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Hi, everyone. Good evening. Uh Welcome back to our Road to Final Series. Thanks for joining us for episode two. This, this episode will cover obstetrics with uh Doctor Branca Ayer who we're really grateful to have here with us. Uh back again doing a talk uh for MSM SMS. Um uh Doctor Aya is currently an ST two OBS Gyne trainee working in the North Central East London Deanery and she graduated from uh King's College London with uh uh I BSC and Anatomy. Um We're also really grateful to have the Medical Protection Society sponsoring uh this event. Uh and it's also been running in collaboration with the 6 p.m. series. So for those of you who are joining us for the first time. Welcome, for those of you who are coming from episode one. Welcome back. Uh and I'll hand over to uh Doctor Ay now to begin the session. Uh The chat is open. Uh So please do feel free to drop any uh questions you have there. And I'll also be launching polls during the session to answer the MC Qs over to you, Doctor Ryan 22. Ok, great. Um Can I just check that you can hear me. Ok. And then you can see my slides. Yeah, I can hear you. Perfect. Um Great. So um good evening everyone. Um Thank you for the introduction and thank you for having me again. Um So we decided after feedback from last year to split it up into an obstetrics and a separate Gynae one. So I think hopefully, um it'll allow us to kind of give us a bit more time to cover stuff. But I have to say, I think I have added quite a lot of things. So, um, obviously, if you run out of time, that's absolutely fine. I'll send you guys the slides, so we will get started. Um And I've got the chart open on my phone. But, um, yeah, we'll, we'll kind of go along. Um And I've tried to make it as interactive as I can. So there's a few Mc Qs and I'll try and ask a couple of questions and stuff. So, yeah, definitely, um, ask any questions that you have and um answer as many questions as you can on the chat. Um Great. So, um I just put that to kind of, um, it's just a little picture to show how daunting obstetrics can be at the beginning, but hopefully by the end, you'll be a happy cat. So, uh the first thing I wanted to cover was antepartum hemorrhage. So, obviously, antepartum hemorrhage is bleeding over 24 weeks, but we'll also cover some of the differentials for bleeding in pregnancy less than 24 weeks as well. We'll go through labor, looking at normal labor, preterm, labor and induction of labor. We'll go through some complications in labor. So, bre presentation shoulder dystonia called prolapse, um instrumental delivery and postpartum hemorrhage. And then lastly, we'll finish off with some conditions that arise in pregnancy. So, preeclampsia, gestational and preexisting diabetes, itching in pregnancy and, and hyperemesis cd. So, starting off with bleeding in pregnancy. So, um first question, you've got a 25 year old woman at 25 weeks, gestation who presents with constant lower abdominal pain and a small amount of vaginal bleeding on examination. Uh BP is 90/60. What's the most likely diagnosis? Ok. So, so I'll wait. We've got seven responses so far, I'll give you guys a couple more seconds and then we'll go through the answer. Ok. So 50% of you guys have said c which is the correct answer. So it is placental abruption. So the things in the stem that give away placental abruption. So obviously, you're, you're over 24 weeks. So it is an antepartum hemorrhage. So, one of your differentials would be placenta. So it's not gonna be an ectopic pregnancy. It's not gonna be a threatened miscarriage. It's very unlikely to be a molar pregnancy as well. So, those are kind of the things that you would be thinking of if it's less than 24 weeks. Um The next thing is constant, lower abdominal pain is another thing. So that's one of your key terms of placental abruption. The third thing is a small amount of vaginal bleeding because often actually with placental abruption, if you've got a concealed abruption, the you might be quite hemodynamically unstable. So for example, a BP of 90/60 with only a small amount of vaginal bleeding. So that's kind of what the question is alluding to. So the correct answer is placental abruption. Next one. So you've got a young woman at 30 weeks, gestation with painless bright red vaginal bleeding. She reports two previous scanty episodes of painless vaginal bleeding but feels like this episode has been much more severe. Obstetric examination finds a cephalic presentation with a high presenting path. The uterus is nontender and cervical loss is closed and cervix appears normal. What do we think the answer is for this one? And you've got the same options as last time? Ok, great. So 71% of you guys have said D which is the correct answer. So it is a placenta previa. Again, the things in the stem that give away placenta previa are painless, bright red vagina bleeding. Obviously, you know, clinic doesn't always present as clearly as this, but often the stems that you guys will get in your MCQ S will be your typical presentations. So yeah, so painless private vagina bleeding. Often women will have a history of previous episodes of intermittent bleeding kind of throughout pregnancy. Um And then you've got a high presenting part because if you think about it, if your placenta is covering your o, the baby's head is not gonna be as engaged, so it's gonna be quite high. Um, the uterus is gonna be non tender, so you wouldn't get the woody hard uterus that you would get with the placental abruption. Perfect. And then your next question you've got uh this actually isn't an a ph apologies. Um This is just bleeding in pregnancy. So her last period was eight weeks ago. You've got a 19 year old woman who presents with a two day history of central lower abdominal pain and a one day history of vagina bleeding on examination. Her cervix is tended to touch. Sorry, but I think you might have to read out the pole answer because it doesn't seem to be showing it to me. Um Yeah, no worries. Uh on mine, it says we've got four responses to to this one. Everybody's answered a I can relaunch it if you want though. Um I don't know. It says verify your account to join the conversation. So I think I might have to. That's one second. So I think it should be, it should be available for everyone. Fine. Um Let me, but that's fine. So you said the most common answer was atopic pregnancy, correct. Yes. Correct. Yeah. Perfect. Yeah. So that, so that is the right answer. So again, you've got someone who's LMP of eight weeks ago. Uh, they've got cervical motion tenderness, which isn't the presence of cervical motion tenderness does not mean that it is going to be an ectopic pregnancy. But in someone who's having this positive pregnancy test, no abdominal pain, some vaginal bleeding. If they've got cervical motion tenderness, then you're kind of considering, could this be an ectopic pregnancy? Great. And the next one, you've got a 25 year old 10 week pregnant lady in complaining of abdominal pain, very heavy vagina bleeding, obs are normal. She's afebrile, um an ultrasound scan on an ultrasound scan, just a bedside one, a fetal heart rate is still present and the uterus is the size expected on examination. Her cervical os is closed. So what do we think the answer is for this one? And your options are the same. And again, if you can tell me what the most common answer was. Yeah. Uh it was everybody's visit would be perfect, threatened miscarriage. Great. So yes, this this is again, just to kind of um take you guys through some of the differentials for bleeding in pregnancy. Um The reason can anyone tell me why it is a threatened miscarriage and not a molar pregnancy? Obviously, it could be a molar pregnancy. But what kind of in the um stem makes you think it's probably not a molar pregnancy? Yeah. So Yeah, that's correct. Ahmed. So, your uterine size is normal for gestational age. And the other thing is obviously, if, well, it depends on the type of molar pregnancy. It is because sometimes you can see fetal parts, uh depending on the type of molar pregnancy and we'll come on to that, but there's a different kind of ultrasound finding that you would see in a molar pregnancy. Um, yeah. So a molar pregnancy, the uterus would usually be larger for dates. So that's correct. Fine. So, bleeding less than 24 weeks, what are some of your differentials? They've kind of gone through them already? So, ectopic pregnancy is one miscarriage molar pregnancy and obviously think about your other gyne causes. So, could this be an infection? Could it be a cervical polyp? Could it be an ectopia and ectropion is more common in pregnancy as well because some of the hormonal changes that you have. Can anyone describe what the top ultrasound image shows? What's that sign called? And what uh when would you find it? I sort of alluded to it just a couple of minutes ago? Yes, exactly. So it's a snow storm appearance or it's also called the cluster of grapes. And when would you see them? A molar pregnancy? Perfect. Great. Um And then the bottom image is basically what you're, you're essentially looking for free fluid and that's a sign of a ruptured ectopic pregnancy. And that's when a and do a fast scan and essentially you're just checking for free fluid between the liver and the kidney. That space is called Morrison's patch. And you shouldn't usually see that space unless it's full, filled with blood from a ruptured ectopic, for example. Great. So just quickly running through ectopic pregnancies. So, an ectopic pregnancy is basically when the embryo implants outside of the uterine cavity and you can find ectopic pregnancies in loads of different sites. But a common exam question is where you would most likely find it. And the pila is the most common site. Risk factors for ectopic pregnancies are previous ectopics. So, if you've had an ectopic pregnancy before you've got a 10% chance of having it again, if you've had two or more ectopics, and it's a 25% chance damage to tubes if you've had previous pelvic inflammatory disease. Previous ST is previous surgery if you've got a coil in situ. So obviously a coil on its own is very good at protecting you against getting pregnant. But if you get pregnant, if you're unlucky enough to get pregnant with a coil in situ, it's more likely to be an ectopic