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you guys, uh, got a GI? You know him Cou this meeting is being recorded. Yeah, So I got my name's us. Um, I, um, president of the option got a society at Cardiff unique. Um, I'm a final yet that student, Uh, so I'm not an expert in the area, but I do have a large interest in it, so hopefully you guys will find their session helpful. Just try and maximize up. Cool. So you have a father do, we'll get started. So the things we're gonna cover today, I'm going to talk about how to take the obstetric history going to talk about the update examination of meaning, the pregnant abdomen, not just the the normal abdomen on. Then we'll talk through COPD and speculum examinations as well, Which is something people after that. We'll nervous to do because you often don't get much practice. And that's cool. And throughout always for some kind of example. Stations, um, as big a on I like you got some questions. Well, so if if you can get involved in the chat, that would be great. Much nicer, having people responding Well, then, just talking to a black screen. Um and then often is offered some sort of spot diagnoses as well. That will hopefully help you. You know, when you're standing outside the room, you can kind of think our this is potentially where this where the service station is going. And so I hope you're hopefully it will be useful for you. And so to start with, this is just sort of an example of what they might have on the door when you walk into to your stational just before you walk in on. My main advice is before you go into a station would be so come up with some differentials in your mind. Of what? Of what? Something could be. So here I've put the examples you're in the emergency department. That two year old woman's who's 22 weeks pregnant is attending with P V bleeding, and this would be quite a common obstetrics station. You take a history on down, you are some questions, so we'll go through first off how I would approach the history. Oh, is he everyone everyone a purchase histories differently. You may have a different way of doing this, and if you do, then great stick with what you know, this is just myself way of going through it. So I see you've got sort of the normal things that you need to consider in your history. Um, that doesn't change. You still need to ask all of those things that you would normally ask any patient. The things that are particularly important in in injection history and in the normal history would be within your presenting complaint. It's really important we ask about pain. So especially some of the abdomen pain or kind of pain down below those sorts of things. Um, discharge, bleeding on fetal movements, their the four things you can't forget to ask about in any obstetric station there. There are really important indicator of how the pregnancy's going on and and any sort of concerns that the woman might have, um, things that are so important past medical history, Uh, sort of type two diabetes, epilepsy, high BP. Because these things are going to make the pregnancy more complicated. Um, and they might need extra tests and extra monitoring. Ast they go. So it's important to ask about those things and brought them out initially. Um, but yeah. Then you kind of carry on your normal history as you would. There's then the two other sort of main sections that you need to add into another set your history, and that would be the actual obstetric part. So in this in this section, I always ask about previous pregnancies, so that includes terminations, miscarriages, still butts as well as the live births. Uh, this sort of things I'd ask about here would be when they were when they had these pregnancies and how many weeks they were when they delivered or when they had the miscarriage, Um, and also how they delivered. So whether it was for joining or by C section um, and then find if there were any complications with any of those pregnancies, because the big thing that you'll learn in obstetrics is so the risk factors for a condition. So, for example, preeclampsia or gestation diabetes is if they've had it before, there are high risk of having it again. So it's really useful. If you know about that before hunt the current pregnancy, then so you want to know if the midwife or consultant lead. That's useful to sort of tell you this how complicated that pregnancy is. And if they've got any issues at the moment with that, if they're taking any medications. So if the the higher dose of folic acid do you sort of starting to think? Okay, so there's some other conditions that are putting them are increased risk if they have attended all their scans on do. If there have been only abnormalities noted, It's also sort of if someone's not been attending scans and you've got them in there in front of you at that moment, it's really important to get a story history as you can, because the next time they might attend could be to deliver the baby or if they're having further complications. Those use use was trying as much information as you can at that time on recess status. Now, this is a really, really important one. Any pregnant patient that comes in, always ask about took that you need that documented in their notes. It is really useful to know about and because obviously they may require anti D on delivery. So which is negative? Uh, the gynie history, them sorts of things you asked about hair would be about had that Smith. Um, if there are any abnormalities detected on these and their sexual health history as well? Because it's important to know if they've got any active infections them. I need to give in certain antibiotics before or during delivery. Um, I've just put these these last two brackets because they're so I've not. I've seen not appropriate of it during pregnancy. But if you're using this basis to take your normal like, I need history as well, you would also asked about contraception a menstrual history. If they're. If they're only newly pregnant, then you could also what method were they on before or on when they were last period was later in the pregnancy. It's It's not really as important. Um, And then it kind of just for a couple of extra things here that you might not always think about, um, when taking your history, because it just kind of goes over your head. But it's These two are really important during pregnancy. So the safeguarding thing, I normally sort of put that into the social history. So it's sort of say okay here, you living at home with, um they tell you on the new circuit and do you feel safe. That's a really important one toe. Ask about particularly young obstetric history. Sometimes you may have to kind of ask it if if you've managed to if you're examining the woman because that may be the only time you can get her on her own. Um, but I'd always any opportunity kind of try to ask about that on but mental health as well. I mean, we should ask this that all patients really how they're doing, But particularly during pregnancy, it can be quite a stressful time. Hormones very high. Um, just asking how they're coping and and if they are requiring any extra support with that is really important. So I mean, this is just the method I use. Some people use the acronyms or mosque in mos see in the bony histories of sort of menstrual history, obstetric history section and snare on the sea contraception. Um, but yet, like I said, just use whatever works for you, um and then sort of going on to the general kind of investigations and management that that you would be considering during a nap step trick station on these kind of things that you'd always sort of think about, um, any kind of daily as as required. So you always you generate off considered a Not the exam. Having a feel of baby on how it's doing, you might consider so of a PVR speculum examination. No, I've got to start on this one and the trans vaginal ultrasound and I'll talk to you about what and movement Observational that's always gonna be useful to figure out. So how stable the mommas urinalysis is useful. Turn to look if there's any infection or cramps here. Hcg potentially if they're if they're a cubicle. Moments, um, swaps a swell. So we'll have to set the stuff. The investigation. So I split my investigations into a bedside bloods on imaging and special tests. I know some people use be boxes, So if that's what you're used to using, then obviously this you can make these kind of things work with that as well. This just how I don't the common blood you're gonna need a your normal routine ones, Um, but then the ones to kind of consider it. If if the woman is bleeding, the clot in the group and saving cost much, um, because they may need a transfusion at some point if they are bleeding. So it's important to know that their blood type on the clotting as well. But just because it could be another cause off the bleeding, it might no. Just got some was pregnant doesn't mean that every condition they have, it's pregnancy related. So it's just important to consider other things as well. Um, hum to the imaging that and so okay, side is gonna be the main one you'd use in pregnancy. Whether that's up there or trans vaginal, you know, we're going to use any others because of see the radiation risk and then special test. So let's see here. I always think about the baby. What the fetus. So CTG and Doppler gonna be this sort of main ones? But let's listen to the heartbeat and then see to do to monitor how the baby's doing. Two. Later on in the pregnancy Gen General approach to management. Then I split my obstetric stations into sort of the initial wrong going, um, cause they tend if it's gonna be in an osteo station, they tend to be fairly acute stations. So you initially want to kind of stabilize Mom and so out of that situation on, then the ongoing tends to be either before or after delivery. So, depending on the picture, but I also like to split it into mom and baby. It just helps the prompt to remember all the different aspects, because there is quite a lot to cover in obstetrics station. So initially, um, when were you thinking about Mom? You want to do your normal 80? Um, and that's no, that's not particularly different to your 80 in any other patient. Um, and you obviously, when you want to contact seniors early because you're gonna need that support if some different. If a pregnant woman keep you on low and just put oxygen on fluids in there cause they're kind of the two most common things that are given in a tree on, then Obviously, this one is just pregnancy related. The anti D if they're racist, negative and they're having sensitizing event really, really important not for that pregnancy, but for the next pregnancy to make sure that the mom doesn't project the baby. But I'm sure you guys probably know about that already. I