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So feel free to write it on the, um on the poll, we'll be keeping an eye on it throughout the entire thing. Um And if we take a few minutes to get back to you on the questions, we're not ignoring you, we're just, we will get around it. So Thursday 15 is a myth. Some of you might already know. We are a teaching series, uh led by F ones. It's aimed at this series in particular is called Thursday 15. It's aimed at preparing you guys for your finals and obviously, it's relevant to all your groups as well as just years or four years. The basic structure of this session today is we'll be going through timed multiple choice questions and then at the very end, we'll go through all of the answers and the topics that each question brought up. Um So if you have any questions about any of the topics, we will hopefully be answering any of your, uh those questions as we run through it. We do these sessions every Thursday and sometimes on Tuesdays on other topics. If you've seen any of them before the, all the sessions are recorded and subsequently uploaded to our meal website and our youtube and our actual website. Um and we'll share the links of that at the end of the session if you fill out a feedback form. So the topics that we're gonna cover today, we're going to include most sleep, about early pregnancy and obstetrics. Uh We'll be going through miscarriage, ectopic pregnancies, diabetes, um, bleeding and preeclampsia. And then we're going to just go on to do some ovarian cancer as well. So, is everyone ready to do some multiple choice questions? I'll just check that there's no questions on the pole and we will go to the first question. So I don't know how you guys would prefer to write, um, your answers down if you wanna get some pen and paper or get ready on the pole to write down whatever answer you want to give and we'll stop. How many, uh, how many minutes are we doing? Per question? Actually, we did about a minute per question. Um, but as we have nine questions, we could probably 11 minute to one minute and a half is fine. Ok. Fine. So, yeah, we'll do 60 to 90 seconds per question and we'll go now with the first question. Mhm. Ok. I won't read it out, but I'll give you a couple of seconds to process it. Just answering a question in the chat just cos it's relevant, I suppose to this bit of the session. So at the moment, we're literally just gonna go through these questions without going through the answers. So we're um yeah, you write down what you think on a piece of paper on your phone or wherever and then we're gonna go through the answers at the end. And then we will ask you to put the answers in the chat and let us know before we actually tell you the answer. Cool. Thank you, Vicky. Um I will move on to question two now, if that's OK with everyone. Yeah, and we'll move on to question three and on to question four. And we move on to question five now done to question six and then on to question seven and on to question eight and on to the last question now. Great. I think that's all the M CQ is done. So we'll move on to the teaching part of the presentation. Now, I think we're just going to quickly run through some terminology and some kind of general obstetric um knowledge there. Yeah. So before we go into the answers, I just wanted to go through just a general way to approach your revision uh and questions um because we're not going to be able to cover everything in this session and we, we may, we may try and do part two. Um but just so you have in the back of your mind of other topics that could come up. And I think what's really nice about um obstetrics especially is that, I mean, there's a very clear timeline of what happens just because of the nature of pregnancy. You know, there's only things can only happen in a certain order really. Um, so I think that's what's quite nice for obstetrics and I think it's important in, um, obviously for your actual clinical practice, but in exams, especially to just, I think, have a really clear, um, timeline of when things can happen to just help you narrow things down. Um So I won't go into too, too much detail over the next few slides, but just I'll just go through a rough guidance of like what the topics will come up in certain orders. So if you just want to move on to the next slide, um so I suppose in early pregnancy and then this also cross over with Gynae. So things like pregnancy of unknown location, miscarriage, ectopic molar pregnancy, luckily we're actually covering quite a few of these today. And then next. Um so in terms of antenatal care here, this list is not exhaustive and also I think the detail in which you need to know of all these topics, I wouldn't worry too much about all the nitty gritty. Unfortunately, I think for the year that you do Ob and Gyne and they do expect you to know a bit more than your average doctor would know um about Obs and Gynae. Um So I think just having a general understanding of you know, timing of when things happen, you know, what, what days do the er sorry, what weeks do the booking visit and dating scans and other subsequent scans, scans happen at uh knowing the criteria for high, you know, high risk pregnancies and who's gonna need uh a consultant, you know, obstetrician led um care versus uh midwife care. Um Other topics um such as VT E very important. Um and yeah, things like um small or large for dates, multiple pregnancy and things like antenatal problems such as high premise of gravida, reduced fetal movements, preterm, prelabor, rupture membranes sounds like a lot. But I think when you think about it chronologically, it will make sense. Um So just bear that in mind when you're doing your and then onto the next slide, um then with an intrapartum care as well. Um Labor, there's clear um timeline of what happens there. So I think just making sure you have a really good grasp of what happens at each stage, what things can go wrong. Um And what, how to manage those situations to an extent. Again, I'm not saying that you, you're not taking your sort of SG any specific college exams here, but I think just having a good understanding of the basics would be good. Um And we are going to cover some of these obstetric complications as well in the session and then on to the next and then don't forget things that can happen postpartum care as well. Um So yeah, this is just a list here of other things that could come up. Um And yeah, definitely, don't forget the mental health element of it as well. Um Very important crossover with psych if you're doing this in the same year as well. So you can definitely see that coming up as an M CQ and also as a OSK station as well. And yeah, moving on to the next. Um So just before we get started, I realize in a lot of the questions you will have seen, you know, G EP and if you're studying OBS and Gynae this year, then hopefully you'll already know what this means. But just in case for those who um may not know what this is. So gravity, it just means to, sorry, I realize what I'm saying. It, I don't know if I'm saying or gravity or gravita um total number of pregnancies and then parity means uh total number of pregnancies carried over the threshold of viability in the UK. That's 24 weeks. Um So here are some examples just to illustrate that. So let's say someone is currently pregnant and they had two previous deliveries that would be G three P two, they haven't yet delivered uh the current uh child and then patient is currently pregnant had one previous delivery and one pre previous miscarriage. Um So that is G three because they, the miscarriage there would have happened over 24 weeks and then um sorry P one plus one. There we go and then patient is not pregnant, had a twin pregnancy resulting in two live births. Er, so that's a G one P one because even though it's a twin pregnancy, it's just the one birth. So I think I misread the second example there. Sorry it was G three P one plus one and the plus one refers to the pregnancy, not car to 24 weeks. Apologies there. Um Moving on to the next. Cool I think um there was a question Zane said, can we go back to the previous intrapartum care slide? Ok. Yeah, let me, there you go. I'll leave that out for a few seconds and you will get the slide as well. So don't worry if you miss anything. Exactly. I'm sorry. We may not have made it clear in the previous sessions of how to actually access them. So, so sorry. So we are working on that now. Um So yeah, if you go on the meal on our metal page, you should be able to see them. I'm gonna share the links at the end to our youtube and website and then hopefully you can also access them on those if that's a bit easier for you as well and you want the Antenatal care one. There you go. Oh yeah. Um Yeah, I'll give you a few more seconds and then we'll move on to run through the answers. So hopefully that's enough um time for you, Zain if not, uh just put it back on the chart and I can go back through it another time. Um So I'll just go back through to the first question now. So this is about a 33 year old lady who came in with fatigue, increased urinary frequency and um she has a BMI of 32. And so the question was kind of asking you to two things, which is what do you think the most likely thing is and then how, what is the initial investigation for? What you think is the most likely thing? So at this point, if anyone wants to put out any answers to what they think, um they thought it was, I'll give you guys a few seconds, put the letter or put