pregnancy. And just uh kind of a reminder, always do a pregnancy test in a woman of childbearing age presenting to a and so symptoms are rupture topic. So shoulder tip pain, syncopal episodes are often pre present in less than 25% of patients on examination. These patients would be quite hemodynamically unstable. They'd be peritoneal on examination and imaging. Obviously, you can see fluid in the pouch of Douglas fluid in Morrison's pouch on ultrasound. And just to remember if someone is vus negative then, and if you're going for surgery, then essentially an ectopic is a sensitizing event. So you need to give them anti D, why do we give anti D, does anyone know what we're trying to prevent in future pregnancies? Yeah, it's so it's vus hemolytic disease. Um and it's not necessarily for this current pregnancy, but it's for future pregnancies and it, and you've got different sensitizing events and yeah. So surgical management of an ectopic pregnancy isn't a sensitizing event. So you must give an if they're negative. Great. So just looking at management options, you've got three management options for ectopic pregnancies. You've got expectant. So you can just wait and watch, do nothing, just monitor them over 48 hours. And you basically need to recheck that beta HCG essentially on day two, day, four, day seven. And you need to check the trend of beta HCG. Is it reducing? Is it staying the same or is it going up? That's your first option. Second option is giving them a single dose of methotrexate, which is a folate antagonist. The third option is a lap salpingotomy or Salpingectomy. So, otomy is basically just making, you're making an incision on the tube and you're removing the ectopic pregnancy. A salpingectomy is complete removal of the tube. So those are the three options. And obviously, patient choice is a big um kind of, you know, you, you, we have to obviously advocate for patient's choice, but there are some um specific nice guideline criteria that you kind of would make you consider one option over the other. So obviously, the size, we'll go to the surgical ones because they are the most straightforward. So obviously, if it's a big ectopic, so a size of over 35 if the patient has any symptoms, so, pain bleeding, if there's a visible fetal heartbeat. So what we call a live ectopic and serum beta HCG of over 5000 would all, you know, you have to offer considered surgery in these patients, uh medical management and expectant management. Obviously, the size is less than 35. Then you can consider those expectant or medical if it's unruptured. Of course, if it's ruptured, you'd go straight for surgery or if they're hemodynamically unstable, then straight for surgery, if they're asymptomatic. So no symptoms whatsoever, serum beta HCG levels are less than 1000 than expectant could be a reasonable option. But it's really important that with expectant management and medical management, you need to choose the right patient. You need someone who, you know, is going to come back for follow up because you will need to monitor them with um serum beta HCG levels and you know, you might have to scan them again. So you need to choose the right patient essentially. Um Yeah. So if serum beta HCG levels are less than 1500 you can consider medical anywhere between 1000 500 to 5000. The nice guideline just says consider surgical management essentially. Um Yes. So you guys will have access to the slides. So you can have a look at these this table and this is all taken from the nice guidelines. Um Perfect. So does anyone know when we would consider a salpingotomy over a salpingectomy? Because obviously the gold standard management is a salpingectomy, just complete removal of the tube. And that doesn't really have any impact actually on long term fertility when you're counseling patients. So why would you do a salpingotomy? Yeah. So that's a good question actually. Ahmed. Would we still go for a Salpingo Salpingostomy when it's been associated with an increased risk of future ectopic pregnancies? So, only in certain situations. And can you guys think of any situations where you would kind of think twice before you'd remove um remove the tube with the ectopic present? Um No, it was, it's more if the other tube is looks damaged. So if they've got any risk factors for infertility, so, you know, the other tube looks uh looks really bad, looks blocked. There's there's a hydrocyon on the other tube, then you might think, ok, this tube looks healthy. So let me just try and remove that atopic pregnancy and then just kind of suture the tube. I haven't seen very many salpingotomy. I've actually never seen a salpingotomy being done whenever I've seen an ectopic being taken to theater, the other tube usually looks perfectly healthy. So we just remove the tube. And if you are doing a salpingotomy, then you have to do a urine pregnancy test and serum beta HCG levels as well. Ok, great. So, moving on to miscarriage. Um, so definition of a miscarriage is basically a spontaneous loss of pregnancy before 24 weeks. Recurrent miscarriage is where you've got loss of three or more consecutive pregnancies and that affects 1% of couples. Uh Majority of miscarriages occur before for 12 weeks and the rate unfortunately increases with maternal age. So we've got different types of miscarriage and we'll go through them in the next slide. So, over 60% of spontaneous miscarriages are associated with isolated chromosomal abnormalities. And obviously, we see women who sadly suffer miscarriages and we see that quite frequently and we have to, we just counsel women that things like there's nothing that they could have done essentially exercise, intercourse, stress, emotional trauma. None of those things have been linked to miscarriages. So, types of miscarriage, um there's just a thing to remember is if the o is open, it's either an inevitable or an incomplete. And the only difference between inevitable and incomplete is incomplete is where some of the fetal parts have already passed. An inevitable is basically where you've got quite heavy bleeding, the fetus may still be alive and miscarriage is essentially about to occur. And a threatened miscarriage is where the OS is closed. Um, and around 25% of them go on to miscarriage. So it's essentially just expected management and just kind of waiting and watching what happens because a lot of people who are kind of diagnosed with threatened miscarriage can go on to have perfectly healthy pregnancies. And a complete miscarriage is where all the fetus, fetal tissue has passed, bleeding has almost stopped and the uterus is no longer enlarged and a missed miscarriage is for example, when a woman goes for a dating scan and uh you, you don't see a heartbeat. So there's no symptoms, you just diagnose it at ultrasound scan. That's when you have a missed miscarriage. So, investigations obviously ultrasound scan we've mentioned already. So blood. So F PC visa status serum HCG levels, uh when do we admit? So if there's any suspicion of ectopic pregnancy? So if they, if they've never had a scan before, if they're having pain, if they're having bleeding, septic miscarriage, heavy bleeding, resuscitation, um you essentially whe when it comes to resuscitation, sorry, when, if, if someone's quite hemodynamically unstable, it's very important to do a speculum examination because if they're in vasovagal shock, it could be that the products are just sitting in the OS and actually just removing the products can uh make them a lot, uh, can, it can improve their hemodynamic stability and if they're over 12 weeks and they're having any heavy bleeding or medical management of their miscarriage and they need to be given an D and if they're treated surgically for their miscarriage, regardless of their gestation, so surgery at any point would give, uh, and if your reces negative, then you'd basically be given an, when it comes to management options, it's quite similar to ectopic. So you've got expectant, you've got medical and you've got surgical um and essentially with medical what you give them miSOPROStol, um you can administer that vaginally orally sublingually or rectally. So lots of different ways that we can administer it either as a single dose or a divided doses. And often the doses depend on digest and the size of the gestational sac. Um surgical management. Essentially, we do an E RPC which is evacuation of retained products of conception. The woman is often put to sleep. Uh We go in with the suction curettage and we remove the pregnancy tissue and they often have to repeat the urine pregnancy test after three weeks. And the reason we would do surgical management, obviously, woman's choice um um needs to be taken into account if you've got heavy bleeding or any signs of infection. So, if you're hemodynamically unstable, then obviously, medical management and expectant management might not be um the right option in that case. So just going through some of the drugs for miscarriage, ectopic and termination. So, miscarriage, you use miSOPROStol. So just remember the mi for miSOPROStol. So a termination, there are two drugs that we typically give for termination. So two for termination. So you give Mifepristone and miSOPROStol. So Mifepristone can sometimes be used for miscarriage, but typically you just give them miSOPROStol, especially if the miscarriage is already started. And Mifepristone is an antiprogesterone and that essentially softens the cervix miSOPROStol. So think of the prost. So it's a prostaglandin analog. It causes uterine contraction and expels the pregnancy tissue. An ectopic is a weird one where we give methotrexate. So those are just the drugs that you use for them for the three different um conditions. So just quickly to go through molar pregnancy. So obviously, you can have, there's two types of molar pregnancies. You can have a complete mole or you can have a partial mole. A complete mole is basically why you've got an empty egg being fertilized either by a single sperm or by two sperms. And a partial mole is why you've got uh two sperms, fertilizing an egg. So you end up with 69 xxx 69 X XY or 69 X YY and the partial mole can have some fetal uh As you can see in that, in the diagram at the bottom, the partial mole can have a, can have fetal parts in it. Whereas a complete mole is the one that looks like the