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Thank you. Um, C As I was saying, I'm gonna be talking about uncomplicated bath, um, changes after extending really in pain relief and lab tests. The B two abnormalities. Okay, first of all, um, I wanted to talk about stages of labor. So during stage one, this includes everything from the start of labor to before the babies is delivered. Stage two is the actual delivery of the baby. And then stage three is what comes next as the mother delivers the percenter. Okay. And now, just to look at that in a bit more detail, um, stayed. One can then be divided into three more stages, the first being forced labor. Now, this occurs in the last eight weeks of pregnancy where you get contractions. But no dilation of your cervix on these contractions might be described as fake. Um, on there, Braxton Hicks, contractions. And he's just preparing your uterus for and the later phase of labor. Um, not during later phase. You get actual contractions. However, during the contractions, there's no dilation of your cervix and said instead you get cervical face mint on. This is when the baby's head will press against the cervix. So if you look at the second image down, um, you see that the uterus expands and the boost then, but the actress cervix doesn't on dilate. Um, on. This is this is why described the Safeco a basement, and then after this, the uterus can thin anymore. And you get actual dilation during the active phase on. And this is I guess you described as full active labor. Now, his diagram of the babies had just to explain that been more so you can stay, See, the babies had pushes down on the cervix, and that causes this thinning that was describing. And then when he can't think anymore, you get the dilation, and then this leads onto the second stage of labor, which is the delivery of the baby. Okay, now, this is a new monitor that I used, but I know there's lots of different ones out there on it describes the different stages of labor. Now I like to think of it, um, in more simple terms, that delivery involves rotation of the baby in order to get into the best position to exit the womb. So as you can see the baby's head for Tates, Um as the head is delivered on D. That means that the, um, the baby's head's perpendicular to the mothers hips. And then, once the heads delivered that, there's then external rotation to get the baby shoulders perpendicular to mothers hips. Teo allow the delivery of the baby and most easiest form. So the new monitor is Does equally funding in cars ever result in everlasting love? The bit silly, But I find it works. Onda verifies to dissent, engagement, flexion, internal rotation, crowning extension, restitution, internal rotation of shoulders, external rotation of shoulders and then lateral flexion on the position of the head comparison pregnancies on it makes liver ease. I don't know, easier or harder. So, um, if you look at the sub occipital pragmatic position, this is going from the center of the baby's head over. Uh, yeah, the Boston of the babies had where meets the back of the neck on This is only 9.5 centimeters. Um, in distance on this is the shortest possible distance that the baby's head could be delivered, making it easiest how that if you look at the perpendicular to that, you get 13.5 centimeters and this is the first came mental, which makes the baby's delivery a lot harder on. The mother would be more prone to tears on, as you might know, the bones, the baby's skull and not fused together. Birth, um, on the spaces in between, because could Fontana's on. These fontinalis can close as the baby's head's delivered, meaning that delivery could be easier as the baby's head's literally compressed. Now talking about the third stage of labor, this is the delivery of the percenter. And on after birth, the nutrition continues to contract Teo Liver the center, um, to get out the out of the mother's uterus. However, the placenta is a very large blood supply, and this means there's a high risk of bleeding after pregnancy on. But this is good postpartum hemorrhage, because on this can occur for most people. Most of reasons main cause is it a a Tonia Um, when there's a lack of constriction of the Spiro arteries within the uterus? Uh huh. On this, Can I have the BG T uterus being overstretched? So if you've had multiple pregnancies, you have a large baby that it might be hard to constrict this by a lotteries to stop any blood flow I'm believing. Um, another reason is the uterus might be tired. So if you have a very long labor, um, or the mothers given oxidation oxytocin to stimulate contractions, then the uterus can actually be tired and then unable to contract forcefully enough to close the spiral arteries. And then the third main cause of postpartum hemorrhage is a C section. So after a C section, there's actual mechanical damage to the to the uterus, which can cause bleeding. Now there's many more reasons than this, but these are the main three I wanted to mention. Okay, now moving on to our first SBA, I said. So Face is described as being a GTP Teo Mother on is currently in labor. She has read that some head positions can cause harm to the baby due to the large diameter. Katie, the midwife reassures favor. The baby is an optimal position. What is the position of the baby's head? So is that a sub occipital bag Matic be cemented Bag Matic See occipitofrontal. The first came in to for a sub temporary break matter. I'll give you, um, a minute sponsor days. Okay, so it looks like most of you choosing a on that would be correct. So just going back to that slide that on by cost on out here, um, you can see submental bag Matic is a smallest, um, length of the baby skull has to be delivered to that for the the easiest on. Um, then, like I said, first came mental is the opposite of that. Okay. And then some of you might accept it from to now. This is short how that is not the optimal position. So it is not the single best answer this question. Okay, now, pain during labor. So contractions start within the uterus. So you begin by kept getting pain from the level of t one t o l. One during pre labor and stage one. Um now a nice way to remember the the spinal levels for May is t 10 Sounds a little bit like belly button. So t 10 is the level of your belly button. And it's below here that you get paying during pre libre on the stage. One of a burn. Um, okay, then during stage two, you get vaginal distention as the baby's head exits the vagina on this area's innovated by the pudendal nerve. So that's S two s for on. Um, you got pain. Here is the babies had me use through the spinal canal, and you also get contractions, which cause reduced blood flow, and you actually get is an ischemic pain. Um, like, three words, um, from, like getting a stitch. And then during the delivery of the center, you get very little pain pain relief. Say they're three main types of put in here and knocks, uh, pethidine an F zero. So enter Knox is just gas in there and it's a 50 50 split of nights when oxide toe oxygen on blocks. Pain centers in the blood brain. Many mothers have put on this in pregnancy on during birth. Sorry, because it's short term on it doesn't affect the fetus. And it's easy for the mother to control as they decide when they want to