what you think it was, Linna, put b anyone else agree or disagree. Mbes brilliant. That's enough for me. Two BS. Um So yes, the answer was b oral glucose tolerance test. And that was because the diagnosis I was trying to get at was gestational diabetes. Gestational diabetes is a glucose intolerance that occurs during pregnancy and that the patient didn't have before, prior to pregnancy. It is quite common. It complicates up to one in 20 pregnancies and is the second most common disorder that affects pregnancies after hypertension, which we'll go through later on in the slide, the risk factors for gestational diabetes, which I tried to get out in the question was uh BMI more than 30. So this lady had a BMI of 32 a previous large, a large baby, um, previous diagnosis of gestational diabetes or a family history of diabetes or an ethnicity of South Asian African Caribbean or Middle Eastern or a background of having PCO S. So the pathophysiology behind gestational diabetes isn't the most clear. But what we do definitely know is that during pregnancy, your insulin requirement increases by about 30%. And that's caused by the increased metabolic demand of having a pregnancy. This initially causes an a degree of insulin sensitivity and then that progresses to insulin resistance. And that gives you hyperglycemia. And also the other thing that affects it is that you have hormones that are released during pregnancy. So your um your estrogen, your progesterone um that these are all antagonists of insulin. So these all contribute to a peripheral insulin resistance. And then that means that the insulin that you're secreting isn't sufficient enough to manage your glucose levels. And so that gives you gestational diabetes. Uh the complications of gestational diabetes for women for the mother themselves is mostly just an increased risk of infection. So your skin um skin infections, uti infections, I realized I've put urinary tract tract infections. Um and the fetal complications for GDM are mostly from the complications of fetal hyperglycemia. So for, for fetuses, they get, they can get glucose transported across the placenta, but they don't get insulin. And so if the mother is hyperglycemic, the, the fetus gets that glucose through the placenta, but they don't get the mother's own insulin. So the fetus starts to produce their own insulin and insulin is essentially also a growth hormone. So as the baby is producing more, more and more insulin to cope with the mother's increased glucose, um that insulin works on the child itself to cause big baby, otherwise known as macrosomia. And also can also make your um organs large as well. It can also cause polyhydramnios which I can't pronounce, which is basically like um the baby's peeing a lot, which is essentially the same thing that you would get in an adult with diabetes where they present with increased urinary frequency. The fetus does that as well. Um They become polyuric and create more fluid around themselves. Uh The increased insulin secretion of the fetus also causes pulmonary this pulmonary sur factor in the newborn. Um It decreases the amount of that. And so it can cause uh respiratory distress syndrome when they're born and it can also cause them rebound hypoglycemia when they're born. So when after they're delivered, they built up all of this insulin that they were producing in response to the mother and that's still in that in their body, in their circulation. But actually, they're not getting the mother's glucose um any more. So they become hypoglycemic. So you have to, that's one of the things that you have to watch out for after the baby is born and I'll move on to the next slide. And so the the screening slash the investigation for this is the oral glucose tolerance test. So if any of the risk factors that I mentioned earlier are present, then you'd want to do an oral glucose tolerance test at around 24 to 28 weeks gestation. And this basically involves taking a fasting glucose and then the mother will drink us. It's usually given in a drink about 75 g of glucose. And if and then they'll measure glucose after that. And if the glucose is greater than 7.6 then this gives them a diagnosis of gestational diabetes. You might also do look to do the oral glucose tolerance test earlier if they've got a pre if they've had a previous diagnosis of gestational diabetes in a previous pregnancy. Um And you could do the oral glucose tolerance test at any point if a woman presents with uh glucose in their urine. And so moving on to management. Uh is there any, is there any questions that I can answer now, just in case before I move on, I hope that's all. Ok, cool. No questions. Um So management for this can, can include just lifestyle um in including kind of diet and exercise, all of the normal things that we would suggest in diabetes. Um If their blood sugars are looking quite, quite high though, we might suggest commencing Metformin or insulin. And you would also do additional growth scans as well. Just to check that the baby isn't growing, is growing adequately isn't getting too big. Um, women with gestational diabetes, you also want to aim to aim to deliver at around 37 to 38 weeks. And this is because it's been shown that women with GDM, they have an increased risk of stillbirth, the longer the gestation goes on. And during delivery, you'd want to be checking um more regularly than normal CTG as well. Just to check the baby is doing ok, postpartum wise with the, with the pathophysiology of gestational diabetes, you would expect that gestational diabetes would resolve almost immediately after the after delivery. So any antidiabetic medication that the woman was on, such as Metformin or insulin would be, would be immediately stopped once delivery happened. Whilst the baby is when the after the baby has been born, you'd want to check for that rebound hypoglycemia that I mentioned before. So you'd want to be doing regular glucose monitoring of the newborn. And in terms of the, the woman itself, you'd want to repeat their fasting glucose in about 6 to 8 weeks after delivery to check that their insulin resistance has resolved. But usually in about 50% of women that have GDM, they go on to develop type two diabetes later on in life. Anyway. So there is a chance that their insulin resistance persists or redevelops that at a later point and just a little quickly on if a woman is pregnant and already has preexisting diabetes, um, the management of this isn't that all too different. It's the same as it is for gestational diabetes. And this applies for type one or type two diabetes. The complications for the mother and the child are the same as well as essentially the complication is resulting from the hyperglycemia and the child produce and the fetus producing too much insulin. But the only difference in management of this is that you would also add in aspirin 75 mgs daily after 12 weeks gestation. And this is thought that this is to reduce the uh the risk of developing preeclampsia. The exact mechanism of why aspirin works isn't fully known. I know that Vicky is going to go through preeclampsia later. But basically, the theory is that aspirin reduces the release of prostaglandins and inhibits platelet aggregation, things like that, which are all thought to be risk factors to contributing to preeclampsia. So that is that is diabetes. Did anyone have any questions on that at all? I'm sorry, if I spoke really quickly. If not, I will move on to the next question. So this was a lady that was presenting with a small amount of bleeding, she's HCG positive. So we know that she is pregnant and her cervical a was closed and we could hear a fetal heartbeat. On the ultrasound. What was everyone's ideas of what it could be. So, let's put D d again, anyone agree or disagree. No, the, we're happy with the, and I'm also very happy with the, so the answer was threatened miscarriage. Um So I'm just going to go through all of the different types of miscarriage and there's a very handy little table here. And so a miscarriage is defined as a spontaneous pregnancy loss before 24 weeks, after 24 weeks, this would be called a stillbirth. Um A miscarriage is incredibly common about. It affects about one in five pregnancies during the first trimester of a miscarriage. The most common cause for a miscarriage, often genetic abnormalities that we might never know about or its issues to do with implant, um implant, implantation or development of the placenta and in terms of kind of diagnosing what kind of miscarriage a woman has had. This is a combination of that clinical findings so that history of pain and or bleeding and also based on ultrasound scan findings as well. So the first one that I'll go through is a threatened miscarriage, which is what this lady had now and yet, and this is characterized by painless vaginal bleeding with a closed cervical. And this is and with also a fetal heartbeat on ultrasound. This is the most common type of miscarriage. It affects about 25% of all pregnancies. And in this type of miscarriage, the pregnancy could still be viable and could still go on to a, a healthy and fully developed um pregnancy, but it could also develop into another type of the miscarriages that I'm going to go, go on to. So, and then the next one that we'll talk about is in an inevitable miscarriage. And so this is characterized by very painful, heavy bleeding with clots. And you would also see an open a on examination and you might also hear, you would also hear a fetal heartbeat. And this is