snowstorm with a bunch of grapes appearance on an ultrasound scan and it's often a spectrum. So you obviously have the benign condition. So you've got partial mole and complete mole and you can and going on to kind of the more malign the malignant conditions like invasive mole ch carcinoma. How does it present? So, irregular vaginal bleeding, ultrasound scan, findings, less common things are high premesis. So anyone that comes in with high premesis, it's really important that we do a scan for them for two reasons because you want to make sure. Is this a twin pregnancy or a single pregnancy? Is it a small pregnancy? So it's always important to organize a scan for the patients who have, who have high premises and haven't been scanned already. We've already mentioned large for date, uterus, hyperthyroidism and early onset preeclampsia as well as another less common presentation of molar pregnancy. Ok. So, bleeding over 24 weeks, what are some of your differentials? We've gone through these already? So I'll just go through them quickly. Placenta previa, placental abruption, less common ones are vasa Praevia and you try and rupture. So placenta Praevia is basically where your placenta implants in the lower segment of the uterus. Um And you can have a no. So you can have a marginal placenta previa depending on how far the edge of the placenta is from the OS or you can have a complete placenta previa where it's completely covering the os risk factors are having had it before high parity and age twins and previous Cesarean section as well. So how does it prevent? Often? It's an incidental finding on an ultrasound scan. And actually a lot of women at 20 weeks will be told that they have a low lying placenta. But as the uterus enlarges, the placenta kind of moves upwards essentially. So at 20 weeks, it's less of a significant finding. So often you would just scan them again and check whether the placenta is at 34 or 36 weeks, um often presents with painless vaginal bleeding. And as we said, if you've got the placenta covering the os, you often find that the fetal head is quite high. You can have a breech presentation or an abnormal light because the head is not able to engage because of the placenta being in the way. What are some of your complications? We've mentioned bleeding already, placenta accreta as well, which is basically where the placenta implants abnormally onto the wall and the musculature of the uterus and again, never perform a ve in a woman with antepartum hemorrhage unless placenta previa has been excluded on a scan because it's, it's a theoretical risk of essentially precipitating more hemorrhage. So how do we manage placenta previa? As I mentioned, you essentially, we scan them later on in their pregnancy. If they've had any bleeding, you admit them and you just observe them for a period of 24 hours just to check, to make sure that they don't have any bleeding over that observation period. If they're less than 34 weeks, we give them steroids and most of these women, if they've got a complete placenta pre and they'd be booked for an elective cesarean section at 39 weeks. Does anyone know why we give steroids? What does steroids help with? So, they're often given for, yeah. So they help mature fetal lungs. Exactly. So they're given for fetal lung maturation. Perfect. So, placental abruption again, this should all be um hopefully just be revision. So it's basically where all are part of the placenta separates before the delivery of the fetus. Risk factors are preeclampsia, smoking, cocaine use as well. Uh previous abruption, hypertension and maternal smoking. Uh we mentioned maternal smoking already. So how does it present? So it's constant pain, plus minus bleeding. As I mentioned, you could have a concealed abruption where you might not get as much bleeding, maternal collapse, fetal distress on CTG on examination, on palpation, the uterus would be quite hard and tender and obviously maternal complications are things like poor urine output and venous failure. How do we manage it? And essentially, we just, if there's any signs of fetal distress, we just take them straight to theater for a Cesarean section. Um and you'd admit them and resuscitate them obviously, before you take them to the theater. Ok. So just quickly, um comparing placental abruption and previa. So in abruption, um as I've mentioned before, the shock is often um out of proportion to the external blood loss. Whereas in placenta previa, the shock is often in keeping with the external blood loss, placental abruption is severe constant pain, placenta, previa, typically it gives you painless uh bleeding. Occasionally you can have contractions as well. In placental abruption, the bleeding may be absent or dark placenta. Pre the bleeding is often red and profuse and they would have had previous smaller AP hs on examination, placental abruption, you have a tender hard uterus, placenta, previa. Often the abdomen is used quite soft between contractions, uh placental abruption. The fetal eye is normal, the head's engaged. You have often you have signs of fetal distress on your CTG placenta previa. You often have an abnormal eye, a high head and usually the baby will not show you any signs of fetal distress. Ok. So, moving on now to labor so quickly, just going through the three stages of labor. So your first stage is basically from cervix being closed to kind of active first phase, which is basically four centimeters onwards. Stage two is from full dilatation to delivery of the fetus. And stage three is basically delivery of the placenta. Um I think that's just showing you the three stages. Um Yeah, and this is just to kind of go through some of the things that we look for when we do vaginal examinations in labor. So obviously, you're looking for dilatation, which is just opening of the cervix station is basically where the baby's presenting part is in relation to the pelvis. And what we're looking at is in relation to the issue of spines, which you can palpate when you're doing an internal examination. So at spines is basically baby's side is in the same level as the spines above spines and then below spines. Um as uh and you can see that on the diagram, effacement is basically how thin and short the cervix is because usually at the start, if you think about your cervix is long firm, it's posterior. And as labor progresses or as we induce labor, essentially, you want the cervix to start becoming thinner and shorter and this usually happens before the cervix starts to open up. So these are just the three things you need to think of is power. So are we having adequate contractions? You need to be contracting at least 3 to 4 in 10 to be progressing in labor? Think about passenger, think about passenger as well. So for example, if the baby is quite large, so uh large, large for gestational age baby, for example, women are typically, you know, they might make slower progress in labor. So it's always important to think about the size of the baby as well. Uh And these are just some of the uh cardinal movements as the baby gets delivered. But you guys can have a look at this diagram in your own time. So just looking at fetal monitoring. Um so this is to do with the intermittent auscultation. So often women on labor ward, obviously, they, we, they're, they're often on continuous CTG. But if, if low risk women are on the birth center, for example, then they'd be having int interim auscultation. And in first stage of labor, essentially, you'd, you'd listen to the FH kind of immediately after a contraction for at least one minute and you repeat that every 15 minutes. And the second stage of labor, you repeat it every five minutes. So that's all from the nice guidelines. Uh And this is just a picture of a CTG. So just to kind of go through a CTG. So you've got your cardio and Toko. So the cardio is basically the heart rate of baby. So a is looking at the heart rate of baby. Usually you have another line underneath as well, which is what's missing in this CTG, which is mom's heart rate as well. And it's really important to differentiate between the two and the top of it is basically the contractions. So how frequently are we contracting? And the CTG should be able to tell you um how uh it doesn't, it doesn't tell you the strength of the contractions, but it will, it will tell you the frequency of the contractions. And I'm sure a lot of you would have heard of Doctor C Bravado, it's just a really good kind of framework when you look at a CTG, so you define the risk frequency of contractions. What is the baseline rate? What's the variability? Any accelerations, any decelerations, an overall assessment? And it's important to know how frequently the woman is contracting because you need to see where these decelerations are in relation to the contraction because you don't want to have late decelerations, which is why the baby is decelerating after a contraction. That's a sign that baby is not getting enough oxygen. And you often have a traffic light system as well when we kind of look at interpreting CTG S. So you, you'll often hear the terms normal CTG suspicious or pathological. Ok, great. So next question, you've got a 28 year old woman. So we're just looking at um rupture of membranes, basically preterm. Um So 28 year old woman who's 18 weeks pregnant attends A&E with a history of clear vaginal loss. She's got a past medical history of large cone biopsy of the cervix and she's allergic to penicillin on examination. It's apparent that her membranes have ruptured. So what's the most appropriate initial management in this case? Are you able to see the um responses now? No, I can't actually, I can see the shot, but I can't seem to see the responses for some reason. I don't know why. Uh Yeah, you might have to tell me. No, no worries. Um, yeah, that's fine. We'll give it another few seconds and then I'll, uh, I'll give you the results. Yeah, I don't know why I can see the chart, the place. So we've got, uh, four responses in total. Uh, 75% got wentw with C and 25% went with B ok, fine. So, B and did you say C or did you say D, sorry, what was the first thing that you said C 75% went for C went for C fine. Um So I understand why you guys have picked C but can anyone tell me, would we give? So, first of all, I guess the question is, is this a viable pregnancy? 