Obstetrics 4

• Vaginal delivery – not CS.
• Give enough time for vaginal delivery.

• - History of PID -- most common [AI 96] 
• - History of tubal ligation
• - Contraception failure
• - Previous ectopic pregnancy
• - IUD use

Ampulla of fallopian tube

• 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

• 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.

• Medical management - β-hCG < 6000IU (early pregnancy)
• Surgical management - β-hCG > 6000IU late pregnancy) - laparascopy with salpingostomy.

Weekly hCG level titre – decreasing titre

• Methotrexate 
• Actinomycin D
• Potassium chloride

• 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

• 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.

• Cervical insufficiency.  
• Done between 14-20 weeks.
• It is removed  in around 36 weeks.

Painless dilatation of cervix prior to viability resulting in delivery of non viable normal  fetus, in absence of bleeding, rupture membrane  or contraction.

• 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  
• 

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]

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.

• 
•  
• On each addition of a baby, the gestational age is reduced by 4 weeks.

Dizygous twins – from 2 eggs

• 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

• 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. 
• 

• 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.

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.

Monoamniotic monochrionic twin because these twins share the same sac.

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.

• Cephalic – cephalic -- Vaginal delivery
• First baby cephalic, second breech --  either C/S or vaginal delivery [IOM 08] 
• First Breech, second cephalic -- C/S

• 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.

• 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.

• Postconception  -  ≥40wks  or 280 days 
• Post LMP  -  ≥42wks  or 294 days [AIIMS 92, UP 97]

• Peeling off  the skin that normally occurs 2 weeks after birth
• Long finger nails

• Placenta function maintained:
• -  Macrosomia (80%) – Big baby

• Placental function deteriorated:
• - Dysmaturity (20%)  
• - Hypoxic and Acidotic baby
• - Higher chance of meconium aspiration

• 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.

• PGE2.
• It is the prostaglandin that is approved by FDA but most obstetricians use PGE1 (misoprostol) to induce labor.
• In exams, choose PGE2.

• 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.