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Can I have one handy? Can I just check? Ok, great. Just gonna wait and see if any more people are gonna join or a minute and I fall. Ok, so, hi guys, my name is Pavia. Um I'm a final year medical student at Manchester. Um and I'll just be hosting the session. So I'll make sure to keep an eye on the chat. Um Sure if you have any questions, you can just pop it on there. Um And I'll let our teacher know what the questions are. So um Vanni, I don't know if you want to introduce yourself now. Yeah, of course. Thanks Pavia. Um So hi, everyone. I'm a final year at Kings and just like Pavia said, if you have any questions, put them on the chat, I'll also be having a look at the chat. Um and um I'll try and make it as interactive as possible. There is a lot to get through, but I'll try to make it as interactive as possible. So if you want to answer any of the questions I ask also, feel free to pop them in the chat. Um Are we good to start? Uh Yeah, I think what I will just say is we've got an hour of teaching. Um, and that's gonna be obstetric teaching and then we've also got an hour afterwards of Os practice. Um So just make sure to stick around for that if that's something you want to do. Ok. All right, over to you. Thank you. Thanks. Um So today we're going to be focusing on. Oh, yeah, just, um at the start here are some partners and just a disclaimer that this doesn't replace any formal teaching from the university. Um So today we're going to be looking at the additional sections and an obstetric history taking sort of structure, um some common and important conditions and how they present and sort of how you would identify them from um your history taking in an OSC and then learn how to counsel and explain certain obstetric conditions and tests or antenatal scans. So, just a disclaimer, we are gonna be talking about some sensitive topics including miscarriages. So, um the normal history taking, um I'm sure you're very familiar with um includes like a presenting complaint, history of presenting complaint systems, review, past medical history, drug history, social history and family history. Can anyone think of some additional sections that we ask in an obstetric history taking? Yeah. So and history. Great. Yeah. Yeah. Gravidity. All great stuff. Yeah. Great. Yeah, some great things are. Um So there's sort of an acronym that we can use to remember um, the additional sections and obstetric histories. So that's mos so it MS for menstrual history. Like I think someone said obstetric history, sexual history and contraception and somewhere in there you'll also ask about their smears. So, contraceptions generally more of a going topic, um, more often than not. So, uh, menstrual and sexual histories, but they're also, um, sometimes important when you're taking an upset history as well. So we'll just briefly look at the menstrual history and the sexual history. So, mental history, you want to know sort of everything about their menstrual cycle. So the most important thing is asking when their last menstrual period is, um then you also want to know the length of their cycle and whether their cycles are regular or irregular. And then you want to ask about sort of any problems with their periods. So what I mean by that is whether they're bleeding a lot of heavy bleeding or menorrhagia or if the bleeding is quite painful. So dysmenorrhea, um and sort of just the characteristics of that. So for menorrhagia, you want to ask how many pads or tampons are using if they, if they leak quite often, um any clots that they're passing. And then for dysmenorrhea, you also want to characterize whether their pain starts um on the first day of their period or sort of um prior to the first day because then that would suggest more of an endometriosis picture. And then you also want to establish when they started, um, menstruating and if it's relevant, um, the age of menopause as well. So you can remember this by the acronym menses. So M just stands for menarche, which is the age that they started E is every X days. So that's their cycle length. N stands for the number of days that they bleed. And then in this, you'd also want to ask if the cycles are regular or not s stands for the supplies and products and how many a day e is a effect on their life. So, um, if they're painful, if they're heavy, all that jazz, um, and then s is the start of their last menstrual period. So, in the sexual history, you want to ask sort of like the symptoms um, of S ti s. So you want to ask if they have any pain, pain on peeing, um, any, um, abnormal vaginal discharge, any bleeding from the vagina, um any abdominal pain and then asking if they get, um, pain during sexual intercourse. So that's the dyspareunia and then any vulval changes or itching. And don't forget to ask about any oral sores or ulcers as that could, that could, um, pain more of a herpes picture. And so the way that you can remember this is sort of the five psi know there's quite a lot of um, um ps in medicine, but these five ps stand for partners practices. So that's the nature of contact or the type of sex. Um So that includes oral or penetrative and even in that, um to establish whether it's vaginal or anal as, as those can, um sort of bring up different differentials. Um The third P is protection from ST S if they're using condoms. Fourth one is past history of any S TI S and then the last P is pregnancy intention. So whether they are, they're on contraception of any sort. And then importantly, don't forget to ask about their safety. Um And um if you are concerned about any safeguarding issues, then do sort of bring that up and say it at the end of the station. All right. So, for obstetric history, you want to think about their current pregnancy if they are pregnant and then also um any previous pregnancies. So, for the current pregnancy, you want to ask about their gravidity, which someone mentioned. So that's the total number of pregnancies that they've had and that's regardless of the outcome of the pregnancy. So these include any um abortions or miscarriages. And then you want to ask about their parity, which is the total number of times they've given birth post 24 weeks or post six months. And this includes stillbirths