breathe. Now, pethidine, you could describe it. The level up from this so other Dean is an opiate on. It's an injection into the mother. Um, it takes 2 to 4 hours to wear off on. Do, um, it's not as good as epidural, but it does allow um, more sensation to be given to the mother so they can experience birth more naturally, he might say, but it does cross the center so it can cause respiratory depression on D impaired feeding of the baby. Yeah. Um, at the jurors, on the other hand, did not cross the percenter on this is an injection, um, next door to the spinal column on Where's your heart? Two hours. But you get total pain relief so on. The mother feels next to no pain from the pregnancy, but she can feel the pressure from the contractions, but not the contractions themselves. On here is an image off and at your oh, so on the injections given into the epidural space on for that you have to insert a needle past several responding ligaments on an Apidra. Was given, um, at the level of L2 L3. Now, this is to avoid the spinal cord because the spinal cord stops just above all. Turn our three at elbow borns that out. Um, so in order to not damaged spinal cord, the injections given below one analogy Okay, No physical or physiological adaptations in on after bath. Okay, So after the baby's born on. It'll take its first breath on normally in the uterus. The baby is not breathing, so there's no oxygen in the lungs. On when there's no oxygen, you get high pox. It pulmonary basic constriction. This is bad. The, um, promoter IV s. It was constrict. So there's no blood flow to your lungs in the baby other soon as they take that first breath than blood enters the lungs on that excess into the left atrium. And this will increase the pressure in the left atrium, causing the closure off the foreman of Arliss to form the faucet valet, Um, and then on. You also have the doctors arteriosus, which passes blood from the, um right from there by age for the right ventricle into the um, aorta. However, bradykinin is released on after birth, which causes this to close. So, you know longer get the blood bypassing the lungs. And you also get blood clots after several days, which would plays there, um, biblical vein on the doctor's phone, isis, and then finally decreased. Proposed it. Landon's after birth causes closer Teo the umbilical arteries. Okay. Uh huh. Lab test for future abnormalities. Say during pregnancy, you can get a screening tests, which, um, give you a relative risk. Score that your baby will have a feet or abnormality such a Z dancing dream, potatoes or address and drink on. Based on your risk score, you might then decide to have another test. It might be more invasive. Say, um, if it's your screening tests comes back as high risk, then you can have CVS um, which is chorionic for the something where UM, themselves from the placenta, is moved from the baby by taking them out through the mother's abdomen. And then these are genetically tested Teo, Um, see if the baby has a fetal abnormality to the chromosomes on. I'm nursing teases because in a similar way, however, the cells are taken from amniotic fluid. Both of these procedures similar in the sense they have a risk of miscarriage. Um, however, you could argue CVS is slightly better because it's performed earlier. However, it does have a slightly high risk of miscarriage. On the flip side, you can get nipped on I PTO non invasive pre natal testing on, and this is when you take a blood test from the from the mother on within the blood. There's a small number of fragments of the baby small number of baby DNA fragments, which has gone into the maternal circulation on by looking at the fragments from the baby's DNA within the maternal blood, you can see if the baby has a chromosome abnormality without performing an invasive procedure. Now this is great. Apart from is expensive, however, we simply just from this year it's offered, um, the NHS for high risk pregnancies. Um, high risk over fetal abnormalities, tires. So I mentioned these screening tests. The um screening tests that most people have is cooled. The combined screening test on this is performed between 10 and 14 weeks, say, between 10 and 14 weeks. If that comes back positive, you have either CVS, so I'm nice and pieces on. There's another test called the Quote Report test. However, the quote report test is given after 15 weeks. So if you have the quadruple test on, but it's high risk, you can't then have CVS. CVS is only delivered between 11 13 weeks. Um, and that's the main reason that people choose to have the combined test instead of a quarter report test because it still allows them to have CVS. Whereas if pregnancy is the detective later, you might be forced. Have quadruple test. In which case, um, you then have to have, um, Nucynta PSAs about for him from this year, you can have nipped. Okay, Another SBA. You're about performing at the jurors on a women entering labor on who is an extreme pain. What ligaments we have to go through in order to give the injection. Is that a the posterior spinal ligament on the interspinous ligament Said they super spinous ligament interspinous ligament on ligament flavor. See anterior longer change, a ligament or a ligament in flavor, the anterior longer change or a ligament ligament. Um, And in spite of ligament on ligament ligamentum flavum or is it a secret spinous on a ligament and flavor. Okay, so I didn't actually say this in the talk. It was just in the image. Uh, you, uh, mostly correct by saying the answer is B is the six months ligament on, um, interest Linus and ligament in favor. That's get that back to that slide so you can see it goes through the supraspinatus into spinous. A ligament of flavor it's Yeah. Okay. On that. Concludes my part. The presentation will be releasing the for your back for me at the end after Sahara gives her birthday her part Electric. Enjoy. Thank you, Toviaz. That was really great. I'll pull straight over to someone mazing. Thank you. Told me that was very comprehensive. Very, very nice piece of revision for myself. So I'm gonna be covering breast and physiological changes in pregnancy. And if time allows, I have a bit of like clinical conditions at the end that you probably might come up with a PT that you don't have to know if you're too. But I thought because PT's coming up soon, some people might wanna look at some clinical stuff. Briefly. So we have time. We'll go over that. So sexually end to see we have time for that. If not, I'll send these lines anyway. You have a copy of those notes? Cool. I'm just showing my screen. Okay. Okay. Amazing. My Katie, my screen. Yep. Good. Okay. Amazing how everyone for those who don't know me my name Salad. Sorry. Um, Andi, um, I'm in the same year as Megan Toby on, but I'm very excited to be giving this lecture today. I'm going to send in a lot of time on breast and breastfeeding and lactation on. Then we'll move on the basics of hematology because I think you're introduced a human collagen, um, around this time and also changes of pregnancy physiologically cool. So if we start talking about the breasts, their pad structures, which means you have two of them and that meant to be identical, and they're at the level of your second year sixth ribs. The main function is lack station in the