because the, the fetus is still alive, but it's, it will, it will definitely go on to miss carry and then you have an incomplete miscarriage. And this again presents with painful bleeding. But in the difference between this is that the cervical os would be closed and you wouldn't get a, uh you wouldn't hear a fetal heartbeat. And at this point in the miscarriage, there isn't a viable pregnancy, but you have the products of conception that is still in the uterus. Uh they just haven't been fully expelled yet. And then you have a complete miscarriage, which again presents quite similarly, um with painful bleeding, closed eyes, um and no beat or heartbeat, but it, you basically don't see any products of conception in the uterus. So this is uh so the difference between an incomplete miscarriage and a complete miscarriage in this case is what you see on the ultrasound scan, whether you see any products of conception still there in a complete miscarriage, there wouldn't be anything there anymore. And the reason in there might have been a previous pregnancy on previous ultrasound scans or a previous positive pregnancy test to prove that there had indeed been a pregnancy. And then the last type is a missed or a delayed miscarriage. So this might present with no symptoms whatsoever. There might be some light vaginal bleeding or some discharge. Um, it's almost always pain free um or kind of no bleeding at all. And this in on examination, you would see a closed cervical and no fetal heartbeat either. And this is you kind of confirm this with an ultrasound scan. Um This is when a a mis miscarriage when there is a gestational kind of sac there um with the products of conception, but there's no kind of sign that it's been expelled yet. So that is miscarriage. Anyone have any, any questions I'm doing a bit of a quick run through. Let me know if there is anything. Otherwise I'll go on to the next question. Cool. So I will go on to the next one. And this one is a 24 year old lady who presents with worsening cramping, abdominal pain. She also had some light vaginal bleeding and she's got a soft but globally tender abdomen but worse in the left iliac fossa. Does anyone have any ideas of what this could be? So part a other people have put a anyone else? More a and I'm happy with that. So, yeah, it was a ectopic pregnancy. So, all done to you. I got that right. And yeah, so an ectopic pregnancy is essentially a pregnancy that occurs anywhere outside of the uterus. Um The more, more common sites of an ectopic pregnancy are mostly in the tubes. Um This is where 97% of ectopic pregnancies occur sometimes very rarely. Uh, a pregnancy might implant in the ovaries or in the cervix or, or in the abdomen, but that's incredibly rare. Um And ectopic pregnancies are not super uncommon. Um They occur in about 1 to 11 in every 100 pregnancies, I think. And they never will un unlike I guess some types of misc uh miscarriage or kind of bleeding in pregnancy, they will never lead to a normal pregnancy. Um And the reason why ectopic pregnancies are dangerous and sometimes fatal. The fact that the the kind of the pregnancy still can still continue to grow, which will give the uh which will lead to dangerous complications for the women. And so the risk factors for an ectopic pregnancy are the ones on the screen there. And the reason why are that the majority of the risk factors for ectopic pregnancy are risk factors that will have led to abnormal fallopian tubes, either the fallopian tubes being damaged or blocked in some way that affect a normal implantation of a pregnancy. So the risk factors for ectopic pregnancy is having a previous ectopic pregnancy. So, whatever caused the previous ectopic pregnancy to happen in the past might happen again. And also having had a previous ectopic pregnancy suggests that you might have in inflammation um and kind of fibrotic changes to the fallopian tube that affect future pregnancies. Another risk factor is pid. So which is pelvic inflammatory disease and that can be secondary to things like um sexually transmitted infections. And that's because any active or past infections can again cause inflammation or fibrosis or adhesions in the fallopian tubes that affect implantation. Smoking is another risk factor and this is because smoking reduces the activity of the cilia in your um in your fallopian tubes and your cilia are what helps transport your kind of your oocyte and your sperm down to the, down to the um down to the uterus so that they can implant at the right place. So if you, if you have reduced cli activity, it means that they're not getting to the place that it needs to go to implant successfully. Um Another risk factor is any previous surgery to the fallopian tubes, that could be if it's any kind of gynecological or any abdominal um surgeries that a patient has had in the past kind of IVF is another risk factor. And that's kind of a, a weird reason and that's kind of because if you, if you are having to have IVF, it might suggest that you have some problems with your fallopian tubes anyway. And that might mean that if you become pregnant, you might have an ectopic pregnancy. Another risk factor is being over the age of 35 and because ciliar activity decreases with age. And another risk factor is having an intrauterine device for contraception. And this is because iuds by themselves, they work by preventing any pregnancies occurring in the, in the uterus. But that doesn't necessarily stop you from getting pregnant. So you could for example, have a fertilized egg that gets implanted elsewhere. That isn't in the uterus. The features of an ectopic pregnancy are kind of what was in the vignette. So some generalized abdominal pain. Um this is because so what causes the generalized abdominal pain is spasming of your fallopian tubes. The the fallopian tubes don't have somatic nerves. So the first symptom of an ectopic pregnancy is quite generalized, generic abdominal pain. It may or may not be unilateral but don't be thrown off if it isn't unilateral and is more global as the ectopic pregnancy gets worse or gets larger. What you will have is that the the ectopic pregnancy will start to cause irritation on your peritoneum. And this is what? And your peritoneum has somatic sensory nerve. So this is when you will get more localized pain. Um that will either be suprapubic or pelvic pain and it might be quite localized to one side. And the other thing that you can get is if that ectopic burst. So any blood or fluid that collects in the abdomen will also irritate your, your peritoneum and it will also irritate your diaphragm just by kind of point of breath, the point of where it is and um that it will be kind of free flowing in your abdomen. And classically diaphragm irritation will cause shoulder tip pain. And so this is why one of the kind of classic um symptoms of ectopic pregnancy is abdominal pain or shoulder tip pain. And that's caused by blood or fluid irritating the diaphragm. You might also get some light vaginal bleeding. Um most, most kind of blood that leaks out from the ectopic will be in the abdomen, will kind of leak out into the abdomen rather than into the actual uterus cavity. So you might not get any vaginal bleeding. And this is this is in particularly important that kind of the severity of an pregnancy isn't characterized by how much vaginal bleeding you get because it might all be in the abdomen. So you might see slight um some kind of dark bleeding or you might not, but that shouldn't rule or rule um that shouldn't rule out a atopic pregnancy to you if you don't have any bleeding. And then the other kind of symptoms are presyncope syncope, hypertension and shock. And this would be a sign of lifethreatening or unstable ectopic pregnancy. And this is when the ectopic pregnancy has ruptured. It's causing a significant amount of blood loss and blood volume, which is causing um, hypovolemic shock. And so this would be very, very late stage ectopic pregnancy and you would want to avoid getting to this stage, uh, by all means. Um, and so in terms of investigations, what you would want to do is hopefully in most, in the UK, most ectopic pregnancies are diagnosed early before it ruptures. And so any woman that presents to Ed with any abdominal pain or vaginal bleeding should have a be be beta HCG done to ensure that they're not pregnant. And if they are pregnant, you'd want to then get a transvaginal ultrasound to check the location of the pregnancy. You might also want to get at this point a full blood count and a group and save in case there is an ectopic pregnancy and the woman then becomes unstable and subsequently needs a blood transfusion and blood components. Um so B to HCG transit, ultrasound and a full blood count with group N save and clotting cross matching. And all of those things would be your initial investigation for an ectopic. And then I'll move on to the next question, which is a question about management of ectopic pregnancy. And so in this vignette, I've given you the size of the ectopic pregnancy, the fact that there's no fetal heartbeat and the serum beta HCG levels. What did everyone think was the most appropriate management of this ectopic pregnancy? Anyone have any ideas? Some fatigue TB both psy. Yeah. So it is indeed c it is indeed iron methotrexate. So the two main managements for an opic pregnancy are medical and surgical. And I've also put expectant on them, which is something that you can do if the woman is stable and well and it's a small ectopic pregnancy