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I mean it was, yeah. So let me just um but you know, it does good evening and welcome to the webinar tonight. We are live, but I believe not much of the audience has arrived yet. So we will give a few more minutes for people to attend, but we will be starting no later than five past eight. Again. Good evening today, staff joined us a bit later. We are still waiting for some other attendees to join and we will hopefully starting tonight at no later than 55 past eight. Apologies for the delay. So welcome and good evening everyone. My name is Mara Chama. I'm a general surgery registrar in Yorkshire and I am the inclusivity lead for the Moynihan Academy, which is the trainee branch of the A S GBI. Um This s this webinar tonight is part of our women's Wednesday series that we've hosted throughout the month of Wednesday, uh throughout the month of March and every Wednesday dedicated to women's health, both surgeons, health and our patients. So tonight, the topic is going to be emergency gy uh gynecology for the general surgeon as general surgeons. We often get faced with uh women uh female patients um suffering with either abdominal pain or acute abdomen coming from a gynecological source. Um And so therefore, we are joined by specialists tonight who hopefully will educate us on these pathologies. So, first speaker is Miss Elizabeth Ebase, who's a, a gynecology consultant at Barts Health and a senior uh le uh honorary lecturer. Furthermore, our second speaker will be Mr Bratt Winter Roach who's a gyne oncologist at the Christie. Tonight will be hosting with me, Adam Peckham Cooper, who many of you will know as the director of Emergency general Surgery at the S GB and he's an emergency general surgeon in Leeds. So without any further delay, miss over to you uh Meat Lizzie. Thank you. Good start. Thanks everybody. Thanks for having me. Um Let me just share my entire screen one second. Ok. Um I am going to put it in slideshow mode and I hope that it works and let me know if you feel that if you can't see the slides change. So we're gonna um pretty briefly. Um the gynecology essential is for general surgeons. I may do this presentation bridging the gap. There's a bit of background gynecologists were the first um to form a group of separate away from general surgeons and develop a body of professionals that were experts and disorders in the female genital tract. However, sometimes there's been been a bit of a divide between general surgeons and gynecology and this has actually grown a bit bigger over time. Um And you know, this is an opportunity to bridge a gap so that you, you know, we can learn from each other. So some other objectives, we're gonna talk about the common gyne presentations, understand different differential diagnoses. And I've got some slides at the end that are gonna talk about uh some interoperative presentations. So the acute abdomen. So I mean, I don't think this is given this is brand new information to anybody but any woman who's having their periods. So who's menstrual who presents with pregnant with pain in an acute setting needs to have a pregnancy test. Yeah. Um that happens almost routinely um in all, in all uh clinical settings. So in acute abdomen of a positive pregnancy test is an ectopic pregnancy until proven. Otherwise, we confirm an ectopic pregnancy with um by doing an ultrasound scan primarily and really what the purpose of the ultrasound scan is actually to try and confirm the intrauterine pregnancy. If you can't see an intrauterine pregnancy, then you look for the ectopic pregnancy and if you can't see the ectopic pregnancy, so you can't see where the pregnancy is. It becomes a pregnancy of unknown location. So, atopic pregnancies. So this is where you get implantation of a fertilized ovum outside the uterine cavity, commonly in the fallopian tube. Um but also they can get more rarely um located in other areas such as abdominal atopic pregnancies survive atopic pregnancies, cesarean section, scar ectopic pregnancies, they're quite common. They're, in fact, um, 11 per 1000 pregnancies. Um and it's still got ama maternal mortality of 0.2 per 1000 that mortality risk has not decreased. Actually. Um, it's um, the most common cause of, of um, maternal death in early pregnancy is still an ectopic pregnancy. Um, despite the, the advances we've made in our in gynecare and access to ultrasound scans, et cetera. So, risk factors. So, previous ectopic pregnancy increases your risk of having another one tubal occlusion from previous surgery, pelvic inflammatory disease. Recent um IVF the presence of an in contraceptive device. Um but one third of women will have no risk factors. Um uh because of we'll have no preexisting risk factors. Um So the other thing about ectopic pregnancy is thinking about the symptoms. So the symptoms usually are present with abdominal pain, amenorrhea. So a period of not having their period, obviously a positive pregnancy test and vaginal bleeding may or may not also be present. So, uh patients may also present with gi symptoms and shoulder tip pain and this might be a sign of um hemoperitoneum. So, these are more concerning signs. Uh other things, you might get abdominal tenderness on an examination, pelvic tenderness, on examination and signs of hyperkalemic shock. When how do we manage ectopic pregnancies. So, typically, atopic pregnancies are managed either conservatively medically or or surgically depending on how they present. So, surgical management is as uh using laser laparoscopic approach primarily. So we do the salpingectomy. So, removing the fallopian tube, which has the pregnancy in or salpingostomy, which is removing just the pregnancy but leaving the damaged tube behind. And the decision is based on um what the other tube looks like. So if the contralateral tube is normal, you would take the pregnancy in the tube, you would do a salpingectomy. If the contra lateral tube is abnormal, you would do a salpingostomy. So just take the problem pregnancy and leave the er tube behind. Um and this is to enable there to be a future pregnancy. We sometimes have to do a laparotomy for a, for an ectopic. And this is if it's a ruptured ectopic and the patient is hemodynamically um unstable and won't be stable enough to con to uh tolerate a laparoscop laparoscopy. Medical management is with methotrexate and this is an antifolate. And again, this can be done um in the early stages of ectopic pregnancy, largely uh defined by the um serum HCG levels, the size of the ectopic pregnancy, ensuring that there's no sign of rupture. And the patient needs to be able to have a regular attendance to an early pregnancy unit because um we monitor their HCG levels um over time and can only discharge them when their HCG levels typically falls less than 10. And there's a new movement now. Well, not so new but more com more what's happening more frequently. Um is because we're, we're catching early pre er ectopic prenan a bit earlier with um the more ready available ultrasound scans, ectopics can be managed conservatively and this is monitoring their symptoms and this is literally we bring them in, bring them back and just be checking their HCG S. And again, this is if we've, if you, if this is an early ectopic pregnancy, that has a low progesterone because progesterone is the hormone that drives the ectopic. So, if a patient has a progesterone of less than 10 and an H CG of less than 1000 even if you've seen the ectopic mass, you can manage the ectopic conservatively. So the other thing you might see sometimes is miscarriage and this can also present with abdominal pain. So, patient can present with acute with an acute abdomen and they could be having a miscarriage. And this is usually um and sometimes this, they'll have pre preceding bleeding. And again, this is a pregnant patient. So you might find that they're passing clots and tissue and at one point, they should have had an a confirmed intrauterine pregnancy. So, uh pelvic inflammatory disease is another common presentation. So in this setting, you get uh patients that present with lower abdominal pain, usually bilateral, they usually have a fever