Hypertension in Pregnancy - lecture transcript

What I It. Right OK. Sorry, it's just telling me there's no signal, so I'm trying to. So Awesome. Ah, there we go. That one I see. I I I I didn't know that. Yeah. Yeah. No. Yeah. Why is she, I was it just gets an idea of like what time service. Hello everybody, my name is Gemma Goon. I'm a consultant obstetrician with a specialist interest in the And I'm here to speak today about hypertension in pregnancy. So my objectives that we're gonna go over a risk assessment for hypertension in pregnancy. Um, we'll look at hypertensive disorders of pregnancy, complications, both, uh, maternal and foetal diagnosis and monitoring, treatment, postpartum follow-up, and counselling and advice on lifestyle and long term health implications. And at the end we'll try and do a little quiz. So simple back to basics, blood pressure. So it's the pressure above the burst on the arteries between cardiac contractions and the systolic measures and the heart contracts and diastolic. Heart muscle relaxers and your arterial blood pressure is a combination of your peripheral vascular def deficiency and cardiac output and heart rate and stroke problems and why is that important? And the reason it's important is because these things change in pregnancy, so your heart rate goes up huge. About 10 beats per minute. So pregnancy parameters are a little bit higher than non-pregnancy parameters. It's about 112 is the national news and that's based on um a a study that looked at a number of pregnant women and looked at what was the variation and used two standard deviations from normal. And your stroke volume goes up, you take on more fluid, you know. So pregnant women, they have a similar number of electrolytes, but they have about 1 litre of fluid on board, so you will get some dilutional effects in pregnancy.

Um, so what happens? So vasodilation happens and this is, um, mostly due to mediators such as ni nitric oxide progesterone that are secreted by% during early pregnancy. Um, you also get a reduction and then for the risk in the systemic systemic vascular resistance and your plasma volume increases because there's an augmentation of that renin angiotensinalosterone system, and the combination of that is, as I said, you get an increase in your stroke volume, you get an increase in your heart rate. So if you look at the graphs, uh, the top one is, uh, systolic, uh, blood pressure. Here at the bottom is diastolic, and there's 3 separate lines, so the red line is um women who are hypertensive with preeclampsia. The blue line is hypertension without preeclampsia, which is thought to be a less less severe disease than preeclampsia. Um, and then the bottom line is the no hypertension, which would be the majority of women who are pregnant. And you can see that particularly with the diastolic, um, blood pressure's drop. Um, which is a lot, mostly in early pregnancy and then a steady rise, um, towards the end of pregnancy and an overshoot in particularly in the preeclampsia and hypertension from the start of pregnancy, so you can see there's a definite change.

And third trimester is generally when most women will be diagnosed with hypertensive disease of pregnancy. Um, and actually there's quite a lot of prediction models that can predict whether you will develop hypertension in pregnancy or not. So, uh, placental perfusion, why is it important? Why does it matter? Like oxygen nutrients. Yeah, yeah, you're not gonna grow a baby, are you, if you don't have a placenta? Exactly. So you need a high flow, low resistance circulation. Cos you need to maximise the amount of nutrients that you're gonna get to your baby. So if you are hypertensive, you won't do this very well. So at the initial appointment, what do we do? Most pregnant women are healthy, they're otherwise fit and well, but we do ask them about past medical history and we ask them about medications. We ask about past pregnancies, why is that important? What do past pregnancies matter? Of a previous pregnancy? Absolutely past it's true of any medical disorder isn't it if anybody asks you a question, well why is cosmetic cry important? Something's happened before, it might happen again, you know, it increases your likelihood, so past history is really important um and past pregnancies. um take your blood pressure and dip the urine.

