known about. Uh But you find that in pregnancy she comes in and her BP is already quite elevated. It could develop in pregnancy. So it could be because she has a tendency towards high BP and the, the strain of being pregnant makes the uh BP increase. Er, and therefore, it's just pregnancy induced hypertension and after the pregnancy it will go away or it could be associated with preeclampsia. So, preeclampsia classically is considered to be hypertension um and associated with protein in the urine and edema, swelling in the body most seen er, in, in various obvious places. So the most obvious place to see edema will be the hand, the fingers because um, they are, they're there in front of you and a woman might report that her fingers have gotten tighter or she's gotten pins and needles in her fingers because the, uh, the, uh, what's the name of that band that goes across the wrist? There's a connective tissue band and it gets swollen and presses on the radial nerve and the ulnar nerve that go through it. And therefore she gets pins and needles. So that's where she may see it. Or if she wears rings, she may notice that her rings have become tighter or perhaps she can't take them off. You may find edema in the feet and in the ankles, in fact. But that's confusing because in pregnancy, nearly half of women will have some degree of foot and ankle edema. And really the only edema that becomes relevant is if you bring your finger above her ankle and press on the tibia, the bone on the medial aspect, let me just check where my own tibia is. Yeah, the medial aspect of your leg. Um And if you press in there and you find that there's an indentation and it doesn't release when you take your finger away, it doesn't disappear. Then that's pretibial edema and that's also edema. Much more scary places to find. It will be if you look in the eye and you look at the retina and you'll see papilledema. So the retina will be, will be puffy and swollen. That's much more scary because that means she's got a very broad body extension of her swelling. All the places that edema might show itself uh would be if she has the symptoms of right upper quadrant pain because that recognizes that she's having liver capsule distension from the edema. So her liver is swelling and that causes pain. Ok. So, with regard to the to preeclampsia, preeclampsia, effectively only happens in pregnancy. Uh and it's the only condition that it is associated with. And um uh it often will have no symptoms to begin with. The disease itself will start uh in the uh in the 20 week times or the in the teens. So maybe it's 16 weeks, 18 weeks, 2022 it will start, then it will begin to show uh biochemical evidence of its presence. But the woman will have no symptoms. Maybe until she gets to 28 weeks or 32 weeks, the the dysfunctions will become evident. So you'll find evidence of renal disorders, hepatic disorders, disorders in the brain with some, some swelling that might cause confusion. Um and disorders of uh blood flow in the brain disorders of coagulation. Uh which is why taking aspirin is a good idea because it reduces platelet stickiness or aggregation is the technical term. And by doing so, it reduces the chances of blood clotting happening. And preeclampsia is a condition that makes women more likely to have blood clots more likely to have deep venous thrombosis or pulmonary emboli. So, the aspirin uh partly will counteract that as well as having beneficial effects on the placenta. The placenta is the other organ that will begin to show problems. Uh And you'll find disorders of uh the um blood flow across the placenta becoming uh more of a problem with areas of the placenta being damaged by the disease. So uh the just at the bottom I put at the bottom of that slide, it says that about aspirin. So, aspirin reduces the incidence of preeclampsia by about 12% which is a significant amount. So if you can reduce the incidence from 100 women to 88 women, that's clearly 12 women who won't have the disease and it's worth doing. So. A a an associated condition is just pregnancy induced hypertension. That's when the, when the hypertension happens in the second half of pregnancy, there's no symptoms or signs of preeclampsia. There's no disorder of blood clotting, there's no disorder of the kidneys or the liver, there's no proteinuria, there's no edema and that as a condition that tends to happen in the future. And if you have several pregnancies where you've got pregnancy induced hypertension, you're likely in the long run to become hypertensive in later life just because that your body is designed to do that as the arteries begin to malfunction in later life. So this is a complex slide which we'll go through slowly but not boringly. I hope so. When you're trying to figure out how severe the condition is, first of all, you depend on the symptoms and then the tests, um symptoms and signs followed by tests. So, um the symptoms are the list there. Um And so you get headache, uh you get visual disturbances. Most of those are related to uh increased edema in inside the capsule of the brain. The visual disturbances happen because again, the the optic nerve coming from the brain out to the eyes becomes pressurized and begins to form a abnormal visual disturbance patterns, pain in the right upper quadrant because of liver distension, nausea. For the same reason, some vomiting for the same reason, progressive edema beginning in the hands or feet. And that's something we haven't talked about before, which is a condition where the woman's reflexes become increased and their intensity and you'll particularly notice this if you're looking at her, um, the, the reflex in her, uh either for the front or the back of her elbow or the knee reflex, um, or the jaw and you'll get quite a marked uh, reflexic response. One of the things people talk about also is clonus, where you, if you hold the leg and then jerk the foot upwards, you'll get that kind