18 weeks pregnant? So this is a, it is a tricky situation because obviously this woman has ruptured her membranes at 18 weeks, right? Um If this lady was 24 weeks and above, we would give her steroids, but because she's less than 24 weeks, we wouldn't really give steroids in this situation. So the main risk if you ruptured your, your waters at 18 weeks is the risk of chorioamnionitis and maternal sepsis essentially. And there are really poor outcomes for mom and for baby and there's loads of papers that show that. So actually, at 18 weeks, often we would counsel these patients. It's really sad when someone ruptures their waters this early because you can't put a cage in because it's contraindicated if someone's broken their waters so often, actually, your only two options are just expectant management, but there's a risk of overwhelming sepsis and death with that or just termination of pregnancy. But before we offer her a termination, we need to admit her, we need to do infection markers and we need to just um do an ultrasound scan as well. So we wouldn't, that's why it's D over C. That makes sense. And B is, is correct, but it's not the most appropriate initial management. I hope that makes sense um for that question, but that is a tricky one because they're all quite similar actually. Ok. So just quickly going through preterm labor. So what are some of the causes of preterm labor? So, infection is a big one, multiple pregnancy, sorry, antepartum, hemorrhage, IUGR polyhydramnios and previous surgery on the cervix. So, I um in this question, this lady had a large cone biopsy of the cervix which can increase the risk of cervical uh incompetence essentially. And that can increase your risk of going into preterm labor and in the baby, there's obviously the risk of prematurity. So, respiratory distress syndrome, neck neonatal jaundice, failure to thrive and cerebral palsy. That's just a picture of a cervical sage. And sometimes if women have had previous preterm deliveries and you can have an elective cervical sage or you can have an emergency sage as well if, which, which might be done if someone is um you know, if the cervix is starting to shorten, then they might come in and they might have to do an emergency sage. So, p prom of preterm prelabor rupture of membranes, it's basically defined as rupture of membranes between 24 and 37 weeks in the absence of any uterine activity. Why is it a problem, as I've mentioned already, if you've got the rupture of membrane, there's a risk of infection and we've spoken through some of the risks of prematurity in the nearly. So how do we investigate the same way we would investigate anyone with a suspected infection. So FPC use and CRP you confirm the rupture of membranes so often you'll do a speculum and you'll see pooling of Lyor or you do tests. So in we do an Amnis which is just a swab that you take and actually, it's a bit like a COVID test. You run it in the re reagent and then you wait for a minute and two lines means that it's positive. That means the woman has ruptured her membranes. One line means that it's negative. And some hospitals do a fetal fibronectin which is slightly different. It gives you the risk of the woman going into pre into preterm delivery or prep premature birth. Essentially, how do we treat it? So, if a woman is stable, no signs of any infection, she's not contracting, you can just give them Erythromycin for 10 days and you try to take them to 37 weeks essentially. Um And obviously, if they are, if it looks like they're going to deliver in the next week, then you'd consider steroids. And we mentioned already the reason why we give steroids is because of fetal lung maturation. OK. Good. Your next labor and secure question. You've got a 34 year old prim admitted for induction of labor. It's a post induction. So she's admitted for induction of labor at 42 weeks. Um She's received propass followed by 5 mg of Prostaglandin. These are just your induction agents and after which we have broken her waters, her cervix was five centimeters dilated on a previous examination. Four hours later, she's still five centimeters. She's contracting two every 10 minutes and she's got an epidural in situ what do you, what do we think is the most appropriate plan for this lady? This weight? Oh II can actually see the options now. Perfect. Um OK. So we got uh maybe I'll wait for a few more responses. So we're kind of split between, well, more people have said D over B and that's correct. So she's only contracting two every 10 and think about the power passenger uh passage, right? So you need to have at least 3 to 4 contractions every 10 minutes. So at this point, we would start her, we would consider augmenting her, her contractions essentially with an Oxytocin infusion and with Oxytocin infusion, you'd basically want the fetus to be continuously monitored, which is why it's not C and that's why it's d the reason why it's not B is because obviously we can always offer her a Cesarean section. But there's no actual indication for a Cesarean section. At this point in time. I think it would be worth at least trying an Oxytocin drip and seeing how she progresses once she has more regular, more frequent contractions. Ok. So quickly going through induction of labor. So why do we induce labor? It's basically when the risk of continuing with the pregnancy outweighs the risk of delivery for either mom or a baby obstetrics. So with anything in obstetrics, you have maternal indications and you've got fetal indications, obstetric indications are obviously the placenta is just giving up basically as insufficiency. So baby is small, wa water around, baby is less as abnormal blood flow to baby. All of those things are intrauterine growth restriction, prolonged pregnancy because obviously, there's a risk of stillbirth. Um if the pregnancy goes on for too long, if there's a non reassuring CTG. So if it's got any of those like decelerations rise in baseline, if the variability is crap severe preeclampsia, obstetric cholestasis, medical reasons, for example, GDM. Uh So we do something, we calculate something called a bishop score to basically assess favorability for induction. A score of over eight means that it's a favorable cervix. Basically, how do we induce? So you've obviously got nonmedical and medical methods of induction so you can do a membrane sweep, which can be offered to women in the community prostaglandins, which basically cause uterine contractions. You've got your pro pessary, which usually stays in for 24 hours. It's a longlasting one or you can put a gel which stays in for around six hours and we examine them after that, you can give Oxytocin infusion. Um You can do an amniotomy, which is artificial rupture of membranes using an amni hook. And that's what the picture at the top shows you. This is just the bishop score and you guys can have a look at it in your own time. Um Things to consider with induction of labor is need for CTG monitoring and monitoring of uterine contractions um during a vaginal examination. So for example, if we've got an emergency buzzer going for a fetal bradycardia, you do want to do a vaginal examination because if you've got a sudden drop in baby's heartbeat, then you're thinking, is this a co prolapse check previous scans for low lying placenta. Um often if you're starting someone on a hormone drip, then you want to give them good, a good pa good pain relief or good analgesia, for example, an epidural and just need to assess progress. Essentially, some of the complications are that you could have hyperstimulation. So the uterus contracts too much and that can lead to fetal distress. You can have uterine rupture, especially in someone who's had a previous Cesarean section. There's a one in 200 risk of rupture even before we give them any hormones, failure of induction. So obviously you can repeat the induction or you can offer them a Cesarean section. Ok. Moving on now to the third part of our talk. Um I don't know if at this point you want to, should we break for five minutes or are we happy to just keep going? I don't know what you guys usually do. Uh We normally just keep going. Um Just saying it going on too late as well. Yeah. Yeah, that's absolutely fine. Ok, great. So maybe I'll just stop to answer any questions if you guys have any questions on all the stuff that we've covered so far. So the bleeding and pregnancy, um and some of the aspects surrounding labor, there was a question before about discussing UT and BB in the 2nd and 3rd trimester. Um Was there anything specific about, about those two things that you wanted answering? So, obviously, with UTI, it's just really important that we treat the UTI and often with UTI, you need to have um a second M CNS after you've treated them. So they, they, they do need to give us a second urine sample. Um Obviously in the third trimester, there are certain, so antibiotics that you would avoid. So you wouldn't give them nitrofurantoin, I believe because that there's a risk of uh neonatal hemolysis. Um Usually we like to give them cefalexin, you wouldn't give them trimethoprim in the first trimester because of the uh teratogenic effects essentially. And BV, there's an increased risk of preterm labor, I believe with BV. And I think there's some kind of uh discrepancy as to whether you would actually treat BV or not. I think it's people kind of um yeah, it's, people are kind of undecided on whether you treated or not if I'm not mistaken. Ok. So if the, if there are no further questions, uh just keep going because there is um quite a bit left to cover. So going on to complications during delivery, here's your next M CQ. So which of the following are not risk factor, you should say not risk factors for a breach presentation. Ok. So um 42% of people have said b which is the correct answer. So actually having a previous Cesarean section is not a risk factor. Um for a breech presentation, all of the other ones are so multiple pregnancy polyhydramnios, placenta, previa and UTR malformations. Ok. So what is breech presentation is basically when the buttocks, the foot or the feet are presenting instead of um that should say instead of the head. Um and it is normal in preterm pregnancy less than 37 weeks. So whenever someone is in preterm labor, it's really important that we do a bedside scan to check that