think when when we don't think about the baby in the management them, um I always consider whether they you could give them corticosteroids. They're if they're if they're going to be born early. Um, trying a sort of the court against always helped mature their lungs. So this, this is you have to be given 24 hours apart, so you need to know that you're gonna have a bit of time, and so before baby is delivered, but you could be helpful. It's necessary if they're gonna be premature. And then the mag sulfate is neuro protective as well, so we'll see if they're born premature, they're not gonna be completed. A balance is to help with that brain. Maybe not to some ongoing management, then. So when when you got really thinking about mom, you got to monitor how she's doing. Um, you might consider that center if she's delivered presents will help speed up the delivery of the placenta. Um, and then with the baby, you might want to consider a ph of you as well, particularly if they're early. You probably consider. So that's just so off my general approach. Just so you've got a rough sort of structure to go for, you know, how I'm gonna be thinking as I as I go through the cases. Yeah, so yeah, I mean, one to the first case, then. So back to back to the one I just brought up at the start. So 32 year olds, 22 weeks pregnant, uh, attends complaining a PD bleeding. Sometimes they'll also tell you the GI and the pee. So gravida is how many pregnancies they had before in Paris. How many deliveries they had. Um se they might tell you that they might know just Yeah, just just go there. So can anyone think of any differentials than sorry? I have not told you about the case yet. I'll expand on the case. Just so So you know. So off. What's going on? So it's Ah, 32 year or 22 weeks pregnant. Had about one day of PV beating. Said about a teaspoon of so bright red blood. And Gemany. It's postcoital. She's not on any pain on. She's not got any past medical history. Um, she has had four pregnancies previously. Um, so? Well, she's grabbing a four power three, So that means she's had she's had four coaches at three previous and one current pregnancy, and she's delivered three times. Oh, three have been vaginal deliveries. Um, and nothing else is off relevant in chief. Oh, no, no significant other past medical history. So if you have a think about your differentials, um, and pop them in the chat, um, then we'll just talk through that. Although I can actually see the chart, I might just escape for a moment. And is it possible for me to see the chatter? Yeah, the there's an option on the top of your sweet. So where it says you're sharing your screen, there's should be a to about it comes up. And then where the button should say, open the chatter box. I can't find it. I mean, if you have Yeah, I read them out for you. So eso we go? But a few quite a few responses. So percent or abruption spoke been quite frequently said, um, ectropion percent of previa, a lot of percentile abruption people thinking about the most emergent presentation of it. Okay, great. So we'll just talk through. The difference was then no. Okay. Say that the differential I came up with that would kind of be my top in the list were these ones. So yeah, you guys, you guys mentioned presentable up shin. That would definitely be on the list. A differential. Um, but I'd still I'd put President Previa much higher up because it wasn't painful. The reading. She didn't have any pain with it. Eso definitely something placental abruption is Want to think about when? If you got PV bigon, but percent of previous is much more likely in a in a pain that's bleed a trophy and something. Some people mention that that's a really good one. Teething about, um, bass. A previa is quite similar to percent premium, but it's more of the vessels are covering it. It's much rarer, so it's just less likely because much rarer, but it's definitely an option. Um, bleeding can be associated with miscarriage. And then again, um, I assist a swell, which is similar to some endometriosis. Um, could be another course of the of the bleeding eso for thinking about. Then how How would we investigate someone with TV reading again? Do you want to put it in a chat and national? And if you could, if you'd be happy to read a few few out for me just to get an idea of how people would it would investigate someone who is whose reading? Yeah, everyone's talking about different imaging modality. So officer and upper transvaginal ultrasound, who could save cross much and you think basically runs up to examine public exam is all nice? Nice. It was listening. So Father Coat say so the investigators I sort of come up with for this one are so the basic labs a year in debt just to rule out any infections, you check the B m's as well. Um, the so a normal blood that we talked about But then, yeah, you're right. Also the group and say the cross much regulation are important with PD bleeding now for imaging, I think some some will mention trans vaginal ultrasound. Now. It's actually really important that you don't do a transvaginal ultrasound in a bleeding patient, Um, on saying that is actually doing a, uh P V examination or a speculum examination. It's really important that that's a void it because the risk with that is if someone does have percent of previa, which is where the presenter is low lying. So it's between off the baby in the opening of the vagina. If you if you're sort of poking an ultrasound probe in now or speculum, there's risk that you're gonna rupture that the presenter and then you you'll get loads of blood coming out, and it's the It's a very dangerous situation to be in. So actually, you want to avoid the trans vaginal ultrasound on a P V or a speculum exam until you've ruled out percent of previa on the way. You do that on the ultrasound, you can have a look on the abdomen and you can see where the percentage is. Um, so, yeah, you're right. Some I think I mentioned Abdo examines Well, yeah, you were doing up there. Exam is well, if you put on here, but, yeah, you just make sure that you avoid, um, the trans vaginal ultrasound or TV examine speculum. That's really important in this case. So on to the management, Then I just talk through this one bit quicker, say a two way because they're bleeding. Um, I would always say this, but she's sort of not acutely. Um, well, yet So I have to say to you, if you keep you deteriorates on and you might consider major hemorrhage protocol depending on the blood loss. So in her case, she's only saying she's getting a little bit of bleeding, So a postcoital so probably not appropriate immediately. But if there was a anymore blood loss, you might start to think about it or if she acutely deteriorate. So if she dropped her BP, Um, if the heart rate goes up, then you would start to be thinking about major hemorrhage critical on in your definition of contact your seniors. Well, um, really on with PB bleed initially. Then you want to do a CT G to monitor the fetus so that I'll tell you how it's doing. The concern with bleeding is that obviously the blood supply to the baby is the placenta. And if there is bleeding, that may mean that as a reduced blood supply to the placenta, so in a good way to monitor that is is with a C T. G. Um, you want to think about anti D if she's recent negative, which in this case, she is, uh, steroids. If she's s and 37 weeks, So she, uh, in our case here, she you'd want to give steroids, so you give your first ocean than a second dose 24 hours later on. If if she becomes unstable, you would start to consider an emergency C section in the case I've just described, it doesn't sound like she is unstable. It sounds like she's quite happy. So if we do our our abdominal ultrasound, we can see a percent of Previa. Then Actually, a zombie she's stable, would monitor her initially, but then we can send her home. So we'll follow up on advice about things like avoiding for sex and baths to to reduce that risk, because after president previous I should like common on. It's only a problem if the percent of stays there and often it it migrates. So back up the side of the wind. In which case that's great because we compete. Keep the baby in for longer on, and that's that's what kind of last. Generally the aim in obstetrics is that you want to keep that baby and as long as possible, because the longer they're in their the better off the morning tree, it's they're going to get the blood. They're going to get the more they can develop before they come out. So that's that's all the key principles. But it's off obstetrics thinking about ongoing management. Then you want to educate the patient about what's happened. And, like I talked about, if she is going home so off what she needs to do, you need to give safety netting advice that if it does get any worse and she starts to get any pain, if there's reduced me to move that, she needs to come back. Um, And so yes, like, I say, presented Previa, you just sort of monitor. And then c section if if, if the presenter is stolen lying at 37 weeks on. The reason for that is, if you can imagine so off the baby's head coming down into the presenter, which is covering the neck of the women, that sort of a joiner that that baby is going to compress the presenter, which is essentially compressing its own blood supply. So therefore, of course, hypoxia to the baby, and that's not gonna end well, so it's really important if they're still present a previous at 37 weeks, you would you would get the baby out by C section. That's the safest way. But hopefully and most of the time they do to migrate up the side, back up to where it where it should be. And then they can deliver as as normal, hopefully not naturally up on here. So if there if there is percentile abruption, that's usually a more acute issue, so they're generally going to be much more acute. Be, um well, you're you're more likely to need your 80 approach Major hammers protocol. Um, and it's more likely to stop being emergency C section. So the percentage of oxygen that is, where is where the percent is actually come off the wall of the womb. Um, and it it means that that the presented they're not being confused very well. It's so discussion. The baby and you, you've got the risk of hypoxia there. And so that is a much more much more than emergency situation. And you're either going to need to get them out there and then or if they if they can manage it, if it's sort of less severe, you might be able to keep baby in. But you would do an induction of labor at 37 weeks on. Do you want to get the baby outsource? So you have the later and great. So that's so That's so looking at PBD. And I just got something on kind of the causes cause I've talked a lot about different causes and I just wanted to sort of elaborate on that, um, say