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That were joined f three doctor Henry Willis who's currently studying a masters out in Delhi, um, with an academic academic job coming up. Um, so I'll hand over to Henry now for the talk. Thanks very much, Ben. Um, and thanks to everyone for coming, I think we've got, still got a couple of people dribbling in. Um, so as Ben said, II, er, finished after last summer, um doing a master's in public health out in Delhi. Um, so forgive me if it's a, it's a little bit late on my end but, um, we'll try our best to get through everything. Um, I've got a bunch of M CQ questions to go through. Um, I think we should be able to get through everything in the hour. But, um, if we don't, we can always uh stop short and um, then I'll have the slide. So, er, a quick on what I used to revise for my final. So mostly um, past medicine and past tests and then various online resources. Um I will go through this but a couple of tips early on is to make sure you're using diverse resources. Um, I was preparing for this presentation just seeing exactly what those different resources are saying there's quite a lot of conflict. So, if in doubt goes back to the guidelines. So let's start. Um, let me know if the slides aren't there. We are. Um, so. Right. I'm gonna give everyone, uh, you're usually quite time pressured in finals exams so you can have a minute to do this and then we'll go through it. No. Oh. Um, you should all be getting the poll as well. We've got some answers coming through. Um Five more seconds want to register your interest and that's us. So let's go through this question. Um Is there a way of getting the results on the share? Yes, I can, I've shared them now so everybody can see um but everyone can see that. Ok. Um So as you can see, we've got quite a spread of results here. Um Most of you going for b thank you for engagement. It's always good. Um And please ask any questions that you have. Uh I'll try and make as interactive as possible um while still trying to get through the content. So, um let's go through this question. Now, I've highlighted some of the key points in the question. Um The, as I'm sure most of you gathered, this is AAA woman with a suspected atopic pregnancy. She's had a transgenic ultrasound. Um And they've shown a adnexal mass. Um The key part, parts of this question are the mild, mild lower abdominal pain. Um, the fact that they've done a urinary pregnancy test is good to note. Um, and as I said, the size of the Adex mass will be important. So it's actually see iron methotrexate. So A to C are all management options for atomic pregnancies. Um, but as we go through the guidelines are quite specific as to what your management options are, um, we'll discuss those in a second. Uh Thankfully, non E or D, er, this is an emergency. This is a stable patient. If you look at the obs, um, she's not an extremist, so no need to do that. And an E is a management for um, a abscess. So we're not gonna do that one either, right? Um I said if anyone's got any questions, uh give shout out. So pregnancy not, this is likely to come up in your exam. Uh It's also the only real gyne emergency you'll have to be aware of when you're starting your F one F two jobs. Um, risk factors. Er, so adhesions, er P ID, er, any surgeon surgery in that area, um IVF pregnancies and also IUD S that's another exam technique point there is that if someone has an IUD in the question, um, think like a topic, um, obviously that there's a small failure rate. I think IUDS are about 98.9 or something like that. Um, and a lot of those will end up being topic um the key features for your exam questions, obviously, abdominal pain, vaginal bleeding, but shoulder tip pain. Um and you wanna shout out what the shoulder tip pain is being caused by any suggestions. No, that's fine. Um So shoulder tip pain is caused by peritoneal irritation. Um That's a ruptured ectopic. So, if they've got that, you're imagining they're quite unwell. But again, that would put that in the exam and you should be thinking ectopic pregnancy. The gold standard imaging is a transvaginal ultrasound. They might try and catch you out with a CT or a transabdominal ultrasound and always think about appendix. Um The, the the differential is miscarriage. Um but again, unless they have a transvaginal ultrasound, that's showing an intrauterine pregnancy, it's an ectopic control, proven otherwise. Uh you might hear pregnancy of unknown origin in the hospital and then obviously infect, of course. Um and then when you are do start practicing, uh please do a, a pregnancy test on everyone. You'll get in lots of trouble, especially if you're an e um if you haven't done one. and this again is an exam technique really related, but internal examination isn't necessary. Uh if someone else is definitely gonna do it and they're more senior. So, um we don't wanna be examining every patient. Now, this is the management. Um as you can see in the question, it's a 30 millimeter er ectopic pregnancy, which means that you're gonna try and manage this medically, I didn't have a fetal heart rate and I put the B HCG in that'd be quite nasty to give you that an exam question. But um this stuff to wrote, learn, obviously, I can go through the table but uh you really need to be learning this. And I said this is a shown by our results. This is a question that can catch people out. I think people would think ectopic must be operating, but a fair few that these are managed and expectant and a medical way. Um So we'll move on to the next question. Give you another minute to go through this one starting now. So another five seconds on that still got some more answers rolling in. Couple more. Give another five seconds hazard a guess if you don't know. And that is us. Um So