the baby is actually cephalic. Um What are some of the risk factors. So you can divide them into uterine and fetal. So, uterine. So, multiparity, if someone has had loads of babies before the uterus is just a little bit more lax. So that increases your chances of um your risk of having breech presentation malformation. So, if you've got a septate uterus, that can increase your chances of baby being bree fibroids, placenta, praevia, fetal things. So we mentioned already prematurity, macrosomia, polyhydramnios just think of it as a big pool. The baby is just swimming around. Um So you're more likely to kind of have an unstable eye with polyhydramnios or if there's any abnormalities in the baby as well. So how do we manage it? So you kind of had, you basically got three options with breech presentation. You can either have a vaginal breech delivery E CV at 37 weeks. E CV is basically external cephalic version, which is basically where we turn the baby. There is a 50% success rate. I have to say I actually haven't seen any successful EC vs but people, a lot of people do have successful EC vs um it when you do them, depends on whether they are Nli Paris or malts. So you do it slightly earlier at 36 weeks for Nala Paris and 37 weeks for MTs. And if you have had a baby before have had a normal delivery before, then there's a slightly increased chance of the D being successful if failed then we basically do um, an elective Cesarean section at around 39 weeks. Ok. So that's kind of everything you guys need to know about. Breech. And obviously, if the baby is footling breech, then you'd, then that's basically contraindication to having a normal delivery. Ok. So next question, um, you are the junior doctor on labor ward. You're called by a midwife to a delivery in which the baby's head has been delivered, but the shoulders will not deliver with normal downward traction. Which of these is your first step in the management of this condition? Let's assume obviously that the um, the buzzer has been pulled, everyone's there. What's the first thing that you would do? Ok, great. So most of you guys have said the correct answer, which is d asking the mom to hyperflex their legs and applying suprapubic pressure. Does anyone know what this maneuver is called? Macros? Correct? So shoulder dystocia, um it's a scary emergency when it does happen actually. And the, the scary thing about shoulder dystocia is that it doesn't just happen to big babies, actually, 40% of shoulder dystocia, right? If I remember correctly actually happens to babies that are just normally sized. So essentially, it's a bony problem. The anterior shoulder of the baby becomes impacted behind the mom's pubic synthesis. The biggest risk factor is macrosomia, particularly in women with GDM because if you just think of them GDM babies have chunky shoulders. So the shoulders are more likely to get stuck on maternal complications. Obviously, it's a difficult delivery. There's an increased risk of bleeding, increased risk of third or fourth degree tears. They are basically tears that go into the back passage. Fetal complications are um, fetal hypoxia fracture of the clavicle, the humerus during delivery and brachial taxus palsy as well. Um, and that's just a picture of the, um, of the shoulder getting stuck. That's why that's your herbs palsy. So management of shoulder dystocia, obviously, it's an, it's an emergency call for help. Um, pull the emergency buzzer, inform the mom that loads of people are gonna come in, ask the mom to stop pushing. And essentially what you do is I do mcroberts maneuver and what it does, you're basically hyperflexing the legs and it essentially widens the pelvic outlet because it's a bony problem, right? So if you make more space, baby's shoulder is more likely to deliver and the success rate is actually 90% even higher when you're combining it with suprapubic pressure. And obviously, you've got some of your other maneuvers as well. So if you need to get access to the baby's shoulder to deliver the posterior shoulder, then you can consider an A pio which can make the maneuvers easier. But for you guys, you just need to know what the initial maneuver is that we do. And actually 90% as it says are successful, babies are delivered just with uh mcrobert's maneuver great. Um Next question. So you've got a 30 year old woman, 41 weeks pregnant. She's being induced in the labor ward. She's got an a she, sorry, she has an AM which is an artificial rupture of membranes. But the midwife notices that the umbilical cord is visibly protruding from the vagina she's brought in for an emergency cesarean section. What's the correct position for her to be in whilst being prepped for surgery? Ok, perfect. So all of you guys got the right answer. So the correct answer is D which is on her knees and elbows. So cord prolapse again, this is not as common as a shoulder disor. You actually haven't, haven't seen a cord prolapse in the two years that I've been doing obstetrics and gynecology. Essentially, it's basically where the umbilical cord descends through the cervix, either on or before the presenting part. Why is it a problem because it's got quite a high mortality rate essentially. What happens is the cord being exposed to the environment, you essentially have arterial vasospasm and you also have occlusion because if you think about it, if you've got the cord here and you've got the head pressing on the cord, you've got that acute cord compression essentially. And that causes fetal hypoxia and all of those longer term and short term complications of that, what are some of your risk factors? The baby being bree unstable life. And if you're doing a rupture of membranes and the baby's head is quite high up because if you think about it, if you've suddenly got a loss of pressure, then you've got the cord coming down, especially if the baby's head is quite high. Also, if you've got polyhydramnios as well. So there's loads of fluid around baby, we do what we call a stabilizing ERM, which is essentially to try and reduce the risk of this cord coming down and prematurity as well as another risk factor. So management of cord prolapse. So consider this if the baby's heartbeat drops suddenly. Um and it's confirmed basically on vaginal examination or on external inspection. Um call for help. It's an emergency, avoid handling the cord. And essentially what you want to do is manually elevate the presenting part to kind of stop that occlusion of the cord uh positions. Either you do left lateral or knee to chest, which relieves pressure on the cord. Consider tocolysis and deliveries usually via emergency cesarean section unless the woman's fully dilated. And this is something this is called bladder filling. And that's often not actually done in hospital. It's often done in the community if they notice a cord prolapse. And what they do is they basically inflate the bladder with 500 mils of IV fluid. And what that does, it basically pushes the head away from the cord because of the enlarged bladder. And then you basically got exaggerated sims on ne and elbow position. Um whilst taking the woman to theater. OK. Next question. So you've got a 36 year old. Now, uh pri private woman who is admitted in labor at 37 weeks, gestation on examination. The cervix is fully dilated head is at direct occipital anterior fetal station is plus one head is 0/5 is palpable. So the wound is fully dilated. Um You've got a pathological ctg, you've got lots of decelerations. Fetal heart is 100 BPM. What should we do in this situation? I'll wait for a couple more responses. OK. We actually have a 5050 for um well, actually, maybe not. Um So most of you guys have said b which is instrumental delivery, which would be the right thing in this situation. So you guys would have seen on your placements and stuff where there are some babies that we decide are going to come in the room. So we do an instrumental delivery in the room or there are some that we take for a trial in theater, for example, plus minus cesarean section is what we would consent them for. In this case, the woman is fully dilated. The head is a direct oxygen to anterior and the station is at plus one. So actually this, it sounds like this is something that could be delivered in the room. So we would do an instrumental delivery. In this case. For example, if the baby was at spines, if it was mild position So either ot or op, um, then we would think, let's, let's do a trial plus minus Cesarean section because you're thinking if this delivery fails and we need to convert to a Cesarean section very, very quickly and we wouldn't continue pushing. In this case, we wouldn't give them a prostaglandin because a prostaglandin is for inducing it. But she's already fully diagnosed. That wouldn't be applicable. And Oxytocin oxytocin infusion also wouldn't be appropriate in this case because you just need to deliver the baby basically. Ok. So, um just quickly going through instrumental deliveries. So the pneumonic is forceps. So you need a fully dilated cervix obstruction should be excluded. Uh You need to obviously make sure the woman has ruptured membranes. You need to consent them often. It's just a verbal consent. If it's in the room, make sure that the bladder is empty. So, if it is catheterized, you often have to just deflate the catheter and remove the catheter, check your instruments, uh make sure you have good working analgesia. So sometimes we do it. If the woman doesn't have an epidural. In that case, you'd have to give her local, local anesthetic or consider doing a pudendal block. Explain the procedure, examine the vaginal area for any signs of trauma, you need to think about which way the baby's head is facing. How high the head is. Do they have adequate uterine contractions? And the station, the station is basically how high the head is and just think about whether you need senior help present in the room. So, maternal indications for instrumental delivery is prolonged second stage. Um maternal exhaustion, if they've got maternal medical conditions, that kind of um contra indicator, you would be a bit more cautious with allowing them to push for a very long amount of time. Fetal indications are obviously fetal compromise in the second stage. So that's either on CTG or on fetal blood sampling. I must say fetal blood sampling is something