of vibrating effect on the ankle. Um So those are all different ways in which that hyperreflexia can be noticed can be noticed. But the big thing is if you don't look for it, you won't find us. And if you don't find it, you won't know how severe her preeclampsia is. So, hyperreflexia tends to be an indicator of fairly severe preeclampsia, not mild disease. So, in terms of the tests, we're going to do, you want to look at renal function, you want to look for proteinuria in the urine that's fairly straight forward. Um And usually more than one plus a protein represents 0.3 nanograms per meal. I forget exactly. But more than one plus tends to represent significant proteinuria and raised levels of creatinine and raised levels of uric acid and urine volume beginning to decrease oliguria. So the woman will begin to produce less urine because her kidneys aren't working as well. Blood test results will indicate decreased volume of plasma because she's losing blood out of her blood volume space into her extravascular space to give rise to the edema. So that gives rise to hemoconcentration. And you will remember that hemoconcentration makes you more likely to develop a coagulopathy because the blood cells begin to be more concentrated and therefore more likely to stick to each other. She will also have abnormal liver function tests um and decreased platelets. There's uh a condition called HEP he LLP, which stands for uh he hemolysis, elevated liver enzymes and low platelets, which is a condition that as it becomes, as it starts to get developing, you then move towards a risk of having something called um well, a widespread coagulopathy in the body disseminated intravascular coagulation, which is as bad as it sounds shortened off to D IC. Uh but that's a, that's a condition that kills women. So if, if you're seeing those things happening, then uh you need to be very careful because you need to be giving her medicine to stop her clotting. So more than aspirin really at this stage, she probably needs to be on Heparin. Uh She may need to have platelet infusion. You, you may want to give her a little bit of uh colloid to increase her intravascular volume, but not much because she can't afford to tolerate that. Um to try to avoid that. There's a test coming in which is not yet fully evaluated, but it may be a possible screening test. It's a blood test for something called placental growth factor, uh which would be done before 37 weeks and probably even before 35 weeks, which would stratify women into being of quite low risk or minimal risk or quite high risk. And therefore in need, maybe a more intensive management of their BP, uh maybe hospitalization earlier or whatever to try to separate them out. Because one of the big challenges is that when somebody presents with proteinuria, some hypertension, a little bit of edema, you as the doctor looking after them. Are you thinking how, how do I tell whether this woman in front of me is going to go on to have preeclampsia and eclampsia or how do I tell if this woman is going to stay like this for the rest of her three weeks of pregnancy or whatever it is, deliver her baby and then get better. So it's very hard to tell this might be a useful test. If we could do that, it would be uh I don't know how far on it is in terms of its uh readiness for, for use, but it would be clearly very handy to have that whether or not it will be cheap enough to be available uh in, in all parts of the world is another thing, of course, but at least it, it coming in will make it more available eventually to everybody. So, yes, the proteinuria. Um so it used to be said that, you know, more than 3 g per 24 hours was significant. But really, that's quite outdated and the protein creatinine ratio in urine is a much more up to date test. Um So that if you're, if you're having an awful lot of protein that will increase the protein creatinine ratio and that will indicate that you've got significant proteinuria. So they and the placental growth factor thing will be that if their, if their levels are below the fifth centile for the population, then that puts them at much more risk of developing preeclampsia. Ok. Um I hope you're all still with me. Um One of the things, so this is about diagnosing preeclampsia, um diagnosing it and then managing it. So huge amounts of effort are put into screening for preeclampsia and at every visit to an antenatal clinic, a woman will probably have her abdomen examined and assessed for the size of the baby. She'll have her BP checked and she'll have protein measured in her urine. So how do you decide if somebody, um how do you decide if somebody is hypertension hypertensive in pregnancy? So this is a question for everybody. And so I'd like you to tell me what some of the answers are in the uh in the chat if you can. So I'm, I just found the note from my wife and talk slowly. Uh So uh a woman, um a woman presents uh at 10 weeks pregnant when her BP is 100/60. Ok. Now you the doctor then don't see her again until she's 28 weeks. I'd like to know uh weather, whether you think uh any one of these three blood tests represents hypertension. So I'm going to tell you some numbers now in a moment. Um ok, so there are three blood blood te BP levels. So her BP booking was 100/60. So uh if her BP is 100 and 50/100 is she hypertensive now at 28 weeks? Uh So yes or no. For a, if your BP for B is 1 30/80. Is she hypertensive? Yes or no. And for c her BP is 1 20/90. Is she hypertensive? Yes or no. If you Yeah, I was going to say if you could write a yes B no or however you want to do it, that'd be great. Yeah, I think that would be the best way if you could. Yeah, I think we've got to make that easy. I think we've got yeses for A, I think we've got nos for B perfect and I've got a, I've got one. No, for C Beano S No. Yeah. So I think general consensus is yes for A and B no and Sino. Mm OK. Let's look at the next slide. So look at the, look at the