and by small, I mean, less than 35 millimeters. And also uh that the woman's beta HCG is below um is below 1000 or 1000 below 1500 in expectant management. What you can do is just closely monitor the woman and also monitor their serum beta HCG. If their levels of beta HCG are coming down over 48 hours, then it suggests that the kind of pregnancy is kind of resolving itself if it doesn't though, or if the serum levels um are quite static or they're increasing, or the woman develop symptoms over a period of 48 hours that suggests that the ectopic pregnancy is causing uh any form of shock or is getting larger, then you would move on to medical or surgical management. The other thing about expectant management is that it's compatible if there is another intrauterine pregnancy at the same time. So you can have situations where the woman has essentially two pregnancies. So she has one that is implanted in the uterus and another that is an ectopic. And so with an expectant management because you're not using any kind of medications that are potentially lethal to the fetus. It would also be safe to use if there was a AAA viable pregnancy. At the same time with medical management, which is what this, uh this lady in yet needed, you would give im methotrexate as a stat dose with medical management. It requires really close follow up and monitoring of beta HCG levels to check that the beta HCG levels are down trending following the methotrexate. So if a woman, if you think that a woman wouldn't be able to comply with regular follow up for whatever reason, then you would, it would immediately rule out medical management. You would then just go on to surgical management as the as the next port of call. If you don't think that she would adhere to follow up what you would be looking for in terms of the beta HCG is a drop of at least 15% in beta HCG by about day four, day seven. After having received the methotrexate, if after day seven, you haven't seen the appropriate rise in beta HCG, you would then give a second dose of iron methotrexate. If that also fails, then you'd go on to surgical management. And surgical management involves either a salpingectomy or a salpingotomy and a salpingectomy would be the first line for women with no other risk factors for infertility. And whereas if a woman did have risk factors for infertility, such as previous history or they used IVF or um they've got kind of other things like such as PCOS pelvic inflammatory disease, then you would go on to do a salpingotomy instead to try and preserve whatever fertility that they have left. If a woman presents in kind of hemodynamic shock, so they're very unwell losing a significant amount of blood, then you would immediately move on to surgical management no matter how big or how high the HCG levels are because this is would be the most life saving procedure that you could do. And in most cases, surgical management is done as um a laparoscopic. But I have seen sometimes where if a woman is particularly unwell or if something goes wrong, then they'll do a laparotomy instead. Uh The other thing with the surgical management is that you can kind of target it so it can be compatible with another intrauterine pregnancy if there is one. So that is my ectopic pregnancy. Did anyone have any questions at all about anything? When would you use methotrexate versus miSOPROStol and Mifepristone? So I think, um and I'm, I'll double check to make sure afterwards. But I think with methotrexate, this is the, the, the kind of gold, the first line for an ectopic pregnancy with miSOPROStol or MIF MIF that's more for um what's the word for termination of pregnancy? And they aren't necessarily always, uh they don't necessarily always work either. Um So I think methotrexate is just what the guidelines stress because it's more effective. Um Yeah, but I'll, I can double check, I think. Yeah, I can double check, misoprost and morphine um terminations of pregnancy rather than no topic. Did anyone have any anyone, any other questions? We can move on to Vicky's questions? Oh, ok. Perfect. So moving on to question five if we can just move on to the next slide. Perfect. So um we've got a 29 year old woman, 35 weeks gestation. She's got abdominal pain, bright red vaginal bleeding. She's looking hemodynamically unstable. She's got a hard abdomen and fetal um stress as well as being shown. So what are people going to do in this situation? Um Any answers, any takers, it might just be my chat uploading. Excellent. OK. So if we move on to the next slide, I can see that someone's put e which is absolutely the correct answer. So just going through the other answer options here. Actually, firstly, in terms of ye is right. So you can see here that she, this woman is basically presenting with antepartum hemorrhage. I appreciate we didn't actually quantify how much, but I think you can guess from the um hemodynamic instability and all the other signs here that this is pointing to one specific um cause of the antepartum hemorrhage and actually for bonus points. Does anyone know what condition we may be talking about here? Any ideas? Perfect, well done. No, Nuria, sorry, sorry. If I didn't pronounce that right. Um But yes, exactly. Placental eruption. So I think in the exam questions, they should make things, you know, fairly obvious or, you know, try and lead you in the right direction because obviously there's multiple causes of uh antepartum hemorrhage. But I think it, you're pretty safe to say that it's if you've got abdominal pain, vaginal bleeding, hemody stability and a hard abdomen, think anti um sorry, placental abruption. Ok. So yes. And if you look in the green top guidelines as well, so I'll talk about resources at the end of the session, but they're a really good resource if you wanna just fact check um what you should be doing. But the antepartum hemorrhage uh guidelines state that if um there is hemodynamic instability and um fetal distress as well, the first part of course, should be an emergency cesarean section delivery. Obviously, this is going to be under supervision of senior obstetricians and you know, the whole team you, you know, so it's gonna be huge team um decision here. But um that that would be the obvious management here and then going through the other answers there. A um that would be used either to prevent or to treat um ncamp foot. Um And then b um also a good idea, especially in um you know, uh deliveries between 24 to 34 weeks. If you're thinking someone is going to have a preterm delivery to basically help with the lung development of the baby. But I think in this case, she's 35 weeks and also this is an emergency. So I don't think that would be your first port call, uh vaginal delivery and then monitor, observe also not appropriate just given the emergency of the situation. That being said it is tricky to know the I think predicting how someone should give birth or when someone give birth is a senior decision. Um, but I think they should make it pretty obvious in the questions whether it should be more of an emergency or something that should be, um, more of a watch and wait situation. Um So yes, that's the reasoning for all those answers there if we just move on to the next slide. So this comes under the broad umbrella topic of antepartum hemorrhage and it's defined as genital tract bleeding from 24 weeks, gestation. It can affect, affects 3 to 5% of all pregnancies and there are multiple causes. So things like cervical polyps, infection, trauma, tumors, um, inherited bleeding issues, all of those things can cause it. But I suppose have in the back of your mind, some important ones not to miss. Um I think placental abruption has to be one of the most sort of emergency type situations and is probably more common than the other ones. Placenta previa as well. Uh Is it can present, I'll talk about it as well in the next uh question. Um but it can present with not very much bleeding, but it can also arrange to sort of a lot of bleeding. Um And then there's a previa and uterine rupture as well. Uh rarer causes, but also to have in the back of your mind. So, if we move on to the next slide, um so I'm gonna focus on placental abruption here. So, um it happens when basically part of all of the placenta separates from the wall of the uterus prematurely. And I've got a little diagram there just to represent what that means because I have to visualize everything as I understand it. And it's fairly, it's, it's not super common, but like I said, just want to have the back of your mind. So one in 100 pregnancies move on to the next. So what actually causes it like with a lot of things in medicine? We're not actually sure of the exact cause. Uh But we know it does more more commonly occur in the third trimester. And there are two types. So you can see they're revealed and concealed. So you can see the revealed type would be more obvious to spot. Um And the concealed part can be, you know, tricky to spot actually, cos you may not see the bleeding until quite late on. Um So just have that in the back of your mind as well. So someone may present with maybe not very much bleeding, but their, you know, observations are showing that they're actually in severe shock. Um So yeah, just have that thought in mind. So, moving on to the next slide. Um So here's a bunch of different risk factors, I think with a lot of obstetrics, you can guarantee that a lot of these risk factors are going to be the same for a lot of different conditions. Um But with regards to placental