Why do we do that? Protein. Yeah, you wanna look for protein, so historically preeclampsia used to be quite a big killer of pregnant women, you know, before there were effective treatments and so it probably is something that historically developed because of that, um, and we used to be very concentrated on looking at the change from the start of pregnancy to the end of. Pregnancy and how blood pressure had changed, actually now what we are quite interested in is somebody books with a high blood pressure, not high that they need treatment, but higher end of normal, that in itself is a risk factor for having hypertensive disease in pregnancy. um, and dip the urine because that can be a sign of end organ damage and kidney disease and it might be the first time you know we don't do primary prevention in this country. You're more and more as you do medicine you will see that we are absolutely excellent at treating disease, but we're not very good at stopping it. So this might be the first time that somebody has been to the doctor's er or seen a medical professional in years. So it you might pick up some renal disease from that. It's not normal to pee urine, so if you do pick it up, it needs to be sent off and it that needs to be escalated. It could be because of a UTI so. If you have a urine infection, you will have lots of protein in your urine, so if it's treated and it clears up, you won't have any protein, but it also could be that you got kidney disease and nobody's known for because you've not been well. So do you know what bloods we take at booking?

And why? It's not my name. So again, historical, you know, it's like all screening programmes, so there is a full. Account because a lot of pregnant women are at risk of anaemia because you are diluting them with a load of fluid and then at the end of it, even if you have the most straightforward delivery, you're gonna bleed a bit, aren't you? So we do what we do, we check for anaemia and we check that again at 28 weeks, we check a group because we wanna know if the woman's Rhesus positive or Rhes is negative because that can affect your baby. So you probably haven't done much teaching on Rhys's disease of the. Newborn because it's effectively a disease that's died out because we have an effective treatment. So anybody who is rhesus negative and they have a rhesus positive baby, in their first pregnancy, it causes no problems. If they then get pregnant again because mum and baby will always exchange a little bit of blood, they may have developed antibodies and they will effectively cross the placenta and that baby will come up anaemic and die, and that used to happen in the 60s a lot and then on to the UK now. It doesn't happen anymore, hardly ever. Um. So we do blood, full blood count, we do a group, then we take HIV, hepatitis, and syphilis, and this is because they are all treatable diseases that can be transmitted to babies in pregnancy and cause harm in pregnancy or shortly after are not easily treated. So for HIV we can treat the mum and we can treat the baby postnatally and if you do that, the transmission rates are less than 1%.

Uh, hepatitis, we can vaccinate babies after their. Born because if you are born with hepatitis and you get, well if you get vertical transmission, you know, you develop it around the time that you're a baby, you're 95% likely to be chronic chronically infected, whereas most of you, if you've got hepatitis, you would be 95% chance of clearing it. So it will become a chronic disease if you get it as a baby, so that's why we do that. Syphilis again, very treatable, easy to treat, and cause very big problems in neonate and we have, we haven't. See many cases, but actually they are on the rise. So those are the, um, blood tests that we take. Most women don't decline them, and if they do, it's either because they're really needle phobic, which we have some cases, or because they're frightened about the results. Um, so it's usually a red flag if somebody says, oh, I'm not sure I want this book. Should we take a U&E? So I'll put that as a question. What do you think? Show of hands, do we need to take a UNE at booking?

Yes. Yeah, yeah. I'm gonna go for yes actually, but we don't. But then, you know, 20 weeks down the line somebody develops severe preeclampsia. We've got no nothing to compare that first year in Eton. So it might be something that would be a good idea to do. Um, money wise we don't have the finances to do it so. Whether in the future we will, I don't know. All schools. Streaming is about money. So what do we do at 12 weeks? Well, we do a dating scan. Um, I'm gonna show you the present and function assessment on the next slide. Um, and I'm just gonna show you a video on you trying to after that. Does anybody need subtitles on the video? In fact I have to put them on. The only thing I would say is that some of them are slightly wrong cos it's a YouTube video. I can put them on and then it, it says train instead of. Childhood myopia is on the rise. Short-sighted vision typically worsens over time and can impact those affected for life. But we can do something if we all act now. Myio Smart spectacle lenses don't just correct your, Uterine artery

