Obstetrics Marrow Pg 415-424 (Obstetrics Complications)
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What is the primary clinical indication for using tocolytics in circlage?

  • Ultrasound-based measurements (correct)
  • Physical examination results
  • History of drug allergies
  • Patient age

    • Tocolytics are used primarily in circlage to prevent preterm labor.

    True

    What is the role of tocolytics in the context of circlage?

    To delay labor and reduce uterine contractions.

    Tocolytics are indicated based on __________ measurements in circlage.

    <p>ultrasound</p> Signup and view all the answers

    Match the following terms related to circlage with their definitions:

    <p>Tocolytics = Medications used to suppress premature labor Cervical cerclage = A stitch placed in the cervix to prevent premature birth Ultrasound = An imaging technique used to assess the cervix Preterm labor = Labor that occurs before 37 weeks of pregnancy</p> Signup and view all the answers

    What is the recommended management for a fetus with Hb < 2 SD or Hematocrit < 30%?

    <p>Repeat Hb and hematocrit weekly</p> Signup and view all the answers

    Delayed cord clamping is recommended for all Rh-negative mothers.

    <p>False</p> Signup and view all the answers

    What should be done for a fetus with severe anemia and gestation less than 35 weeks?

    <p>Intra-uterine blood transfusion</p> Signup and view all the answers

    Anti-D injection of _____ µg can neutralize up to 30 ml of fetomaternal hemorrhage.

    <p>300</p> Signup and view all the answers

    Match the following conditions with their corresponding management:

    <p>Hb &lt; 2 SD or Hematocrit &lt; 30% = Repeat monitoring and fetal surveillance Hb ≥ 2 SD or Hematocrit ≥ 30% = Intra-uterine blood transfusion if &lt; 35 weeks Normal FMH = Anti-D injection not needed Increased FMH = Administer Anti-D based on volume</p> Signup and view all the answers

    Which of the following is considered a risk factor for abortion?

    <p>Increased maternal age</p> Signup and view all the answers

    Congenital syphilis is known to frequently cause recurrent abortion.

    <p>False</p> Signup and view all the answers

    What is the definition of abortion as provided?

    <p>Pregnancy loss occurring at monosomy (Turner's syndrome) &gt; Trisomy 16.</p> Signup and view all the answers

    The prognosis of pregnancy in patients with syphilis follows the ______ law.

    <p>Kassowitz</p> Signup and view all the answers

    Match the following conditions with their characteristics:

    <p>Monosomy = Turner's syndrome Trisomy 16 = Associated with some pregnancy losses Congenital syphilis = Increased risk of stillbirth Kassowitz law = Prognosis based on previous pregnancies in syphilis patients</p> Signup and view all the answers

    What is the most commonly confirmed endocrine cause of recurrent abortion?

    <p>Hypothyroidism</p> Signup and view all the answers

    Trisomy 21 is considered the most lethal trisomy.

    <p>False</p> Signup and view all the answers

    How many consecutive pregnancy losses are required to define recurrent abortion?

    <p>23</p> Signup and view all the answers

    The most commonly associated chromosomal abnormality in recurrent abortion is __________.

    <p>Balanced translocation</p> Signup and view all the answers

    Match the following causes of recurrent abortion with their respective categories:

    <p>Hypothyroidism = Endocrine Causes Antiphospholipid syndrome = Maternal/Confirmed Causes Septate uterus = Uterine Causes Balanced translocation = Chromosomal Abnormalities</p> Signup and view all the answers

    What is the minimum number of painless abortions for a woman to be considered under this management protocol?

    <p>2</p> Signup and view all the answers

    Progesterone should be administered at ≥ 12 weeks in cases of recurrent painless abortions.

    <p>True</p> Signup and view all the answers

    What measurement is crucial for monitoring in women with a history of recurrent painless abortions?

    <p>Cervical length</p> Signup and view all the answers

    A pregnant woman with a history of __________ abortions should be monitored according to the management protocol.