abruption, um you can see here that obviously having a previous placental abruption will uh increase the risk of you having one in, in the in the next pregnancy, preeclampsia. Any fetal complications there, advanced maternal age multiparity, fallopia as well. Um pregnancy following seeing assisted reproductive techniques, uh intrauterine infection, premature rupture of the membranes, abdominal trauma and smoking and drug misuse. So you're gonna see these come up time and time again in most risk factors for conditions in obstetrics and then moving on to the next slide. So, like I was saying at the beginning of this, of um this topic that you should have um different causes in the back of your mind. So placenta Praevia just to go into a bit more detail about each of them. So that's when the placenta is fully or partially attached to the lower uterine segment. I have some diagrams coming up. So don't worry, I will show you what that means. Um Then you can also have vasa pra, that's where the fetal blood vessels run very near the internal cervical os. Um And then you can have uterine rupture. So that's a full thickness, destruction of the uterine muscle. Um And it usually occurs in women with previous cesarean sections or previous uterine surgeries. Um Then you can have other things like I said, they're like malignant lesions, uh benign lesions and infections as well moving on. So, in terms of what you're gonna find in your history, so obviously, if this, if they're not able to speak, their G CS is dropping cos of their um cos they're in shock, you know, you're not gonna have time to maybe get all the history from them, but you can probably ascertain that they're in pain. Um You can see as well that um they'll be bleeding may not be visible if it's concealed. So, like I said, just keep monitoring the observations and they'll obviously be over 24 weeks gestation as well to sort of meet that criteria of the antepartum hemorrhage and then other important parts of the history that if you're able to get um they're, they'll be relevant things like have they had ruptured membranes, any particular provoking factors, what their fetal movements like um social history, obstetric history, uh gyne history and any past medical history. And also this is an assisted um conception as well and moving on to the next slide. Perfect. Um So, in terms of examination, like I said, you may just need to go straight to putting out a 222 call um getting the, you know, obstetric uh hemorrhage teamed together. Um and in any case though, an a three assessment is always gonna be um a good first step. And whilst you're doing an examination cos even in emergency, you do need to do some sort of examination. You might feel that the abdomen is um tense or woody as you might have seen in some of the past me questions. They may not give that to you as obviously as that. But I think if some form of description of it being hard, tense and tender means that it's likely this is a placental abruption and then like I said, signs of shock as well. Um Other useful investigations are ctg check on how the fetus is doing um various blood tests there as well with the Klein Hauer test that's gonna be useful to know sort of how much an TD to give if the woman is rhesus negative as well. Um Ultrasound scan can also be helpful. Um But if it doesn't show a placenta abruption, it doesn't mean that there isn't one because it has a poor negative predictor value, basically, um and a speculum as well um can be done to check if uh but also just double check that placenta previ has been excluded. And that's with anything like a um a digital examination or a speculum and an antepartum hemorrhage, just try and ascertain whether there's been evidence of placenta previa in previous ultrasound scans. Ok. Moving on to the next. Um, so in terms of management, I think a lot, like I said, um, at the beginning of this question as well, I think deciding when to deliver is quite a senior led decision. But I think just have a basic understanding of when you're gonna deliver and, um, why that would be as good for both your MC Qs and Oss. Um But yeah, like I said, don't get bogged down in the nitty gritty of it all. I think just having a broad based understanding is good. So, um from the sources that I've gathered, it depends basically on gestation and degree of fetal distress. So, like I said, they're fetal distress and I think that's also taking into consideration the maternal health as well, emergency cesarean sections. And you can read a bit more about that in the Green Top guidelines. If you want to look at that. Um I think if there's no fetal distress and um mother's also stable less than 36 weeks, you may want to try and give it a bit longer um just to improve um chances of the fetus surviving and just also um their own the fetal health as well. Um And if there's no fetal distress over 36 weeks, um you may also want to consider uh labor, but you may not necessarily need to go for a Cesarean section. You could probably try inducing and I just had a little star there just saying. So MTD within 72 hours of onset of bleeding if the woman is rhesus negative and is not sensitized, um that is to prevent um a reaction in the next pregnancy if the baby turns out to be rhesus positive. So just have that in the back of your mind as well because bleeding is a sensitizing event. Um Okie dokes. So, moving on to the next. So this is question six. So we have 31 year old lady G one P zero. She has a routine ultrasound um at 20 weeks, sorry for the spelling there. Um And it shows a normal crowns rump length. That's basically what that is for that for that for 20 weeks. Um But the placenta is lying 15 millimeters away from the cervical Os. So this was, this might be a bit of a tricky one, but um you might still be brushed up on your obs and gyne knowledge if you're studying it this year. Um So a what condition are we talking about here? And b uh what answers did you guys put? If you wanna just put these in the chart, any answers at all? Very good, very specific Lyness. Um Yeah, excellent place placenta previa and well done um for over put A as well. So we are moving on to the next slide. Excellent. Yes, it's 32 weeks gestation and exactly we are talking about placenta previous here. So if you move on to the next slide, um actually just sorry, just to explain why the other answers weren't correct. So, um, all the ones below 30 weeks is too soon after the 20 week scan to know whether the placenta's had a chance to migrate upwards, which it does tend to do. Then the other two answers were 32 and 34. And I just know from looking at the guidelines that 32 weeks is when you are gonna next check, unless there's obviously any is if there are any issues in the meantime, they'll go and see obst before that. Um But if there's no issues until then they can just be scanned at 32 weeks. Um And then 34 weeks, I suppose if there's any issues at that 32 week scan, they can consider doing one then and later than that as well. Um So moving on to what actually is placenta previous, so very well done uh for those who answer correctly. So, um it's when your placenta lies directly over the internal Os. Um And if it lies less than 20 millimeters from the internal Os, but it's not completely covering, it's called a low, low lying placenta. And I think it can be confusing. Um The terminology can be confusing. Um I think there are different degrees as well of placenta previa, I think in general um saying placenta previa is when it directly covers internal o low line placenta, that's less than 20 millimeters away. However, if you describe the grade as well, um then that's also fine. So how common is it? So, one in 200 births um and then you can see that it's very common that uh women may have a low lying placenta at the 20 week scan. But then that reduces significantly to what happens at delivery. And that's why we have that repeat scan to check if it's still low lying or still a placenta previa. So, moving on to the next slide. So yeah, this is this slide here is just to describe the different grades that you can have here. Um So you can see the ones that are minor mean that the placenta is not as close to the cervical us and then the ones in the major category are either completely co covering the o or partially. Um So yes, that's what they mean when we're talking about minor and major, moving on. Um So same again as a lot of the other previous risk factors here. So previous history of uh placenta previa, previous C section, increasing maternal age, increasing parity, smoking, cocaine use during pregnancy, previous spontaneous or induced um abortion deficient endometrium cystic conception. So, yeah, you can see a theme here with a lot of these conditions. Um Moving on to the next slide. Um So in this condition, uh a key way of differentiating from the previous one is, I suppose a the amount of hemorrhage may be less. Um but in this case, it's usually a painless bright red vaginal bleeding, which can, so that can, it can vary. But more commonly, I think you're gonna see it sort of less um less volume of bleeding than the potential abruption. And like in the previous question as well, these are other important parts of the history that you need to consider if you are able to take the history. Um and this is gonna be useful um for clinical practice and then obviously your OSC as well, just make sure to have a really clear er structure of what you want, what information you'd like in an obstetric history. But yeah, moving