production of breast milk, but also they can be involved in sexual arousal. Each breast is divided into 10 to 20 lobes each of the lo. These lobes are then divided into lobules, which then divided into acid I, and we'll get to that eventually. Um, the main thing about breasts on this is really relevant. Many breast conditions most best conditions that you'll see is that it responds heavily to hormones. So your home is like estrogen and progesterone have a really profound effect on the growth of the changes that occur in your breasts, and you should really keep that in mind any time. Looking at any breast condition, and usually so we look at the anatomy of the breast. This is a transfer section off a breast. If we start from the most interior structure you have the nipple and the nipple. Around the nipple is the area, which is the pigmented section, which usually has Montgomery, too, because that are these basically a little like vesicles off sebaceous containing sebaceous fluids, which keeps the nipple moist on Diz. Actually, antiseptic in itself is, well, the back. The most posterior bit of a breast is where the breast rest on your pectorals. Major muscle. So usually, if you go to breast surgery and you see a mastectomy, whether cutting off of breast, you'll be able to see the remains. What remains the back is the Pectoralis major muscle. I started surgery simply. It was very cool, so I thought I'd mention it. Also, it's a very important anatomical landmark because, for example, when someone's having a mammogram, um, you want to be able to see whether that any to moment Mets if they have breast cancer that are sticking to the pectoralis major muscle because the prognosis for breast cancer differs based on where the lump is, um, from the nipple. Basically, what happens is a lot of these activities ducks or milk duct drain ethnic people. So, as you can see, you have these lobules in these breasts and these lobules or where milk is produced and then ejected into each into many elected for stocks. And then these intervals ducks joined to become bigger and bigger to form one fine like difference. Ducks duct then drains out of the nipple. So, like I said, you have, um, 10 to 20 lobes within each breast. So, like a couple of these, a couple of these lobules and make up one lobe and within each lobule you have on the old eye on D's alveola are not similar too long. Galya like they kind of are. But they're not. Airfield then said they're filled with fluid things like colostrum or breast milk. Eventually and all the old eye are made of different types of a pretty Liam to produce milk and then to secrete milk. And we'll get to that eventually, um, most of the breast. So initially, when you're younger, a lot of your breast is glandular in tissue, and then as you get older. This deteriorates, and a lot of the glandular tissue is replaced by fatty tissue. Um, as you can see her, this breast, all the yellow lumpy. But it's their adipose, and you have lots of that in your breasts. Whether you're male or female on do this is clinically relevant, because when ah female is having a mammogram when a female is being screened for breast cancer, if she's over the age of 40 she will have a mammogram. If she's under the age of 40 she have an ultrasound. And this is because on a mammogram for a younger female, all the glands, that issue is going to block any lumps any malignant or benign lumps on day, whereas all the women mostly just have fat. So it's a lot easier to visualize lumps and a mammogram. And I older women as compared to younger women, that's why that's important. And then you have a coupon ligament. So Cooper ligaments essentially kind of what? Keep your breasts up. There are help to suspend your breasts on the chest wall. On the essentially just a strong band effect of connective tissue. Onda Century Just work to support the breasts and over time with wear and tear, they get more droopy on you get. You get more droopy breasts as you grow older, essentially, and it's because these ligaments just tend to deteriorate because the connective tissue becomes weak over time. So in terms off, um, different parts off the breast when someone asks you if you find a lump on somebody and they ask you which part of the breast you can find the lump where the lump is the correct, the clinically correct way to describe where lump is is based on the quadrants off the breast, so each breast is divided into four quadrants. You have your upper in accordance, your lower in accordance, your upper outer cordon on your lower article drink. So it's quite straightforward that way. Think of it as a clock, so going s before you kind of. Based on that, um, I'm still on to the pool really quickly. Okay, A 57 year old post menopausal woman presents the breast clinic, complaining of a painless lump in her left breast. There's associated dimpling off the left breast. What is the most likely location off this lump? Okay. And give it another five seconds. Okay. And did that. Yeah. Amazing. Most of you got it right is correct. So theon, sir, is see the upper outer quadrant on D. The reason for this is because the history of this woman, first of all, she's 57. So she's older, relatively. She is post menopausal, which is a risk factor for breast cancer as well. She got a lump in her breast. They may differentials for lumps, but the fact that this lump is painless, um, that she is post menopausal, that she's 57 that she has associated dimpling on the breast, which is like skin changes suggestive of a difference. With diagnosis of breast cancer and breast cancer, lumps are most likely to present in the upper outer quadrant off the breast, and therefore, that is the most likely answer. So I put the option of the exhilarated bottom as fifth option. Anyone tell me why I might have done that. Why? But why? They are the exit. Yeah, right. So exhilarating nodes. Yes, that's correct. Basically. So I put the exit specifically there because obviously your lump has a very rich love lymph nodes draining system, but in, um because upper outer quadrant breast cancer the most common. They are also next year exhilarate and therefore breast cancers are most likely to mess metastasize First exit and therefore sometimes you can find the lump in the axilla as well. Because of that, see how great job guys Amazing. I'll go over the lymph lymph drainage. Short lease. Well, cool. So you're just emphasize that the about according to is where most people are likely to present with a lump. Let's talk about the arterial supply off. Your breast is very straightforward. I'm really going to go through the main want you to know. So if we look at the aorta, this is your sending aorta. This is the art of years, um, after descending aorta. So if you look at the art of ureter, you have your break. It's a folic drunk which is here on the right, which gives off your right carotids and right subclavian. Right. So you're right subclavian as it passes through your chest, then becomes the exhilarate artery to subclavian artery, then becomes exhilarate artery. So the main branches your breasts arise from these arteries. So from your subclavian artery, you have the internal thoracic or the internal mammary artery, which supplies the median portion off your breast. You then have the lateral