top line of the slide. Now consider your answers and we want to vote again. I was gonna say to David, do you want them to vote again? Yeah. Yeah. Ok. The fact that you're questioning their answers kind of makes me think. Well, maybe that would suggest something, wouldn't it? Ok. I still got C and B as a know. Hm. Ok. So let's look at that then. So, um, the first, the first line of this slide says a lot of out the screening protein and BP. So if the BP is over 100 and 40/90 or 30/15 of the booking BP, so 100 and 50/100 is definitely hypertensive. I think everybody said that both times. Yes, I did. Yes, they did. OK. 100 and 30/80 is 30/20 above her booking BP. I would say that's hypertensive Joshua's asked if we could, if you could repeat the scenario again and the options. Uh OK. So the scenario was at booking her BP was 100/60. And then at 28 weeks, it was one of the three numbers, 100 and 50/100. Everybody agreed that was hypertensive. 100 and 30/80. Everybody said that was not hypertensive. I would disagree. I think that that's 30/20 compared to her booking BP, that's probably hypertensive and you should be watching that. The last one is a bit more difficult because it's 20 over 30 of the uh booking BP. So 100 and 20/90 compared to 100/60. And, and that one is, doesn't fall into an obvious A or B category as it were, it's not dead obvious. But I think that given, you know, given the fact that her diastolic BP is 90 her diastolic at booking was 60 I think that would be quite risky and I'd want to keep an eye on her, but she would not be categorized as being hypertensive is that, does anybody anybody want to put in the chat? I don't understand that and we'll come back to that at the end or do you all understand it now? Or do you all think that I'm not talking nonsense? Maybe it is the better way to put it. You've silenced them, David ah clearer now. William says perfect. I like William Isabel says we understand. So I think we're ok. Ok. So I mean it it's just um it's just one of those things that so we need to be so even like her BP at booking might have been really low. And it's also important to know that in the second trimester, in all women in pregnancy, whatever your BP was at booking in the first trimester. If that's when you came in the second trimester, it will be lower and then it will start to come back up to to normal initially and then maybe even a little bit more higher than it was at booking. And that's normal so that it, it drops in the second trimester because the, the blood flow, the blood vessels are increasing in number and uh as the placenta develops, so there's a much greater space for the blood to be going around. So the pressure drops, but then as it gets to be a bigger baby and requiring more pressure to get things going, the BP starts to come back up again and may be normal or may become above normal. And then we've got to decide how much above normal but the booking, sorry, the booking BP is really important. Ok. So we will, we will screen for it. We will try to categorize people into being at risk of preeclampsia or not. If she's hypertensive, we will give her uh suitable antihypertensives. Um We will not give her ace inhibitors like Ramipril. We will give her Nifedipine. Uh we will, which is a vasodilator. We will give her methyldopa which affects uh receptors for blood vessels in the um uh alpha receptors and blocks them. Um Sometimes I have to forget, I have to remember the stuff from thousands of years ago, we will do blood tests like checking her urea, her creatinine uric acid platelets, hemoglobin, liver function tests because those are the first indicators if they begin to go abnormally. If they become abnormal, those are the first indicators that will tell us that she's developing a problem. We will look carefully at the baby. We will do fetal movements, we will check for growth, intrauterine growth retardation. We will check for the baby's growth. The baby's growing normally, that's great. If the baby stops growing or begins to slow in its growth, we will be more alert. Uh We will do sometimes twice, uh two or three times a week or sometimes even daily, which is a real pain. If you live far from the hospital daily, cardiotocographs, um 20 minute measurements of the baby's heartbeat, looking at its variability uh and so on to, to watch for any signs of ill health in the baby. And then we will deliver the woman depending on her symptoms, how bad they are, how much of an impairment there is in the baby, how much risk there is to the baby and how much risk there is to her. And that will depend on her BP, on the health of the baby and on her biochemistry for her renal function and her liver function. If all those things are normal and her hemoglobin is normal and her platelets are normal, then you won't be rushing. If they are very abnormal, then you will be rushing. Um and you, you may want to deliver her normally by vaginal delivery or you may want to do it by Cesarean section. Uh because maybe she's too early to try to attempt vaginal delivery. So the antihypertensives are the safe ones to use are methyldopa, Nifedipine. Um not beta blockers, not diuretics and not ace inhibitors. So the beta blockers are, are less good because they um cause problems. They, they drop the BP too much and that will affect the baby. Calcium antagonists are ok to use a Nifedipine and that acts directly to be vasodilatory. So does hydrALAZINE, but hydrALAZINE is a very uh quickly acting drug. So if you gave somebody some hydrALAZINE, if I gave an injection of hydrALAZINE to sue now, in half an hour, she'd be on the floor. She would be, she would fall on the floor and faint because her BP would have fallen so much and she would need to re equilibrate her BP. I don't plan to do it. So you'll be glad to know you're 400 miles away. You're quite safe. Diuretic diuretics are not safe to give because you do not want to drain her intravascular volume anymore. And