I can show you the results kind of. So, um most of you getting C uh couple with D and a couple with B as well. So let's go through this one. As I'm sure most of you have identified. Uh This is a question about endometrial malignancy and uh well, post menopausal bleeding um really important as an exam technique question to think, what are they trying to ask me about? It might not always be obvious. Uh And they can ask you everything about the, about the question we could be going to management, we could be going out to risk factors and especially these questions where, which one's correct? Which one's incorrect can be tricky, er, because you tend to have to know more information. So, what is the answer? And as most of you got correctly it's c so we'll go through these, um, none of you got a, uh, the next appropriate investigation will be, actually increases the risk of endometrial malignancy, which will go through exactly why, um, ICC is the correct answer again. We'll discuss that. Um Endometrial thickening should always be investigated really a big take home here. So, after your menopause, um you shouldn't be getting a th a thickened endometrium. Um and then e something you might have got, we're trying to get here atrophic vaginitis, which is a differential for postmenopausal bleeding. And that would be the treatment for that um endometrial cancer. So, let's discuss this. Now, the main risk factor is to do with lifetime estrogen exposure. It's an easy way to remember it because there are about seven or eight different ways that you can increase that um, early menarche, late menopause. Um And it's to do with unopposed estrogen exposure. So the combined oral contraceptive use decreases your lifetime risk of about 30%. And I think it's because of the progesterone. And if you look at the menstrual cycle, again, I a quite a big proponent of first principles. So if you remember this, it's easier to remember in the follicular phase is where we have the building of the er endometrium uh simulated by estrogen. Um anything which increases your time in the follicular phase and reduces your time in the luteal phase will increase the risk of um endometrial proliferation. So, a adenocarcinoma of the vast majority. Now, uh there's about 10% I believe that el elsewhere. Um they're just serious or clear cell carcinomas. Um Lynch syndrome is something to remember. Uh You will have probably know more about H NPC or hereditary um uh colorectal carcinomas. Um But these can also increase your risk of uh endometrial carcinoma as well as uh increasing your risk of ovarian cancer and something to be aware of for exams. Um 90% of these will present with post menopause or bleeding. Um but also uh be mindful of your other cancer symptoms such as weight loss, appetite loss, um fatigue. Um and you're unlikely to feel a mass. Um A lot of these will just present with uh about postmenopausal bleeding. Um I've included this here. So two markers are not usually helpful like they, if you would have done the um past paper for the, on the finals website, the um UK MLA er website, they've got a specific question that catches you out about um uh C A 19 C A 125. Sorry. Um The Gold Standard investigation again, remember this exams is the TVU S and anything over four millimeters um is pathological and needs to be investigated with a hysteroscopy with biopsy. Um always important to remember in cancer questions that if you have a definitive diagnosis, that means tissue. Um So if it's got what will lead to definitive diagnosis in the question, you're thinking you need biopsy. Um vast majority of these will need surgical treatments. So usually a total abdominal hysterectomy and bilateral salpingo, oophorectomy. Uh a bit of a mouthful. Um Sometimes they do lymph node excisions depending on staging. Um and minus chemo again, if there's metastatic disease, we'll discuss Figo staging, which is a gynecological cancer staging. Um a little bit later in the presentation. Um it might be important to remember protective effects. So, er combined oral contraceptive pills. One, as I said, um multi parity, again, you've got more time in the progesterone phase. I can't, I can't point, can I um more time in the luteal phase? Excuse me? And um nulliparity. So again, lots of er time in that follicular er sorry multiparity. So lots of time in that er luteal phase. Um smoking is another one, but it's not worth remembering because smoking could increase your risk of most things. Um postmenopausal bleeding differentials. So, as I said, atrophic vaginitis, which is the post menopausing menopausal um fi the vagina as it says, um this is mostly gonna be postcoital bleeding uh if you have in your history. Um And again, vaginal dryness is another symptom. You might get um be mindful of fibroids, these tend to reduce after the menopause so unlikely to be included here. Uh Endometrial hyperplasia is exactly what it says on the 10. So you'll get to the endometrial thickness over four millimeters, but then you, you won't find it to be cancerous and you might also get localized benign endometrial polyps. Both of these need to be ruled out with a biopsy. Um and also to be mindful of cervical malignancy. Um this tends to be in a lower age group. So your endometrial malignancies sort of um 60 plus, but your cervical malignancy is younger, more 30 to 40. Um Any questions at this stage, one person in the room like little crack on then. So next question, uh you can have a minute for this one. Um So most of you getting back to us now, I'll give you another five seconds and fab thank you very much for engaging. Um So these are the results of the poll. Um mhm. How does that work? So, um as you can see, uh a lot of Ds here, uh a few CS and a couple of Bs. Um no one fantastic saying a or E er which is good