with an antibody, um, hemorrhage. So I have used problem acronyms. A pH is an anti partum hemorrhage. So if it says P v bleeding, you want to be thinking about antepartum hemorrhage on these are some examples of an antibody, um, hemorrhage. So so ignore the other one on the left, you turn in rupture. That's very, very rare. More focus on the other three. So placental abruption is the one I was talking about, whether percent of actually. So it comes away from the womb, and that's the one that's it's very painful. Yeah, you'll know about if they start screaming in pain on that sort of characteristically is is described as having the woman hazards off awoody abdomen hard woody abdomen. So that's where you're abducted. Um, we'll help you out. So if you examine the woman and she the wind feels fine. Then you're thinking probably more of a percent a previa or maybe one of the gynie causes that we talked about here, like ectropion or afternoon. My access. Um, whereas if it's a hard with the abdomen, you don't You're gonna be thinking percent abruption. Um, yeah, where's your percent of previa? And of us? A preview where the either the placenta itself or the cord are covering that opening. Um, and these are these are not painful, and they're they're not as dangerous, but yeah, the key thing to remember if someone comes in with PD beat and do not a form a PV exam or a speculum or transfer, don't ultrasound until you've excluded placenta previa. Um, yeah, that's that's really important. Um, okay, great. So just go to the next case, then, Um so, again, any, um, you got 33 year old women this time of 24. Just 34 weeks. Presents it, like for a routine prenatal visit. So in this case, you're you're being asked to examine the patient's abdomen. Um, So if you have a think about how you might do that going to order my, uh, animations. I've missed it. but we'll we'll go with it. So introduction. So, so, so off These are These are kind of the normal things you have to do to explain the concern. It's so important that you you do this well in a in an obstetric examinations. It's, I suppose, let's say, for the update, one more for sort of PT. But it is just so important that you make the woman feel comfortable. It's possible, um, making sure that you you explain what you're doing. You offer shopper and you're getting the consent of the patient on you, so I'll maintain the patient's dignity throughout. That's that's so important that you do that. So I'm giving, you know, locking the door, giving them time to get undressed at last, that speed, talking through your doing all times and just helping to maintain their dignity. Possibly have one of those cheese. They're not the best, but it's better than nothing. Um, so with this and so far you want to follow, I think whenever and think so. Pregnant abdomen. You always think about just the actual soft tummy part, just just feeling that. But actually you still want to follow all the normal the normal procedure that you do in an examination. So remember, like your general inspection, this one eso looking around the bed that there might be a lot of clues around the bed with medications through about charts, looking at their jobs. Um, and then looking at the patient themselves. Are they comfortable? Are they visibly in pain? Have they got any scars on their abdomen? You might be able to see that as a C section scar already there. Then you you know that they have previously had a C section. You might wanna ask about why? Because that's usually due to complications. Um, but it may not be looking at sort of their color. Um, it definitely pale. Then you might be thinking this and blood loss going on here, or there might be anemic, or there's sort of normal sort of things. You don't want to go to that off. Hands on the face in the hand. You're looking for a couple refill. Any discoloration I am, if they're well perfused. So your temperature and post will will help with that. I would always offer to check BP so something you would always want to think about in pregnancy is have to get pre eclampsia. So any opportunity that you can't just check that pressure was take it onto the face, then say mill, asthma. It's off. Suppose that brownish box kind like freckles? Um, that occurred during due to that hormone changes during pregnancy, so you could look out for those. That's a nice outfit down. One of someone has that again looking at. So any power, any jaundice or any edema. So if they're damaged that she might be thinking about for your cramps Here, Um, and you're going to remember a swell like a pregnant. A pregnant woman can have known pregnant conditions say, just remember you normal stuff onto the abdomen itself, then so inspect the abdomen, as as you normally would. You might see Scotch straight A so that kind of like stretch marks looking at the shape of the abdomen, Um, and you might be able to see fetal movements, depending on how far through there it's that runs off 24 weeks about normal. Um, you you might be able to see those see any scars is where you look more closely up, and then the main but exposed that everyone does think about is the palpations off the abdomen? So, uh, you want to have a general feel off off the abdomen identifying kind of the borders off the uterus, So having a fear of the way around on and then the three million things I suppose that they want you to talk about your summary would be the light if you to lie to you, whether they are longer TUNEL. So talk to bottom if they're oblique. So that's more diagonal or if they're translators, so that's off horizontal. It's post lying sideways. Um, so it's a three to lie. The presentation would be our They had first. Or are they feet first, uh, ahead first to be folic feet. First breach on, then the engagement as well, at least a juvenile ski. They're not gonna be expecting you to be able to. I think it's sort of the way that the proper way to do it would be in fifths of how much of the head is is engaged in. That's off. It signifies how close out of labor. They're not going to expect you to do that. I think they want to know. Is it engaged. Is it not on but would be enough for a nox level. Um, some of the things that you would want to do some special tests to be the synthesis funder height. I'm saying, though probably be a tape measure in the room. If you If you ask me this examination eso you want to measure from the pubic bone to the top of the uterus. So you have a good feel for where that is, um and then measure it. It should roughly line up with gestational age. I think they get processed minus or two centimeters either side before it's class is abnormal. Um, but that that's sort of what you'd be expecting. And I would say if if the measurement you have taken is massively different, the a, the gestational age Just have a thing. Cover measured the right place. Unless, unless you think you're thinking maybe it Maybe there is an issue here, so something making it they go smoother. We'll talk about that later on. Um, fetal heartbeat, then, is the final sort of special past that you do so using the probably the Doppler, the force. Well, you wouldn't measure the heart heartbeat kind of before 16 weeks just because they can't always pick up. Um, And it could make some woman by anxious if if it can be heard. So the advices only start to measure after about 16 weeks on Did use the doctor Oates of initially. And if they're greater than 28 weeks, you can probably hear on the called the pin our stethoscope. And it's basically that metal cone thing. Um that you you'd have a listen. Um, and you should be up to here on that after about 28 weeks and kiss, um, legs and feet then. So don't forget to kind of complete your examination as you normally would. So you wanna check for calf pain? Because obviously pregnancy is a risk factor for DVT's, um, so just give us a squeeze. And I'm looking for ankle edema as well, cause that might indicate come to, uh, right and then fact patient. Restore the clothing, give them some time to get dressed again. And then I say so. It's a completely examination, um, things that you might think about, depending on what you found. You might want to do a speculum. A PD examination. You might want to docs down by the abdomen. PT, uh, TV. So and or you Yeah. You know, you say your analysis if you thinking preeclampsia look for protein. So lots of lots of things to kind of consider That's quite a lot you could say there, but yeah, hopefully that stuff just and overview off here, the pregnant abdomen. Yeah, I just treated like a normal examination. Don't forget all the other bets and try not to let it straight. You, but Yeah, sure, sure. I'll be fine. So, back to back to the original case, then, um, so following your examination. So So you've done the examination, and and also a the end of your examination examiner. Right. Say something on examination, You know, to patient is comfortable at rest. Fetal eyes longer to, you know, with a cephalic presentation on no engagement. Um, synthesis. Fundo height measures 33 centimeters. Fetal heart rate is 145 on. So what sort of differentials might you be thinking? So if the symphysis fund or height is 33 centimeters and she's 24 weeks pregnant? Um, yeah. What? What would you be thinking and snitch do you mind, um, reading out if you have the examples that people have said Eso um lot of people talk about molar pregnancy ease Macrosomia. Yeah, love microsomal is to me a party. I draw me a was said as well. Yeah, one of my great yes. Yeah. So macrosomia is kind of the time you used to describe a fetus that is bigger than expected. Um, and I said, These are kind of your main causes off that on. So I first, if we go through each one, suggest a shin of diabetes. You Dixie would expect so that the North usual. Why it? Cause it's sort of a big baby. But for some reason, it does probably to do the glucose being too much glucose, possibly stimulating extra birth. Um, play had drama. News is another one. So this is where there's extra sort of fluid on the wound. So it's not that the baby's bigger, but sometimes it is. The baby's bigger, but there's a lot more fluid than you'd expect. Um, so 2020 in Sorry. And that's a. That's quite, of course, is a problem. Driving us, including gestation, diabetes, 20 and transfusion syndrome, is another one that's quite complex. And we get going to that. And then congenital anomalies can also cause it to be bigger than than you'd expect. Um, the ways that we don't investigate this, then, um, they're people wanna put person things in the chat for how you'd investigate to go This this kind of less the differentials. If if you're thinking about gestational diabetes or polyhydramnios is being a few most common ones, I should have my reading them out again. Good. Yeah, but everyone saying talk