and live births. And you wanna ask if they've had any scans so far, if anything abnormal has been picked up, and then you want to ask um how far into um their pregnancy they um are at the moment. So we've got a question in the chart how to ask patient if they have an abortion in a sensitive manner. Um I think the key, um, the key sort of idea to asking patients quite difficult questions is to warn them beforehand that you're going to ask something sensitive and to let them know that if they don't want to answer, they can, um, I'm just trying to make them as comfortable as, as possible. Um And just to let them know that they don't have to answer anything that they don't want to. Hopefully that an that answers your question. Um So, um the trimesters of pregnancy are, so your first trimester is until 12 weeks. Your second is 13 to 27 weeks and then your third is 28 to 40 weeks. So it's quite important to establish when in the pregnancy, the woman is as different trimesters, sort of bring about different problems. And then you also want to sort of, you, you can, if, if the station warrants it um in the osk specifically, then you can also do syce or fundal height. Um And that, that essentially um after six months or after 24 weeks of gestation, symphyseal fundal height should match gestational age plus or minus two centimeters. So just to recap how you sort of do s fundal height, um You identify the fundus at the top of the uterus, um then you place the start of the of the measuring tape face down and then you sort of track it all the way down to the pubic synthesis. Um, and then that should give you, um, that should give you, um, a number and it's in centimeters, not inches. Um, all right. So when we are taking a obs, uh, an obstetric history, there are certain red flags that we want to rule out. Can anyone think of any sort of key things we want to elicit from an obstetric history or things that would make us worried? Yeah. Personal bleeding. Yeah, definitely fees, movement. I actually don't have that on the list. But, yeah. Yeah. Pain. Yeah. Headaches. Yeah. And spot of bleeding. Yeah. Amazing visual disturbances. Severe nausea. Vomiting. Yeah. Great. So, yeah, so the sort of main symptoms, um, that loads of sources sort of told us, um, were headaches, blurry vision and persistent swelling in the hands, all of which sort of point towards a preeclampsia picture, which is very important to pick up abdominal pain plus pain in the shoulder tip. Why are you worried about, or, or what does pain in the shoulder tip? Sort of represent anyone? I have no idea. Yeah. Ectopic pregnancy. Exactly. Um, so, um, if an ectopic is ruptured, um, then that can sort of cause irritation of the diaphragm. Yeah. Exactly. Exactly. Cushing. And then, um, that sort of gets referred to the shoulder tip because of the dermatomes. Um, and then you've got PV bleeding, um plus or minus uh any passage of products of conception. So that would indicate a miscarriage and then a fever. So, maternal pyrexia is something that's taken very seriously. Um Perfect. Ok. Some other um presenting presenting complaints that you'd see um are pruritus or, or itching, we'll look at um a condition that this sort of presents with um symptoms of obstructive jaundice, any abnormal or offensive discharge, calf swelling, which someone put in the chart is great and then shortness of breath. So, when we're thinking about any previous obstetric histories, if they're not, first time mums, then you want to ask, um, have they had any spontaneous um, terminations are e miscarriages or any plan? Once again when you're, when you're talking about this, it is very important to be sensitive. So, um so definitely do sort of warn them that you are going to be asking quite a tough question if, if it's um if it is sort of relevant for this woman. Um And um oh, and do um give them the option of um of not wanting to talk about it as well that will make them feel more at ease. Um Whether there were any complications during any of their pregnancies or any abnormal scans or screenings that um that they had, were the labors that they had uh spontaneous or did they have inductions? What the mode of delivery was? Or was it spontaneous vaginal? Was it induced vaginal or was it, um, C section if it was C section, was it emergency or elective? And then we also want to know a bit about the birth weight and the current health of the babies as well. So with regards to what we're gonna talk about today, um, are the ones that are underlined. We're not gonna refocus on, um, on labor complications. Um, cos there's loads to talk about postpartum hemorrhage and all that jazz. Um Any, if anyone has any questions so far, please feel free to put them in the chat. OK. So first one we're going to be looking at is preeclampsia. So this is a multisystem syndrome and it's really only picked up. Um or it can really only be diagnosed post 20 weeks gestation and the etiology of it is essentially um there's abnormal place or there's a maternal microvascular disease. So essentially at the core of it, it's a, it's um it's a vascular condition. Um And with this sort of endothelial dysfunction, you get the symptoms of edema, proteinuria and hypertension in the mother. If it's not treated or if it's not managed, sorry, then um you that can then go on to um become eclampsia, which is essentially where you've got all the rest of the signs and symptoms plus seizures in the. Um So there are certain risk factors that sort of predispose mums to preeclampsia. So the high risk risk factors are hypertension um in previous pregnancies, but also just chronic hypertension, diabetes, mellitus, antiphospholipid syndrome, um lupus and then chronic kidney disease, which can also, um, which is also sort of associated with hypertension. And then some moderate risk factors include um increased maternal age if, if this is their first pregnancy, um, they've got high BM I and um, if this is a multiple pregnancy plus um sort of history of pe as well. So the signs and symptoms in preeclampsia, a lot of them are the red flags that we look out for and the questions that you always need to ask in every obstetric case you're taking. So you ask about headaches, you ask about visual disturbances and you ask about swelling