on to the next slide. Um So like if like with the previous question, if this is uh I, you know hemorrhage, um and if you feel that there are hemodynamic unstable, this is an emergency, um You may need to put out a 222 call, do A two E assessment. Um in terms of what you might find, sometimes they're just gonna be asymptomatic. Um and it's picked up incidentally on the ultrasound scan at 20 weeks and then they'll have no symptoms, no bleeding, the placenta will migrate upwards. Um And the 32 week scan, there's no issues. Um However, if they do present in hemorrhage, um you want to look out for things like, you know, either bleeding, they're not gonna be in pain. Um, and the line of presentation may also be abnormal and that's where I put a little star here as well. Do not perform a ve because you may trigger bleeding because of where the placenta is actually so close to the cervical or of, you know, of vagina examination would, um, you know, potentially trigger some more bleeding, make things worse. So, moving on. Uh, so in terms of investigations, you wanna do your basic, um, you know, vital sign investigations and like, er, in the previous question there as well, full blood count user knees LFT S Klein Hauer and then group and safe or cross match depending on what you want. Um, and the ultrasound scan here can basically give us a definitive diagnosis and that's why it's useful to know at the 20 weeks what you know how, um, low lying the placenta is and that can help in management as well if they do present in, um, you know, hemorrhage and CTG as well to monitor the fetal wellbeing and then moving on to the next slide. Um, so in terms of management, uh so, yeah, like I said, it's typically identified at the 16 to 20 week scan. Um, and if it's identified or placenta previa or low line placenta is identified, they're rescanned at 32 weeks. And then again at 36 weeks, if at the 32 week scan, it's still found as low line. Um And if that's still present at 36 weeks, um delivery via C section is recommended um just because of the significant risk of spontaneous labor and associated hemorrhage. So the hope is that most women's placentas will not be as close to the oz by the 32 week, uh 32 week um time period. Um but in cases where that isn't the case, then we do need to act accordingly to prevent the risk of hemorrhage. So, moving on to the next. Um and sorry, I also put a little star of steroids there as well. So if we are considering delivering early as well, we can consider the use of steroids to help with um fetal lung development and then complications. Um So yes, you could, you know, fatal could be fatal if you bleed too much um rare as well. You can get placenta reta, which can develop from having uh placenta Praevia. I wouldn't get too bogged down in details of this, but just be aware that is a, a risk, a complication of having placenta Praevia. And that's when the placenta grows too deeply into the uterine wall that can obviously put you at risk of bleeding as well. Um And then a fetal hemorrhage as well and that can lead to uh asphyxia, birth injuries, all sorts. So it's a good one to just know how to manage and have in the back of your mind. All right. Moving on to the next slide. So this is the seventh uh question here. So we have a 36 year old woman G two P one has a routine appointment at 22 weeks. She was prescribed 75 mgs of aspirin in her first trimester, last pregnant 12 years ago. BMI 36 and BP is 13, 1/90 no protein. Um So what did everyone put down for this question? Any answers at all? Yeah, well done. And it was a bit of a tricky one. Cos um you may have thought the age range would have been correct here. Um But if I if we move on to the next slide and I can explain why if we move. Um sorry, we move on to the next one as well. Just so then we, so this I got from the nice guidelines. So if you want to look, have more information about hypertension in pregnancy, nice has the guidelines for this. There's actually not a green top guideline at the moment for this. Um So if you look here, the risk factors for preeclampsia here are I think we've been through these as well before. So you're gonna see a huge uh pattern in all of these conditions there. So moderate ones that include first pregnancy, age 40 or over. So that was the um what do you call it? I suppose. Yeah, the red herring in that, in that questionnaire. Um, pregnancy interval of over 10 years of more BM I of 35 or more family history of preeclampsia and multifetal pregnancy. Those are all moderate ones. So if you have two of those or more, then you're gonna give 75 mg of aspirin. In terms of high risk factors, you only need one of these to give the, the aspirin. So, hypertensive disease during previous pregnancy, KD autoimmune diseases such as sle antiphospholipid syndrome, type one or type two diabetes and chronic hypertension. So if we go back one slide again, um we can see here that A is just one moderate risk factor. So that's not gonna be the answer. B um although one is a one, moderate risk factor being 36 is not a moderate, moderate risk factor. So it needs to be over 40. Then um C has um two moderate risk factors there. D again has the wrong age and the BMI is just a moderate one and then e is um the age is wrong there as well and the pregnancy interval would count as a moderate one, but it's just one of those. So that's why it sees the answer. So we move on to the next uh slide after this as well. So, preeclampsia, I thought it was a really important one to cover. It's very, very common and can be fatal again, if not managed properly. Um I think in the last year, four people actually died from preeclampsia itself, so it can be fatal. Um And one not to miss, but obviously, there are lots of complications that you can die from as well as a result of not managing this. Um So it's really, really important to know how to spot and the start of how to manage it, I would say, um because obviously you'd need um you know, a full team to sort of manage this. Um So in terms of what actually is it? So prec cancers is defined as pregnancy induced hypertension. And I have a nice little slide later on which sort of shows the difference in um preeclampsia, preexisting hypertension and then uh pregnancy induced hypertension without protein. But the key factor here is that you're gonna find a protein urea as well. Um So that's protein in the urine and around 0.5% of pregnant women can then develop severe preeclampsia. And that's where it's very life threatening for both mother and baby. And unfortunately, the exact mechanism of preeclampsia is also unclear, but theories suggest that it's to do with poor placental perfusion secondary to abnormal placement. So we move on to the next slide. Um So in terms of diagnosing someone with preeclampsia, so they need to have hypertension and a systolic of 140 a diastolic over 90 on two occasions and they need to have significant proteinuria. So the first test you would do would be um a urine dipstick test and then you would then use that sample again, um or sorry, another sample to then further test how much protein is in there. And then as this is also happens after 20 weeks of gestation, moving on. Um So in terms of preeclampsia, actually, in a lot of cases, and even with a really, really high BP, they can be asymptomatic. So the um basically, the symptoms will obviously relate to how severe it is, but not in all cases. So I think it's important to be just very hot on how high the BP is and is there protein in the urine? Um because the symptoms may not necessarily correlate to how severe it is. But if you get the high BP and you have some of these other symptoms like headaches, visual disturbances, edema, abdominal pain, then you know this is heading more in the severe category. And then in terms of clinical signs, you may notice hyperreflexia as well, papilledema and um abdominal, you know, tenderness and then moving on to the next slide. Um So just a quick point on how to differentiate between um these three things here. So, preexisting hypertension um is when pregnant lady has had high BP before the 20 weeks, gestation. So may just have hypertension. Um you know, normally when she's not pregnant, um gestational hypertension also occurs after 20 weeks like preeclampsia. But the key differentiating factor is you don't have protein in the urine and then preeclampsia is when exactly you have twen uh hypertension after 20 weeks. Um And the proteinuria is the key factor there, but you may also have other severe symptoms like I was talking about there or other um organ involvement. Ok. Moving on to the next slide. Um So in terms of what you're gonna do, so at any antenatal appointment or if anyone's attending pregnancy assessment unit appointments, you will have noticed if you're, if you've been on placement in these areas that they're very hot on checking BP, urine dipstick, they pretty much do that for everyone. Um And then fetal heart auscultation as well. Um when appropriate. Um So in terms of investigations, this is gonna depend on how severe uh the preeclampsia is and whether you're admitting someone for it or whether you suspect that they may be developing complications from it. So you're not gonna necessarily do this in everyone with preeclampsia all the time. Um But things to look out for is like your basic bloods LFT S in particular because um Hellp syndrome can happen uh as a complication of preeclampsia and that's something to be um aware of and it's definitely an examinable topic as