that's not very commonly done. So even in North Middlesex or in Europe, we don't really do any F PS but it, I think it does still come up in some of your M CQ. So it might just be worth going through it if it's still coming up. But often most units actually aren't really doing any fetal blood sampling um anymore. So you've got two types of instruments of choice. Basically, you can do a Kiwi or a suction cup delivery um or you can do a forceps living. Um The kind of rule of thumb, I guess is that the forceps essentially have lower fetal complications but greater maternal complications. Um You're often allowed three kind of pills if there's no reasonable progress and the attempt is often abandoned and you, you have to get senior help in that case. So AKI B is basically a handheld disposable one too. It can be used for all fetal positions and it's it can be used for rotational deliveries as well. Maternal risks are lower pain and perineal injury. Fetal risks are, there's a higher risk of baby having swelling in the head and retinal hemorrhage forceps delivery. So you've obviously got nonrotational which are used if the baby is kind of either facing down or looking directly up. So oa ro as well, you can use Wrigley's forceps to a different kind of forceps at cesarean section. You can use keys, which I must say that I, I've never seen a keys being done. There's not many people that are actually competent and trained to do keys, but you can in theory, do a key lens for a rotational delivery. The thing with forceps is there's a higher rate of 3rd and 4th degree tests. So you need to have a very low threshold for giving an episiotomy, especially with a forceps delivery. And almost all women who are uh so primary women who are having a forceps delivery will have an episiotomy to kind of avoid that tear extending into their back passage. And it's very, very important to protect the perineum when inserting the blaze and also when pulling uh the baby out as well. Ok. So that's kind of a quick tour through instrumental deliveries. Um I think this is your last M CQ question for um for this section. So you've got a 29 year old multiparous woman in established labor contracting regularly, four centimeters dilated she was having regular painful contractions before they stopped. And now she's got sudden onset, severe continuous lower abdominal pain. The fetal heart rate trace is difficult to identify and the tocometer is not really registering a signal. What's the most appropriate management? Ok. Yeah. So most of you guys have said d which is the correct answer. So uterine rupture is basically, this is a case of a uterine rupture. Uh uterine rupture is basically a full thickness, tear of the uterine muscle typically occurs during labor. It's quite rare, but it does have significant maternal and fetal risks. So, risk factors are anything that makes the uterus weaker. So previously, section I've mentioned already having had a previous myomectomy. So often uh patients who've had a myomectomy, they'll be counseled as to whether they can have a normal delivery or whether they would advise them to have an elective cesarean section, induction of labor, multiple pregnancy and multiparity as well. I think that makes you just a bit more lax. So sudden severe abdominal pain that persists between contractions, shoulder tip pain, vaginal bleeding, you can have regression of the presenting part and also kind of scar tenderness, palpable fetal parts as well on examination and from the end of the bed, they'd be in hypovolemic shock. They'd be quite tachycardic as well and you'd have um fetal distress on the CTG management, essentially stabilize the women, take them to theater for a cesarean section and then you'd have to repair the tri no. Oh, sorry. Last complications during delivery and CQ. So this is looking at PPH. So you've got a 36 year old woman background of preeclampsia suffers from a major PPH. After delivering twins, the obstetric consultant examines her and suspects. U try and h to be the cause protocol for PPH is initiated. Um You've got bag compression which fails to control the hemorrhage, which of the following drugs should be avoided in this case to manage her PPH. So these are all drugs that you'd get for PPH, which of them would be avoided because of her preeclampsia. Wait for a couple more responses. Ok. Yeah. So most of you guys have said d which is the correct answer. So ergometrine should be avoided in anyone that has any kind of preexisting cardiovascular conditions including preeclampsia. You'd avoid carbs in anyone that has a background of asthma. So those are just the two things that we need to think about when we're giving medications for pph. Good. So we'll quickly go through primary PPH. How do we define it? Basically, it's a blood loss of over a liter after Cesarean section or over 500 mils. Um, risk factors. Um And essentially you think of the forties. So tone tissue trauma, thrombin, most of the times it's either tone or trauma and the remaining time the tissue or thrombin. So risk factors for poor tone, high BM I age of over 40 Asian ethnicity, uterine over distension. So the uterus is over distended, it's gonna take longer to contract. So, polyhydramnios, multiple pregnancy, macrosomia induction of labor, prolonged labor, sepsis as well, uh placental problems. So, previous abruption, previous PPH and if you do suspect atony, basically binal compression works really well as a first time and you give them drugs, oxytocin, ergometrine, carboprost, myops you can give, you can do surgical measures as well. So putting in lots of hemostatic sutures, um intrauterine balloon tampon, which is what it shows you on the right. Obviously, if you suspect trauma, then primary repair of laceration and tissue. So you can do a manual removal of placenta, which is basically where you go in and you essentially just remove the placenta. You have to give them prophylactic antibiotics and give them IV Oxytocin as well to have the uterus to contract. And if there's any coagulation abnormalities and you have to correct them after discussion, discussion with hematology. And again, that's quite rare. The most common things are tone trauma and tissue. Ok, perfect. So we're currently on the last section of the talk. Hopefully you guys um are finding this useful. Do you guys have any questions for uh the stuff that we've covered already? Anything on instrumental deliveries or any other complications during delivery? Ok. Fine. So if you guys do have anything, I'll um just feel free to put it on the chat and then I'll try and answer it um best I can at the end. So, moving on to conditions in pregnancy. So we're just gonna try and cover GDM preeclampsia, itching in pregnancy and high premesis. Um So conditions in pregnancy, you have got a 32 year old pregnant woman, South Asian origin, 10 plus zero weeks into her second pregnancy. Um She's had one normal delivery at 39 weeks and no other previous pregnancy. She's got a strong family history of type two diabetes and she's offered a fasting glucose test at her booking visit and her fasting glucose level is 7.2. What's the most appropriate initial management? Given her fasting glucose level? Ok. So most of you guys have said d which is the correct answer. So the answer is insulin in view of the fact that the fasting glucose level is over seven. Um So let's go through GDM. So GDM risk factors and screening questions. So these are all some of the things that you'd be thinking of. Um and if, if present, you basically offer them screening using OG TT. So BMI of over 30 family history of diabetes, even the first, so first degree relative ethnicity, South Asian Chinese, a Caribbean Middle East, previous macrosomic baby weighing over 4.5 K GS and previous GDM. And if this is the case, then you'd usually do a 75 g two hour oral glucose tolerance test at 24 to 28 weeks. Often in Europe, we actually do an earlier one at 16 weeks as well because our population, we've got a lot of gestational diabetes in view of our uh quite high South Asian um population. Um So the easy way to remember diagnosis of GDM is just remember, 5678. So fasting glucose level of over 5.6 e greater than or equal to 5.6 and a two hour O GT or greater than or equal to 7.8. And that's your uh diagnostic criteria for GDM. So once you have diagnosed GDM, they basically often get seen in the diabetic antenatal clinic. Within one week, you counsel them on the complication of diabetes. The importance of monitoring of glucose and the importance of glycemic control, uh ways to manage GDM. You often start with diet control. Um then you can move on to Metformin or insulin. So if your fasting, this is taken from the nice guideline. If your fasting plasma glucose is less than seven at diagnosis, then uh it's appropriate to actually have a, a trial of diet and exercise for 1 to 2 weeks. That doesn't work, then you can start Metformin. If that doesn't work, then you can start insulin. But if it's over seven at diagnosis or if the fasting plasma glucose is 6.0 to 6.9 and you've got other complications like big baby, lots of fluid around baby, then you would think about starting insulin essentially. Plus minus metformin and obviously, diet and exercise kind of goes throughout regardless of what other pharmacological agents you're taking. So when it comes to complications of GDM, you can again spread that into maternal and fetal. So, maternal complications and increased risk of preeclampsia, increased risk of infections, higher rates of induction of labor and cesarean section, higher rates of miscarriage. Obviously a bit earlier on in the pregnancy, fetal complications, there's an increased risk of malformations, especially cardiac malformations, increased risk of baby being big shoulder dystocia. We've mentioned already polyhydramnios, well, and longer term risk is an increased risk of diabetes and obesity in later life. So, care of women with GDM, they often get seen in the diabetic clinic, as I've mentioned already, they have a detailed anomaly scan with a four chamber heart view and they have growth scans every four weeks from 28 weeks onwards. And you have to monitor the abdominal circumference of the baby because that's the most sensitive marker of macrosomia. Um and they essentially have to check their sugar levels four times a day. So