Obstetrics 4

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Obstetrics 4
2014-11-18 23:36:18
Ectopic pregnancy cervical incompetance twin Postterm Gestational
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  1. Fetal demise, 34 weeks, footling presentation, obstetric management?
    • Vaginal delivery – not CS.
    • Give enough time for vaginal delivery.
  2. What are the factors that predispose ectopic pregnancy?
    • - History of PID -- most common [AI 96] 
    • - History of tubal ligation
    • - Contraception failure
    • - Previous ectopic pregnancy
    • - IUD use
  3. What is the most common site for ectopic pregnancy?  [AIIMS 94, AI 93, IOM 2067,61]
    Ampulla of fallopian tube
  4. What is the diagnostic criteria for Unruptured Ectopic pregnancy?
    • β-hCG titre ≥ 1500mIU and TV sonogram – no intrauterine pregnancy . This level is called as discriminatory threshold of β-hCG
    • OR
    • β-hCG titre ≥ 6500mIU and abdominal ultrasound – no intrauterine pregnancy
  5. What is the management of Ectopic pregnancy?
    • Ruptured – urgent surgery to stop bleeding
    • Unsure – repeat USG and hCG level in 2-3 days.
    • Unruptured – medical or surgical depending on the level of β-hCG.
  6. How do you determine wheather you do the medical management or surgical management in Unruptured Pregnancy?
    • Medical management - β-hCG < 6000IU (early pregnancy)
    • Surgical management - β-hCG > 6000IU late pregnancy) - laparascopy with salpingostomy.
  7. How do you know that methotrexate has worked in Ectopic pregnancy?
    Weekly hCG level titre – decreasing titre
  8. What are the various drugs that can be used in ectopic pregnancy?  [AIIMS 03]
    • Methotrexate 
    • Actinomycin D
    • Potassium chloride
  9. What are the causes of Cervical Incompetence?  [IOM 2066]
    • 1. Congenital - rare
    • 2. Acquired:
    • - D & E operation,
    • - induced abortion by D + E,
    • - vaginal operative delivery through an undilated cervix,
    • - amputation of cervix
    • - cone biopsy
  10. What are the types of cervical cerclage? Which one is better?
    • Shirodkar Cerclage  - suture left in place , C/S  is required
    • McDonald  Cerclage  -  suture is removed , C/S is not required as the suture  is removed.
  11. What is the indication of cervical cerclage? When is it done? When is it removed?
    • Cervical insufficiency.  
    • Done between 14-20 weeks.
    • It is removed  in around 36 weeks.
  12. How do you diagnose the cervical insufficiency?
    Painless dilatation of cervix prior to viability resulting in delivery of non viable normal  fetus, in absence of bleeding, rupture membrane  or contraction.
  13. What  is the most common cervical cerclage procedure?
    • McDonald Cervical Cerclage -  suture goes in and comes out and goes in and comes out like the purse string suture, and tight it down  and cervix is hold externally  
  14. What is hemochorial placenta?
    A placenta in which the maternal blood is in direct contact with the chorion is known as hemochorial placenta. Human placenta is of hemochorial type. [AIIMS 1991]
  15. What is Hellin's rule?
    Hellin's law states that twins occur once in 80 pregancies,[PGI 00]  triplet once in 6400 (802) pregnancies and quadruplets once in 512000(803) pregnancies.
  16. What  is the mean gestational age at delivery of twins?
    • On each addition of a baby, the gestational age is reduced by 4 weeks.
  17. What is the most common type of Twins?
    Dizygous twins – from 2 eggs
  18. When are  the various types of monozygotic twins splitted?
    • Split within 3 days – Dichorionic diamniotic
    • Split between day 4-8 - Monochorionic diamniotic 
    • Split between day 9-12 - Monochorionic monoamniotic 
    • Attempt to separate after day 12 – Conjoint twins