that doesn't go down. So, persistent swelling is what well is what we're sort of worried about other symptoms that they can have is nausea, vomiting, um abdominal pain and reduced urine output. Uh the signs that um that you'd get on examination are hypertension, high BP and then hyperreflexia and clonus. So this sort of indicates a neurological involvement um in the preeclampsia. And so these these patients have a higher chance of seizures down the line. So the only definitive management really of pre of preeclampsia is delivering the baby, um if it's sort of severe and uncontrolled to control the hypertension, er, the first line is labetalol. Can anyone think of um a situation where we weren't given labetalol? Yeah, exactly. Asthma. So we want to avoid giving beta blockers to patients with asthma. Um So you can then give any of the three sort of listed there. We um in practice, they also tend to give calcium channel blockers. So in this case, um Nifedipine to women of, of black African Black Caribbean descent as the evidence shows that it works better in these patients and then to control seizures in eclampsia if they do get them um is magnesium sulfate. All right. So the next condition we look at is Hellp syndrome. So that stands for hemolysis, elevated LFT S and low platelets. So this typically occurs in the third trimester. 10 to 20% of people with severe preeclampsia actually go on to develop help. It's actually on the same spectrum with preeclampsia and other hypertensive disorders during pregnancy and the symptoms are quite nonspecific. So it can be quite difficult to, to, to differentiate this from preeclampsia clinically, you'd have to do a blood test to um see sort of the deranged LFT S and um and um the platelets and stuff. Again, the definitive management is delivering the baby. So next is intrahepatic cholestasis of pregnancy. So, this manifests after 24 weeks gestation and it's thought to be due to um sort of the decreased flow in the um in the maternal sort of bile ducts um due to the increased estrogen and progesterone. So that's all flows. Uh that sort of slows the flow of bile um the symptoms that it presents with are pruritus is the main one on the palms and the soles. But it's important to realize that um it's important to note that they don't get rashes if they do have a rash with the itching, then it's worth thinking of other differentials such as polymorphic eruption of pregnancy. Um which is more of a sort of hives picture. You, they can also get right upper quadrant pain as it is sort of um associated with the hepatobiliary system. They can also get symptoms of obstructive jaundice. So this includes um dark urine and pale greasy stool. They can also just get nonspecific gi symptoms like nausea and loss of appetite. So the management is they can get um ursodeoxycholic acid um but it's an off license use. Um And then they can also get chlorphenamine for the itching. And it's important to remember if you do get this as a station. It's like a counseling station to sort of explain um to inform the mothers of the increased risk of stillbirth. Um and all patients who have intrahepatic cholestasis are planned for induction at 37 weeks to decrease this risk of stillbirth. So, next one is chorioamnionitis. That's essentially the infection of the chorion and the amnion. Um most common organism that causes this is group B strep. So that's what GBS is. It can also be caused by e coli and anaerobic bacteria. The symptoms that they present with are a fever as it's an infection, abdominal pain, um offensive vaginal discharge, evidence of premature rupture of membranes. And this is sort of like a cardinal. This is like um a tell in the history, um sort of point towards um this diagnosis because if you've got the rupture of membranes and it's a lot easier for infection to ascend, then you can also get maternal or fetal tachycardia that you can pick up on the CTG um and then uterine tenderness as well. So the management is essentially what you do for most infections. You'd um initiate the sepsis. Six, monitor the mother and fetus quite closely and then um e eventually um deliver the baby. So, um VT E subvenous throm babism is a really um common and important um sort of diagnosis to keep in mind during pregnancy because pe is the leading cause of maternal death and can lead to maternal collapse as well. So, the symptoms of DVT and PA I'm sure you all know. So DVT you'd get a really um swollen, red, painful calf unilaterally and then signs uh or symptoms of pe um shortness of breath, chest pain, tachycardia and low oxygen TS. Can anyone think of any sort of general risk factors with et E that we think of? Um and some obstetric specific risk factors? Ok. Yeah. Smoking. Yeah. Travel. So immobility. Yeah, definitely active cancer. Yeah. Previous CT E Yup. Great. Any obstetric specific ones you guys can think of. Yeah. Great. Amazing. Yeah. So the biggest obstetric risk factor actually is, yeah, exactly is being pregnant itself. So that's, um, that in itself increases women's risk of VT ES. Um, and then I think someone said multiparity. So, yes. So, parity more than three increases your risk of VT ES multiple pregnancies. So that's twins and triplets. IVF. And if they currently have preeclampsia as well and then the general risk factors, you guys mostly got so immobility. So that can either be due to long travel or surgery. Um A family history, any thrombophilia. So like antiphospholipid syndrome, increased maternal age, high BM I and smoking as well as someone said. So we offer um V ce prophylaxis for women with four or more risk factors and if they have four risk factors or more, then you start prophylaxis immediately in the first trimester until six weeks, postnatally. If they have three risk factors, then you start um prophylaxis at 28 weeks until six weeks. Postnatal. If it's just two or less, then you don't start prophylaxis and we tend to use low molecular weight heparin. So that's either enoxaparin or adults par and depending on what your trust uses. Um And to avoid warfarin and dula during pregnancy. So we're gonna spend a bit of time on ectopics. I know it's more of a gyne topic. Um But it still is a differential of PV bleeding. So, ectopic essentially is where the embryo is implanted