before breakfast and then uh two hours or one hour post meal, um often if you've got uncomplicated GDM. So GDM, that's just um um kind of treated with diet control. You would usually induce them. Uh The new guidelines are 40 plus four, but the nice guidelines say 40 plus six weeks. But obviously, if they're on insulin, if they're on Metformin, then that's a high risk GDM and you'd, you then induce them much earlier than that. So, for example, by 39 weeks, if they have not given birth by this time, then either you induce them or you, um, kind of do a, uh, book them for an elective cesarean section. If there's any maternal or fetal complications, then you'd consider elective birth before 40 plus six. Um, what's the risk of giving corticosteroids in women with? What do we have to kind of think about as a kind of unwanted complication, I guess of steroids. Uh poor glycemic control. Yeah. So it often can actually shoot your sugars up and that can last up to 24 to 48 hours after. So the sugars are very high. Often these women will then be put on a sliding scale. Um whilst they're having the corticoids and until the sugars kind of come back down. So during labor, it's important to have continuous CTG consider sliding scale insulin, especially the sugars are um greater than seven. That's our threshold for starting sliding scale insulin. And it's important that these so women with GDM um delivering the baby basically cures them. So you'd essentially stop all the Metformin, stop the insulin post delivery. But obviously, if someone's got type two diabetes or type one diabetes, you go back to what they were on before. That's kind of your um rule of thumb basically with postpartum C. Yeah. So I've mentioned this already discontinued blood glucose lowering therapy immediately after birth. It's very important to counsel them about the risk of GDM in future pregnancies and the risk of type two diabetes as well. So lifestyle advice and the GP basically has to check their fasting plasma glucose at six weeks or HBA1C after 13 weeks. So just a few additional things for women with preexisting diabetes. So, preconception counseling is very, very important. So you want to aim for A HP A1C of less than 48. And actually, if it's as high as 90 then we would even advise them against getting pregnant, high dose folic acid, 5 mg, preconception, arrange dietician review and you want to stop things like um gliclazide, any other oral hypoglycemic agents except for Metformin, you also stop the statins, stop them on any ace, stop any ace inhibitors because those things are uh linked to teratogenicity in the baby and very important to do a retinopathy and a nephropathy screen as well. Again, um uh counseling them on hypoglycemia and especially in type one diabetes. If they're quite unwell, exclude DK, assess renal function retinal screen. And women with type one or type two diabetes are often delivered much earlier than women with GDM. So usually the nice guidelines say between 37 and 38 plus six before 37 weeks. If there's any complications and postpartum, I've mentioned already returned to what they were on before their pregnancy because your your insulin requirements often they reduce quite drastically after giving birth, um advise them to snack before and after feed to reduce the risk of them having hypoglycemic episodes and insulin and Metformin are both safe to use in breastfeeding. Ok. So next question, a 38 year old woman in her first pregnancy is 36 weeks pregnant. She presents to labor ward, feeling dizzy with a mild headache and flashing lights. She's got a past medical history of lupus renal stones and malaria. Her BP is 100 and 58. Over 99 she's got two plus protein in her urine and those are her bloods. What is the most likely diagnosis? Yeah. Ok. So all of you guys have, have selected the correct answer which is hellp syndrome. So hellp stands for hemolysis, elevated liver enzymes and low platelets and that's a complication of severe preeclampsia. So correct. That's the answer for that one. Um Next question again to do with preeclampsia. So you've got a 26 year old woman who was admitted at 34 weeks gestation with preterm labor. She's got a BP of 100 and 75/1 05. Urine analysis reveals three plus of protein urea. She's commenced on magnesium sulfate and labetalol. And now she's complaining of reduced fetal movements and your CTG shows um late decelerations and a fetal heart rate of 90 BPM. What would you do next? Ok. Yeah. So again, you guys got the answer right. It is emergency Cesarean section. So you've got enough things. Yeah. Which kind of the, the baby's telling you that the baby wants to come out. The mom sounds quite unwell as well with such a raised BP. Um, and you've already commenced magnesium sulfate as well. Um, so why do we give magnesium sulfate in this case? What's the indication for it? Prevent seizures? Exactly. So you can also give magnesium sulfate on a separate note in preterm deliveries as well. And in that case, it would be for neuroprotection of the baby and reducing the risk of cerebral palsy. But in this case, in someone with severe preeclampsia, you're starting IV magnesium sulfate to protect them against seizures basically. And often if you have gotten to the stage where you're starting IV mag sulf, you are going to deliver them pretty soon. Ok. So going through preeclampsia. So preeclampsia is defined by hypertension, uh BP of over 1 40/90 pro urea um and it develops after 20 weeks and usually resolves within six weeks of delivery. So, pathophysiology essentially, you have an development of an abnormal placenta which then kind of releases these proinflammatory proteins which causes endothelial cell dysfunction and it causes vasoconstriction of the vessels which then gives you the high BP. And there's a very good video on osmosis. Actually, that kind of explains and goes through the whole pathophysiology of preeclampsia, some of the risk factors. Um You can divide risk factors of preeclampsia into high risk and low risk um high risk and moderate risk. Sorry. And if you've got either one high risk or two moderate risk factors, then essentially you would be started on aspirin 1 50 mg from 12 weeks until delivery. Um and essentially, it must be started less than 16 weeks for it to be effective because aspirin is thought to help with the trophoblastic invasion, which all happens in the first trimester. So you want to start it as early as you can basically. And um yeah, you guys can be to the high risk and the moderate risk factors. So, clinical presentation, we've kind of uh been to them already. So you've got headache, flashing lights, epigastric pain or severe pain just below the ribs, nausea and vomiting, sudden swelling of the feet, fingers or lower limbs. And that's important to ask in kind of every consultation. Basically, signs. Um You have hypertension, you've got protein, urea, epigastric tenderness. They have quite brisk reflexes. Um Obviously, preeclampsia is a uh pre mediating condition to eclampsia which is having seizures and it also increases your risk of placental abruption as well. And we've mentioned hellp syndrome already. Um So how do we investigate essentially? You basically want to do F PC clotting LFT S urine PC. You wanna check the urine, uh your, their, their electrolytes as well as their creatinine. When do we admit someone to hospital. So if they've got a sustained systolic BP of over 160 any concerning biochemical investigations. So they've got abnormal LFT S, abnormal kidney function, any signs of pulmonary edema, signs of impending eclampsia or if the, the suspected fetal compromise, how do we treat it? So we basically give them antihypertensives. Your first line is labetalol, unless they're asthmatic, then you would consider giving them Nifedipine instead. Um second line is Nifedipine and third line is methyldopa. What's the concern about methyldopa, postnatally? So often women that are on methyldopa will actually stop it and get changed to something else. So what's the risk of continuing methyldopa after delivery? Does anyone know? So there's a small risk of postnatal depression with methyldopa, which is why we usually switch it to some other antihypertensive agent. And usually these women will be seen in our maternity day units. They have blood tests twice a week, they have BP monitoring at least every 48 hours and we do CT GS as well to check for fetal monitoring. So they'll come in a few times a week just for the preeclampsia monitoring. Um And obviously you wanna do ultrasound scans for baby. Um You wanna check the growth of the baby, you wanna check the fluid around the baby and you wanna check the blood blood supply to baby as well. So decisions on delivery, usually preeclamptic women get delivered kind of 37 weeks, but obviously before 37 weeks. If you've got any deterioration in thuds, eclampsia, abruption, abnormal blood flow to baby or if you've got any deterioration in the blood as well. So, consideration obviously, if you delivering someone preterm and you want to discuss with neonates, give them magnesium sulfate for neuroprotection and give them corticosteroids for lung maturation. And yeah, this we've kind of mentioned already. So just postpartum, basically, often these women will be sent home with antihypertensives and the GP will then review them in two weeks time. Um And if their BP is kind of coming down, if it's too low, then they would consider dis uh discontinuing those antihypertensives basically. And um days 3 to 5 post delivery, usually when these women have a BP spike. So it's very important to kind of bring them in. Um uh either, you know, community midwives can check their BP or they come into the maternity day unit after delivery to kind of check their BP, check their P et bloods, check their compliance with the medications and just quickly going through how we treat eclampsia. So do an A two give them magnesium sulfate IV bolus and then the infusion and if you have any repeated seizures and you're treated with diazePAM. So the first line management for an eclamptic seizure is magnesium sulfate the bolus and then the infusion and um sorry. So the signs of magnesium toxicity. So it's really important to monitor the respirate, tendon reflexes, um urine output as well. Does anyone know what the antidote is for magnesium sulfate toxicity? What