thoracic artery arising from your exhilarate artery over here, which supplies the superior and lateral portions of your breasts. And then you have the anterior and posterior intercostal blocked branches that also come off theater and thoracic and various other branches to supply the inferior face of the breast. So if anyone ever asks you for the arterial supply of the breast, if you say these three things, that is all they would have expected to know, obviously the breast as many other collateral supplies as well. But those are not as important. These are the major ones. If you can then think about being a strain. Aged surprise is actually very similar. It's basically the same, except some small differences suggest. Like your internal thoracic artery. You have your intern thoracic vein, draining almost the exact same area. You also have your lateral karassev vein, which is the same with lateral thoracic artery, also draining a very similar area. But then to drain the inferior breast, you have your Zytiga Spain. If you remember the Zytiga's venous system, you have your Zytiga staying on the right side, which strains into the superior vena cava all of these veins that drain the superior vena cava. But the only thing I would say about venous drainage is that the right breast disease vein drains into the supplement. Okay, but where's on the left breast? You have your hem years, I guess. An accessory hum years ICUs veins instead of your sickness veins If you remember your venous anatomy, that's the main anatomical difference between both breasts in terms of venous drainage. Finally, the star of the show, as always, cause breast cancer is breast lymphatic drainage. This would say, I would say, is very important. And I would definitely learn the main names off the main lymph nodes where the breast strain and I'll go over them now. So this is the first train of lymph nodes. Can anyone tell me the name, this chain of lymph nodes? Anybody take a wild guess? Left lateral. Sure, it's less specific thing that actually a bit more specific in that exhilarate. Yeah, perfect. Yeah, said the zero degree lymph nodes, as you mentioned earlier. Very important, really. These are the cells that show when it comes breast cancer, and 75% of your breast drains into the exit. A real in fluid, which is pretty substantial. Um, then you have another chain here, which is your infraclavicular and central lymph nodes. And then your parents sternal and posterior intercourse is nodes. Sorry, guys, if you wouldn't mind annotating on screen, that would be great. Sorry. Thank you. Um, and you also have abdominal nodes. Um, but if a consult and asks you where the breast drains, then just the exam real implodes infraclavicular parasternal and post your intercostal, and they will be more than happy. And just emphasize again. That's breast lumps that are most likely to rise in the upper outer quadrant are most likely is to metastasize to exaggerate lymph nodes. Cool. Great. So let's talk about the development of breasts. How did they even come about? Um, so in the very beginning, you don't you basically just have these ducks that have no answer them. So you have, like the nipple, and you have the doctor for his ducks that don't have milk in them. They're underdeveloped, and they don't really lead to any things. There's nothing really happening, but Once you hit puberty, your body is like, Oh my God! So many hormones on this has a profound effect, basically. So, as you can imagine, the stars of the show in puberty are estrogen and progesterone. So the effect that Easter gyn has and your breasts is it causes doctor elongation and by ification. What that means is that it makes the duck selective for stocks longer, and it makes them branch out more. So It's like a tree, so the tree just grows and becomes more complicated. And progesterone causes the formation off your alveola at the end of these branches. So you get these, like lumps off tissue of glandular tissue at the end of these branches, and that's what Progesterone does. So, for example, this is probably pretty. Please excuse my drawing. I am no artist, but this is before puberty. It looks a bit like a tree in December, if you know what I mean. It's dead. There's no leaves. That is very little branching. It just kind of like dead really on. Then you have the magic of these hormones acting on them and then off, like during puberty and after you can see it's a lot more elaborate. There's more like fruit at the end of the branches and the the branch of themselves are more elaboration. Complicated. So that's the effects of the hormones. So that's dies like that. Let's look for the deep into that. So this is a histological micrograph off a breast on diet would say this is quite early in pregnancy, maybe early in the third trimester of pregnancy. Can someone of chats tell me what a is? Please take a wild guess this is. I wouldn't expect you to guess this. It's it's complicated, but have ago. You can Yeah, perfect age. Adipose. Yeah, because the blink big wide lobules off basically nothing. And that is always going to be at opposed. Yeah, perfect. What is B, B and C are interrelated, but a different, and I understand it's hard to see, but look at the So Can you tell me? Can you tell me what kind of cells they are? So B and C are different kinds of cells? Sorry, this is really mean of me. It's not a very it's not very soon. Then I'll tell you. So be It's actually myelopathy Leo cells the cells. On the outside of your audio light and C are the column, the epithelial cells that produce the breast milk that produce the colostrum inside the Advil. I will look into that later, but I did this work kind of looks like, um, anyone. I want to have a go. It's saying What D is D is pointing to the insides off these of your life. So what is a It's pointing to the white, the white center. Why's it wipes? What does it contain? It's not quite the ducks. If you see lots of little white dots, there could be ducks. But this specifically is actually the colostrum. So all these acid ideas alveolar they they have. If you remember your saliva gland system or your pancreatic duct system, you have these. You have these ass and I, and they like, kind of secreted into a little pool. And that's what this is that is secreted colostrum quite early on the third trimester of pregnancy. So, yeah, you consume in later when you have time to have a better look. Um, cool. So let's talk about those types of epithelium. Okay, so the main this is what your breast. Advil. I look like Right, So you got on the outside? You have acid night. Which of these milk producing columnar epithelial cells where? They're on the inside of these bits. Here, they're on the inside. Moved producing. Call him in. Epithelium on On the outside. You need cells to squeeze the milk out to these cells. Produce the milk. Now you need these cells to squeeze the milk out into the docks. And therefore you have my appetite. A little cells, they're on the outside on be my with the other cells are special because they really rich in oxytocin receptors, and therefore they respond to oxytocin. So doing breastfeeding. Um, the breast feeding reflex, as we talk about later, causes a release oxytocin. And this oxytocin then binds the myoepithelial cells, causing