ace inhibitors are teratogenic. OK. So uh this slide picks out this is from the nice document at the beginning, but it just talks about management depending on slightly raised BP to severely raise BP and then the things you would do that might be different. So in the most severe situation, you'd be looking at blood counts three times a week, fetal heart listening every time CTG S uh cardiotocographs, maybe as time goes on ultrasound, maybe every two weeks. If it's growing well, that'll be fine. If it's not going well, then maybe you need to do not ultrasound because it won't change. But you need to do other markers of fetal wellbeing. Cardiotocographs are more immediate and also blood flow measurements in different parts of the fetus, like the umbilicus, like it's middle cerebral artery, things like that. Ok. Here's, here's a not a case, 28 year old woman in her first pregnancy, 26 weeks presents to a midwife with lower um leg edema can't get on her shoes because her feet are swollen. Her rings are tight. Her BP is 1 35/85 and at booking it was 100/60. So I hope now you would all agree that she, although her BP is not over 1 40/90 she's hypertensive compared to her booking BP. Yeah, I hope uh she checks the woman's urine and notices that there's protein and she's 26 weeks. Gestation. The fungus is at 26 centimeters. That's pretty much what it should be. The fetal heart is 100 and 30 the baby's moving well, so what should the woman do? Well, you've got some answers there in green bed. Rest stop work if she will. Um Think about giving her a, an antihypertensive. One of the ones we've just looked at here, Methyldopa, Nifedipine or hydrALAZINE sent her to the hospital to be seen and assessed and then advise her about the symptoms. So if her symptoms are, um, going to get worse, if she, um, if she gets more swollen, if she gets a headache, those sorts of things, she needs to, first of all, then get in touch with the midwife. And then secondly, after that, she needs to, um, she needs to alert the woman to see somebody quickly. Ok. So thresholds for considering planned early birth, um if you can't control her BP, if you're using three different types of hyper antihypertensive in the right doses and you can't control her BP, then you need to think about delivering her. If her pulse oximetry, if her, the oxygen levels in her blood are less than 90% of normal, then again, you should be thinking about delivering her. That would be pretty serious. It's almost impossible for a healthy person to drop their pulse oximetry level below about 96. Um I tried to do it once when I was operating one day and I was bored uh between cases and I put the pulse oximeter on my finger. Um and it was 99 or 100 and I held my breath for a minute and a half. And by the end of the time I was bursting, but my pulse, my, my po two was still only at 96. So to get down to 90 does mean there's a major drop in the amount of oxygen coming in. That's, that's a big drop in oxygen levels. Clearly, if she's developing deterioration in liver or kidney or blood levels, if she's getting neurological symptoms, headache, um spots in front of her eyes. So that word visual scotomata is a posh medical word for flashing lights in front of your eyes or if she's had eclampsia. So she's had a fit. Um if she's developed an abruption of the placenta where uh there's abdomen, abdominal pain and there appears to be a hemorrhage behind the placenta. That's a very strong indication for delivery because that means the placenta is at risk of simply pulling away completely and then the baby will die. And also if you're doing blood flow measurements on the umbilicus, um and the blood flow measurements show that when the baby's heartbeat isn't working, that the flow is reversing. That's a very bad sign. Or if the cardiotocograph is flat and non responsive, that's a very bad sign. And clearly, if the baby is dead, that's, well, that's the, that's the worst of, of all, of course, but if the baby is dead, you will then probably not want to do a Cesarean section uh because you will be putting a scar on her uterus uh from the point and from for further pregnancy, she will have a scarred uterus and no baby to show for it and be more at risk of all the problems of ruptured uterus in the future. So you will then try to deliver her vaginally. But before that, you would do anything to get her delivered if you could and don't forget steroids for long maturity. So if you're delivering her at 36 weeks or anything before that, you should probably give her um some corticosteroids in divided doses. The amounts vary somewhat depending on which you're using. Uh, just look them up. Dr Google will tell you if you don't know, um and look them up and give them to her 12 hours apart. Ideally before you deliver her. So these are the things to be very aware of in terms of management. So, being aware of the risk of clotting, uh being aware of the risk of convulsions, the the the hyperreflexia, the increased um reflection in her reflexes, the increased tension in her reflexes in the ankles and the knees. Um If her BP is uncontrollable, that's risky for her because it can cause a bleed in her brain watching for hydration and renal damage. So you want to make sure there's enough blood flow going around that the kidneys don't suffer um renal damage. And obviously, from the point of your fetus, you want to make sure the fetus is as well as it can be or if it shows signs of deteriorating, that's when you would want to think about delivering. So particularly with regard to clotting, if the platelet count falls below 100 and 50,000 micro per microliter. Then that would be an indication that there's a risk of clotting uh for convulsions. If she starts to become hyperreflexic, you'd start her on magnesium sulfate in that dose and watch out for side effects. So side effects will be respiratory depression, particularly if she has uncontrollable hypertension, you would