Doppler measures the velocity of blood flow inside the uterine artery. During this history, the blood flow is very fast, and this depends on the woman heart contractions. The flow pattern during the diastoy depends on the terminal vascular resistance, mainly the spiral artery. The spiral artery is the terminal branch of the uterine artery, and it is now, highly coiled, with very high resistance. This will result in a Doppler graph characterised by a sharp rise and sharp decline during the system. So this is because when you're not pregnant, the uterus isn't really a functional, but I know it, it does have its actions but um around once a month, but it doesn't need a lot of blood for the majority of, of the time that it's there. during a diastomy is characterised by. Early diastolic notch and reduced in diastolic flow during the normal pregnancy, cytotrophoblastic cells will migrate outside the developing placenta. It migrate into the deci and the part of the myometrium. This is called a trophoblastic invasion and. These cytotrophoblastic cells are called extravellar cytotrophoblast because they don't share in the formation of the renal. This trophoplastic infusion will result in remodelling of the spiral

arteries in which the spiral arteries become dilated capacitance with very low resistance. This it changes, but it changes the shape of the uterine artery Doppler. I mean the notch will disappear and the in diastolic flow will markedly increase during your pregnancy with abnormal placentation like in cases of preeclampsia or foetal cross restriction, the trophoplastic invasion is inadequate. I mean, few cells will invade the decidu and will not reach the myometrium. This consequently will result in inadequate remodelling of the spinal arteries. These abnormal changes will result in an abnormal uterine artery Doppler, which is characterised by the presence of early diastolic notch and reduced end-diastolic flow. And now to summarise, as you see in the non-pregnant uterus, the highly convoluted, high-resistance spiral arteries will result in a diastolic pattern characterised by early diastolic node and reduced end-diastolic flow. But during a normal pregnancy, due to remodelling of the spiral arteries, The notch will disappear and the indiastolic flow will markedly increase. But with placental diseases like preeclampsia or FGR you may find an abnormal uterine artery Doppler, which is something in between the non-gravi uterus and the healthy pregnancy.

And this. Abnormal uterine arterylo at 20 to 24 weeks is defined by a pulsatility index, more than 95th percentile and or the presence of early diastolic nodu. And now, how to measure the pulsatility index? Well, during Doler's study, when you mark the Psystolic points and the In the historic point, the Doppler indices will be directly measured, which are the SDHE, resistency index, and pulsatility index. On this chart for uterine artery pulsatility index plus the EI and any value above the 95th percentile is an abnormal value. OK. So, um, we also risk classify women into who will develop, um, hypertension in pregnancy, and women with renal preexisting renal disease, essential hypertension and diabetes are high risk, so these are automatically classed as high risk and aspirin will be given to them, and those scans will be done in about 26 weeks. Um, and we use Thomas in Sheffield, so we don't do a lot of research here, to be honest. Um, I, I hold my hands up. I'm not a big researcher, but I have to take part in studies, but one of the things that our obstetric lead did was he, um, joined us to this

uh algorithm called Tommy's, and essentially it uses a foetal founding foundation medicine algorithm, um, and maths is important as a prediction tool, isn't it? So what this does is rather than what we used to do, which is we'd sort of. Assess women early in pregnancy and then see them a lot later in pregnancy and we still do that, we don't see them a lot early in pregnancy but we do a risk assessment early in pregnancy now because actually we used to classify a lot of women as low risk midwifery of care when it was the first pregnancy, but realistically we don't know because they've not been pregnant before so we don't know if they're gonna be low risk or high risk. So you put your pregnancy type er it has to be done um early in pregnancy so. Around the time of the newal translucency scan, it's not accurate if it's done after. Um, so the foetal prevalent is between 45 and 84, which is the same for if you're having your combined screening. Um, maternal characteristics go in, so date of birth, height, weight, racial origin, if they smoke, um, if the mother of a patient had preeclampsia.

I don't think conception methods goes into stummies, but it's on this one. Um, and then a bit about their history, their obstetric history like if they've had it before, um, and, um, measurements that are taken now. So they use the mean arterial pressure of, uh, the first and earliest lookinging blood pressure. Um, they use a uterine artery, so don't confuse this with umbilical artery, umbilical artery is looking at the blood flow to the baby and that's when the lady, and the uterine artery is the blood flow to the uterus, um, and that. Measured at booking actually in this hospital um and then you do a Pap A. So women don't, if women don't want to have combined screening, we can still take bloods for PapP A and do their Tommy's risk assessment. And what that does is it classifies women as low, medium or high risk. So it doesn't say that you're going to or not, but low risk women have a risk of less than 1 in 150 and high risk women have a risk of 1 above 1 in this place. It gives you an individual risk. The high and it enables you to give different care so high risk women will be seen um and scanned later in pregnancy and given aspirin. Moderate risk women will receive two scans, um, and women who are low risk will not receive scans unless there's another reason obstetrically that you wish to scan them. Um, so when do you think after this talk it might be more important to have good blood pressure control, 1st, 2nd, 3rd trimester or post nasal, so show of hands for first time.