about G t t. Okay, because so incest and your other ones Guys from the diagnostic general investigations going to mention ultrasound as well? Yeah. Just, uh yeah, bm skits. Great. Yeah. Yeah. So yeah. So you guys know this already Say you did it obstetrical she's house is doing, um, consider you could consider. So uti so sometimes infections can course of the other, but the main one you go sit on the test is gonna be your glucose tolerance test. Um, that's your votes, not for gestational diabetes. Um, well, come on to talk about more about lying a minute, but yeah, saying that so obviously with you off the routine, but you might consider like a glucose or HBA. One C is, well, the's wouldn't be diagnostic gestational diabetes, but can be pretty useful just to know to know about under your imaging, you probably don't up well. Yeah, I I This either ultrasound will be fine because you want to have a locker. What's going on? You know, if you've got twins, you might be having a look at that. You wanna have a lock itself? How big the actual baby is, whether it's the fluid that's causing the largest size, or if it's if it's the fetus, um, so that can help with that. And then, as I mentioned before, we start checking in on the baby as well. Um, or a glucose tolerance test Say this is the gold standard for gestation. Diabetes. Um, so it's it's glucose that is measured on fasting, A 75 grand blue Kristen because they're given and the glucose is measured two hours later, um, and thesis off your normal values. So at fasting, you'd expect it to be less than 5.6 and, uh, two hours. You'd expect it to be less than 7.8, uh, to the way that I remember. This is this song. 5678. I'm not going to sing it, but that just helps it stick in my mind. If it helps you, then great. If you have another way of remembering it, then then use that. But it's just about them over for me to remember. Um, So moving back to this, then if we if we think back to our management, then of the over gestational diabetes patient, Um, any ideas of how how we manage that joining a puppet in the shop? Yeah. Yeah. People are rightfully not jumping in and saying insulin say, talking about lifestyle, lifestyle advice to most stepwise management, that lifestyle, the metformin, then insulin make appointments, um, consulted. Let Sultan lead pregnancy. Good. Good point is, well, brilliant. Yeah. Sounds like you guys. I know your stuff pretty well already, eh? So I've just split this into some conservative medical surgical this time. Just a little bit less acute. Um, social conservative things. They're going to need some cough. Regular capillary do for is monitoring about four times daily. I think it is that they're supposed to do and they're going to need ultrasound scans. So four weekly just to keep to monitor. So are the fetal growth on Look at the amniotic fluid volume Because, yeah, there there is high risk that is gonna be a larger baby. So medically, then is kind of what you guys were jumping in with, um, the sort of standard, step wise approach the mentioned applies. If the fasting glucose is less than seven, you would start with the diet and exercise followed by in the nude. Step up the metformin. If that's not controlling, step up the insulin and then finally step up to, uh, another pronounces or glib, then come, I'd which is a sulfonylurea. Um So, yes, it's all around a mix in a quite a weird order. Um, in terms of diabetes management, compared to that your type normal type one or type two diabetes. Um, I remember the first two of the M two like diabetes mellitus, and then I d just I was think of Instagram just helps me to remember the m I d. Is yourself a stepwise approach. Um, if the fasting glucose on that on that glucose tolerance test is greater than seven. When you initially test it. You're going to skip the first two? Um, it's It's an Indian fixing fast, basically. So you're gonna go straight? We give insulin possible is metformin. And then, if that's not working, then it's been Carmine. Oh, see that these decisions will be a consultant that Don't worry if if you get in there and you start panic and you can't remember the specifics, there is quite a lot of specific management in obstetrics, and it is always gonna be the consult when he makes that final decision. I think in your skis, they just sort of want you to have a rough idea off of what's going on and roughly how you're gonna manage a manager patient. Um, if I'm able to surgical management, I kind of think of surgical is the delivery. Um, just because that's sort of your only surgical management for most of the, um, obstetric stuff. So the patient will will need a either in induction of labor or C section at 37 weeks, because chances are that baby is going to be pretty. Think on, but it gets the air gets dangerous if they're in there longer than that, because you've given them a chance to get even bigger. So you'd want to give you steroids because there are gonna be a little bit early. Um, you, during the delivery itself, the blue Coast needs to be monitored hourly. Uh, they need to be given a dextrose, An incident infusion. If the growth phases in between four and seven. The only the only time you you might not do this is if the gestation diabetes is managed by diet alone. Um, then they can keep the baby in a little bit longer so that you could keep them in, uh, so that they come to a more, more naturally. But if they're if they're on metformin or insulin, they need undocked in of labor or C section at 37 weeks. Um, you can stop the treatments after delivery or Aleve these treatments because it should resolve. Generally, it does improve something immediately after birth on but breast feeding. But you do postnatal. You don't follow up tests of the fasting glucose the past six weeks. Um, there are quite a few complications associated with and gestation diabetes post, like for, um, I split the complications into so maternal on fetal. You always want to think about both. So we're made over doing the complications, the maternal ones. So just some of gestational diabetes is a higher risk of preeclampsia. Uh, they are high risk of having long term diabetes. And it says, we talked to diabetes. Um, risk of sort of polyhydramnios so excessive fluid on the uterus risk of preterm delivery. That's partly to do with the management. But I also want you to do the condition itself on because the baby is larger, they're more likely to need an instrument of delivery. Therefore, there are high risk of tearing. Um, so there's the maternal complications. The fetal ones then said, because as you guys said, you're gonna have macrosomia. The baby's gonna be larger. They're at risk off shoulder dystocia, which is where one of the shoulder is going to get stuck on the way out. Um, and it can damage the nerves, um, of that arm on leading to so about a week er on, because probably smaller, less less function in the arm. Um, and it can also cause of the laid or prolonged labor, because if it's a bigger baby is gonna be harder to go um, they're higher risk of cardio megaly. Um, opathy. He's, um, high risk of every three poise is So this is where you got high hemoglobin. They're more likely to be jaundice. The possess is higher Billy Rubin and then after delivery. There are high risk of hypoglycemia, presumably to do to this off the high blood sugar levels during pregnancy when they delivered atlantal drops. So they require regular feeds if the Broncos probably of his lesson, too. Um, so they require regular feeds. And if the blood glucose is less than two, you would consider IV dextrose or energy feeding. Um, and then that looks at risk of tacky near so faster breathing rate on, actually to the reduce the factor. Production s So that's where your corticosteroid, they're going to come in, and hopefully it will reduce the risk of that. And I just took about management then. So you see, diabetes is not uncommon in our population. Some people may have it before they get pregnant. Um, and that has managed in a while. I started different to how gestational diabetes is managed, and it's important to make the distinction because there are two different conditions just a sugar. Diabetes, Very much. It's of induced by the pregnancy and resolve generally resolves after birth, whereas pre existing diabetes is someone who already has it. Um, and this this is the way you manage it. See, you want to aim for good control before pregnancy? Um, they will be given 5 mg of folic acid until probably weeks, so that that's off the high risk pregnancies. Just to help make sure there's no neuro, no problems because they are at higher risk of preeclampsia. They would also be given 75 mg of aspirin from 12 weeks until birth. Um, but they do come off this off after delivery. Um, the target levels are the same as in gestation diabetes. So it's a more normal at 47 than 48. And and if they've got type two diabetes, you'd only use metformin prosom minus insulin. Do you wouldn't use any of the other drugs that the CompUSA in type two diabetes you switch them to metformin inches or no Internet? I don't need it. Uh, they get a retinopathy screening after the booking clinic on that 28 weeks to check for complications in there. Always on, they would have a sort of slightly earlier plant delivery. So 37. Well, it's I mean, it is. No, it's not completely. Not massively earlier. But it would be planned, and you wouldn't let them go further. And 39 weeks because of again a similar similar risk of the baby being much bigger during delivery on during labor. You do Sliding scale, insulin regime. Um, yeah. So? So I think that's that's how you do that. All the imagine of pre existing diabetes, and so what? We're going to try next case. So is this case three? So we've got a 31 year old woman who's 29 weeks pregnant. Um, come to any complaining of a headache? Um, I've been four minutes head Justice market. Yeah. Yeah. Can you think of any sort of, um, different shoes? And actually, I'll give you a bit more on the history, actually. And so if we say, presented in place. So she's got a frontal headache started about four hours ago. She concedes things are flashing, actually bit lightheaded. Um, hasn't had a headache like this during pregnancy. Um, normal fetal movements, um, slightly swollen hands and feet But other than that, no shot PB bleeding, No discharge, no. No other condition. No other symptoms of night. And one of our scans have been normal up until this point. This is a fast pregnancy. She's never been pregnant before. Um, vicious. Positive. And that's that's off. That's nothing. Nothing else of note in her past. Medical history, your drug history of family history. Eso What differentials you thinking, then? A woman with headache. So I scheduled the next side. Yeah. Yeah. You Before you give the