use hydrALAZINE, which you need to be very careful with in small boluses because it is so dramatic in its effect that you would drop her BP very quickly, which again, you don't want to drop her BP completely. You want to bring it down to a safe level but not to get it down to 140/90 even because that might be too low for her and she will then stop perfusing. Uh And again, for hydration, you'd use colloids, not crystal lights and you'd want to be having, you'd want a central venous pressure lining. You'll need an an this probably to help you to do that to watch for CVP and make sure you're maintaining that. And from the point of view of the fetus watching for growth amounts of likewise growth blood flow in the umbilicus. And if she's below 3034 weeks, give steroids. So she's been, if she's had a baby in the past with eclampsia or preeclampsia, then she should take aspirin for from 12 weeks on. And the risk factors would be never having had a pregnancy being over 40 it been more than 10 years since her last pregnancy being obese, 35 kg per meter squared or more a family history of preeclampsia and a twin or triplet pregnancy or more in the UK. It's not licensed for this indication. You're not supposed to give it, but it, there is evidence that it works. And if you do what you need to tell the woman, we would need to tell the woman in the UK that there is a risk from giving this. But actually the benefits are to reduce your chance of SIA you need to be able to communicate the risks of all these things to the mother uh to be able to show her. Let's just see what this thing says. Always a risk to go off and do this when you're uh so the risks of early complications. So this is an interesting table you can use. Can you all see that? Can you see it too? See um uh your hypertension convulsions, renal function brain? Yep. Well, can you see a slide that now or maybe we've lost the slide? But can you see something that says at the top risk of complication and early onset preeclampsia? No, no. OK. Uh Right. My one says, communicate the risks. And so II clicked on the link at the top and if you, if you go on that link, what you will find is that you go to a slide that says uh maybe I can. So it tells you how you can calculate her risk for preeclampsia. There's a risk calculator which is fine. So go to that link when you get, uh when we finish and have a look at it, it's worth looking at because you can then get some indicators of what her risk would be, which will be useful to you and her management. Now, are, are you, are you back with me on the risk factor where we know I've lost my uh OK. Uh What can you see now uh communicate the risks and implications. We're back on that one. OK. Right here. Um So from the patient's point of view, she needs to be aware of, of things like this, the high BP, the convulsions, the symptoms of the liver function, like the, the the abdominal pain, the confusion, all those things watching for the baby's movements and so on. One of the things about this is you, you need to impart these risks but not scare her as it were you want to imply the risk but not make her life feel that she can't go from day to day because she's so afraid she has to watch for the baby's movements all day every day. And it's trying to find a fine line between making her aware of the risks, but also saying, but you have to live your life every day. You know, you have to go, you have to go shopping you have to go and uh make the food or whatever. So it's kind of trying to find the, the balance between those two things. Other people, you're going to have to work with other teams will be things like people in the labor ward, the anesthetist who you're going to need to work with. If you're going to be delivering her a blood bank for uh fresh f and plasma and platelets, particularly I put down here avoiding whole blood and I put, why? So I'd just like you to think about why you wouldn't give her whole blood if she was uh having quite severe preeclampsia with her BP being high. Um and signs of renal dysfunction, signs of liver dysfunction. Why would you not give her whole blood? Because that might be healthier. You might think uh anybody want to put some suggestions in the chat as to why you wouldn't give her whole blood risk for embolism worsen hypertension. Yeah. Oh cos put in a, a long word, hypercoaguable state. Yeah, from volume overload. That's the one I would be most worried about the volume overload. So you would, I, you would want to give her um colloid uh um replacement but not um whole blood because you're going to give her extra fluid that she doesn't need. If you give her whole blood, what she needs are the cells, the platelets, the proteins, the clotting factors, but not the extra fluid. So, blood blood normally is about 65% fluid, 45% cellular material. And that's what she needs. Not the extra 65% fluid. So, I would be more inclined to say, uh to give her, um, concentrated cells rather than whole blood. And, and you take much more control of the flu replacement. Clearly, laboratory support for all those tests you're going to be doing and uh it will be, you know, it's great. If you have somebody in the lab, you can phone up and say, what do you think of those tests? What do you think of those results? Do you think we ought to act on them, you know, in your experience of seeing these before? Because if you're there, the, the lab person will have been there this year, last year, the year before the year before that, maybe they will be in the hospital a lot longer than you. They may know an awful lot more about this condition than you do really? So, it's really smart, I think to depend on them for their advice as well as all the other people around you. Ok. So I think so these are the learning objectives. I put up first of all and we have in a fairly long winded way maybe, but we have tried to cover them all and I think we have gotten to the end of what we want to talk