I think that's important. OK. OK. 2nd trimester, so that is 12 to 2, 3rd trimester. OK, after we give birth, postnatal. OK, very interesting. So I think there's arguments to be fair for all of them. Um, the first trimester is where your presentation happens, so if you have hypertension in your first trimester, that automatically puts you at higher. Risk of having both preeclampsia and a small baby and poor pregnancy outcomes. Second trimester, it tends to be a stabilisation period, so you tend not to have too much problems during this time, but it's where the early severe onset preeclampsias can show themselves, um, and at 20 weeks we also look at the foetal growth for all women when they come for their anatomy scan. Third trimester is when most women will develop preeclampsia and pregnancy induced hypertension, um, so we do see them more frequently during this phase. And we aim, if we do develop hypertension to try and control it as best we can and get them as far as we get in pregnancy, because we know that it's best to be born between 39 and 41 weeks. So we want our women to get as far along in pregnancy as possible. Postnatally is very important for cardiac function, so there's a lot of evidence to suggest that there's, um, cardiac remodelling after you have your baby. So, um, there's actually some randomised trials that are going on looking at ACE inhibitors and whether we should give those to women and actually echo. Numbers of women who've had postnatal, uh, have had preeclampsia during pregnancy and pregnancy induced hypertension do often show a moderate degree of ejection, um fraction reduction which usually resolves over a period of a few months, um, because we don't do them often, we don't know how often, um, women are being affected. And a high density of pregnancy affects 10% of women, so in a hospital like this, you know, we've about

5000 500 deliveries. That's 550 women, isn't it? That's quite a lot of women. So if you've had pre-existing hypertension, you're at high risk for superimposed preeclampsia. Um, preeclampsia was diagnosed as hypertension above 135/85, um, and proteinuria. Pregnancy induced hypertension is hypertension without proteinuria, and the big difference is with preeclampsia you've got end organ damage, proteinuria is your kidneys aren't working because. Leaking protein, your kidneys should not leak protein, so hypertension without protein generally is less severe. Um, and your risk factors, so the other way of classifying them if you don't use the algorithm and in many centres across the UK they do this is use the nice risk factors. So if you have one high risk or two moderate risks, you will be advised to take aspirin. Actually it's not hard to get two moderate risks if you have a BMI of 35 and it's your first pregnancy. That's you, you're on aspirin for the rest of the pregnancy. Some women can't take it because of asthma, things like that, so some people have more sensitivities, some people get quite bad reflux with it, so.

um. So this is just a little, there's a few slides that I've put about preeclampsia and these are all patient information leaflets cos a lot of women won't know about signs of preeclampsia and they will often put things down to pregnancy like oh I'm. Sick. Oh, it's quite common in pregnancy. Oh, I've got a bit of a headache, I must be tired. Oh, there's a bit of flashing lights, don't know what that's from. Oh, I'm going to the toilet a lot but I'm not really peeing. We don't often see shortness of breath actually due to poor monone do we? That's very rare, but that was uh one of the commonest causes of death, um, when, er, we didn't have good treatments for preeclampsia. Um, it's very rare before 20 weeks and mostly it comes in like the trimester. Oh, no. Is something wrong, there we go, um, so if you look at the this chart, this comes from molecular medicine, what happens is that you've got a placental dysfunction that happens early in pregnancy, it's not something that happens, you know, later on, um, so around the time that you start to get that secondary invasion, that's when you get this placental dysfunction. You might not see any systemic effects. So the first thing you might see is you might see a bit of foetal growth restriction, don't't grown that well, that a small baby, um, you will then get the. Of the antigenic factors being released, a bit of systemic vasoconstriction that causes hypertension and at the end stage you're gonna get major organ damage. Now most of this is mild and reversible, um, complications, so strokes, seizures, hormonal edoema, we don't see that because we do really good fluid restriction on women who created and that's probably one of the other big changes as well as the introduction of. Magnesium sulphate and um IV labetalol to help control blood pressure um we fluid restrict women quite significantly who have preeclampsia because that we know reduces their risk of of pulmonary bleeding and death.