news. Um So key question points here. Um We wanna be thinking about the time frame. So the last six months is really important. Uh is this is a, is this like a subacute presentation? This is a chronic pain problem. So, in the other six months, we would call chronic, um we have painful periods, uh, probably could have put in a bit in the question about how heavy they are, but they haven't mentioned it. So these are painful periods and we don't know if they're heavy but they're probably not, um, investigator for inflammatory bowel disease is also an important, um, part of the question because this is about endometriosis or dysmenorrhea. But, um, the answer is d er, and we'll go through exactly why that is. So an urgent referral to gynecology under two weight is not indicated here. Um His history is not suggestive of gynecological malignancy. Um uh Ovarian cancer is not likely in this under 30 age group. Uh It doesn't have any sort of post coital or intermenstrual bleeding to suggest cervical cancer. Um B so a routine referral to gynecology is something you might think about in endometriosis. However, this can be something that should be managed in primary care initially. Um Imaging is not always helpful. So you may see endometriomas on imaging, but it's unlikely. And I said this history is very suggestive of endometriosis, which the treatment of is a trial of hormonal contraception. Um and a simple analgesia which she's already been taking. Uh We want to do something about it. She's coming to you with pain. So, advising to continue simple analgesia and return in six months. Uh isn't gonna help her. Um which is good. No one put that. So, endometriosis. So your main symptoms are chronic pelvic pain. Um This menorrhea sets painful periods. You may get pain during intercourse and that's if you have endometrioma around the cervix or vagina. Um Most of the time you're gonna get a normal examination here. Uh Your geeky medics, your past med may tell you occasionally you'll get abdominal masses. This has been very, very severe disease. The vast majority um won't have uh imaging findings. Um and some may not even have, may not even have a noticeable endometriomas on um laparoscopy. Uh Your risk factors are important to remember. Um A lot of them are quite similar for gynecological conditions. So it, it's probably worth going through these and you might get asked specifically on these in the exam. Um important to know that tumor markers aren't useful here. Uh They might try and catch you up with those in the exam and the di um the gold standard uh diagnostic diagnostic tool here is a laparoscopy and a biopsy. Um Again, that's an important, simple fact to remember management wise, endometriosis you want to start in primary care. So simple, analgesia and hormonal contraception is your first line. Um But if there isn't any change or it's not tolerated after 3 to 6 months, then you should be referring to uh gynecology and there they will do the er laparoscopy and biopsy. And if they see endometriomas, you may have seen uh in your placements that I come back to the theater. Um This has been shown to improve fertility and the pain. Um I've put here about the taking months and years to reach diagnosis. You will interact with very frustrated women with endometriosis. If you have uh gynecology jobs, um people tend to be bounced back from primary care quite a lot. So it's really important to know this in depth and lots of hospitals will have a specialist endometrio endometriosis center or service. Um And depending on where you are, you can refer to that specifically. OK. Um Sorry, I just take a quick note on the inflammatory bowel disease. So you sometimes get endometrio endometriomas in the bowel. So it can be misdiagnosed as inflammatory bowel disease. Uh All right. So let's keep going. So, question four. you can have a minute for this one. OK. Another couple of seconds, a few more responses coming in now. Um Fantastic. So uh well done again. Lots of engagement here, which is good and the vast majority of people getting the right answer. So the right answer is a um this patient will repeat smear in 12 months with a return to normal recall of HPV is negative. Now, uh let's quickly look at the question quite a short ques question prompt and to be honest, less relevant really is this is a simple fact recall question. Um And important to take in the parts of the smear result. Um They might not include she's not asthma test before in the exam. Sometimes you have sort of, it's implied that the woman isn't local to the UK and therefore won't be involved in the testing program. I'm no one put beer, but only samples that are HPV positive are sent for cytology. Um HPV, six and 11 are strongly linked to genital warts. Uh, women should be, it's three years from the age of 25. Um, and with low grade uh dyskaryosis or I, one of, uh, most of the time you don't need treatment. Um, and we'll go through exactly why that is so cervical cancer. This is a really important topic to know well, for your exam. Um, it's one of those questions that is likely to come up in some shape or form. Um, and unfortunately it's sort of a rote learning of the, er, testing pathway in the UK. Um, these are facts that regularly come up. They seem to regularly like to test you on which strains of HPV. Cause what? Um, it's 16 and 18 or so. 33. Um, so it's sort of 16 and 18 are the ones we, um, tend to focus on. And in the UK. Now, uh, Children, all Children, so that boys and girls are vaccinated against all strains of HPV. And that's including six and 11, that's between 12 and 13 years old and there's a 90% reduction of cervical case in vaccinated women. Um, and across the UK, there's been a decline in cervical cancer, um, mortality because of sort of early recognition co of the