them to contract and to squeeze the milk out of the Advil I into the milk trucks of that make sense. Also, just another aside. And breast cancer, um, the main, most popular kinds of breast cancer or breast cancer that you get either within the lobule. So within the epithelial cells are in the duct, you can either get a doctor called carcinoma or a lobular carcinoma. That's a very basic classification of breast cancer. Great. So what happens in pregnancy to the breasts if we assume out now, look at the breast from the outside water, the changes that you're likely to see in a pregnant woman. Um, because she has so much, so much glands, the tissues so much hypertrophy off her breast tissue, she's going to need an increase in vascular supply, so you will see someone's breast. You'll see increased vascularity. You'll be able to see the little lines of blood supply on the inferior service in the lateral service of the breast on the areola response to Eastern and progesterone on. In response to that, it gets more pigmented and not exactly sure of the exact physiology of that. But I know it's due to hormonal changes, and that causes hyperpigmentation and therefore the areola gets darker. And also, as you know, the estrogen and progesterone cause the proliferation of the doctor prettily, um, and the ducks and just make more glandular tissue. So this is a micrograph off a woman who is in the third trimester pregnancy quite well in actually towards the end, and you can see that these are her like alveoli, and they are filled with colostrum, and it's getting very to breastfeed, basically, as you can see, um, yeah, great. Let's talk about milk production lactogenesis that actually starts in the third trimester of pregnancy, which is like, Yeah, trimester. And it is triggered by the surgeon release. So Easter Gyn is released and acts on the hypothalamus to trigger secretion off prolactin. Um, prolactin is the milk. The creating stimulating hormone on prolactin is then released from the anterior pituitary and acts on breast tissue. And what does that do? Well, as you can imagine, it stimulates the breast tissue to produce colostrum and cholesterol. Basically, is a very basic thick former breast milk that contains lactose casein and alpha lactalbumin. And these, um and these are These are antiseptic properties on also some amount of nutrition in them. However, you don't fully produce a lot of breast milk at this point, because progesterone, which is still really high in pregnancy at this point, inhibits the full extent of prolactin. And therefore you're not getting a full breast milk production. It's quite it's quite inhibited and controlled. But once birth happens and once the babies out there is a sudden drop in progesterone and the seven dropping progesterone as well as estrogen on human presented lack region causes a sudden rise and production because it's no longer inhibited. It no longer is. Stop the progesterone, and therefore prolactin has a sudden stimulate tree effect on the breast to produce breast milk. And therefore you get, um, nice, continuous low breast milk. However, this affect is quite short lived. It only lasts up to 40 hours because what's gonna happen is that after 40 hours, the breath mint release has to happen manually. Um, so you have a 72 hour deadline for the mom to start breastfeeding manually. That means for a child to start sucking on the nipple to manually simulate the oxytocin hormone loop to simulate breast milk production. So, up until 40 hours, post partum, it's end of crime driven, which means the mom don't have to do anything. Just the fact that she's given both is enough for trigger breath production. But after that is done, that period is done. She has until 72 hours to begin breastfeeding and to, um, kind of engaging the use it or lose it since system where if she doesn't breast feed by that point, then there's a good chance she's going to struggle to breastfeed after that point. So let's talk about this manual requirement of breastfeeding. Why do you need a child to suckle on the nipple for it to continue the flow of breast milk? Well, how does this work? We're basically every time the child suckled on the nipple. The nipple has receptors that then engage in a feedback loop to release oxytocin and production. It's quite simple. So the oxytocin and then released assist triggered by the suckling on the Net pool acts on the my opinion cells that we talked about earlier. And this causes contract shin and release of breast milk. The prolactin, as you can imagine, is just triggers the breast to produce more breast milk. Port active, however, is inhibited by dopamine, and this is relevant in cases. I think you might have heard this new election. Not really sure, but basically, if somebody's had a miscarriage quite late in their pregnancy and they've already started producing small amount of breast milk, they've lost the child, but it's still producing breast milk, which is quite sad because it's constant reminder to them that they were pregnant, and therefore you can, in severe cases of depression, prescribed dopamine on this will. Then they But the prolactin and this mom, who just undergone a miscarriage will no longer have to breastfeed. I mean, produce breast milk, if that makes sense. Cool. So if we then move on to another SBA, we just learned to the pool, Okay. Laxation of amenorrhea, which is lactation. A little positive. Pausing off your men's normal menstrual cycle or bleeding happens in breastfeeding. Um, I want to know if you know how this happens. Let's take of time going to stop it now. Yeah. Amazing. You guys really clever? Cool. I think I'm really is too easy. Um, yeah, great. So mostly got it right. It is, in fact, the fact that prolactin inhibits the positive release off gonna draw been releasing hormone from the hypothalamus. And obviously, if you remember, you need gene or itch to stimulate the secretion of LH, which is involved in ovulation, and therefore, if you inhibit this, you're going to inhibit ovulation and therefore probably not going to be able to conceive during that period. So this leads me onto the part where I talk about advice for breastfeeding moms and we can learn a lot from this. So first we talked about is that we still breastfeeding moms, that they should be aware of the fact that they kind of have natural contraception. Obviously, this is only for moms were exclusively breast feeding and explain why. Later, Um, a few other advice piece of advice we can give is, for example, the fact that if they can use it or lose it, so if they don't start manually breastfeeding by 72 hours, they're going to fire very difficult to breastfeed after and stuff like that. So let's go through this kind of stuff so they use it or lose. The phenomenon as we talked about earlier means that the mom must start manually. Breastfeeding no later than 72 hours. Post partum on this is to stimulate the, um, order crying oxytocin, breast milk. Look also stress plays a massive rolling breastfeeding. Tell them to relax posted every stress has been associative with not very great outcomes from breastfeeding, things like like delayed initiation of lactation, lesser volume of milk being produced less of frequency off. Being able to breastfeed things like that have been