Clotting abnormality is quite rare. You do sometimes see women with um help which is a type of preeclampsia, so it's hemolysis, elevated liver enzymes, and low platelets. It's a condition rather than just precancer on its own. Um, and there's quite a lot of pre-eclampsia information on Tommy's which is, as well as being something that we use to discuss, and it is a charity which does a lot of research in pregnancy and has a lot of patient information inlets, and I would recommend to you all, if you're struggling to understand any topics in obstetrics, look at Tommy's or look at the Royal College of Obstetricians and gynaecologists patient information leaflets cos they often explain things in a way that we're not very good at. So why is fluid balance important? So what have we said happens in pregnancy, you get a lot more fluid. Do you get more electrolytes? No. So if I dilute you even more and give you loads of fluid and then you're not really peeing, what's gonna happen? You get the same amount of salt but more water. It becomes more dilute. And what happens if you have a low sodium or a low potassium?

Yeah, potassium, you get cardiac effects, low sodium, you'll get seizures. So our bodies really need a fine balance and I think this is something we're not very good at in obstetrics because most midwives are excellent and they're very good at individualised care and looking after women, but they're not nurse trained now so they don't know as much about it and we're getting better, you know, we're getting better. Teaching and training but fluid balance is really really important. Yes, these women they're young have been healthy, but their bodies unlike yours when you're not pregnant will not cope with big changes very well because they don't have a lot of reserve. um and this is from Embrace so the reason I put this up is because I wanted to show you that actually preeclampsia is not a big cause of death in the UK. Treating it, um, so we per 100,000 maternities in the UK about we have about 10 deaths, um, which is quite good, it could be better, it could always be better, but in terms of, um, looking at other countries, it's not a bad rate. Um, and of those, 0.4 are caused by preeclampsia. So we're doing quite well with preeclampsia, not as well with thrombosis and cardiac disease.

Um, and then the other thing that I wanted to point out on this is that one of, um, you know, as somebody who specialises in maternal medicine, nearly 70% of women have a preexisting medical problem that either directly, so the one that's the purple line is a direct cause of death and the blocked purple is indirect. Cause of death. So nearly 75%, 70% of women had a pre-existing medical disorder and had died from a direct cause of obstetrics, uh, uh, from the pregnancy and probably about 65% in the non-direct. So this is quite a complex group of women, this is excluded obesity, if you include obesity it's probably higher. Um, of the women who did die from preeclampsia. Uh, it's fairly evenly split, so intracranial haemorrhage, stroke, uh, cerebral edoema because of the eclampsia, um, pulmonary edoema again quite rare, 2 in 100, and then HELP syndrome. An acute fatty liver growth of pregnancy, so in total 8 women in the last triennium. And I think that's down to the fact that we have very good national protocols, um, for managing severe preeclampsia. So most hospitals will do the same things. And if you come to medical emergency, standardisation is really important to how you improve your practise um if everybody is doing the same thing.

um, so again it's just need a slide saying that we are OK at doing preeclampsia. um, so foetal complications, so we get foetal growth restriction, any lectures on foetal growth restriction? No, OK, so, um, the main thing to remember is you've got a different, you've got different types of growth restriction, you've got symmetrical, so the head, the tummy, the legs. Small and you've got asymmetrical where you can see there's a big head there. Now in prem babies you'll also get a bigger head compared to the abdomen. um but essentially as the baby gets towards term they should be about the same and what we do, what we do know about babies just like us, so if we put on weight, we, we don't put it on our heads, do we, we don't get really big heads, we put it on our tummy and the same if we lose weight, we tend to lose it around our skin, babies are no different. They will preserve brain function, they're. Very clever, so what you look for is a loss of weight around the waist, and that's called asymmetrical growth restriction and that is associated with poor placental function. And whereas symmetrical um birth restriction tends to be things like congenital diseases. It might just be that that baby is constitution small, there's absolutely nothing wrong with them, they're just how they