about. Uh, now. So these are my questions which I think you have. So I'm going to go back from that. Oops, oops be gone this way. OK. So I'm going to essential and stop sharing. It should be coming back. Perfect. Yeah, I can see you. OK, great. So well done. So I don't want to pick on people but you know several people said volume overload, hypervolemia, hypervolemia. Yeah, risk of volume overload, I think, you know, those are all good answers and you saw what the, what the risk was. Uh Yeah, good. OK, so, so you've got some questions now uh to put up uh for people to have a look at. That's the first one. Oops, I've lost it. So sorry. Oh, it's, it's here. Ok. So a 39 year old woman is 32 weeks pregnant in her first pregnancy, history of hypertension. Her medication was changed to methyldopa before pregnancy. BP is controlled. No proteinuria baby is growing well, no symptoms suggest the one most likely diagnosis or calcification of the clinical findings. OK? You've got oh varied answers. OK. So let's look at this. So um thankfully, we don't know who put these up. So it's all anonymous, which is great. So I can talk about them and people won't feel hurt. Um So I would say that in this situation, the most likely answer is normal pregnancy. She was hypertensive before pregnancy. She's on methyldopa. It's well controlled. She has no hypertension at the moment. So the people who wrote chronic hypertension um are almost as correct. Um But she doesn't have hypertension at the moment because her BP is, is normal. She doesn't have pregnancy induced hypertension because she's not hypertensive. She doesn't have preeclampsia because there's no proteinuria and she has no symptoms and the baby is well grown. So remember the preeclampsia was hypertension with symptoms, maternal evidence or fetal evidence if I remember rightly in that slide lots way back. So she has none of the signs or doesn't fit any category of preeclampsia and she doesn't have eclampsia because eclampsia is the lightning fits associated with preeclampsia. So for those of you who wrote B or E I think, you know, I would need to, I would need to have written the question better for you to be distinguishing what her real category was. That's a bad question on my part. Um because she does have hypertension, she will have hypertension after she finishes the baby. So II thought this was normal, which is why I be inclined to say that. But I think also from the point of view of other things that say that you've got chronic hypertension is probably also an adequate response so well done. OK. Can we, can we go on to the next one? OK. Here we are. So I'll let you read that. OK. Right. So a young woman uh in her first pregnancy is referred to the clinic. She's 1st, 1st visit. Uh fit and well, BP today, 100/60 and seen by the midwife she had a headache and some nausea, booking BP was 100/60 BP. Today is 1 60/100. So therefore, she is by definition, she is hypertensive already. So which of these is the most likely to support a diagnosis of preeclampsia. So remember that it's hypertension plus maternal signs, uh blood signs, proteinuria and fetal abnormalities. So, II think that in this situation, what, what are we going to, how are we going to categorize this? Um So that's not enough to say preeclampsia. Uh This is not enough edema. So um some people said edema, some people, most people uh said, so actually let me just remind myself, I think that number of uh let me go back up here to protein. So it's more than 0.3 g for 24 hours, but that's outdated. But 0.5 so 0.5 would support diagnosis of preeclampsia and three pluses of protein and urine testing would certainly support that. So, uh A B and E are the most likely to support that diagnosis. Um If you only had, if you only had one to choose, I would probably have chosen e because this, this is now uh out of fashion and less considered, less reliable as an investigation and and and more messy because to do that, you have to take 24 hours worth of collection of urine and then measure the amount of protein in the urine and that's unreliable because if a woman's doing it at home, she may often go to the toilet and not collect that bit of urine and whatever. So I think three plus the protein will be the biggest one. So seeing things in a yellow light now that's uh whoever put that down, one person probably said yes to that. That's a um that's an interesting answer because that's that plus headaches and other things indicate cerebral cerebra, cerebral uh involvement uh of the preeclampsia. Um And therefore, I think that d would be relevant here, edema. Uh If it was significant edema in the fingers or pretibial, I would agree also with that. Uh Isabel has said pre treated preeclampsia would also be correct. So, yes. Uh So you mean if she uh had hypertension that was being treated? Yeah. Uh Let me think about that. So if she had, if this was her second visit with her BP, 100 and 60/100 and she, so if her, her BP, the second time visit was still 100 and 60/100 on Nifedipine or methyldopa and she has one plus of protein. Um I II, you, you might admit her for admission, but you probably wouldn't say that she was preeclampsia because of that. You need, you need to have more than just the BP to say that she's got preeclampsia. So some, some signs, some blood involvement or some fetal involvement as it were to indicate that, does that make sense? You know, right in the chat if you want further discussion. And meanwhile, so maybe we go on to the next question of the last one. I think there's one more. OK. So, mm commit yourselves. OK. I think that's everybody because that's 99% of people. I suspect that means everybody Uh 92 and seven now. OK. People are changing their mind. Fair enough. Um So let's have a look at this. She's 32. Uh when she booked her BP was 160 sorry, 1 20/60. Now it's 1 40/95. So by definition, she's hypertensive. Um her, her weight is 35 our, our BM I actually her, she