screening program. Um This is to give an idea of what your stagings are. It's um cervical interstitial neoplasia. Uh I can't remember the exact name of the grading, but if they ask you that, that would be pretty harsh. Um This is how you measure it on colposcopy. So, the difference between dyskaryosis and the C in is the dyskaryosis is to do with your um er cytology. So, looking at how um differentiated the cells are uh and then your, your grading system is just looking at the cervix. Um and the two can override each other. So, if you have high grade dyskaryosis, then you tend to get your last procedure. Um even if on observation, you might not have as severe um staging. OK. Um Here we have it again. Um you may get photos in your exam um matt or then can weigh in and tell me if that's not true. Um Again, you're ectropion and this is a medical term, doesn't look as angry. You can see that the um say M 12 and three look quite different. Um ectropions if you are following the Instagram is that uh turn out, turning out of your um transitional cell from the squamous cell. Uh a thing that covers the er ectocervix um if that makes sense and that's caused by estrogen exposure, but this is a er differential when it comes to post coital bleeding. Um, most cervical cancers are picked up in the screening program these days and they're picked up very early. Um, you're very unlikely to see advanced cervical cancer in your practice unless you see women from abroad or if you work in a different setting to the UK. Um, but yeah, so if I go back to this slide, this flow chart is on the government, if you Google gov.uk, um, Cervical screening program, they have the entire um step by step guide effectively to the er screening program at which stage women will be recalled. Um I suggest you have a look at that. I could go through it in length, but we don't have the time today um in terms of treatment. So high grade dyskaryosis, as I said, regardless of can staging is treated with a large loop excision of the transformation zone. So that's your between the endo and exocervix. Um And then can two plus tends to be treated in rare cases, can one would be treated but it would be very unusual and I wouldn't um put that in the exam, er, after your, let we're gonna call patients back after six months. Um And that's for another smear test to carry out cytology and make sure that those cells um are all normal. Um You'll follow up your women with low grade or cm one in 12 months. Um And that's to ensure no, no further change. The reason why we don't treat with a left procedure. Anyone know that for the low grade and the CM one. So the reason why we don't use the L procedure on those low grade and serum one is because the vast majority of those changes in the cervix revert back to normal. Um So you'd expect after six months that you see a normal cervix. Um ok. Um This is the Figo staging. So we use this for, uh and it's important to know about for all gynecological malignancies. So it's effectively to do with, it's which organs are affected. Ok. So your, your stage one is confined to that organ. All right, as you can see here. Um Then if you have a tumor that's going beyond the cervix, perhaps into the upper third, two thirds of the vagina or into the uterus, then that's stage two. And if it's going past the pelvic wall, we can see here. It's hopping from the uterus into the ovaries. Isn't that's stage three and then going to other organs at stage four. Like you'd be pretty, pretty harsh for them to test you on this. But in terms of a factor, no, it's the same for all gynecological malignancies. Um So that's the, the staging and they might ask you what uh type of staging you would use for a gynecological malignancy. So that's your answer. Um OK. Question five. We can have another minute on this. So it still waiting on a few responses here. So we'll give you another 20 seconds. Yeah, here we go. Another five seconds. Fantastic. So this one is, I've got a bit of discrepancy across the board. So I know, um, it's tricky on the online setting but if anyone wants to weigh in with, uh, which que answer they chose and why, um, that would be great. Anyone feeling brave, uh I'll give it a try. Um, so I chose a because having a read through the question, the part where it says the fundal height was appropriate, ruled out a molar pregnancy for me. The fact that when we did the speculum, there was no blood in the vagina. So the bleeding has stopped and the cervix was closed, makes me think that she's not actively having a miscarriage. So I was between A&E and the reason I said discharge is because there was no blood in the vagina and the baby was stable and the mum was stable. So fantastic. Thank you. Right, Chantal. And do you wanna go further and classify this? Um Is it threatened miscarriage? It is exactly. Thank you very much. Um So this is a threatened miscarriage. It's a question of um it's not quite antepartum bleeding. I'll go through that later, but this is a bleeding in pregnancy. Um This question um And what I'm trying to get at with here is um as Chantel has correctly identified that this is a stable woman with resolved bleeding. Um and the key points in this question. And for when you're answering these exam questions are, whether the cervix is closed, um whether, whether she's still bleeding, um important to note if uh the obs and the bloods are OK. Is it a stable woman? Um And depending on the gestation, um this is Ansip sorry, depending on the gestation. Um This is um yeah, you, you want to check the fetal heart rate, obviously, if it's earlier, then um it's less relevant. Um unless you'd see if it's present rather than checking the rate. Um So, uh this is a threatening miscarriage. Now, this, these are your classifications of um of miscarriage. Again, it's