are. um, but these things can be associated with early delivery because the placenta function is so poor, neonatal death, um, and then long term, you know, if you were a small baby. You have a higher risk of hypertension, cardiovascular disease, diabetes. So it's not something that just affects the baby when it's born. Um, and there's different ways that we can monitor women, so one of the things that's really improved since COVID is we offer a lot of home monitoring and home monitoring apps that we can then follow up so women have a bit more autonomy, not dragged them to hospital, which is quite disruptive if you're having to come to hospital a couple times a week. And then I just wanted to talk a little bit. About research in Obs and Gynae, so the CHIPS trial which looked at um controlling blood pressure, either being really strict about it or a bit more laid back, found that actually if you were very strict with your hypertensive control, you would have no increase in adverse outcomes, um, but you would it for both routes, so things like you know early delivery, but you had a reduction in severe preeclampsia in the route that you're more tightly controlled and strict. Controlled them so because of that we are, we've got tighter controls so during the time I've been in obstetrics our, um, targets have gone from being the same as hypertension, so 140/90 to 135/85, so much more like renal and cardiovascular disease targets. Um, and the parrot trial was done a few years ago and this looked at frontal growth factor, um, with suspected preeclampsia, it's a multi-center trial. So that's always good when it's done in more than one place, um.

And it was a randomised controlled trial, so patients were randomised to groups, which again is one of the better ways of conducting a trial um because you then should get a more normal effect because in reality you know the patient groups are random. Um, and what they found is that the median time for diagnosis was 4.1 days compared to 2. So it's only 2 days difference. But if you've got a lot of women, that's quite a lot of reduction in care days needed. Care plan A, so that it, it might, you know, across nationally amount to quite a reduction in in spend um and when they reported the difference, uh, it found that more more severe outcomes were found in the concealed testing, so 5% to 4%. Now it's a small number, so they did, I. I don't know how they got statistical significance, but they did get statistical, so it is significant. And again nationally if you do something that drops a a rate of 1%, that can be quite a big save. So we now use this.

What I would say is it should be used in certain groups. I think we're with blood tests, blood tests are not free. This is an expensive test. um but it is used. Useful for the women who aren't easy to diagnose. So if you've got somebody who is hypertensive and I, for example, look after renal patients and diabetes patients, they might already have protein in the urine. It can be very difficult to tell if they're preeclampsia or it's just their normal renal disease. So I find it very useful for those. Um, then the treatment depends on on gestation and severity. If you've got somebody who's presenting at 25. Weeks unless they're severe precancer, you're gonna try and get them to at least 37 um most women from a diagnosis of moderate to severe preeclamps well moderate to preeclampsia will get about 2 weeks out of pregnancy, so realistically if you're diagnosed at 25 weeks you're probably gonna be delivered about 27, 28 weeks. Um, you will admit them initially, but not all of the car is inpatient if they're well and we can stabilise them on anti-hypertensives. You want to take some bloods and do those regularly, you want to assess. Mental well-being, so by CTG and ultrasound, then we're not very good at that. So, um, ultrasound only has like a 20%, uh, pickup rate for babies that, um, are stillborn. CTG is slightly higher, but again only great for that time of analysis. Um, regular observations, you want to start them on hypertensives and deliver them if there is uncontrollable, um, severe hypertension or any signs of any organ damage.

And severe preeclampsia is like an NI, you know, we should all know that it's urgent and you need to put out your 4 2s and treat it as normal, and essentially you stabilise the mum and then you deliver the baby. It's hard cos a lot of people think, oh, you know, you're automatically, oh I need to save this baby, but actually without mum there is no baby is there? So always in our jobs is look after the woman first. Once she's stable, think about the baby. Um, normally we keep people in for a couple of days after delivery depending on how the blood pressure is, and then they have regular, regular monitoring periods for a couple of weeks and follow up with the GP. And they can consider switching to a once daily formulation, so there's a lot more antihypertensives that are available postnatally. Antenatally we are quite limited, we tend to use albetalol and amfedipine, but there are more and more that we're finding are safe. And this just shows about the long term risks, so