    <p>painless</p> Signup and view all the answers

    Match the following management considerations with their respective details:

    <p>Progesterone = Administer at ≥ 12 weeks Cervical length = Key measurement to monitor History of abortions = ≥ 2 painless abortions Active space = Surveillance in management protocol</p> Signup and view all the answers

    Which of the following is NOT a clinical criterion for diagnosing APLA Syndrome?

    <p>History of thrombotic events after pregnancy</p> Signup and view all the answers

    Lupus anticoagulant antibodies can be directly detected by ELISA.

    <p>False</p> Signup and view all the answers

    Name one type of thrombosis associated with APLA Syndrome.

    <p>Arterial thrombosis or Venous thrombosis or Placental thrombosis</p> Signup and view all the answers

    The specific antibodies involved in APLA Syndrome include Lupus anticoagulant Ab and Anti-__________ Ab.

    <p>Cardiolipin</p> Signup and view all the answers

    Match the following diagnostic criteria types with their descriptions:

    <p>Clinical Criteria = Based on medical history relating to thrombosis and pregnancy loss Lab Criteria = Based on antibody testing results Sapporo criteria = A set of guidelines for diagnosing antiphospholipid syndrome Sydney criteria = A newer standard for evaluating antiphospholipid syndrome</p> Signup and view all the answers

    Which of the following is considered a diagnostic criterion for cervical incompetence?

    <p>History of ≥2 painless spontaneous abortions</p> Signup and view all the answers

    The shape of the cervix in cases of cervical incompetence typically resembles a T shape.

    <p>False</p> Signup and view all the answers

    What is the primary management technique for cervical incompetence?

    <p>Cervical circlage</p> Signup and view all the answers

    Cervical incompetence is diagnosed when the cervix measures ______ cm or less during a transvaginal scan.

    <p>2.5</p> Signup and view all the answers

    Match the following scenarios with their corresponding diagnostic criteria for cervical incompetence:

    <p>History of recurrent abortions = ≥3 Hegar dilator No. 8 = Without resistance Foley's catheter No. 16 = Filled with 1 ml water Cervical length = ≤2.5 cm</p> Signup and view all the answers

    Which test is used to estimate the exact volume of fetal maternal hemorrhage (FMH)?

    <p>Kleihauer Betke Test</p> Signup and view all the answers

    Anti-D has no role in cordocentesis if sensitization has already occurred.

    <p>True</p> Signup and view all the answers

    What is the recommended dose of Anti-D for a patient in the first trimester after an abortion?

    <p>50 µg IM</p> Signup and view all the answers

    The _____ test is a qualitative test that helps differentiate between vasa previa and placenta previa.

    <p>Singer Alkali Denaturation</p> Signup and view all the answers

    Match the following minor antigens with their risk of sensitization:

    <p>Kell = Risk of Sensitization Lewis = No Risk of Sensitization Jidd = Risk of Sensitization Duffy-B = No Risk of Sensitization</p> Signup and view all the answers

    What is the most common cause of immune hydrops fetalis?

    <p>Blood incompatibility</p> Signup and view all the answers

    Non-immune hydrops fetalis is caused exclusively by blood incompatibility.

    <p>False</p> Signup and view all the answers

    What is the 'Buddha sign' indicative of?

    <p>Scalp subcutaneous edema</p> Signup and view all the answers

    Immune hydrops fetalis typically occurs when fetal Hb is less than _____ g%.

    <p>4</p> Signup and view all the answers

    Match the following types of hydrops fetalis with their descriptions:

    <p>Immune Hydrops = Caused by blood incompatibility Non-Immune Hydrops = Caused by other factors such as infections or abnormalities</p> Signup and view all the answers

    Which of the following are common causes of non-immune hydrops fetalis? (Select all that apply)

    <p>Anemia</p> Signup and view all the answers

    Placental chorioangiomas are potential findings associated with hydrops fetalis.