things just to learn really. Um The important points here are on the cervix. So if it's closed, um you've either got a miscarriage that may happen, all that has happened um as we can see with the threatened and then complete and missed. Um If your cervix is open, then the miscarriage is either um happening, it's inevitable um or it's happening and it's not finished. Uh And that's where you've got your inevitable and your incomplete miscarriages. Um management wise, uh as with all sort of surgical presentations, it's important to, you can either watch and wait. Uh You can either do something conservatively which tends to be in GS uh medical um or you can operate. So if you, if you think about these questions, even if you know the answer with that uh structure, then you can tend to come to some sort of reasonable um, reasonable answer. Um, a threatened miscarriage, he tends to discharge. Um, women who have recurrent episodes of bleeding could be admitted. It'd be pretty harsh to get you to eek that out of an exam question. But for when you're practicing, um you will see women with multiple episodes of bleeding in pregnancy getting admitted for observation and your inevitable miscarriage again, doesn't need to come into hospital unless someone is bleeding heavily or is uh unstable, then they can miscarry at home. Um And this can be allowed up to two weeks to complete on its own without any um any medication. Um So again, the complete miscarriage and miscarriages happened, we don't need to do anything about that. The, the real tricky ones in the exam are you're incomplete and your mis miscarriages as to what to, what to do about that. So, um, a missed miscarriage which is a closed cervix with pregnancy tissue still present. These women will often be asymptomatic will come in and find that the there's no fetal heart rate. Um Again, sort of practice note, these are, it's generally quite traumatized women. It's important to be sensitive. Um You wanna give me Mifepristone, which is uh a cervical sort of ripening agent opens the cervix and then miSOPROStol to help deliver with the baby. Um And with an incomplete miscarriage, if you're treating it medically, then you'll get the miSOPROStol because the cervix is already open. And again, that will help uh encourage contractions and um deliver the pregnancy tissue. Now, if you have an incomplete miscarriage or um sometimes a mis miscarriage at late gestations that the patients are unwell if they've got a septic miscarriage, which is an infection, um, if they have had hemody instability, if they're going into shock, they've got high heart rate, low BP and or if you've given the drugs and they haven't worked, then you, that's your indication for surgery. So this is transcervical vacuum, aspiration. Some of you might have seen it in your practice. Um And Oh yeah, yeah. So if the cervix is open, then your management management would change. You wanna um you wanna keep that woman in? Oh and thank you. Sorry, I need to keep an eye on the chats. Um Yeah. So that's your cervical surgical management. It's under general anesthetic and it's not because you can't do it on the spinal because it'd be quite unpleasant to do. So, um an TD is really important. So, uh you will know that um about hemo hemolytic disease of the newborn, which is when you have um a a rus positive baby rus negative mother, um mother producing antibodies against uh rus positive uh blood uh blood cells, red blood cells um which then attack the blood cells in um in the fetus. Um It's really important to give anti D uh antibodies um to these uh recentin of women um who are over 12 weeks gestation with a what we call a sensitization event. Um It's something which I can't really go into in detail given the time we've got today. Um and sort of the general topic of, of the presentation. So if you need to, so you should probably go away, read up on it if you don't know about it. The important exam fact is that if someone is rhesus negative and they have a sensitization event, which is any sort of bleeding, traditionally, you would only give this to surgical patients but and I think passed says only give it in surgical patients. But the latest um hematology guidelines in conjunction with the Royal College decided to say every woman with a sensitization event. So any bleeding after 12 weeks, you give an TD if they're, if they're rhesus negative. Um uh Ben, are we sending out the slides? One of the, the gentlemen, we were sending out the slides. Um I've got links in the um in the notes to the guidelines I've been using. So have a look at that. Yeah. Any um woman at over 12 weeks gestation get anti D2 if she's recess negative. Uh And yes, the feedback form is how you get those slides. I one. So let's keep going. Question six and you can have a minute for this one as well. So I'll give you another 20 seconds. So we can get everyone with an answer in. Hey, uh a couple more seconds, there's a few more trickling in. Um Fantastic. Um So, uh does anyone else far from Chantal want to be brave and um talk us through your answer to this question? That's fine. I'll talk you through instead. Um So as you can see, vast majority saying C a few A's and a few B's as well. Um Having my life, that's this question now. So I think this was missed out, but this um that it's normal. Um So as you can see, the answer is um sorry, my connection, I think, oh, error. Um The answer is C um which is to give labetalol orally and discharge with regular follow up. Um And why is this? So a is unnecessary um as they're asymptomatic and don't have any um high risk features of preeclampsia, which we'll go into. Um B again. Um This is a woman with pregnancy induced hypertension important to know that this is part of the question. You've got a high BP in pregnancy