outside the uterus. Can anyone tell me where in this picture, um, which sites the embryo most commonly sort of implants? Yeah. Great. Yeah. So it's the, uh, in the ampulla of the fallopian tube. Um Great. So, uh, some risk factors for ectopic pregnancies. If you've had a previous ectopic, you'll see this trend quite a lot. The, a, a risk factor for something is having had that before. So, a risk factor for ectopic is if they've had a previous ectopic before. Um Others include endometriosis, uh pelvic inflammatory disease as there's quite a lot of scarring that can happen inside the uterus. So, so then um the embryo just implants somewhere else, having an IUD or R US in situ as again, um if it's taking up space in the uterus and the embryo can just implant somewhere else. Um And then IVF as well. So, symptoms of ectopic pregnancy, the most common one is abdominal or pelvic pain, which can either be right or left eye like fossil pain, amenorrhea is a big one. So ask about th that, that's why it's really important to take a brief menstrual history and ask about their last menstrual period as to when it is and you get bleeding during the first trimester. So that's why it's also um important to know what trimester they're in because if they're in the second or third, you know, it's probably not gonna be the cause of their bleeding. If that's what they've come in with, then if it's ruptured, then you can get a shoulder tip pain because of what we said, the diaphragmatic irritation and then uh signs of shock as well. Um So I've underlined the right I fossa pain just because if you get an OS station, uh with a woman who's come in with, right, I fossa pain, it's also such a very common general surgery presenting complaint. Um, and it's quite easy to just focus on the general surgery causes when you get that as an OS station. So just to remember to ask about the guy who causes a right SCLE fossa pain and rule them out. All right. So now we're gonna talk about miscarriages. So, miscarriage is the loss of an intrauterine pregnancy before 20 weeks, gestation. If a woman loses um their pregnancy, post 24 weeks, it's um it's usually called a stillbirth. Instead of a miscarriage. Miscarriages can be classified as either early or late. So early tends to happen in the first trimester and late tends to happen in the second trimester. So, early miscarriages are usually due to uh chromosomal abnormalities of the fetus and in the second trimester, it's more due to maternal systemic illnesses, um such as antiphospholipid syndrome or any uterine structural abnormalities. So, in antiphospholipid syndrome, you'd have that typical history of recurrent miscarriages plus a history of arterial and venous clots. Um And just the definition of recurrent miscarriages is three or more. Um The risk factors for miscarriages include if they've had a miscarriage before and also increased maternal age and then the risk of miscarriage also increases if they have sort of chorionic villi sampling or amniocentesis as well, which we'll talk about later. So, symptoms of miscarriage are PV, bleeding, abdominal pelvic pain, and then passage of products of conception if they don't have this sort of last um sort of complaint that they've come in with. It's also, it's also reasonable to keep ectopic in mind because um ectopic does present with very similar symptoms. So there's a classification of miscarriages. I'm not gonna go through all of this. Um You will be able to get the slides um if you fill in the feedback, but there's a classification based on whether the sural Os is um open or closed and whether the woman's having um PV bleeding and this is based on their history and speculum examination. All right. Any questions so far? No. Ok. So now we're gonna be talking about uh causes of antepartum hemorrhage. So that's um that's PV bleeding um prior to labor. Um But sort of after 24 weeks of gestation, so often ectopic and miscarriage are managed by the Gynae team, not the obstetrics team, but antepartum hemorrhage as it's after 24 weeks, is managed by obstetrics. So the first one is placenta previa. So this is when the placenta is, sits low in the uterus. You've got sort of two types or sort of classifications of placenta previous. So you can have a low lying placenta which sits less than X centimeters from the internal cervical os. Does anyone know what X is? How far from the cervical wash? Do you think it sitss? Yeah. Great. Two. Yeah. Exactly. Um, and then placenta previa is when it actually covers the internal loss. Great. So, the symptoms of placenta previa usually presents with PV, bleeding. But do you think it usually is painful or painless PV? Bleeding? Yeah, painless. Exactly. So, it's very important to, to, to ascertain whether um the woman has any pain at all. Um Because often actually placenta P pre isn't really diagnosed um, by women coming in with symptoms, it's often just picked up at their routine 20 week scan. So, risk factors for placenta previa include if they've had a previous placenta previa in the previous pregnancy and uterine scarring. So, any previous C sections, multiparity and multiple pregnancies. So, twins or triplets, any structural abnormalities like fibroids, increased maternal age, smoking and then IVF, all right. So, placental abruption, this is when you have a partial or complete detachment of the placenta before labor. Um And the picture here sh sort of shows, um, quote unquote true placenta abruption in A and then a concealed abruption in B so a concealed is actually quite dangerous because they still present with this pain. Um And um, but they don't have any PV bleeding because what's happened is the blood is sort of pooling behind the placenta. So it's not actually coming out. So it's painful PV, bleeding. So, it's a very important symptoms to sort of differentiate between placenta Praevia. You can also get back pain, which is a sign that it's posterior abruption and then uterine contractions as well. So, on examination, um you guys are probably seen in like, um, question by questions um in the stem, they'll say that um the patient has a woody tense uterus. Um So that's what you'd find on examination and then um fetal distress as well. Yeah. Ok. All right. So risk factors again, if they've had