history, everyone was jumping out saying the frequency of it. So it's only going to say you can't say about not sure if he mentioned any history of seizures. No. So, yeah, I didn't mention seizures. That's it Doesn't really important distinction to make. Yeah, so, yeah, you get other ones of migraines, tension, headaches. So, yeah, that you start the other important difference, that sort of thing. Nice. Nice. Yeah, definitely. So I think I am a slides in the water. I just kept to this one first. Go through the differentials, so yeah, prayer Can't hear. I've put helps injuring just cause us. That can be a complication in the camps here again because it's a complication, but because she's actually seizing, she's it's not yet. It comes here, but I don't think you'd be penalized for mentioning any differentials. UM, potentially gestational hypertension. So this is where you get the high BP before it's pregnancy injuries. But it's before 20 weeks. So the preeclampsia has to be. Um, yeah, it's, I think, from 20 weeks on end. Preeclampsia is it's associated with protein in the urine. So that's the last one reason why I keep mentioning to of the year in depth as well, as well as to what the infection is to consider. Pretty clumsy. But some people have said migraine. Um, and that's really important, like I mentioned before. Just because she's pregnant doesn't mean you can't have any other conditions. So migraine and tension, headache, any any of your salt primary headaches would also be important. Um, so investigations wise and these the ones I've I've come up with for preeclampsia or for headache as the presentation, um, ophthalmology. So the reason for this is, um, she might have popular Dema on the movies. Times of interesting to cranial pressure of the BP is really high. You'd want to do a neuro exam because with preeclampsia, you'd expect some hyper reflexia. Um, which you can You can see that on your, um, abject on TV in speculum So obvious. Just standard ones. And you want to do the jobs and obviously the most important one. And your obs is that BP? Um, if her BP is up, then you start to get worried. If you if you do, you know your analysis in this protein urea. Then again, that those are the two together you need the high BP on the protein urea for the dymista preeclampsia bloods. I'm not gonna talk to you much about because, uh, the next side will will reveal. Um, but yeah, again. That's sort of normal imaging and special tests. So if I get back then tea, the test results. So project How reluctantly. So, Sarah, who is that you want date today? So always checking your patient details. A four. You dive in to do any sort of test results. We've We've got her. Fbc here on her lefties. Um, does anyone wanna have a gas? Uh, what is going on here or what these results? Sure. You gotta be a lot of people coming out for help. Brilliant. That's what we want to hear. Yes. So have the I mean, the definition of it. Well, what it is, is he Melissa's elevated liver enzymes on low platelets at us? It is an acronym that some is. It describes self a complication off protimes here. So if that BP stays high, was left untreated. Um, it's likely that the patient may progress to help syndrome on what we can see here. Is this low platelets? Um, the elevated liver enzymes. There were more. A little bit high from higher side. Ah, and yeah. So And the hemolysis is the other thing is Well, so you have really good nice spot, guys. Um, if we come into the management, then, um so talking through the management of preeclampsia, um, initially, this is part of acute situation. Um, this is a really important when you do the 80 year, because this could progress quite quickly. We've never We've only mentioned that if prayer prayer counts here does progress, it can become a counselor, which is where the money they start season on. That's really dangerous. for both mom and baby. And it's also really scary. If you're the junior doctor, they're having to look after them. Uh, so you want to do a T straightaway contact seniors, because chances are that baby's gonna need to come out. Um, other things you can do in the meantime, they're wise. He's on their way. I will be too low. A lot of the BP medications and not suitable during not not safe during pregnancy, but libido low. It would be a safe one. Um, that anytime you wouldn't use that would be if they're asthmatic, service you to be to broker. So then you be thinking about nifedipine or anything dopa on. Do you do you use the IV marks. So fate here for the month. This is to prevent seizures. Um, on unusual one, but important one here. Normally in your 80 you want to give fluids. Actually, you you need to food restrict her head that the problem is a, uh, BP sky high. Um, yeah. If you don't feel restricted system to go higher and higher, so do not get foot. Um, you know, and actually suddenly starts bleeding. Thank good fluid give corticosteroid because that may well need to come out early if we can't get that block. BP under control. Um, you've got to give them access, getting back self it. So then ongoing. You need to talk to the mom threw out on partner throughout counts of the patient. It's quite traumatically to go through. Um, so an education, this is more is more sort of long term. They wanted her ongoing. I mean, kind of after that, either the babies come out or after the acute situation has has resolved count their education. So they're gonna have Teo on the next pregnancy. They don't need aspirin. 75 milligrams from 12 weeks until bus. Because if they've had a prayer, can't you in a previous pregnancy that high risk off preeclampsia and the next pregnancy? Uh, on aspirin is the way that we, uh, reduce of it generally say, Mr Station of Diabetes procantare will resolve on delivery, so hopefully should be able to stop. Um, the antihypertensive. Or you may need to switch it or mostly go out if it doesn't come down. But it should. It should come down on the lft should return to normal. Um, so they would need is an emergency C section if they've got either help syndrome or clamps here. But if they've got preeclampsia, you might be able to prevent that from happening. If you get the BP down with, um, and then baby PDV. If there are really no need to be, they may need to review anyway. If there's been some complications during pregnancy, Um, we'll say some other sort of some of the other risk factors and four preeclampsia, um, the divided into a either high or moderate risk. So you're high risk factors are gonna be pre existing hypertension, previous hypertension in pregnancy. So this is of any kind. This is either gestational hypertension or pear. Trump's here, uh, existing auto immune conditions. For some reason, I'm not sure why that's associated with clumsier. Diabetes are the type one or type two on chronic kidney disease. Is your high risk factors for preeclampsia on the moderate risk factors are being aged over 40. Having a hobby, Am I If there's a big gap in your pregnancies, if you've got a multiple pregnancy or this is your first pregnancy, and if you've got family history of preeclampsia on the reason these are divided. Well, it's important to know the division is because that effects here, you gonna give the aspirin too. So to prevent your county, you're gonna give aspirin 75 mg from 12 weeks until birth on. That's for anyone with one arm or high risk factor or two or more, more direct. We'll see if they got one of each to think what? One high. So they're giving it. Um, I just thought I'd use this this patient kind of talking to her hand over. I'm not sure how it is other unions, but certainly a part if we have to do an SVR hand over even if you don't have to do it in your in your unit, it's useful to know for the ward. So the general sort off the structure. I suppose you you to think about who are you for your situation? So that's the situation. Who are you? Where you calling from? Who is the patient on why you called him? Because it's normally the red you're calling. So it may say the open by new regimen, this case, and I'll talk you through the the example of the previous case in a moment. But this is just my general approach to the next spot. So background, then so brief history of presenting complaint, including the key negatives. But don't tell them everything. This is a quick way of having other patients any significant past medical history. So in in pregnancy, that's how they got diabetes. Have they got epilepsy? Had the girl had hypertension and in recess status as well in obstetrics assessment Then, uh, you want to keep keep observational, your examination findings and any initial so test results and the recommendation would be you talk differential. Um, what you've done or you're going to do and what you want, the person you're calling to do so usually the rich. So if I use this case then a small example Esper I'll just sort of talking through what I would say. I hope this is helpful for you both because we don't have to do this this and called it say so you would call the Wretch. They'd say, Hi, I'm the unknown to go anywhere you don't introduce yourself, so I say, Hi, my name's ass on a medical student in any calling about ex patient who is 29 weeks pregnant. I'm concerned that she has severe preeclampsia on GLP syndrome. Uh, she said that some of your situation move on to the background then. So she said, You on gravity. One paranoid she presented with a five hour history of headache she's not have before. You notice some swelling in her hands and feet, and it's feeling lightheaded. She's not got any bleeding. Fetal movements are normal and no signs of infection. So far, the pregnancy been uncomplicated and she is reaches positive. No significant positive mystery, no allergies. So moving on to the sort of assessment then they may have given you, like the news chart or something. Um, so I'd say the pressure is significantly raised at 175 over 100 year, and it was positive for protein. FBC showed low platelet count anemia. A lefty's showed Hyperbilirubin India on elevated liver enzymes. So then you may want to. That's that's the assessment moving onto the recommendation. So I'd say without the French, I think she's got preeclampsia and help syndrome, and I'm worried about that. This might progress to a counselor, so I think she reprised urgent admission on IV infusion off libido, low magnesium sulfate on corticosteroids. Is there anything else you'd like me to do? In the meantime? All right. Pretty Say, please. Can you come in? Review This patient is everything you don't get any time. So sorry. That was That was quite waffle. It's just me talking about hopefully helpful if you have to do an expert in your skin to So if this does progress two accounts here, um, you're gonna have to acutely manage this patient, So that's gonna be