after 20 weeks. Um We have to treat this. Um See, as I said is the most appropriate option. Um Anyone wants to hazard a guess as to why d isn't an option? Um So I think most of you will have identified as things as no one answered it. But Ramipril ace inhibitors are contraindicated in pregnancy and that's due to a risk of fetal renal damage. Um And then ea few people put e uh this will be the correct treatment if this is a woman with preeclampsia, which we'll go into. So this is a question about pregnancy induced hypertension defined by uh a BP of 100 and 40/90 from 20 weeks. Um And the vast majority of these are asymptomatic. They're gonna be picked up by the community midwife. Um They're gonna come into the labor board uh either stressed or confused as to why they've been sent in. Um And really what we're worried about is this developing into preeclampsia. Um I haven't spoken a huge much about pa pathology during this uh talk cos I think most of you have probably passed that and on to the Oh fantastic. Thanks be in French. Um Post, most of you pass that on to the more hopefully more challenging management questions, but preeclampsia is not particularly well explained. Um We think it's to do with stiffening of the uterus and a sort of a physiological response to improve blood flow to the placenta is to increase the BP. Um As a result, increasing BP is a worrying sign that preeclampsia might develop in the future. Vast majority of women won't go on to develop it important signs to look out for um edema, uh breast reflexes and visual disturbances and maybe papilledema if you're doing some fundoscopy and the preeclamptic women will look like a preeclamptic woman, they tend to have swollen hands, swollen face and you'd probably be able to see them. Ok. Sorry, e everyone, we just got a quick, uh, quick um, coms issue. Er, and we'll be back shortly. I think he should be coming back in now. Yeah. Um. Oh, got you. You're back in danger of uh, presenting internationally. Uh, let me share my screen and finish this off. Yeah, let me just make your cohost again. Got it. You should share again. Sorry about that. Joining late, I'm joining from sunny South Delhi. But um uh internet connectivity is a, is an issue. Um Where were we? So did I get, did I get as much as management? Um Matt or where did I get to before I go a little bit before that? Yeah, for management. So um um important things to note rise in urine PCR um A rise in alt, these are risk factors, strong, strong risk factors for your development of preeclampsia. Um Risk signs, shall I say? And if they're coming up in the exam questions that someone has protein, urea, rise, nail T and or face swelling, leg swelling, then you really want to be thinking about your preeclampsia management. Um I'm not gonna read through these risk factors, but you need aspirin from 12 weeks if you have one high risk or two moderate risk. Um Most of your management of pregnancy induced hypertension will be in the community and these women will be on a mixture of oral labetalol and Nifedipine. Um second line is hydrALAZINE, but you'd be again unlucky to be questioned on that in the exam worth remembering. Um preeclampsia is that state before eclampsia which is seizures and eclampsia is the dangerous thing to mum and baby. So you won't be stopping that. Um magnesium is your treatment and I put in Red Hair delivery because you might forget that when you're thinking about your medicines. Um if someone is severely preeclamptic and you can't control the BP, the answer is delivery and depending on how unwell they are that might be through um induction, instrumental or mo more likely for example, questions a Cesarean section and if someone's having seizures, you wanna be thinking magnesium and delivery of baby, those should be easy marks to get in exams because um that will always be your answer is get baby out any questions about anything actually at this point because war that I'm like disconnected again. Oh, there we are. So yeah, just if you've got any questions, let me know. Um question seven, I'll give you a minute for this one. Um a couple more coming in another five seconds. Um We've just got a question in the chat Henry. Yeah. Um Is there a diagnostic criteria that separates P IH from pre preeclampsia? Um This is a, that is a, that is a good question. Um I, as far as I'm aware, there's not um a specific diagnostic criteria I could be wrong. Um Let me find out, I'll find out and get back to you sh um during when you're answering the next question. Um All right. So we finished this one. Lovely. So this is a reassuring answer. Um Vast majority of you, you have got um B and then we have an instructive A um which is, is good because we'll go through this. Um The reason why it's not a, is that definitive management section and scenario. So this is um um this is an antepartum bleeding question. Um Important to recognize that um the key things in our question are that she's being induced. Um She's had one previous Cesarean section. These are risk factors, what we're about to discuss. Um She's an unwell patient. That's what I'm trying to get out of here. This is a shocked woman with high heart rate, low BP. We need to do something about this quickly. Um We have fetal bradycardia, we need to do something about that quickly. Um What we're really pushing towards here is Cesarean section. Um I said if this was uh what's the most, what's the immediate management? You might think about that fluid resuscitation, that be mean. But again, definitive management is your key and this will be asked in lots of different ways. Um So you used to do a antepartum hemorrhage after 20 weeks. Er, ectopic pregnancy shouldn't be here. That is not antepartum because it's not us 20 weeks. But, um, again, we're thinking