a previous abruption, multiparity, uh increased age, they have current sort of preeclampsia or any of the hypertensive disorders, history of any thrombophilias, smoking, the use of cocaine during pregnancy. That's uh a classic one that I sort of see in question banks and they could also throw that in in the ay, so don't forget to ask about recreational drugs and the history taking and then trauma as well, right? So the last one on antepartum hemorrhage is vasa pre. So this is where you, where the fetal vessels. Um So that's the umbilical artery and veins sort of run across the internal cervical. Um And this increases the chance of them rupturing following rupture of membranes. Um And so that sort of presents with this um PV bleeding. Um That's also painless. Um And the classic sort of CTG that you'd get, um, is a fetal bradycardia as well. So, the risk factors are, if they have placenta Praevia, then they're more likely to have Vasa Praevia if they um have conceived with IVF and then if they have twins or triplets or more so, multiple pregnancy. All right. So that's us looking at the most common or most important conditions um in obstetrics and now we're gonna have a quick look at how to sort of counsel um different conditions and also um the antenatal scans um or the downs antenatal sort of screening program. If no one has any questions about what we've done before, please feel free to put them in the chart. All right. So how to counsel? It's a lot less explaining than you think you have to do. So, the first half of your counseling should actually involve you taking a brief history from the patient just so you know what's been going on. Um So that would include the presenting complaint, the history of presenting complaint and then just for good practice asking um about any past medical history, drug history, um allergies. Um And then you want to ice them. So ideas concerns expectations, especially concerns you want to ask what the patient is particularly worried about. Um And then you also want to establish what the patient already knows about what you're gonna talk to them about just so that you can um target your explanations and your counseling according to what they already know and what they don't know. And then when you're actually explaining it, you want to not give them too much information at one time, you want to chunk and check, uh, to make sure that they actually follow you. And, um, cos I assume that you're, that you'll have loads of information to give them, but you don't want them to forget what you've told them. So when you're explaining also include the the the potential complications of what it is um that you're counseling them on and then any um management plans or next step if it's relevant, so it can end up being quite patient. L which is good. Um And you want to keep checking their understanding and consistently asking if they have any further questions because then that can guide what you say during the consultation in the station as well. So yeah, I think the most important thing is to explain is to be able to explain things in a suitable manner um in a very patient friendly way and avoid using jargon when explaining things. So how to explain, we'll be looking at how to explain a disease. So we want to first explain to the patient what normal is, then then sort of to build off of that, explain what the condition is and how that's different to normal, what causes it if there is an apparent cause um any problems and complications that can arise from this condition. And then what the management plan is or what the management options are, and then the patient can choose from all the options that you give them and then with a procedure or a test, you want to explain what it is, what you're looking for with the test. So the reason for it, the details, so that's really nicely sort of, you can structure that quite nicely with um the before during and after. So what's gonna happen, be before the test, if they need to do any prep for it, what's gonna happen during and then what to expect after any benefits and risks of the, of the test? And then if it's relevant to the um to the osculation, then also assess the capacity to consent for the test. So we're gonna cover all these um all these different counselings. Um But we're gonna focus more on the downs and the diabetes cos we've looked at sort of the other things a bit more. So downs antenatal screening is offered to. So should ask, how do you assess a capacity to consent? So it's those four things of um sort of how you, how you sort of assess and deem that someone has capacity. So if they're able to retain information, if they're able to weigh the pros and cons, um so it sort of for things that they need to hit for them to be deemed to have capacity. Hopefully that answers your question in, in an ay station. Um, they'll probably sort of link that in with like a counseling station. Um Yeah. All right. So, um, downs antenatal screening. So all pregnant women are offered downs antenatal screening between uh 2010 and 20 weeks gestation. So between 10 and 14 weeks they do one specific test and between 14 and 20 weeks they do it, um, they're offered another test. Does anyone know what the names of these tests are in these sort of time frames? Yeah, great. So the combined and the quadruple. So between 10 and 14 weeks, we offer the combined test in between 14 plus two or 20 weeks and we offer the quadruple test. So 14 plus one just means 14 weeks and one day. So that's what the plus one means. And then 14 plus two means 14 weeks and two days. So the combined test looks at three markers, beta HCG, nuchal translucency and PAP A which is pregnancy associated protein. Um Does anyone know if, if, what, how do I phrase this? What would the levels show if the screening was positive for um for Down Syndrome? Does anyone know? Yeah, great. Yeah, exactly. So your A CG is gonna be raised, your new co transducer is also gonna be thicker and then your pa is gonna be decreased. Great. And then for the quadruple test, you've got the beta HCG again, you've got inhibin a alpha fetoprotein and estriol. So that's E three, the third estrogen. So does anyone know what these results would show if it comes positive? Yeah. Great. Yeah, high HCG and high