do we give if we're suspecting that we've kind of overtreated with magnesium sulfate? So we would give them calcium gluconate. That's the antidote of choice. Basically with magnesium sulfate toxicity. And it's always important, obviously in obstetrics, anyone with a seizure, we kind of think that it's preeclampsia. That's kind of our first diagnosis, But it's very important to think about other causes of seizures as well. So, could there be a clot? So, could it be a cerebral venous sinus thrombosis? Could it be a stroke? Could it be hypoglycemia? So, never forget the glucose. Could it be hyponatremia infection or um intracranial mass as well? So, those are some of your other differentials that you think of with seizures? Ok. So I think we're coming towards the end. Um just have um itching in pregnancy and hyperemesis um left to cover. So um next time, see you for you guys, a woman complains of severe itching at 34 weeks. Gestation. Um itching started two weeks previously, has been stopping her from sleeping. She's itchy all over her body, especially in her hands and feet. She's not noticed any rashes and her mother reported similar symptoms when she was pregnant with her second child. She's otherwise. Well, what's the most appropriate action in this case? What do we need to do first? Ok. So most of you guys have picked e which is the correct answer. So you have to do bile acids to make sure that it's not obstetric cholestasis because it sounds very much like obstetric cholestasis. You're having itching, especially in hands and feet, which is worse at night. Um And she doesn't have any other rashes on her body. So just thinking about some of the other dermatological things that can give you itching and rashes. So you've got atopic eruption of pregnancy, which is just an eczematous itchy red rash. Um polymorphic eruption in pregnancy, which is usually associated with the third trimester. Often you have lesions first in the abdominal stria and you treat that just with emollients, topical and oral steroids. Um We've got pemphigoid gestationis which is much more severe. That's why you've got blistering lesions. As you can see in that picture often it's periumbilical and then it spreads to your trunk, back buttocks and arms. Uh that's again seen in the second or third trimester and because it's much more severe, you're treated with oral steroids. Ok. So quickly covering obstetric cholestasis. So it's often in the third trimester. We said it's in the palms and soles worse at night. Other features you can get are jaundice, malaise anorexia. You can get an ob obstruct um uh an obstructive picture. So dark urine and pale stools and you can get steer as well because of the malabsorption and investigations, you'd find raised bile acids, you might have abnormal LFT S or the the liver function test can be absolutely normal. So, management essentially is you repeat liver function tests or the bile acids, basically, every 1 to 2 weeks, consider also deoxycholic acid for symptomatic relief. But it doesn't really have any impact on the neonatal outcomes. So, outcomes for baby and essentially, if your bile acid levels are very high. So if they're over 100 then there's a very, there's an increased risk of stillbirth. So we would induce these babies at around 35 to 36 weeks. Ok. So this is your last M CQ for the session. You'll be happy to hear. Um So yes, I've just seen the the message on the chat. So yeah, if um yeah, if anyone has to leave, thank you so much for attending. There's just a few, a few more slides to go. So if you, if you do have to leave, don't worry, you can always have a read through the rest of the slides. Yeah. So just going through this M CQ. Now, um you've got a 19 year old woman who presents to your surgery 14 weeks into her second pregnancy. She's had a normal dating scan at 10 weeks. She visited 24 hours ago for excessive nausea and vomiting and was started on oral cyclizine. However, she's still unable to tolerate any oral intake, including fluids and her urine dip is positive for ketones. What should we do next in this case. OK. So most of you guys have said e which is the correct answer. So you would need to admit her to hospital. So your criteria for admission in this case is that she's unable to, to tolerate any oral intake. So you would need her, she needs to have some kind of IV hydration. Um either IM or IV antiemetics and that can be done either in an ambulatory care setting, again, be part of the hospital or admission to an under gynecology. Basically, if she doesn't get any better despite the IV fluids and despite giving her antisickness, so, hyperemesis, gravidarum. So essentially, it's a spectrum of conditions. Uh The part of physiology is that you have rising levels of HCG which triggers your chemoreceptor trigger zone in the brain stem. And essentially, which is what causing causes the um the severe nausea and vomiting and the things that you need to make sure is that um it there's an increased risk of high Preis in multiple pregnancies and you want to make sure that you're not dealing with a molar pregnancy. So always make sure as I've mentioned before, these women get a scan, uh check your T FT S as well because beta HCG has a TSH like activity. So often these women can have a transient hyperthyroidism and often when you repeat these blood tests in six weeks' time, the thyroid function test will be completely normal. It usually occurs in the first trimester and it subsides by 16 weeks. But some women, a small fraction of women do have high premises throughout their pregnancy. Unfortunately. So, when do we consider admission if they're unable to keep down any fluids, if they've got ketonuria, weight loss, if they've got any other comorbidities like diabetes and always do a urine dip to check for infection. Um, so management, so you essentially, um, there's a new guideline that just came out a few months ago and there's a med, there's a medication called Zona, which is basically a combination of doxylamine and pyridoxine. And that um has now been commissioned to be given first line. You can also give other things like cyclizine, prochlorperazine, promethazine. Your second line medications are metoclopramide and non Dansetron and your third line, if those things don't work are corticosteroids. So things to consider, especially if patients are being admitted is your fluid of choice is normal saline, naught 0.9% with added KCL. It's really important to monitor electrolytes daily in these patients because of risk of hypokalemia and the cardiovascular complications resulting from that. Um combination of drugs work very well. So you can use two first line medications before you consider using a second line medication. Thiamine supplementation is very important to all women being admitted with nausea and vomiting in pregnancy. And obviously, if these symptoms continue on into the 2nd and 3rd trimester, it's really important to do Cial scans to check growth of people and sometimes actually very sadly, women, um the symptoms are so severe that women do consider termination of pregnancy and the RCOG guidelines do say that all therapeutic measures should have been considered and offered before considering termination of pregnancy. Ok, perfect. So that is the end of um everything that I think you guys would need to know for obstetrics that was a lot to cover. Um So sorry if I kind of went a bit fast in some of the sections, but I'm sure you guys um will, will have access to the slide so you can go through it in your own time and take your time to go through everything. Um This is just some of the use resources that I use. So osmosis is great for um explaining pathophysiology. They've got some really nice slides on like um management, um presentation, investigation and stuff, nice guidelines. They've got some good guidelines on ectopic pregnancy, diabetes, hypertension in pregnancy. Past medicine is really good for your testing, your knowledge and stuff. This was a textbook that I used. The one by um Lawrence. Um and Tim and this is a, this is another book. So 450 single Best answers. Some of the MC Qs that I used in my um talk was from this book. So it just got some useful um questions that you guys can use to test your learning. Yeah. So that is everything I hope that was useful. Happy to answer any questions that you guys have and thank you for staying um s uh so long on a Wednesday evening. Very good. Thank you so much for that session. It was II think I can speak for everyone. They say it was really good. Uh Very comprehensive covered all the high yield stuff that we need to know and um some really good in there as well. Uh I think all the thank you are coming through in the chat. Um And yeah, I'll just echo that. So thanks. Uh Thanks again for taking the time and for doing this. Uh And thanks everyone for attending as well. I appreciate it's, it's late on a Wednesday. Uh but we hope it was useful. Uh Please take a second just to fill out the feedback. It helps us to continue running the session, uh running these sessions. Sorry. And um our next one will be on Monday 29th covering orthopedics. Uh The link for the event will go out on our Instagram uh but just save the time and the date uh and the link will be out soon. Uh But yeah, if you have any further questions, just pop them in the chat. Otherwise we can, we can call it there. The recording will be available for you. Uh Once you fill out the feedback. So thanks again guys. And thanks Veronica. No worries. I was just gonna say, I don't know if there's a, a section in the feedback form cause I'm doing the Gynae talk as well. I think that's in, I think it's the first week of May. So if you guys have any gyna topics that you'd like covered, um you can maybe let me know on the, either on the chat or on the feedback form because then I can try and cover those in the um in the talk. That would be great. Yeah. Yeah. So, uh if you guys just either drop them in the chat now, I think on the feedback form, there's a section for um there is a text box in one of the one of the uh questions. So just leave any recommendations in there and we can, we can look through them. Great. Thanks guys and thank you for being um uh for staying till the end and answering all the questions and stuff. That was really great. Thank you. Thanks everyone. See you later.