about bleeding in pregnancy. Um, your ID out for moles again, more likely to be picked up in that first trimester. Um, and you're thinking your exam question is big for date. It says one in the um UK MLA er, practice paper. Um, and these women tend to present with hyperemesis. Um, your, most of you should know what a molar preg pregnancy is, but it's a noncancerous um cystic tissue instead of pregnancy tissue. Um your ve are previa and your placenta, Praevia, these are sometimes mixed up. So your vez are Praevia is where you have um veins covering the cervix, placenta, previa, uh placenta, covering the cervix and these are more likely to be picked up on ultrasound. Um less likely the vasa previa. Um and if these rupture and the bleeding's uncontrollable, then the reason why I put delivery by Cesarean section slash observe is because it's to do with how stable they are. If they're bleeding a lot. Um and they're unwell, get the baby out. If they're not, then you can wait. Um percent of abruption. Um Vast majority of these in a question setting will be delivery. Um These tend to occur pretty late in pregnancy can be pretty severe and then the question, you might not have got it. In fact, you don't need to get it, but this is getting at the scenario of uterine rupture. So your risk factors here is the previous Cesarean section and induction with Oxytocin can really increase your risk of rupture. You have about a rate of about 0.05% of um return ruptures and vaginal birth after cesarean sections. But um this can increase sort of 10 fold with Oxytocin. Um So this is what I'm getting at. You don't actually need to know this to answer this question. You wanna see This is a bleeding woman. She's unwell, let's get the baby out. Um, postpartum hemorrhage. So I thought I'd cover this here. Um Although it's not in the question, um because it'll almost certainly come up, um, your forties really easy to remember, tone, trauma, tissue thrombin. Um And it's any bleed over 500 mil within 24 hours of delivery, uh lots of different causes. Um, regardless of the cause. This is your um management plan. Um Well, in fact, no, the pharmacological and the surgical is to do with A&E but um, you want to try and stop the bleed mechanically. Um If it's a retained placenta, you want to try and encourage that to be delivered, uh You want to remove the placenta um and tend to take them to the theater um for you to run eight and E eight and e you want to palpate the fundus, make sure that bladder is um catheterized. Um You wanna give drugs to try and clamp down on that bleeding. So your Oxytocin, Ectrin and carboprost. Uh There may well be a question asking about you to run at me and asking about medical treatment. Um, important to remember the sort of single things that mean you can't give the drugs. If someone's got pregnancy induced hypertension or previous hypertension, you can't give ermetrin and you can't give carboprost asthma. Um Again, this came up in the UK MLA practice. Um and then you can give progesterones as well. These can either be given rectally, um uh sorry, prostans, um Prostaglandins, you can either give these rectally or orally or some miSOPROStol. Um There's usually a role for TA X A. Most women will get it in practice, but uh it won't come back on exams because it's um ambiguous, er and then you're surgical. So it's important to be aware of a balloon tampon or technique, which is where you put a balloon in the uterus and inflate it. Um Your B Lynch suture, which is a technique done intraoperatively to um clamp down the uterus and stop bleeding. And then some of these women will end up having hysterectomies if you can't control uterine tone. Uh A note here on the left about secondary PPH. So that's anything after 24 hours, up to six weeks and it's vast majority retained products. So that's usually bits of placenta that been left in perhaps after a cesarean. Um and those can become infected uh or just in inflammation of the wound lining endometritis. Um All right. We've got time for one more question. So we have a minute for this. So another five or six seconds uh uh um in answer to your question, Chantal, there isn't a defined criteria. It's just defined as high BP with features of preeclampsia. So, usually protein urea is the key and then you're worsening liver function. Um If you can find a uh specific criteria, then it's on whether it. Um So let's share these results. So good. I think this is another instructive one. We've got quite a variety of answers here. Um And I think I, when I wrote this, it was intending to be tricky. Um This is a question about um nausea in and vomiting in pregnancy. Um And the answer is a, so we've still got a majority getting it, which is good news. Um But we can go through and it's a good learning one. The reason why it's a will, will go into um at the start of the bottom because I know everyone said we're gonna give uh Po Domperidone. Um Both of the last two D and E er are about discharging. Now, this is an exam technique really question because you don't have to know the answer to know that we probably shouldn't we be discharging this woman. Um She's got uh an AK so she's got high creatinine, she's got deranged electrolytes. She has low uh sodium um And she has a low lower egfr, especially for a 19 year old and with two weeks of nausea and vomiting, clinically dehydrated. This is someone you wanna be keeping in and monitoring your renal function. So that's sort of a good first point to, to know is that if someone, especially young patients are unwell, um, you wanna be, especially in exams, you tend to are side of the course unless you know you're sending him home. Um The top three are all options. Um They're all different antiemetics and we'll go into why it's cyclizine as your first line and I should