and high in Inhibin. A. Um so a nice way to sort of remember that is high. So the H I in high sort of um represent the A CG and the Inhibin and those are gonna be high in the test. And so the other two are gonna be low, go ahead. So a screening result is considered positive um when the result is a high risk result. So what that means is um the screening program has taken a cut off as one in 100 and 50 as their cut off sort of result. So a low risk result essentially means that the chances of the fetus or the baby having down syndrome is equal to or lower than one in 100 and 51 high risk result is the chances are equal to higher than the odds um of a of one in 100 and 50. So what happens if the screening does come positive? Well, that's up to, that's up to the mother. So that's so they can choose to have no further testing. They can choose to have noninvasive prenatal testing. So that's a blood test. We'll, we'll have a quick look at that and then also prenatal diagnostic testing as well. So these are the options that you can offer the o offer the other if you do get this as a station. So you can always, always, always remember that they do have the option to just do nothing. All right. So the noninvasive test is a blood test and that detects placental cell free fetal DNA. But it's still actually only considered a screening test. It's not diagnostic. The invasive diagnostic techniques um are sort of like a gold standard of prenatal um diagnosis. So you have C vs or chorionic villus sampling and you have amniocentesis. So, does anyone know at how many weeks gestation we can do chorionic villus sampling and amniocentesis. Anyone can has to guess mm, not quite, it's actually earlier than that. It's earlier than 2028. Yeah. So, so you actually do chorionic villus sampling between 11 and 14 weeks and then you can do amniocentesis sort of any time after 15 weeks. Um These do come with their own risks of miscarriage. Um And this picture just sort of so shows um how the technique is performed. So for C VS, you're taking a sample from the chorion, that's where the placental will sort of develop. Um This has a higher chance of sort of a false negative because you can have um sort of m mosaicism in the placenta where some cells um where some cells do have the TRS U 21 and some cells don't. So if in your sample, you have cells that don't have it, then that can lead to a false negative. So, amniocentesis is in that way, sort of a bit more accurate. All right. And then this is just a, um an is chart that I got from me. Um So some other sort of antenatal scans that mothers are offered are in this timeline. Um I think it's just, it's just good to sort of have an idea of when certain things are offered. So you can tell mothers that they do have an anomaly scan between 18 and 20 weeks. Um and this does scan for Down Syndrome too, but it, but it's not very good at detecting down syndrome changes on the scan. So if they are worried about Down Syndrome, then these sort of um these sort of screening tests are a lot better at picking it up. So that's something you can also mention if, if they ask that in the OS station, then then um it's a good point to say it, it does, it does look for Downs but it's not um it's not as good. All right. Um That's it for Down Syndrome or counseling, any questions or we'll move on. So just to remember um sort of the structure of, of counseling. So you take a brief history, explore their knowledge of diabetes during pregnancy, explore any of the concerns or any questions that they may have and then you start to explain, but don't forget to chunk and check. So diabetes preconception, this is when the mother has diabetes. Um sort of chronic diabetes mellitus. So that's, um, either type one or type two. So, before they want to conceive, it's important to change their antidiabetic medications to insulin, you want to discontinue any of the other antidiabetics, change them to insulin plus minus Metformin, depending on how good their diabetic, um, control is, advise them on lifestyle changes. So a healthy weight, avoid smoking and alcohol, all the regular stuff that they want to maintain a HBA1C of less than 6.5%. So that's um 48 millimoles per mole if you use the other system. And then also that they should be taking a higher dose of folic acid. So that's 5 mg as opposed to the 400 mcg. So they need to take a high dose folic acid as well as um Vitamin D And then it's also, it's also worth sort of advising and mentioning that if they have um nausea and vomiting in the first trimester, then that can affect their glycemic control. So if they do get sort of really bad nausea, vomiting to sort of safety net for that as well. So during pregnancy um advise them that um they're going to have regular checks of the blood glucose and that they should be regularly checking as well at home. Inform them that that they have a higher risk of preeclampsia and pregnancy associated hypertension. And that aspirin would will, will be offered at 12 weeks and that they will have extra growth scans um because they're at higher risk of uh polyhydramnios and sort of larger for gestational age babies. And so on that note, um sort of counsel that the labor may be quite difficult because the baby will be larger. So that's associated with higher risks of birth trauma, shoulder dystonia for the baby. Um, a higher chance of there being um, a forceps delivery or the need for C sections as well. So that's for when um when the mother has chronic diabetes and then there's also gestational diabetes. So, gestational diabetes is usually diagnosed sort of um in the third trimester, um late second trimester, early third trimester and it's diagnosed with having a fasting glucose of um 5.6 or more or a two hour glucose um test of 7.8 or more. So that can, there's like the 5678 rule that you can um use to remember the values. So the risk factors is if they have a high BM I, if they have had a previous um macrosomic baby, if they've had previous gestational diabetes in the previous pregnancy, a family history of diabetes and then certain ethnicities also predisposed. So um on that antenatal scan or testing timeline that I put up um it, I think it mentioned at what weeks you would do the oral glucose tolerance test. So does anyone know or remember at what weeks we offer? Um people at high risk? Yeah, exactly. 