is obese with a BMI of 35 not overweight. Um and uh her BP. So now she's hypertensive. Uh there's no protein or urine and she feels well. So no symptoms, no biochemical evidence, therefore, not preeclampsia. Um She was normal intensive. Her BP was normal at booking. So this is not chronic hypertension. Her BP has her BP had um sorry, my words aren't coming. Her BP has increased in pregnancy with no signs of preeclampsia. So this is pregnancy induced hypertension, I think. And some of you have been flipping your votes around. So the 99% who first or the 90 something percent who said pregnancy induced hypertension have run away from that now, down to 72%. And you're all flipping to either normal pregnancy, which I don't think this is, you can say it's a normal pregnancy if her BP is 1 40/95 which by definition is hypertensive. So I would say a is the most correct answer here, the most likely classification of her clinical findings. Um feel free to disagree if you dare feel free to challenge me on that. If you want to think, why didn't I say normal pregnancy or whatever? What do you think? So, I do believe if we want to, I do believe there's a question in amongst all this. Um Do you want it? Do you want a question whilst we wait? 00 yeah, sure. Yeah. Uh Isabelle asked quite early on uh how do you prevent edema when you are not given diuretics? How do you prevent edema when you're not giving diuretics? Well, so edema is a sign of um all right uh of low protein in the blood, you can't prevent it and, and you don't really want to prevent it either because if you prevented it, then you'd be blocking one of the signs and one of the indicators of the severity of the illness. So I would say uh how would you prevent it? I would say you don't, I don't think you'd want to prevent it. Um because it's an important indicator of the worseness of it. So women who are very ill with preeclampsia, they will have digital finger edema, they have toes, they'll have abdominal edema, which you will, you will experience by listening to their abdomen with a Pinard stethoscope if you use those old fashioned methods, um I still have a Pinard stethoscope over my uh memory counter over there as well as a brain and uh some teeth that were from somebody. Um sorry and, and my pelvis here uh very important to have these reminders of your past. Um But you, if you listen with a pin or stethoscope, you will see a ring on the abdomen when you take it away because there's uh edema in the skin. You will see edema in the eye. If you look and with the ophthalmoscope, you will see edema around the, the, the retina in the papilla papilledema. Um And you will see edema in the liver because she'll have right upper quadrant pain. You can't take, I don't think you can take away that edema and I don't think you would want to take away that edema because in doing so, you will then be diminishing her intravascular volume by taking away the edema and giving her diuretic. You would diminish her intravascular volume even more because that's where the fluid is going to come from and you will then be making her even more hemo concentrated and that's not what you want to do because that will then increase her risk of being hypercoagulable and having a DVT. Does that make sense? Not to me? But I'm as well. It does. Um Joshua says, um and I don't know if this is relevant to a question that you put up. He says, um what about the management of atypical presentations of preeclampsia? So, uh I asked Joshua, I ask you give me an example of what you mean by an atypical presentation. Sorry. If you give me an example, I'll try to address it. And if anyone else has got any questions, pop them in the chat. Yeah, we are running over. So hopefully everyone's staying. So just what it says in relation to antihypertensive medication. So do you mean where the antihypertensive medications don't work? Joshua, I've invited you to stage if you can come on to the stage and ask a question you, you then please do but also feel free to writing in the, if you'd rather if you can do that. Sua Yeah, if you don't mind coming, sometimes it's just easier to say the question than to type it. Yeah, it's much quicker. Yeah. Whilst we're just waiting on Joshua, does anyone else have any questions? II think you've scared them off, David. Maybe. Sorry. Yeah, I hope that, you know, in, in terms of what I've said that, that they, you know, pre typical atypical presentations mean that things don't fit into a box neatly So sometimes you'll find that people are maybe normal tensive but have got disorders of their um renal function or, or liver function. I mean, I think the, the important thing to remember about preeclampsia as a disease is that it's not just about hypertension. It's a multi organ disease in the body which uh is caused by factors from the placenta. OK. Push out. Uh So you said eight weeks, eight weeks pregnant hypertension, sorry, BP. 100 and 30/80 past seven years ago, I had preeclampsia. Do we give aspirin? Um uh I would say, and if this is so Khel for this, if it's been seven years since the last pregnancy, I think probably the weight of giving the aspirin is probably not sufficiently strong. OK, Joshua's come back with a question. Um So Joshua, uh so Kusha, does that answer your question? I hope, I think I would probably not give aspirin in that situation. Um And the other thing I would do would be the phone, phone, some person who was far more expertise. There's always somebody in a country who is the most knowledgeable person on this in England. The woman who I would say is the most knowledgeable person is a woman in London called Catherine Nelson Pear. And she's the guru, the, the, the high priestess if you like of medical problems in pregnancy and she's written textbooks on it and so on. And I think she'd be the person who I would ring and say so, what would you do here? Uh Or I would talk to my expert in my own hospital. Um But I would, I'd