well, but I won't go into too much detail about that, but just understand that LFT S are quite important in severe preeclampsia. Um as it may show that they're developing this complication clotting factors as well and there's this new um, blood test called the PLG F. And basically, if they have a low uh level of this, it can also be a very useful predictive factor of whether um they're gonna develop preeclampsia or not. We don't worry too much about it, but just also have it in the back of your mind. Um And all of these um results are gonna help make a decision on where the house of how severe it is and when to deliver. So we move on to the next slide. This is a, a nice guideline summary of what to do. Um So, you know, if you find this useful, you could take a screenshot of this and just have it in the back of your mind. But it basically just helps you differentiate what to do depending on um the BP, which is ie how severe is this. So you can see that um if you're more in the 1 40/90 to 1 59/1 09 range, um you may not necessarily need to be admitted. Um We can offer pharmacological uh treatment and the um regularity in which we're testing things like BP, proteinuria and all those bits is less. But if it's severe, um you may need to admit uh them and monitor them in hospital and offer more regular um monitoring and may need to decide about delivery a lot sooner. Um But I think that's a decision that would be made with seniors around, so, don't worry. Ok. So moving on to the next slide. Um So if we're just talking about um, preeclampsia where we're not necessarily admitting someone, but you just want to, um, you know, examine them and investigate so you can do your regular BP assessment. I'd refer back to that table to know exactly how often that is. Um And then, you know, proteinuria, blood testing, CTG ultrasound and the umbilical artery Doppler. And I think I would really suggest if you've got, if you're doing Ob and Gyne this year, really attend one of these clinics where they assess these um this measurement because I think it's really hard to explain without having gone to one or um it, it is a bit complicated to understand, but it basically just helps um understand uh how, how good the placental and fetal circulation is. Um So it's just another measurement that obstetricians use and then moving on to the next slide um in terms of medication that we can use. So, labetalol would be the first line. Um I suppose another trick point that they could put in a question is if um so a pregnant lady had asthma, what would you use? So you would avoid something like labetalol, nifedipine as well can be used if labial's libit is not uh suitable and then methydopa as well if the other two aren't suitable. Um in terms of remembering the doses, I don't think maybe necessarily need to know that, but those are there if you need. Um And I put a little VT E exclamation mark there as well. I'd suggest revising that in your own time. But um ladies with preeclampsia are at high risk of VT E as with all pregnant ladies and they just have that in the back of your mind as well. So, moving on to the next slide um in terms of timing of delivery here, I've again, put the nice guidelines here. Um So you'd hopefully try and uh deliver 36 7 weeks after. Um And no, no, no later really than that, even if they don't have severe preeclampsia, um just because of the risk that this poses to maternal health primarily and then also fetal health as well. Um If you're delivering any earlier, it's mainly for the benefit of the fetus. Um But then, sorry, not, sorry, mainly for the benefit um of the mother because delivery is basically the only actual cure to pre come. So all these medications are just gonna help, um buy us a bit of time and manage the condition. But actually delivery is the only actual um what's about cure. Um So in terms of how early you're gonna deliver, um you can basically judge it based on how severe the preeclampsia is and that's why we're putting the maternal health first here actually. Um So in terms of 34 to 36 weeks, um So just take into account the, you know, risk factors that are here on this, on this side here. So, um if the BP is not able to be controlled um progressive deterioration in the liver function and other organs there, neurological features, abruption, all those things are gonna point to an earlier delivery and how early that is again, that's gonna be a senior led decision. Um but just have those uh severe um symptoms there in the back of your mind. So, you know, roughly when you would um say delivery should be done. Ok. And then moving on to the next um this, I won't go into this too much details. It's similar to what we just went through. But if let's say you're admitting a woman and you think that they may need to be um with severe preeclampsia and they may need to have delivery. Um You're gonna do what you were like we said in the pre previous lives, an antihypertensive treatment only you might give this IV as well. The other thing is we may um give magnesium sulfate uh in order to prevent seizures even though they may not be showing no, not be fitting or showing any signs of eclampsia. Um You would maybe consider magnesium sulfate um IV to prevent that um important to restrict the fluid as it can. Um Sorry if we just go back. Um Yeah, because risk of fluid overload is huge in uh ladies with severe preeclampsia there. So don't give lots and lots of fluids. Be very um careful with the amount you give and delivery again, is the ultimate cure. And how early that happens is, like I said, on the other side, it's gonna be a multitude of factors. Um Moving on. Um So in terms of what happens after delivery, um that is actually the most risky period for developing eclamptic seizures. So, um yeah, you're gonna need to monitor them at least 24 hours postpartum. And then in terms of the decision of whether antihypertensive should be continued, you're gonna monitor their BP regularly as well afterwards. Um II, don't think you need to know the details of when anti anti hypertensive should be continued, but just be aware of that as well. Okey dokes moving on. Um And this is just to hammer the point of why it's so important to manage preeclampsia. So we've already been through a lot of these. Um But yes, so there's lots of maternal complications which can happen and also uh fetal complications there as seen on the slide here and if we move on. Ok. So uh question eight. So what did we put for this? So a actually what condition are we talking about here? And b what um would be the most appropriate treatment for this condition? Any answers? Yeah, excellent. And do you wanna say what uh lys do you want to say what condition you think we're treating you then. Yeah. Perfect. Exactly. And I think the clu cells, er, gives that away. So, exactly, bacterial vaginosis. Um, and so we move on to the next slide. Um, so just to quickly go through where the other ones aren't the right answer. So, benzylpenicillin although is safe in pregnancy, um, would be the treatment for syphilis, um, fluconazole, um, and nitrofurantoin are not to be used in pregnancy, although fluconazole, not any point, nitro is used for lower uti I treatments, but um can be used in, you know, beginning of pregnancy, but in the third trimester to avoid um fluconazole can cause um sorry. So fluconazole antifungal and shouldn't be used in pregnancy, just check that on the B NF. And I can see that it says you can't use it. Uh and then e doxycycline um that's treatment for chlamydia. Um and you shouldn't be using um tetracyclines because of the possible discoloration of um baby's teeth. So this moves on to if you move on to the next slide. Um The reason why I put this question in this um teaching session is because I think another important thing to have in the back of your mind is just knowing what medications can and can't be used in pregnancy. I just think it's such a common thing that could come up in questions. So, um this is more of a just general overview. It's not like a meant to be specific um prescribing for everything but just to have in the back of your mind and uti S trimethoprim um don't use in the first trimesters. It can be tetra teratogenic nitro, like I said, don't use in the third trimester. Um penicillin can be safe um but avoid coamoxiclav. Um like I said, tetracyclines like doxycycline can cause tooth discoloration. Um And yes, there are basically lots of other antibiotics I put on here, which can be used. Um and maybe just take a screenshot of this and just all make your own. Basically whenever you're revising, just have in the back of your mind. What can and can't be used in pregnancy? Um So this is kind of a crossover here between sexual health and um obstetrics here and if we move on to the next um question, er sorry slide. Um So topical with what we just talked about antihypertensives. So just know in the back of your mind that um beta blockers and Nifedipine they're fine but don't use ace inhibitors or Arbs um especially in the 2nd and 3rd trimester. Um and then anticonvulsants, magnesium sulfate can be used. Um but um and other things like lamoTRIgine Keppra as well but avoid valtrate. So, moving on to the next slide, er and then VT E as well. Another really key er topic in, in obstetrics. Um Heparin and low molecular weight. Heparin are gonna be used. The are gonna be the ones to use cos they don't cross a placenta Dox and Warfarin not to be used and things like alter plays. Um That's gonna be a case based. Um you know, decision. Um