again. Most of you won't work innton Gynae. Most of you will work in the community. And so if you see somebody who has had pregnancy-induced hypertension or preeclampsia, then their risk of hypertension is high. So lifestyle counselling is really important for these women. Um, and this just shows the significance and increase, so most things between 2, at least above the, um, background risk if you've had hypertension in pregnancy. Um, I talked to a little. A bit about left ventricular remodelling and that that might be a future treatment. It might be that every woman who develops pre-eclampsia gets some proper follow up and there might be some primary prevention. Do you have any questions? No? OK. You got more lectures? I finished a bit quick. So enjoy your 20 minutes. Thank you very much. You. So. I do. Yeah. Yeah you get August that So uh It I Trying to figure out what what. Do you wanna stay here for a bit or? The the loud. Oh yeah I just I've got this is like the teaching is the sessions this is your liaison.

So, yes. Oh. Don't worry. I'm so confused because I'm just trying to. When there's no. Yeah, I just wanted to, yeah, I guess I think I'm. Have in I would like to take blood pressure. is on a hill. Also, if you've got a young patient, do not take their blood pressure twice. It kind of sends a hypokalemic shock. No, she was 13 years old with anaemia. No, she, she just fainted and then, and then kind of woke her up again, gave her some water. Yeah. Yeah, because she was like, oh, I get dizzy because of my having periods, so we took her blood pressure and it was so normal, so I took it again and then she fainted. That was your fault. You are absolutely. No, please, trying to report myself. be in that one. I know what's going on. So You 3A teaching. I've got PTS teaching and I've got your above teaching as well. There's two different teachings. One's my older one's going for all of them. it's it's, it's so. And then I've been like I myself I have to

do my landlord who kicked me out. Yeah. Does she want to just get rid of it? I'll share it. We can like share it on Spring as well like it's not planning on selling it. I don't know what that means, but it was really it was really for parents not to get hold of the pool, yeah, you thought about that, there's not nearly enough space for opponent. It's we haven't even met. Yeah, no, I, I just, there's a GPs who didn't come into work one day, but this GP was because he couldn't get out of the drive. So usually he thinks he drives. It was because his driveway heating system had failed, so he couldn't clear off the snow off his driveway, he didn't. And then he for 3 days, yeah, yeah, are they living and then he said he was talking to me like, oh yeah, my brother just lives next door, like they lived in like these two semi-detached houses somewhere like they lived in mansions next to each other. They were still like half a mile between the houses.

Yeah, it's crazy how the other half raking it in. You have friends? How do you, do you? Oh. 3245 lawyers. I I don't know do you do do a jitsu. It's. Oh Good. OK, I'll, I'll let it go. And then the part is you've meant to like do that really fast and break now shut down. I thought we were friends. You don't wanna show us that bit. No. Well, I didn't want to be too muted, so technically you meant to slap them in the face because that's what gets them to bend over, but I was like I'll probably go a bit far. That'd be a way to get kicked out. But no, when I'm bored in like, I just start going through committee drives because I have no business being like there's no need that I need to look at all this training stuff. I just enjoy being noted. That's so, um, yeah, what I was gonna say I did some other crap here in that lecture. Would you just be taking. She went through it so quick.

Well, why didn't you think there were, there weren't that many points that we know. We all interesting. Hypertension I just remember like the first one yesterday was really good she was good they were presented the same way I was sleepy. Yeah, when she was like, right, should I do the lecture, and I was like, No, I know, but it makes sense to do it whilst we're actually learning how to lift the baby. I thought we were doing bimanual exam I'm assuming it's it's like. I figured it was bimanual examination and manual bimanual like bisexuals yeah yeah like like transvaginal. I 2 hours it's better be 2 hours we've gotta get do we what we do we're in and they say they say on the email she might be in clinic. I thought it was. I need to tell myself I'm in for 8:30, but I'm thinking I might go try and find the clinics now we're 8:30 clinic, uh, specialty gyne I've got no idea what it stands for I think. it Yeah. No. I was not in that you just walk around.

Get my steps in. Yeah. Gym session ever cause I was so late, I was like just going through everything like with no rest breaks at all, it was disgusting, like 25 gs. And I'm still. No, he's good, he's good. I. I. I. I. I. I. I. I. I. I. I. I. I. I. I. I. I. I. I.