your your tip Go 80 approach. So I just sort of talk through the key things in a comes here, so I can see everything is the patient is now season. Um, you never see once you don't, you're 88. You're gonna re assess if interventions that performed, um and you want to receive review your investigation? Results of it is available and ankle for help. Really? Israel. So this is so off. Would be my approach to it in a comedy. A patient. So 80 stayed was the mother. Same as with prayer counter. You should You need to give her that Max elf on beetle. Well, you could give a hydroxyzine or the pain if she's asthmatic. Continuous CTG. So you need to monitor the baby with through, Um, if there's signs that they are a Popsicle, you need to get him out. Mother needs to be in Hates to you until it's stable, and she needs to be monitored on. It's really important one into that fluid balance. So we talked about restricting fluids. Um, that's really important to prevent Point Pramono edema or a kidney injury. Um, on the definitive treatment for a company has to deliver the baby. So that's why it's important you contact you seen his earlier so that they know they need to come in on. They need to, perhaps surgery, because you need to get a baby out. That's the only way to stop the problem. Cool. So we're a case for now. I think that might be a good time to have, like, a five minute break. Just have, uh, have something to drink. Um, yeah, there's There's any five cases in total, so we've only got a couple more today, But yeah, if we if we need to have a break now, um and then we'll pull crackling in five minutes. Every shoot off this meeting is being recorded like Station Co. So I'll just I'll just get straight back into it then. So next case case for, um, you're on label would now. Ah, 26 year old woman who gave birth with that hour ago attends what doesn't attend phrase that long but is complaining of TV bleeding. Say you probably wouldn't have seven minutes and a history of some from someone like this, but less less everything to make maybe about different shoes if I give you a bit more of history. So we could say she gave birth to twins vaginal E about an hour ago and passed the placenta about half now ago. But she's still got blood coming from down below that she's not not entirely sure how much, but she's also feeling quite light. Headed hasn't backed out, and she she says she did have an injection after the procedure, but after the delivery, but she can't remember exactly what it was. She had a previous miscarriage at 12 weeks about three years ago, but not nothing else in know past medical history and no other pregnancies. So what's in different shows you've got Okay, straight on, um so the this is the way I think about my differential special about what we call the supposed bottom hemorrhage. So she she's bleeding after having given birth. And I split this into I don't if you guys have heard of it. But the forties would be so main things that I would think about in my differentials. So tone, tissue trauma and thrombin, um, tone is your your you to our intern. So the uterus hasn't contracted down properly That cause bleeding tissue. When we think about the placenta, if if parts of it are retained with inside that again is stuff to do with that prevents the usually from coming down, so that can cause bleeding trauma. If there's attack on delivery, I can cause bleeding, and throwing them is like a regulation disorders. You also want to think about, um, other things then, because you can't forget that Yeah, patients may have other conditions. Are other things going on not related to pregnancy. So there may be some vaginitis inflammation. There may be a malignancy. Um, that's yeah, that could be quite side. Very sad case. Sometimes the fetus can mask that, um so Avonex, right beyond Concordes, that bleeding on, maybe some polyps or erosions as well. But your top differentials that you'd always be thinking about would be the forties. Particularly tone is is the most common, um, some risk factors. And for four p. Ph. The way I remember is a big, old long bleed. So big uterus eso like a multiple pregnancy macrosomia gestation. Diabetes old, as in older mothers, to increase maternal age long will be like a long, complicated labor. So if they need induction is instrumental. If there's maybe a C section on, bleed it. So big Old long blade bleed would be like a previous P p H and P H. Or if they have some sort of eating disorder. Um, so so the fourth one. That would be the reason that you you need to remember like a clotting studies and things. And so the actual definition then over p pH would be I think it's great than 500 mils of blood loss after vaginal delivery or 1000 know. So Lita after C section Um, and they sort of is quite it's quite hard to know how much it is though. If you think about assume you're been on the label waters quite hard to quantify. But C section is easier. They sort of measure the the the cheese and things that they're being used. Yes, if it's if it's a primary PPH, which is what it is in this case, then it's within 24 hours of delivery where there's a secondary PPH be between 24 hours until 12 weeks. Primary is much more likely to be tone Secondary would be more likely to be one of the other three or one of these. Did you guys get three days cause anything that that helpful? Um, probably not trying, but management over P. PH. So this isn't a keeps an aura. You want the 8. 80 straight away. So everything about what? All right, So you would be so other maintaining in the airway. If not, you would think about a junks on equally on a contract writing you quite early to bill it to the PPH you put out of the two. You say that would be a crash course? Um, so, yeah, seniors will come down with with that breathing thinking about your oxygen. So this is pretty quite used to saying this that you 15 minutes of oxygen by normally be circulation. Then you want to assess the compromise of looking at cat brief. Oh, heart rate, your pressure. Potentially. That EKG is well, it said three wives or cannulas. Take off your Bloods, including the group the same across March, cause that leading, but also like a crossing screeners we just talked about and then you want to resuscitate. So what's your power to twos? I think that the blood's team will the blood bank, so I will come down with that. Cool. Um, I think initially it's probably Oh, negative. And then they try and get crossed much. But while they're on their way, you want to start without the fluids on. Then what? You get bloods go up to four units by the inning or cross much, much day months. GCS check that B. M's keep the more you know, the normal sort of things. Um, and you're kind of exposing for you basically want to find out the course. That would be the most important thing here. Um, so again, reassessing if if any interventions reviewing investigations soon as possible wouldn't call it Help is important. Cool. Uh, next case, then. Oh, actually, if I just talked about how you're actually gonna manage a BPH So if they the most common one, is gonna be toned. So in that case, you you need to. Well, you wouldn't perform it, but a senior would perform. And you might you might say this and you're asking. So once I performed my 80 approach and stabilize the patient, um, I would then either of them after my machine. Oh, my senior, with that perform by manual, you touring compression on this is essentially, um, a red shirt off someone more senior would have a gloved fists and they would insert it into the vagina on the A move. This is that by putting a fist into the uterus helps. It's a consistent contract down on that stops the bleeding. Um, so that's known as a bimanual. You try and compression. If that doesn't work, you would then take him to surgery, and you'd use an intrigued rival in Tampa. Nod. So what's case scenario you to go for a hysterectomy. But that's not really You never really comes to that. These days. The balloon does a similar thing to surfaced on. That is Yeah, that that was shortly. Most common. Obviously. You want to go for the next tedx. And so if we've heard about South Side, we've got our issue. You want to check your percent of trauma, have a look at the actual opening of the vagina itself and see if there are any tears. Thrombin is your parting studies. So, um, it's five and a 21 year old woman who is 30 weeks pregnant. It's come to any kind of discharge. Take a history from the patient. Um, so if I if I had a bit to that. So she's going to say this started this morning About five hours ago? Uh, she felt her underwear. So some through she's sick for a couple more pounds since then. It was kind of a watery, clear discharge. No particular odor. You know, I had it before. No bleeding. Pain fever, normal fetal movements. She's currently 30 weeks pregnant. Singleton pregnancy is uncomplicated. She's had one previous premature pregnancy that it was delivered at 34 weeks. Vaginal, but no other complications. You know the previous pregnancies? Um, recess. Negative. Um, no, others off significant medical history. What? What are you thinking in your differential? Is that, uh, get my reading. The Mountain Dew shot group? Yeah. Evidence took about a ruptured membrane. So crumbs Okay. Brilliant. Yeah. So that would be That would be my top one. Here is. Well, um this this specific terminology I always found a bit confusing with this. So it is definitely a problem because it's premature to of membranes. It is. Rough remembers before labor has to start it, you know, in any pain. Um, but because she's a 30 weeks is well, it's gonna be a pre term premature rupture, remember? And so it's actually people. Yeah. Great. So it wasn't test results back from from this patient. So again, Checking, checking patient details, you say So. This is a high vagina Swab off this patient on this here. Is this old on this date would like to compare to any previous test test results on bit showed her that said there's a moderate growth off great b strep. Uh huh. It's sensitive to both penicillin and clindamycin on resistant to doxycycline. That's the sort of thing that expect if they if they showed you some results like this. Um, so you talked about the French? Those other things you you don't think about would be like an infection. Could could cause some discharge. Uh, probably wouldn't cause such a gush as she's described. But you need to have any to have a list of other things as well, Your honor. In quantity. It's something to think about. And it can be sort of normal. Vaginal secretions for for some people is well, um, investigations. And so that side your normal, you know, like terminations. I've put a star here again just because if she's ruptured membranes, which you're not sure whether she has a know initially you can