related stress. And as you can imagine, stress has an effect everywhere, and it has an effect on breastfeeding as well. Asked them Teo, When they're breastfeeding, ask them to empty their breast. What I mean by that is breastfeed until you feel like there's no more to give, and this is actually weigh more important than you think. Basically, you might have heard of this before, but there's this thing called for milk and hind milk. Okay, so as you can imagine, your breasts produce a certain amount of breast milk on every time this milk is injected into the docks. Obviously, the part of the breast milk that is more watery is able to flow through the ducks easier and quicker, and therefore the baby received that milk first. Unfortunately, these watery bits don't contain the fat in the the breast look, and the fat gets left behind in the breast. This fight is really important for the growth of the fetus, especially in the beginning when it's just been born. Therefore, you need to ask the moms to fully empty their breasts to make sure that the baby gets as much fat as it can from the breast milk to encourage growth that makes sense. Therefore, you want them to drink. The four milk on behind book hind means behind that make sense. This is an example that kind of shows you what they look like. So if you look at the image of the left that's formal, it looks very diluted. Just looks like white colored water. But the milk on the right is has more body to it, and that's because of the fat. That's that's kind of what you want. Great old. Another reason for him to your breast is you can get lactation alone, mastoiditis, which is inflammation of your breasts if you have. If you have a lot of breast milk left behind and it stays there, it can get infected and cause problems, so you don't want that either. Basically, we talked about national contraception because of the inhibition off the hormone Lexus, so that's the thing to be aware off on. I feel like Mom. She really know that because nowadays people think it's cool to formula feed because it's easier, especially working moms and stuff. But they're actually really significant risks, not breastfeeding. For example, The risks for the child itself is that there's a significantly higher risk of developing upper respiratory tract infections and your infections for Children who are not breast fed equally for the mother, this is a significant, small but significant higher likelihood off developing breast ovarian cancer as a risk of developing Type two diabetes and metabolic syndrome as well later on in life. If she doesn't breastfeeds and finally I every mom should aim to breastfeed if possible, for a least six months postpartum. And this is because breast milk has really important nutrients apart from milk. Apart from just fat and glucose, it contains antibodies like Iga Immunoglobulins that are really important for initial immunity. Also has other anti inflammatory, antiseptic agents like lysozyme or Lactoferrin, that act on their own ways to produce the baby with temp to give the baby temporary immunity. The reason the baby needs his temporary immunity is because they don't develop their own immune system until about six months after birth. So if you could take this graph, it's taken from the classic immunology text text book. But, um, in the very beginning, the baby's basically have almost no antibodies of their own, and they're relying completely on the mum to give um to get her i g antibodies by the placenta. Once they're born, they no longer have the placental access, and they can no longer get I g antibodies. And therefore they rely on the IgE antibodies they get from the breast milk. And that was really important to breastfeed because they need these antibodies because they don't have an immune system off their own at this point. Great. So I briefly mentioned the immune confidence of breath like earlier, such as IgE Antibodies. Um, let's talk. What laughter Faron. So Doctor Ferrier is a chemical present in breast milk that has an antimicrobial properties. Essentially, what is able to do is prevent the prevent proliferation off. Pathogens on is an anti inflammatory agent as well, which is good because you don't want that you want. You don't want that in. Children in babies also have life designs. Lysozyme is increased production and also help encourage macrophage activation in case the baby has to fight any infections That's really useful to have, and therefore you can see why it's quite important in pregnancy. That's kind of the end of my breast feeding and breast and milk bits. If we then move on to hematology really quickly, I've got some definitions. I was like, I'd like to see if you guys know what they are. I don't. You majority is a bit of a new concept right now, and therefore it's going to go over some quick definitions and terms. So can you guys tell me in the chats what we call a state of lower than normal hemoglobin levels, please? Yeah. Perfect anemia. Exactly. Great. Cool, humble beginnings. A state of higher than normal hemoglobin levels. What we call that someone is kind of someone said half the answer. David, you got out the answer. Yeah. Polycythemia perfect. Yeah. Great. A measure of the average size of RBC's. What is this cold when you go get a get a blood test done. And one of the measurements is Yeah, great. The mean corpuscular volume refers to the average size off the RBC's in a person. Great. What we call a state of higher than normal platelet levels. Yeah, perfect on. Besides, dose, it's amazing, guys. Okay, Last one, a state of lower than normal platelet levels. Yeah, perfect. Um, beside a pina. Yeah. Great. Great. You already know this stuff. You know, I wanted, um great. But that's a reversion then. So let's talk about I'm going to go over the hematological changes in pregnancy. But I also thought it be really useful to go over the other physiological changes pregnancy because there is so much happening. I think pregnancy is so incredible. So let's go over each system, Really briefly have just highlighted the main high yield point in its no to the cardiovascular system. So the main thing you have to remember is that progesterone is raised throughout pregnancy, and this has many effects. The main vascular effect of progesterone has is that it causes basal dilation, systemic beta dilation. So throughout the body, your arteries are going to dilate Onda. This means the peripheral vascular resistance or the after load in your body is decreases as a result. And this is important because if you have basically relation, that usually leads to a reduction in blood pressure. So in order to maintain this, your body reacts in such a way to increase heart output's so it reacts to the decrease resistance Thio and then uses systemic vasoactive substance is to then increased cardiac output. Increase stroke volume on this is to make sure that the fetus gets enough, um, an adequate amount of perfusion. So in pregnancy, you got this increased chronic output and increased blood flow. On any time in the heart, you have a sudden increase in blood flow anywhere you got a murmur. That's exactly what a murmur is. A mama's a vibration you pick up because there's an increased flow somewhere, and therefore in pregnancy you get a physiologic systolic murmur