So you, you might have to give that in a life threatening pe kind of emergency. But um yeah, you need senior decision for that and then moving on to the next, I think that ends. Actually my slides. I think that's question. Is that over to you now? Julie? Yes, hi, everyone. So this is the final question. Um And so I'll go through it now. So this is a 65 year old lady's presented with abdominal bloating, increased tiredness and some nausea. She's got some unintentional weight loss. She's never been pregnant before. No other past medical history and she, um, had her last menstrual period about nine years ago. What would you suggest in terms of investigations or what you would do as her GP see C A 125 and Lauren. Anyone agree or disagree? Oh, go see. Brilliant. Um, so, yeah, exactly. Ca one T five, I feel like I slightly gave, gave it away by saying I was talking about ovarian cancer in the first slide. Um, but well done so. Yes. So I'm speaking about ovarian cancer. This is the fifth most common cancer in women and has a peak age of incident at about 60 years, which is what, um, and this lady in IET was about 65 years old, around 90% of uh ovarian cancers are the type epithelial and they can either be originating from one ovary or both and they can be either solid or kind of cystic. And the reason why epithelial cells are the most common type of histological subtype of ovarian cancer is because epithelial cells are what lines are lining of our ovaries. So every time we ovulate that lining of our ovaries burst and then they, that lining has to repair itself. Um And that means there's constantly new cell growth appear um occurring at the epithelial lining of our ovaries. And as we know, the more kind of cell growth is happening in one area, the more likely it is that that kind of cell growth can become um dysfunctional and cause things like cancer. And so this is why epithelial um tumors are the most common. Uh the other next, most common are sex called stromal tumors. And these are tumors that are derived from cells invo involved in hormone production. And the most rare is germ cell tumors and these um occur from precursor cells of our gametes and they occur in about 2%. So, very rare. Um the more kind of epidemiological thing to remember is that epithelial tumors rarely occur in women less than 40. Whereas germ cell tumors are more likely to occur in, in women that are younger than 40. Um And in terms of the risk factors of ovarian cancer is some kind of related to what I spoke about in terms of ovulation. So the fact that the epithelial lining of our ovaries are disrupted every time we ovulate means that one of the risk factors for ovarian cancer are, is a prolonged duration of ovulation. So things like having um early, early periods or late menopause or having never having been pregnant means that you've had more ovulations. Uh which means that you're at a slightly more increased risk of ovarian cancer. Another increased uh another risk factor is prolonged estrogen exposure. So things like um age, um obesity and any hormone replacement therapy can also put you at an increased risk. And also, of course, like most cancers, um a family history will also um give you an increased risk. So kind of similarly a a thing that's protective against ovarian cancer. Things that mean that you've had less time ovulating and less exposure to estrogen. So that includes uh pregnancy, breastfeeding and um and in terms of the kind of pre preventing less ovulations, any kind of hormonal contraceptives are protective against ovarian cancer. And the uh clinical features can include, they're, they're very kind of commonly very, very, very vague. Usually you don't get symptoms until the cancer has spread unfortunately. And then these symptoms are caused by local invasion in your pelvis or your abdomen or kind of ascites which can give you abdominal discomfort or pain bloating and a change in bowel habits. The kind of thing to look out for. Um, in ovarian cancer is a woman that is roughly the age that we for which is about 60 years old with any of the risk factors above and any nonspecific systemic cancer symptoms. So, nausea, um, weight loss, fatigue, any b symptoms, those are the kind of, those are the kinds of people that we want to be thinking about ovarian cancer. For in terms of investigations, our initial thing that we want to look at is a ca 125 level, ca 125 is elevated in about 80% of ovarian cancers, but is raised in less than 50% of stage one disease. So it's, it's quite sensitive but not very specific as well. So it can be elevated in anything that can cause peritoneal irritation. So you can get a ra 125 level in benign ovarian cysts, uh any endometriosis, um and also in kind of even menstruation, um can give you a ac a 125 level in younger women who are at more increased risk of getting germ cell tumors. You also want to look at um and AFP B HTG and LDH as these are more common in those kinds of ovarian tumors. And that can, if those are raised and that gives you an indication that perhaps they do have an ovarian cancer even if they are a bit young, um that they might have a germ cell variant and what you want to do in terms of imaging is initially an ultrasound of the abdomen and pelvis and together with their CA 1 B5 level and something called their menopause score, um which is essentially if they're kind of in uh uh having menopause going on right now, postmenopausal and including their ultrasound um score, which is basically an indication of what uh which is scored based on the findings of the ultrasound. This gives you an RMI score, which is another word for risk of malignancy index. If this is raised, then this uh kind of triggers you to go to the next point of investigation, which is to do a ct abdomen and pelvis. And this could be a definitive way of kind of diagnosing. Um finding out for sure that there is an ovarian cancer or it can be kind of done um help with staging as well to see if there's any local uh local or kind of further widespread metastases in terms of management of ovarian cancer. It's like most cancers, it's a combination of surgery and chemotherapy, in particular with ovarian cancer, it's more platinum based chemotherapy. II didn't have time to figure out exactly why it's platinum based. Um but I'm guessing there's some fancy pathophysiology behind that. And unfortunately, in um in terms of prognosis, the prognosis is usually quite poor with ovarian cancer and that is because it's so nonspecific at the early stages that it means that mostly diagnosis is in, in advanced stages um when it has metastasized. So there's not so much of a good prognosis for ovarian cancer. Um which is why we're talking about it in this talk so that you guys can all um be thinking about it earlier on. Did anyone have any questions about that at all? Because we are done with our questions? I think there was some kind of other commonly examined obstetric topics that I think he wanted to go through as well. Nothing. Sorry, I realize this list is not definitive as well. I just had in the back of my mind, things that we didn't really cover but just could be exam points, things like sort of indications for increased folic acid, all of these sort of infections and what you're going to do based on um yeah, what you're going to do about them basically in pregnancy um in terms of like osk stuff, vac counseling, ctg interpretation, multiple pregnancy stuff that could come up and um always things like the complications like help as well, just have in the back of your mind, but you're gonna cover those by going through question banks and other things just to be aware of that. We haven't covered some of these and then moving on to the next, just quickly about where you can find some further useful information. So geeky medics teach S and G nice guidelines. So the hypertensive disease ones one I use for my section there. Green top as well. Um That's produced by the R CG. Some of them have been archived. So um but these are the ones that are still in use. So the antepartum hemorrhage and placenta, previous one patient info is also great for just anything. Um but also has OBS and Gynae sources there. Buso is like the undergraduate society for OBS and Gynae er run by students. They have some good OSK stations on there as well. Um OBS pod is very good a podcast if you're interested as well. Um And there's a really good youtuber who put uh some CTG interpretation videos on there. Um I use them a lot for some revision now. So just so, you know. All right, I think that ends our session. So let me pop the feedback link in the chart. One sec and Achy Dikes should be there. All right. Well, thanks so much for attending and any questions feel free to ask. Um I will now actually also put the link to the other areas that you can get our videos on one sec. Let me get that. Oh yes, of course, Lauren, I will go back to the preeclamptic complications slide for you quickly. OK. Yes, it is various. Um Yeah, just I think have a good general understanding of these and I think by going through lots of questions just um in you know, past ques they go through a lot of these as well, especially the he syndrome, um, type questions. So, yeah, I hope it's been useful though. Ok. Wow. Unless there are any other questions, I think that's, that's everything from us. Cool. Thanks, everyone. Yeah. And we'll see, hopefully, see you next week and we've got Ent and Dermatology next week if anyone's interested. So. All right. Thanks so much, everyone.