you can do these examinations. They sort of more invasive examinations. But you don't need what to minimize the number of times you do it. Because because if these numbers have ruptured, there's much higher risk of introducing infection. Eh? So you just sort of do this without caution. Saying so similar to the bleeding is you know, you don't want, you know, you put anything on the introduce anything new. Uh, check Arab's, see how she's doing, she's stable. Your analysis So supposed to rule out infection and then high vaginal swabs as I just showed you the results of those normal bloods. Yeah. No, it's a management then of a problem. So you want to let seniors know about it? Isn't It's not such an urgent sort of issue. Um, but you would want to admit her for 24 hour obstacle. Want someone has ruptured, remember, is if they're going to go into labor, it's usually within the 1st 24 hours. Um, with her, then you then one, actually, with anyone you want to give prophylactic go right through my son too. Problematic antibiotics for about 10 days because there's risk of chorioamnionitis in his risk of a juicy infection up there. Um, because any membrane sort of actually a barrier to the outside world. So you just want to give those prophylactically. And if you're ever not sure about the antibiotics you want to give, always just go with the idea. Prophylactic antibiotics with the guidance of micro. You know, according to the local guidelines, that's so that's always gonna let you get out of jail free card. You can always set up. Um, baby, you just consider corticosteroids because Yes, they said that they are quite that it's going into labor in the 1st 24 hours. However, if they don't, you can solve. Educate Mom about what's happened, and it's more sort of expectant management than, um, in your education. And so the patient can go home after 24 hours if they're stable. But you want to make sure they're not having baths and not having sex, you know, not doing it any soft. Uh, anything that could trigger labor, like probably charging anything that yeah, you already occurred Injuries, labor or could introduce infections. Um, it's getting to avoid and also safety not as well that come back if you do start contracting. If there are any concerns, um, so yeah, expected management until it least 34 weeks, because you do want to keep the baby and there's always you can. But because of the risk of infection, you probably would induce labor about about 34 weeks. But it will be a senior like discussion, Um, and another baby, if they're born this have coming out of 34 weeks, they would be managed by the new Monitor team now say, because our patient has Group B strep, so you actually don't need to give the antibiotics immediately. It's sort of not not an issue until labor. So during the labor is then when you would give the common but was was a penicillin. She was sensitive to say that that's when he started Teo give you penicillin. No, you don't need to worry about it before you just get a prophylactic prophylacting antibiotics To anyone who dropped down the brain's prematurity. Teo problem interactions Cool said. Last thing I thought kind of cover is the actual PV on the speculum examinations. So this is kind of the the full examination, um, again that you kind of think about so you always want to explain really, really important in the PT Inspector. It's a very invasive, undignified examination, very uncomfortable for the patient. So making sure that she consents and that she is comfortable throughout definitely have a chaperone. You know, nurse there with her. Who could support her own, I'd say, ideally, if you know, chaperone particular. If you're a male yourself, um, just to make her feel comfortable, possible maintain maintained dignity throughout, so it goes without saying, but it's really important um, German inspection. And so, actually, positioning them initially is very important. Eso you already have explained that they need to undress from the waist down and apply down cover themselves. But once they've done this. So the way I describe it, So So I said, can you bring your heels to your bottom on that in these four to the side? Sit up. Yeah. And I mean, the other thing you want to just ask him to kind of relaxes much as possible is so difficult in that situation. But that does make it easier for me. You. Then you start off inspecting the area, you know, having a look for the normal things you be thinking about. So also is discharge any obvious bleeding? Scarring, right? Masses and rashes have a muscle and then onto the actual exam itself. So a reconfirm concern at that point just to make sure. Um, get your gloves on. You don't want to put some, um, some lubricant on your gloves. Um, and in your skin exams. Always make sure you call it lubricant. I know someone who could leave, and it's just not very professional, so just make sure it's the Lyrica on your Gove's, Um, you then yes, saved. Separate the labia with your nondominant hand and gently insert warning the worm. Frieda, insert your gloved index and middle fingers off your dominant hand kind of pointing like a gun. You then twists or 90 degrees. Um, so your problem is facing upwards. And then that's when you start. You start to fail for various things so you won't have a fear of the rules. The vagina walls to it says any masses or irregularities on with the cervix. Then you're so you're assessing it's position, whether it's kind of smooth or irregular. Um, if there's any tenderness, so we're really be relevant at this source in an obstruction works already pregnant. But excitation off the cervix would indicate P i D or atopic pregnancy was just basically a p a. D would be pregnant. Um, you don't feel before disease for any masses, the uterus. So the way you do that is with you got hands, um, 100 side and then the non dominant and is outside. You'd place it so above the pubic symphysis. Um on left the uterus up toe to feel for it. So size and shape as well. Um, not so much easier. Leone pregnancy that big of the uterus gets, the harder it is to kind of do that. Um, And then you show up with the ovaries as well, and for any masses and quite a tenderness there, Um, the then removed that gloved hand. Look at your fingers. Any blood or discharge, cover the patient. Make sure you provide them with paper towels to solve, clean themselves up on give them privacy. Well, you got to give them so crazy at that point to get dressed, or you would go on and do your speculum examination. So again, I do is yeah, three confirmed consent and then one of lubricate the actual speculum itself. Um, it's quite a federally thing to do. So if you can practice this than try to before before you're up to our ski or before a natural patient so similar Sort of Tell that to the PT examine that you separate it. Maybe with the non dominant hand you're inserting that speculum sort of sideways. Um, so with the screw up, the that sort of towards one of her legs, and then once it's in your gonna rotate at 90 degrees. So the school year at the top, Um, open it slowly. It might be uncomfortable. You know, You want to reassure her during during this point, um and then talk. Tighten it. There's the screw on it that you used to tighten you Then inspect the cervix. Cillis is so the main, the main point of it, including the OSS. And during pregnancy, you might be looking at how open and close this, but in an osteo, they're not gonna be expecting you to know how dilated someone is. That's that's well above our level on looking for any erosions also's masses discharge. Um, anything. Anything like that. Really On then afterwards again, remove solium Be really careful. I I wouldn't shut the speculum. Are you removing? I would keep it slightly. Earth, Um, because it's very easy to get things trapped in that very uncomfortable, um, again. And cover the patient and thank them. Um, and you try and try and keep It is dignified as possible. Um, don't have done your examination or c somewhere to findings. Other things you may then consider would be like your analysis, your vagina swabs, Um, and after examination. If you don't double already on possibly an ultrasound as well, depending on on what's going on, what you found. So, um, so this slide, I've been briefly going to talk about C t gs. Um, I don't I think it would be I'd be very surprised if they put this in our ski at first off the level that we're at, Um, and if they do put it in there, not gonna expect you to know the details. They just want to know that you've got sort of a systematic approach, Teo, to follow it. Um, on. Yeah. And they just know that if you're if it doesn't abnormal to you, um, you contact the Sr. If you ever unsure. Always just contact a senior. They just They just want to know the Noski that you're gonna be safe. Um, so if I go through the way that I did, I would approach it. I think this is This is the way they don't give you medics say doctor, see, bravado is how I remember. So, doctor, the fine risk. So this means sort of determine to time in the context of the city that you're looking up, um, to determine is the pregnancy high or low risk? Because if it's high risk, you might have a slightly lower threshold for intervention. Um, thinking like maternally Is there any diabetes, high BP, asthma, smoking or drug history? Um, and then of the actual pregnancy itself, is it more to progestation? Are they post date? Have they have any previous sections? Is only intrauterine growth restrictions on anything like that. Really? You want to be thinking about before you didn't look t um the fascinated didn't It is contractions. So I'll get this issue of, uh, put it easier. Um, so contractions, you be looking at the number of contractions in a 10 minute period. Um, and each big square is one minute. So I think here, though, people say that too, in a 10 minute period here. So these this level, this lower section is your contractions on this upper section. Is your fetal heart heart be? So how many contractions in a 10 minute period. So this would be turned in town. That's how you describe it. You want to start? I think I think about the degeneration. How long are they? Um, you could you might consider the intensity, but you can only do that by examining them. So I wouldn't worry about that one. It up to you The bra is your baseline rate. So that is, um, you sort of average fetal heart rate. So that's looking at this line here. So this average you don't heart rate it Probably about 1. 