due to the increased cardiac output on flow. And you also notice that you go see pregnancy pregnant women that they might have like swollen legs on. This is because off the increased plasma volume in their body, onda, sometimes pretty woman can have decreased albumin on and many things that contribute to change them cortic pressure that can eventually cause that them their legs to swell up and finally also noticed that some pregnant women, especially in the abdomen, have like varicose veins, varicose veins, the fancy way of saying veins that are dilated and kind of more apparent, and they pop more than just like very fact veins, basically. And this happens in pregnancy because, as you can imagine, the uterus is under a lot of pressure from this random big blob of masters started growing, and therefore this heavy mass is pushing down on the uterus, which then press is down on the pelvic veins of the vena cava. And therefore, venous return becomes really difficult, and therefore a lot of the veins become just really dilated. And that's we get varicose veins. Let's talk about hematologic. Allchin is in pregnancy, so firstly, anemia in pregnancy is actually one of the most common hematologic A findings in pregnancy and most times it's normal and has no net effect on the mother or the child is. Usually it's actually not too bad at all. But it happens because, as you can imagine, in pregnancy, you haven't increase in red blood cell loss, but you also have an increase in plasma volume. Unfortunately, the relative increase off the red cell mass is not enough to keep up with the increase of the plasma volume. That is, you have a higher increase in plasma volume than Red Cell Mass and therefore the plasma is just more diluted and you get a relatively lower concentration of red blood cells, and that's why it comes up is anemia. But really, like most mothers aren't affected by this. You also get a physiologic decrease in platelet count. In some mothers again, this usually has no net effect and presents with no real symptoms and is usually gone unnoticed. But can we picked up on bloods on Do is just a just a finding. It's physiological, it sounds to be concerned about. Usually you haven't increased white blood cell count. Is this reactive neutrophilia really again? Nothing to be concerned about is just something you pick up on Bloods Onda. You would have sometimes because because you have any human being going inside you, and this human being requires so many more red blood cells. Your body's trying the red blood cell turnover. It is so high. Sometimes the mother's body can't keep up with the iron needs and the folate needs, and therefore you may notice a decreased iron and fall it count on bloods. And finally, a really important hematological change in Mom's pregnant mothers is the fact that they're in a hypercoagulable coagulable state which means they're more prone to developing things like a deep vein thrombosis or even things like intrapartum blood loss. And this is because of an increase in fiber, no gyn on other chemicals that involved in blood clotting. So this is this can be This can be quite bars. If it gets to it, risk pretty changes. So because again, the mom is kind of breathe for herself on her child. There's an increase in oxygen consumption by 20%. And because the uterus is pressing up on the diaphragm, it's decreasing the intrathoracic space, and this results in a decrease in total lung capacity. Residual volume, functional residual capacity as well as the expression is of volume. And basically all you need to know is that this is why some moms who are pregnant can present with breathlessness is because they are just able to breathe less essentially. But that is also why they tend to hyperventilate on. We haven't increased minute ventilation, right, because they're trying to compensate for that lack of total lung capacity that make sense and okay much in earlier. You are in a state of increased cardiac output in pregnancy, and this obviously means you have more blood flowing through your arteries, and therefore there's more blood flowing through the kidney as well. And the results in a higher, um glomerular filtration rate, which is actually good because you have less toxins in your body that way as well. However, if you do remember, um, in pregnancy, you also have a state off reduced peripheral vascular resistance because of progesterone. This triggers your Ross system, which is like your sympathetic system, and this increases water retention from your kidneys. So a lot of pregnant women will complain about feeling water. Attention will feel about what company or feeling bloated and things on. This is usually why on because of the increased intradomal pressure that the uterus is putting on them and on that bladder, this can cause increase. You know the frequency as well on If the kidneys overloaded with all this increased cardiac output, this can over like, overwhelmed the kidneys and overwhelmed the glucose carriers in the kidneys. And therefore they're not filtering all the glucose, and some glucose can end up in your urine. This is usually pathological. It's it's usually normal until the surgeon threshold. So this isn't you know something to be worried about. End of crime, um, changes in pregnancy. So as we know, hormones have a huge part of playing pregnancy, especially progesterone. We've talked about it today, but you might have heard of gestational diabetes, and this is due to human presented. Lacked a gyn it Human pleasant accident is a hormone produced by the trophoblastic cells in your placenta, and what it does is that it promotes the production of insulin like growth factors. Therefore, pregnancy. Pregnant women have more insulin production, and over time, by the 20th week in pregnancy, the women can woman can develop incident resistance on If this gets bad enough, essentially, and if the hypoglycemia is not well controlled if her diet is out of control, this concludes the gestational diabetes. If she doesn't control this well, then this can have effects of the baby's well hypoglycemia in fetus fetuses. Feet I fetuses was clearly fetus. Sorry can lead Fat Baby's basically because hyperglycemia promotes fat production in fetuses and therefore you get fat fat babies and this makes delivery more difficult. It's essentially tell moms how to have a nice diet when they're pregnant, because they can have problems in labor, and you don't want that basically, and this is what I mean by problems in labor. If you have a fat baby, it's going to struggle to get out. And you can get the single shoulder dystocia where the shoulder becomes lodged against the pubic symphysis, and you find it really hard to remove the baby from there. And that's a potential complication of gestation. Diabetes. Great on just more under current stuff. In general, there's more fat and little production because the mom needs to supply nutrients for herself and the child, so it's normal. That's kind of what the pregnancy weight also is that you put on finally some quick G I stuff. Lots of pregnant women will complain of God off of reflux, and this is normal because progesterone, while the concentrated violation also relaxes the lower esophageal sphincter. So again, progesterone is a bit of a cup culprit, really, and