be inclined to say no in that situation. Uh Joshua says, OK, I want to know about any hypertensive medication involved. Say when preeclampsia comes for 20 weeks. Now, let's just say that's a, quite a, that, that's a good thing because you're picking on an unusual situation. So if somebody presented with hypertension, proteinuria, et cetera, before 20 weeks, the things that should be going to your mind are why and then what to do about it. So, the potential reasons for this might be that she's got a multiple pregnancy, the more worrying reason might be that she's got a molar pregnancy uh where there's a large placental mass and no baby. Uh And you would need to manage that aggressively by evacuation of the uterus. Uh or she may have some other endocrine disorder that's making this happen. Um So, uh it's, I think that in that situation um before 20 weeks, I would, then I would, if she was hypertensive, I would start either methyldopa, a simple drug to take dead easy, will work and then try that. And if that doesn't work, add on top of it, Nifedipine uh to see where you go on and then ultimately much more strong things like hydrALAZINE if necessary. Um William says, uh if patients have peptic ulcer disease or asthma, what conditions? So you could give them, you could give them aspirin, but uh you could have it and carry it coated so that it goes down to the lower inters tract and avoids the peptic ulcer with regard to asthma. Um, you, you might say, I mean, it's a question then a risk, isn't it? Are you more at risk of giving her an asthmatic attack or giving her risk preventing her having preeclampsia and it, you know, and the balance of risk will be, which one do you decide to go for? I would discuss that with the patient. I would say if we give you aspirin, it may give you an asthmatic attack. If it does, then we'll take you off it and try something different other ways to try to maintain your risk being lower. But if, if it doesn't give you an asthmatic attack, then I think I would keep going with it and do that with her knowledge and her understanding that this is, you know, these, these areas are um individualized and often complex and difficult and you, there's no one rule that's going to fit any of these. So, enteric aspirin might enteric coated aspirin might work for peptic ulcer. It will not work for asthma, but I think you should still maybe give a trial of it and see what happens. That would be my thought. Joshua says, especially since now, is this a continuation of your question? Studies show that an ace inhibitors are not necessarily contra the first, they're not contraindicated, but they are teratogenic still. And that hasn't changed. So I would be inclined to do something. I wouldn't use an ace inhibitor. I would use one of the older safer ones because they're safer. Uh Hansa says, do you approve the systematic use of aspirin in patients with preeclampsia? No, I wouldn't approve the systematic use of anything uh with preeclampsia because every patient is different. Um But if you have a strong risk of so, aspirin is not about treating preeclampsia. Aspirin is about preventing preeclampsia. And therefore, uh you would want to think about how much you would uh how much you would want to give it in that situation. But if she's already got preeclampsia, then I would not use it because it's pointless. You, you can't prevent it then and you said in which dose. So I would not use it systematically or routinely. I would use it if she's got risk factors and if she is willing to take it, uh and I would say 75 to 100 mgs depending on her BMI or her weight. If she's under 100 kg, I'd use 75 Williams says risk and benefit. Yeah, exactly. You know, life's, life's not A plus B equals C. Life's A plus B could be ABCD or E sometimes OK. Those are great questions guys. And I II love the fact that you're responding to me like that. It, it shows you've engaged with the topic and I'm really enjoying it. I gave another lecture in another country. Er, on Tuesday, er, on the physiology of pregnancy. Er, not a very exciting topic maybe, but there were no questions and I thought, oh, that's terrible. Whereas I love all these questions. Ok. They keep you on your toes, don't they? Oh, that's the whole point just as long as we don't ignore protocol. As long as that's not what we do. Oh, yeah. Protocols. Yeah. Yeah, we all know what we should do about protocols and so no systematic use. No protocols. No, I'm not keen on systematic approaches to anything or protocols you probably pick that up by. Yeah, I can't box you in, can we? Well, you can if you, if you want to but you won't be able to. Brilliant. Well, I don't think we've got any more questions. Um OK. Thank you all for your thank you. Yeah, they're all coming through. Uh We do have some medal education events this weekend. Hopefully, if you're following medal, you would have received an invite. Um Otherwise you can catch it on metal, you can just go to metal and you'll see it there. David's going to take a quick call. Um We've got ophthalmology, we've got a six part course of that if you're interested in it. And we've also got conquering breast cancer by all means, we're just about finished, please fill out your feedback form between three minutes. He seems like he might, so please fill out the feedback form and I'll pass that all on to David. And once you fill out your attendance certificate will be on your medal account. Are we going to have the presentation slides? Will you have a recording? We have a recording. Yes. So you can see them on the recording if that's ok. Perfect. That's it. I'm going to stop the call now. Ok. So will I Miss Miss Miss, will I get a certificate? Yes. You may have a certificate. Yes. For everything you're teaching. I will send it. It'll be on your medal account. Ok. Thanks. Miss, as with everyone else's. So yours will say teaching? Thanks, Miss. Ok. Take care of yourself. All right. Take care.