  19. How can we find chorionicity by ultrasound?
    • By performing an obstetric ultrasound at a gestational age of 10-14 weeks
    • Monochorionic-diamniotic twins are discerned from dichorionic twins by the presence of a "T-sign" at the inter-twin membrane-placental junction (that is, the junction between the inter-twin membrane and the external rim forms a right angle),
    • whereas dichorionic twins present with a "lambda (λ) sign" [AI 10] (that is, the chorion forms a wedge-shaped protrusion into the inter-twin space, creating a rather curved junction).
    • The "lambda sign" is also called the "twin peak sign".
    • At ultrasound at a gestational age of 16-20 weeks, the "lambda sign" is indicative of dichorionicity but its absence does not exclude it. 
  20. In which type of twin pregnancy does twin-twin transfusion  syndrome occurs?
    • In MONOCHORIONIC DIAMNIOTIC TYPE of twin pregnancy -  the  twins who share the placenta can have TTTS. One is donor  and the other is the recipient,  often the donor does better in later life. 
    • More blood is coming from donor,  that goes to the recipient. Thus, the recipient is larger and the donor is smaller.
    • The recipient being larger makes  more  urine,  and thus, there is polyhydraminos in one sac and oligohydraminos in other sac.  This it is also called as Oligo-Poly syndrome.
    • The smaller has such less amniotic fluid that the membrane are wrapped  around it  and thus it cannot move, we sometimes call it STUCK TWIN SYNDROME.

  21. What is twin embolization syndrome?
    In Monochorionnic Diamniotic type of twin pregnancy, if one twin dies, the tissue thromboplastin from the detoriating twin  can go through the anastomosis in the  umbilical cord, and reach the other twin and cause problem in brain, kidney etc.
  22. In which type of twin is there Umbilical cord entanglement problem?
    Monoamniotic monochrionic twin because these twins share the same sac.

  23. Blood chimerism is most likely to occur in [AI 11]
    A) Monochorionic monozygotic twins 
    B) Dichorionic dizygotic twins 
    C) Singleton pregnancy
    D) Monochorionic dizygotic twins 
    D) Monochorionic dizygotic twins

    Chimerism refers to a condition where an organism shows different cell lines that originated from two different zygotes. 

    Mosaicism refers to a condition where an organism shoes two different cell lines that originated from the same zygote. 

    Monochorionic dizygotic twinning is a rare event, however it has increasingly been reported following assisted techniques of reproduction. Monochorionic dizygotic twinning when present has a high frequency of blood chimerism.
    (this multiple choice question has been scrambled)
  24. What is the mode of delivery in twin pregnancy?
    • Cephalic – cephalic -- Vaginal delivery
    • First baby cephalic, second breech --  either C/S or vaginal delivery [IOM 08] 
    • First Breech, second cephalic -- C/S
  25. What is the outcome of birth order in twin pregnancy? [AI 12]
    • Birth order contributes to poor outcome in twin pregnancies. 
    • There is two fold increase in neonatal death amongst the second born twins compared with the first born. 
    • Second born twins are at higher risk of birth asphyxia associated with malpresentation, placental insufficiency or placental separation. 
    • Hyaline membrane disease occurs more frequently in twins than singletons. Most frequently both twins are affected with RDS, however when only one twin is affected with RDS, it is usually the second twin
    • Intracranial hemorrhage may occur as a result of prematurity itself and no difference in the incidence of ICH have been observed between the smaller or larger twins or between twins delivered vaginally or abdominally.
  26. What is indication of internal podalic version? [UP 96]
    • Internal podalic version is rarely indicated in a singleton pregnancy.
    • Its only indication is the transverse lie in a case of second baby of twins.
  27. What  is postterm Pregnancy?
    • Postconception  -  ≥40wks  or 280 days 
    • Post LMP  -  ≥42wks  or 294 days [AIIMS 92, UP 97]
  28. How do you diagnose posterm babies?
    • Peeling off  the skin that normally occurs 2 weeks after birth
    • Long finger nails

  29. What are the problems with Post-term baby?
    • Placenta function maintained:
    • -  Macrosomia (80%) – Big baby

    • Placental function deteriorated:
    • - Dysmaturity (20%)  
    • - Hypoxic and Acidotic baby
    • - Higher chance of meconium aspiration
  30. How  do you manage Postterm cases?
    • Dates sure, favorable cervix -   Induce labor, IV Oxytocin, AROM
    • Dates sure, Unfavorable cervix -  PGE2 to induce labor, If the baby is not large and the mother doesnot want to use medicine,  so NST and AFI twice a week ,  and if baby gets in trouble , deliver 
    • Dates unsure  -  conservative,  so NST and AFI twice a week.
  31. Which prostaglandin do you use for induction of labor?
    • PGE2.
    • It is the prostaglandin that is approved by FDA but most obstetricians use PGE1 (misoprostol) to induce labor.
    • In exams, choose PGE2.
  32. How do you manage the meconium cases?
    • In labor - amnioinfusion 
    • After Head is delivered – Suction nose and pharynx 
    • After body is delivered – visualize vocal cords with laryngoscope and if meconium seen, aspirate it out.