this causes this means that your lower esophageal sphincter is not able to regulate the acid as much, and therefore you get reflux, the progesterone, all the results in reduced gut motility. It relaxes the gut, and this can cause constipation and women You can also get Goldstone's because the Stasis off, um, bile on the gold bladder and hemorrhoids. Not gonna go over that right now because there's no time, but I'm happy to answer questions later. Great. And other SBA this. Okay, Sorry. That is the end of my year, too. Freaking good presentation. Um, if we have time now, I'm quickly gonna brush. We have, like, five minutes. Yeah, if you If you want to stay for some very, very quick, very just like fax clinical teaching Benz Day, that'd be great. Um, it's nothing life changing rights that a few slides in You wanted, but so I wouldn't blame you. Didn't get this sp a because it is a clinical one. But go for it. A 37 year old pregnant woman who was 25 weeks and gestation presents to any with confusion, nausea and vomiting and headache. Her BP is 180 over 100. Um, dipstick test shows protein urea. Her liver function tests are normal. What is the most likely diagnosis? I'm gonna wait for about 40% of you to vote for about 38. 38 39 39 40. Great. Perfect. Yeah. Well, don't guys Yeah, Great it is. It's pretty clumsy. Uh, so I thought we talked a bit about pregnancy. Hypertensive disorders again. I'll get back to the SP once have explained what they are. But preeclampsia is a type of off pregnancy hypertensive disorder. So I mentioned earlier that in pregnancy you get an increased BP, and this is can usually be normal. Not all women get this, but it can be normal. And it's considered normal when it happens after 20 weeks. And when there is no associated protein it picked up in the urine or there's no organ dysfunction like she doesn't have renal failure or liver failure. Associate it with this hypertension on the threshold values. For this is a systolic to be over 100 40 or the diastolic to be over 90 on two separate measurements on two separate occasions. So this is usually normal, usually doesn't have much of an effect on the child or the mother, and it's fine. It's just incidental finding. However, you start to worry when the month comes in. Well, 20 weeks off the gestation Onda, she has other symptoms, like abdominal pain or she's confused. She's not here. She's vomiting. She's complaining of a headache. Other CNS symptoms. She's complaining off problems with her urine as well. And then you saw him to think right? Isn't something more serious going on something potentially fatal. And you do a urine dipstick test you get and you find out it has protein in it and you're like, Oh, please, that's really bad. You do some kidney function tests. Do you find the kidneys are doing well, either? Also really bad. And that is quite typical preeclampsia, where what happens is you get these defective arteries in your uterus and your placenta and in your kidneys. And because they are not as dilated and anonymous perfused they should be. They cause hypertension. And this arterial hypertension can cause. Endothelial dysfunction can really mess up the arteries in your organs, and this has essentially a can really bad effect off, causing organ failure. So usually in pre eclampsia, the organ that's usually first affected is your kidneys. So SBA if you're getting kind of a pre eclampsia picture, Ah, women, who is more than 20 weeks in just a shin, comes in with hypertension that above the threshold on gall. So she has protein, urea, usually very classic SBA thing on day kidney dysfunction. Then you're like, right, this is preeclampsia that is quite textbook. Ah, complication off preeclampsia, a type of preeclampsia is help syndrome. Actually, 85 85% of patients who have help syndrome had preeclampsia basically. So, basically, if you have help syndrome, you most likely have pretty fancy. It's called help syndrome, because it stands for human lysis, elevated liver enzymes and low platelets. These are the classic findings on this kind of preeclampsia, and essentially, it's complication of preeclampsia, and it's due to just further and do the little dysfunction. And your clotting system is confused on there are clots happening on your body is very confused, and it goes into this acute state. It's quite bad, okay? And the most severe version of this is called a cramp CIA, and this is when you have hypertension and protein urea and also associated with seizures like convulsive seizures on day or coma as well. So this is when this disrupts the arteries in your brain and this Lisa seizures, and this is really insist fatal. This is associated with mobility, high high rates of morbidity in both the mother on the child. And so this is something you really have to look out for. So going back to the SBA really quickly that those are all my slides, by the way, I'm going to be really quickly. Um, so if we go back and we look at this woman who presented, um, Okay, first of all, she's 37. So already the fact that she's over 35 years old is a high risk pregnancy. Okay, And then she's 25 weeks into gestation to the special reset for gestation. Hypertension is 20 weeks or after, and that's usually when you present with hypertensive problems. Okay, presents with CNS symptoms of confusion, nausea, vomiting, headache because the stocks is in our blood on. But she basically just very unwell, basically. Then her BP is through the roof. That's not good either. That's already kind of pointing in a very specific direction. You do investigations. You get you, um, dipstick, test protein. Urea. Boom. You're pretty much yours. Protein. You're pretty much preeclampsia. The reason I put in liver function test is because if it came back elevated liver enzymes you, then you might think off Hopes Syndrome as the diagnosis, A scam paired preeclampsia. So yeah, that explains it. Well, those are my slides. I hope that was helpful. Thank you for sticking around if you stay till the end. I think the feedback from should be in the chat now. So if you feel that in, that would be amazing. But everyone, I hope this is really helpful. Thank you for attending. We'll be doing a case nine revision. Two weeks from now on, pediatrics and immunology. That's something you wanna revise. But, um yeah, thank you. Guys sticking around. He said the feedback phone. We did appreciate it. No, thank you both. That was really great. I've put the feedback form in the chap. If you feel that in, you should get access to the slides on metal. A said at the beginning. We've also made makes extra SBA is and some cheat sheets for your vision. So you make it for the in to get access for those, and we'll see you on them Monday, the eighth in two weeks. And if if you want to as well join some finally easy sessions, if you want to go into some more clinical aspects of medicine too, with the stuff guys. So that was Ah, very informative. Very high yield session. Onda. Yeah. Thanks for Julian. For those of you to go into private detection today as well and shows a bomb Couple of a long evening for you guys. But thanks for Tinian to both of you did. Oh, my God, That's finished. Like, really already? It was like a know in 10 minutes. I convinced yet? Yeah. I'm going to stop recording. Yeah.