30 probably would would be quite fair. I think, um, normal is between 110 260 if the younger you'd expect it is. And if the fetus is that a no, your stage of gestation, you'd expect it to be about higher. And it's that off near and delivery, you'd expect it to be on the lower side. Um, but still within that range and some things that can cause, like, a tachycardia. So if if it's a bit more up here, well, the most concerning one would be high pox here. Possibly that infections like Korea. I'm near, um, new notice us if this hypothyroidism, uh, anemia, or like certain arrhythmias, congenital heart conditions. Um, if there's a bradycardia, you might be considering, like some called compression, possibly called products, or it could just be that the mother is has had an epidural or a spinal that so, Yeah, it's important to consider some of the bigger picture before looking at these. So contractions, first baseline rate. Um, then it's this off for this really kind of the main things that you can sit up of the actual rates of variability. This is demonstrated on here. Um, so how much does the heart rate differ from? From one to be to the next? Uh, you do? It is normal for a fetus to have quite a variable heart rate. Think between about five and 25 is what they what. They like to see it as that. That's normal. Or here it says 10 and 25. Um, which is something different, too? An adult patient and you expect in adults to be quite constant. But actually you want the variability. It shows that they're responding to the different stimuli within the uterus. So that's a good thing. Um, if it's reduced, it might just be that they're sleeping if this reduce your ability. But other reasons, I suppose we would be hypoxia would be your main one. If there's if there's not much variability. Um acts on the holidays. So the next to the accelerations in detail orations Which of these air acceleration? So this is sort of a zit shoots up. It goes a bit faster for but and then it So it comes back down again. Um, these aren't too concerning, particularly if they are with the contraction. Um, you kind of expect them to be with the contraction, um, in December rations. So this is a problem. There's a prolonged deceleration. Um, a normal deceleration would just look like an acceleration, but in reverse. So it would be more of a W rather than in him. And again if that If that w is sort of with this contraction, it's not too concerning. Any other type of deceleration is concerning. So the main things you'd sort of be worried about if you took a CT G would be if there's not much variability if it's sort of more of a flat line than a jagged line, Um, if the heart rate heart rate is particularly high or low, or if there are some decelerations that don't much the contractions, those will be the main things that you would you be worried if if you show those things and you would contact to see you, this is an example of prolonged deceleration and that I think that's that's particularly concerning, um, and the main. The main factor that causes any of these abnormalities is high pox. Yeah, and that's kind of that's kind of CTG in a not show on, then. Oh is. Obviously, it's the overall impression. Are you happy with that all? Would you like senior help? Um, if yeah, so any other things I just described. If if you see those, you you be concerned is. And if you see this decelerations or loss of variability, Yeah, you would be concerned about, um, you want to get a senior vote because you probably need to get the baby out because they're likely to be our boxes or soon they're actually be a box said That's just a quick overview of CT's. I don't want her confused or worry anyone. I don't think this would come up in our ski. I think it's very mean. Certainly would. I don't think it comes in a card. If one don't, I can't speak for other units, but if they did, they wouldn't expect much knowledge, so don't stress too much about these. Cool. So I think, Well, I've got some SPF people want to do them. But if we're not, if they don't want to, then this is off the last the last minute thing to cover. So just a few like spot diagnoses that will hopefully help you to solve. Stop thinking about you. Differentials on diffuse Get stuck. I feel help guide you. So if we got PV bleeding on, it's painless. Then you're gonna be thinking percent of previa. If we got PT bleeding, it's painful. Placental abruption, TV discharge. So it was like a golf during pregnancy. Well, it was just discharged. Probably be more like an infection. But if it's a Gush A Z But in our last case, you thinking about people, Um um, if there before. But if she's 32 extremely a p problem, whereas if it's after 37 weeks, then it's just gonna be a problem. Abdomen. So I've got the pain on here. There's no sort of one specific, most common diagnosis, but it is quite common presentation, so differentials for this would include labor, and obviously, if there early, it might be a preterm labor that before 37 weeks um, miscarriage for central abruption would cause update pain, then might not be bleeding with a percentile abruption, because it could be a concealed abruption where there's bleeding into the uterus. But actually it's not made its way down and out of the vagina. So, you know, just be aware of that. Other things that can cause a dependence or less common, would be like an ovarian cyst, a malignancy or your general causes of acute abdomen. So appendicitis cause cystitis, pancreatitis, any of those shows things don't forget those in your differentials. Um, headache. We've covered pretty camps. Yeah, uh, or other prime because it's Regis fetal movements. You be thinking about miscarriage or stillbirth, depending on when it's happened. So a miscarriage would be before 24 weeks or a stillbirth. If it's that post 24 weeks, Um, other things that could cause reduce fetal movements could be like all ago. Hydramnios, which is the other is reduced. So it, uh, baby polyhydramnios so too much fluid in treating on growth restrictions can cause that, um, some congenital malformations or as we just talked about with CTG, if there's hypoxia. Um, than that cause it was as well. But these are kind of your top with top things that you would think off. Um, yeah, but with with these presentations, um, cool. So I mean, I'll just take a pause there. I don't know if people would rather I've got some SPF is that I could go through or, you know, it's sort of nine o'clock now, so I don't know. People would rather stop there. It's kind of, you know, you go through a bad leg, pulls through them. Yeah. Yeah. Okay. Cool. Just a test. If you guys have been listening, so can you need opposed for these new shoes? Yeah. Course. So. Fast. Question. And 38 year old female with a BP off 155 over one. Oh, three in the trimester of pregnancy. 24 hour urine collection. She is no 240.5 once a pretty So which complication would indicate progression to come see you. I can actually see the pole. I see. Great. Cool. So, yeah, most of you got that right. So see is yeah, is correct. Um, I'm just glad they begin. Yeah, So it's gonna be tonic clonic seizures would indicate a few people a help syndrome. That would be a complication off of times, you know, But the clasico sign off country is type of seizures. Court next. 1 41 year old who has recently had a positive pregnancy test, comes to the GP. If some advice is a second pregnancy, she has a BM. I have 22 type two diabetes. So what advice should be given And regarding what? So off medications or supplements she she needs. It's sorry. No, I can actually see the poet enough from generate out. Yeah. So it's going to be split between, um a and see. Okay. Cool. Um, so the right answer here is actually a eso I can see why people thought. See, say folic acid, 5 mg from now until birth. Say she would be on the higher dose. But it would only be for the 1st 12 weeks. Um, that she take the folic acid. Um, so the correct answer is is gonna be the aspirin. Um, so from 12 weeks until birth, because she's a higher risk off preeclampsia because she is 41. Um, and she's got type two diabetes So she need that extra? Yeah, the aspirin. Great. So question three. So we got a 28 year old woman who has started six weeks pregnant, presents the day companions. So they're continuous at their pain this morning about bloody discharge. Examination reveals a firm with the uterus, which is tender. Heart rate of 110 BP 98/65. So what's the most like donations here? Yeah, pretty much. Everything's gone for B. Ah, fuck, yeah. So yeah, that hard, Really abdomen is correct. Touristic. That is gonna be percent reduction. She got their pain. Where? A lot of pain with a bit of blood. Um, absolutely. Question for 24 year old, who is that seven weeks pregnant Comes in complaining of pain, less PVD. So which examination or investigation should be avoided? An issue? He I think pretty much everyone has gone for. See 99% spoonful. See amazing people. Happiness Li I d. Oh, yeah, I said absolutely. We talked about why I quite a lot, you know, last question. And so following vaginal delivery, a 23 year old female with no significant positive history has lost 700 mils blood. What's the most likely cause of this? Yeah, Majority from four D. Yep. Said always thinking about your forties. But the most common minus is gonna be that tone. A nice one. So just that's just a recap. What we covered today and then I finally just got about future or tips for your for your skis. So I always say before the station, you've got a little bit of time to read that initial description like come up with that list of differentials in your mind. So you've got an idea off what questions you're gonna ask on so that you have a list at the end. If if you're taking that history and you're really not sure what's going on, have have three things in mind that you can say no matter what what they want. Um, attendant. After each station, just forget about the last one. Doesn't matter how you did in that station. You just need to focus on the one that's in front of you. Um, how easier said than done? I appreciate, but it's really important, even if you've had, you know, if you really feel like you've not done well, doesn't matter. forget it. Me one with the history. Always try. And after about those red flags when upset trick history always ask about me, says status, um, investigations I follow. So a bedside bloods imaging special tests. Um, and then for management. I saw in and obstetric a station. I always did the 18 ish 88 initial longer management, but I always make sure you consider the mom and the baby. There's two. There's two people involved. Um, and then the last thing I would just say is like confidence. You've worked so hard for these down. Just go into your best. And if you're confident in what you're doing, the Examiner will set. That can stop listening as much. And so, yeah, just just go in there, go in good E best and good luck to everyone. Yeah, that's that's that. Well, I've got to say I didn't know if there were any questions. Um, I could try to answer some of them, but yeah, that's a That's a lot for me at the wife