have really highlighted initial management plan. Um because your IV the reason I like I cyclizine is because that's your first line treatment for um this is hyperemesis. So um not all nausea and vomiting pregnancies is, is not nausea and vomiting in pregnancy is hyperemesis, gravidarum. So that's defined as more than a 5% pregnancy, weight loss, dehydration and electrolyte balance. It's quite loose. Um And those are your risk factors which as I said earlier, it's that um molar pregnancy can be one. and not all symptoms of pregnancy are caused by pregnancy. So important to be mindful of other things that can cause you to vomit. Um Other things include metabolic conditions, neurological conditions, think about drugs. Again, they'd be harsh to do any, do this to you in an exam. But in real life, a lot of women will come in. Uh unwell with other things and then be sent to Gynae and you'll end up having to work out if they've got appendicitis. Um management wise. So you want to try and keep these women in the community. But the key point in this question was that AK I um she had a borderline hypokalemia and a hypo borderline hyponatremia. So a hyponatremic hypokalemic metabolic acidosis. A alkalosis is your um your sort of classic vomiting. Um, getting rid of all your hydrogen ions, getting rid of all your electrolytes. So that's trying to get to that. Um Your first line is your cyclizine or your promethazine. So you, your um uh I can't, I can't say it's like your antihistamines and then your fya as well. Um Zombia is something you'll see in practice. Uh you'd be unlikely to get it in the exam. Um, but it's a relatively new combination of Vitamin B and the antihistamine so that the Vitamin B is the proxamine antihistamine is the doxylamine. Um If those don't work, then your second line are your metoclopramide, domperidone and Ondansetron. Um Anyone know why Ondansetron is second line, why you wouldn't, why you try and not give it in pregnancy even though it's relatively safe spinal bravery, risk of risk of cleft risk of cleft. Exactly. So, um there's a theoretical ish risk of cleft palate in the first trimester. Um It's pretty rare if anyone knows the stat and wants to share it with the rest of the group cos I don't. So the uh Royal College um say that metoclopramide, sorry, Ondansetron is safe in pregnancy and that as long as they account stood on this very, very small risk that it can be given readily as a second line drug. Um Meto remind is, is something that we tend to try and avoid again in the second line. Um There's a risk of extra pyramidal side effects such as Oligo crisis t just kind of easier. Um comes up a lot in exams again, rare in practice, but we try and avoid it and Domperidone is better because it doesn't cross the blood brain barrier. Um So you're much less likely to get those symptoms. And in fact, you can give that in Parkinson's um key things here, add potassium to your IV fluids. Often they're hypokalemic. So you should be titr that um and these women should be given uh B vitamins to avoid vernies and copy which as you all know is caused by B vitamin deficiency, mostly seen in alcoholics. Um You have potential complications here. So as we discussed, ak I um the problems are vomiting a lot. So your oo esophagitis and yeah, mallory vice tears. Um and there is an increased risk of VTE er possibly due to the dehydration, but it's not particularly flare and there's no evidence that um high premises have increased risk to baby. So you can counsel women that you see it, that, um, at least the baby's ok, but it can be very unpleasant and there are actually a small minority of women who end up getting terminations because of, um, uncontrolled high premesis. So, um, it's been a whistle stop tour. We probably could have done two sessions on and g, and I haven't covered these topics. Look at these topics. Um, I've tried to go through the UK content map, um, and cover some things that I thought were important. Um You'll likely see questions on all of these. Um, as much as the ones I've discussed really and it's really good idea to have a good idea of normal labor and how normal labor progresses. Um, again, you can answer these questions based on first principles about all the rote learning. Um Has anyone got any questions before I let you go and beg for feedback? Um, so they'd have thiamine during the admission and then, um, while they're vomiting. So it's to do with oral intake is while you're supplementing the thiamine, you send them home with oral or you give them IV paron if they're in hospital Entel. Um, but if there's no questions, then that's everything for me. So, thank you very much. Um, other things I think, Ben, if you wanna put my email on there, I'm happy to discuss um, other things about, um, what I would have done if I was thought I was applying to G earlier, lots of stuff you can do early. Um And then obviously f two F one related questions less to do with finals apart from this because it was a little while ago that I have to answer any questions on email as well. No problem. I'll pop that in the chat now. I can just put my own email on the chat on that, but I don't know. It's true. Can you? Um uh thanks so much guys. So yeah, the link to the feedback forms also in the chat. So please fill that out and you'll get the slides sent through following that. Alright, thank you very much. Right? Thanks very much lads. I will be get to bed. Yeah, say goodbye very much. Great talk. Um Let me yeah, just send, send me feedback shit so I can try you on my uh usually we get pretty good responses and everyone says where they've come from so you can so I can put I gave international. Um Yeah. No, thanks for certificate as well. Cheers lads, right. Bye bye. See you later. Thank you. Thank you for coming Henry.