24 to 28 weeks. Great. So often they don't really have symptoms. They, they just get diagnosed um, at 24 to 28 weeks. Really? So management is, if their fasting glucose is less than seven, then we usually, then they usually um, offer lifestyle changes and lifestyle advice. If there's no change with just lifestyle interventions for two weeks, then you can start them on Metformin and add insulin as needed. But if their fasting glucose is quite high and it's above seven, then the first line would be to start insulin immediately. Um Plus minus Metformin, you can add that on later if that glossy milk control isn't great. So for antenatal care, you want to make sure that they're checking their blood glucose levels regularly, they will have more frequent antenatal visits than usual as well. Um Just to keep a closer eye on them. And then you also want to educate the mother on increased um risks to themselves, but also to their baby. Um It's important to emphasize the importance of good glycemic control to reduce these complications, um to educate on self monitoring and to adhere to the management and the medications. And then of course, um the usual lifestyle measures. So during labor, you want to advise them that they are going to plan for complications and to inform them of these complications. So it's quite similar to what we saw before. So the increased risk of forceps delivery emergency C sections and shoulder dystocia for the baby and then postpartum care for the mother. You want to sort of monitor for any persistent high glucose in the blood before discharge. Um to constantly check the fasting glucose around 6 to 13 weeks, postpartum and then annually to have the HBA1C um checked because they are at a higher risk of diabetes mellitus. And then for the baby, you want to monitor the glucose closely for the 1st 24 hours because they are at high risk of really severe hypoglycemia um as well as respiratory distress and jaundice. So you actually want to, you want to get newborns feeding within 30 minutes of birth to avoid that hypoglycemia. So, the complications just in this format is um hypertension in the mum, increased chance of ac section. A type two diabetes going uh sort of in the future and then future gestational diabetes. And then for the baby macrosomia hyperglycemia, like we said, metabolic syndrome a lot later in life and then also an increased risk of stillbirth. All right. Um I'm just wary of time, so I'm just gonna whiz through um the next bit. So for brief presentation again, um just to remind you of the structure of counseling. Um So what normal is, is you want is the, is that the baby is usually head down what the quote unquote disease? It, it's not really a disease. Um But what happens in breech presentation is that the head is up and then the feet and the buttocks are down. It's mostly idiopathic and you confirm it by ultrasound. So usually breach babies do sort of, most breech babies turn by 36 to 37 weeks. And if they don't, that's when you need to counsel the mother. So around 3 to 4% of fetuses in um in the UK are breach at the time of labor. So some risk factors are multiparity, fibroids or any previous breech babies for the fetus is if they're preterm, if they're macrosomic, any abnormalities, and if there's twins or triplets, and then if they have placenta, pre polyhydramnios or oligohydramnios. So that's just a lot of amniotic fluid or very little amniotic fluids. So, the management you can offer external cephalic versions. So that's where they try and manually rotate the fetus from the outside. It's got a 50% success rate. Um It does have its own contraindications um that, that you can read up in your own time. But um the main one for external clic version is um if they've already ruptured their membranes, then that's then E CD is contraindicated. Um and then a vaginal delivery carries loads of risks. But I, if mothers do want to do it, then um then they can, but it is very painful and there's a risk of fetal head entrapment as well. So electric C section is actually the most common mode of delivery and is actually advised cos it's not, it's painful, it has less complications. So, for the baby, when you think of breech babies, um, think of developmental dysplasia of the hip. Um, so that's when essentially the head of the fever doesn't sit in the aab very well and it can slip out. There can also be, um, complications o other complications like cord prolapse, um, fetal head and trapment, like we said, birth is fixture. Um, any hemorrhage, intracranial hemorrhage, sorry. Um And it also increases uh mortality, unfortunately. All right. So we've gone through sort of um atopic pregnancies, but just in terms of counseling, um this can, again, you have like a similar structure, but this can also somewhat be a breaking bad news station because um what's happened is a woman has lost her pregnancy. So it's very important to be sensitive when counseling about ectopics. So, to explain you say what normal is. So usually, so the Enbrel usually implants into the uterus wall. What happens in ectopics is it's implanted outside the uterus wall. Of course, you can list all the, all the risk factors that we talked about before. Um There's no sort of one cause for it, but all these risk factors can sort of add up if untreated, then that can lead to a rupture, massive hemorrhage and death. And then also when you're talking about sort of management, then you do want to um make sure that they're able to make an informed decision and, um, tell them of the risks of any surgery. So that's bleeding, infection and, and damage to any, um, any sort of organs around as well. Um, when you're going to talk to them about, um, something as sensitive as this, it's, it's, it's worth again, like warning them that bad news, um, that you have some bad news to tell them and to remember to offer any psychological support to you as well. So the management can be split into conservative medical or surgical. Usually, ectopics are managed surgically mostly. So that's why laparoscopic a inject toy. So they remove the fallopian tubes. Um That's when they present with pain. Um and the masses um is quite large. So that's more than 35 millimeters. And then they have a really, really high be to H CG. Medical management is reserved for when they don't have pain and they have sort of low H CG and conservatives not really done. Um Not really doing that much. So, the MTX in medical signs for methotrexate, so they give them one dose of methotrexate and that sort of um renders the atopic unviable, then stops their heart. So, placenta previa, again, the structure of counseling um very important. So what normal is is that the placenta usually is at the top or to the side in the uterus. In placenta previa, the placenta is low in the uterus. Again, the causes um sort of recall the risk factors. So that's also why it's quite important to take a brief history at the start because if they do have any risk factors, then when you're counseling them as to why they have placenta pre or ectopics, that then sort of um helps them to understand why they have um well, why they have it and what to put them at higher risk. So the problems and complications include, of course uh p bleeding. If the bleeding is really bad, then shock and then it can lead to fetal intrauterine growth restriction as well in premature birth. So the management it's usually picked up at 20 weeks, like you said. So it's picked up in 5% of women. But actually, this decreases to 0.5% of women at delivery because um the placenta can essentially move. Um So you advise pelvic crest. So that means no penetration. So no uh penetrative intercourse and no vaginal douching and I don't. And um it's important to document and no clinicians should do bimanual exams on them rescan at 32 to 36 weeks to check if it's still low lying and if it is still low, then to keep scanning every two weeks and to advise for um elective c sections to prevent any major hemorrhage during labor. And the last one to sort of learn how to cancel is preeclampsia. So again, the structure history, what their knowledge of preeclampsia is any concerns and then start to explain. So what normal is is you don't is that they don't have any hypertension, swelling and protein in the urine. What the disease is is that the placenta has developed abnormally? So you don't want to use big words um such as a placentation, but just say that there's something abnormal with the placenta and this results in high BP and increased risk of clots. Um and then the cause would be your risk factors that we talked about before. So the problems and complications to sort of inform the mothers of is they have an increased risk of major events such as heart attacks and strokes, they have an increased risks of placenta abruption. So in, in patient friendly language, that would be the placenta coming away from the uterus wall, an increased risk of um stillbirth and sort of growth restriction of the um of the baby and then if not controlled well, then it can go on to become eclampsia where they can have seizures. So management, um they, the mum and the baby need to be monitored very regularly. So that, so f for the mom that includes doing urine dips, regular blood pressures and then um the relevant blood test for the baby, it's a CTG and ultrasound as well as the umbilical artery Doppler velo symmetry. So that's essentially just an assessment of the placental and the fetal circulation, medical management. You can give aspirin sort of low dose aspirin. So that's between 75 to 100 and 50 mg from 12 weeks if they've got risk factors. Um And then you also want to offer antihypertensives. So we said the bet first line, if they're asthmatic, um then either mm methyldopa or Nifedipine and then BTE prophylaxis as well as they have increased risk of um P ES and DVTs. All right. So that was me. Um If you have any questions, please do pop them in the chart and do stay for osteo practice. It's great to sort of put into practice what um you've learnt hopefully from the teaching session and the facilitators are, are great. So please say, and if they, if you guys fill in the feedback form, which I will pop into the chat, um If you could provide us some feedback and then um you'd be added to the list and you can sort of get the slides at the end as well. OK. Thank you so much Giovanni. Um Yeah, guys just make sure to fill out the feedback form, especially if you're not gonna attend ay practice because again, it just makes sure that you get the slides afterwards. Um in terms of AK practice, if you are planning on staying, could you just pop a yes in the chat? Just so I know who is going to stay? Ok. So I think there's about nine of you. So we've got three facilitators. Uh So we've got Ben Mustafa and Catherine. Um Ben and Mustafa. Do you want to introduce yourselves? Hello, I'm Ben and I went to tell him my camera. But yeah, hello guys, I the stuffer. Ok, thanks you guys. Um In terms of the breakout rooms, we've just made the switch from using Zoom to using Medal. So this might be a little bit messy. So just bear with us. But Ben and my Stafford, do you guys already have breakout rooms that you can join? I think so. Yeah. Should I go into that now and then? Yeah, yeah, that would be great. Um ok, so for the people that have that are planning on staying, what I'm gonna do is just read out your names and then assign you to like breakout room 12 and three. Is that all right with everyone? So Kishan Baru and gift, if you could go to breakout room one and then Abby Irene and Manor, if you could go to breakout room two, Jesselyn Joseph and Janella, if you can go to breakout room three, if there are any problems, I'll just make sure to join them. But yeah, I think the breakout rooms are by name, not by number. All right. Ok. Um ok. In that case, um I don't know who's joined what already, but um maybe Abby Eleanor Farina if you join Ben's breakout room and then gift Irene, if you join um Catherine's and then fell on and said that if you join more staffers, um someone's asking. So how do we join the break rooms? I think if you click breakout sessions, it should be on the left and then just pick a session to join. Am I good to leave Pavia? Yeah. Yeah, you're good. Thank you so much for that. That was really good. Thank you. Have a nice evening. Um Yeah, Irene. If you just join with Catherines, maybe, whichever one it lets you join I think is probably the best way to go with.