    <p>True</p> Signup and view all the answers

    What is the term used for the syndrome where mother and fetus exhibit similar deformities?

    <p>Mirror syndrome</p> Signup and view all the answers

    What is the type of suture used in the McDonald Circlage?

    <p>Purse string in portio vaginalis</p> Signup and view all the answers

    The Shirodkar Circlage has a lower success rate compared to the McDonald Circlage.

    <p>False</p> Signup and view all the answers

    At what week is suture removal typically done for vaginal circlage?

    <p>37 weeks</p> Signup and view all the answers

    If vaginal circlage fails, the next step is to perform an __________ circlage.

    <p>abdominal</p> Signup and view all the answers

    Match the types of circlage with their characteristics:

    <p>McDonald Circlage = Lower success rate and no bladder dissection Shirodkar Circlage = Higher success rate and bladder dissection performed Wurms Circlage = Applied when cervix is dilated, emergency procedure Abdominal Circlage = Performed in non-pregnant females post-failure of vaginal circlage</p> Signup and view all the answers

    Study Notes

    Tocolytics

    • Tocolytics are used to suppress preterm labor.
    • Used in combination with cervical cerclage as tocolytics can help to buy some time for cervical incompetence.
    • USG based (Length # Cordocentesis

    Cordocentesis

    • Fetal blood is taken for analysis
    • Indicated for fetal anemia.
    • Hb of fetus < 2 SD or Hematocrit < 30% is considered mild anemia
    • Hb of fetus ≥ 2 SD or Hematocrit ≥ 30% is considered severe anemia
    • If severe anemia is detected at ≥ 35 weeks, delivery is recommended.
    • If severe anemia is detected at < 35 weeks, intrauterine blood transfusion is recommended.

    Rh Negative Pregnancy

    • Delayed cord clamping is recommended in Rh-negative pregnancies if the mother is not sensitized and the ICT status is positive.
    • Early cord clamping is recommended in other scenarios.

    Fetomaternal Hemorrhage (FMH)

    • A normal FMH is < 4 ml.
    • Anti-D injection 300 µg/1500 IU is sufficient to neutralize up to 30 ml FMH/15 ml fetal RBC.
    • For every 1 ml of extra fetal blood (over 30ml): 10 µg of additional Anti-D is given.
    • ↑ FMH (Increased Fetomaternal Hemorrhage) can occur due to:
      • Abdominal trauma
      • Instrumental delivery
      • Twin pregnancy
      • Intra-uterine death
      • Manual removal of placenta.

    Anti-D

    • Rosette Test is used to screen for FMH
      • (+) ↑ FMH = Positive result
      • (-) ↓ FMH = Negative result
    • Kleihauer Betke Test is a quantitative test used to estimate the exact volume of fetal maternal hemorrhage (FMH)
    • Dose is within 2 hours of the test
    • Singer Alkali Denaturation Test is a qualitative test used to differentiate between vasa previa and placenta previa and to detect FMH

    First Trimester Anti-D

    • Indicated for abortion, ectopic pregnancy, molar pregnancy, and chorionic villi sampling.
    • ACOG recommends 50 µg IM
    • RCOG recommends 300 µg IM

    Second/Third Trimester Anti-D

    • Indicated after amniocentesis, external cephalic/internal podalic version, unexplained bleeding, antepartum hemorrhage, fetal death, and abdominal trauma.

    • Dose: 300 µg IM

    • There is no role of Anti-D in cordocentesis if sensitization has already occurred (ICT+ve).

    • Delivery occurring within 28 days of anti-D administration if sensitization has already occurred (ICT+ve).

    Miscellaneous Topics

    • Minor Antigens have different risks of sensitization:
      • No risk of sensitization: Lewis, I-Antigen, Duffy-B
      • Risk of Sensitization: Kell, Kidd, Duffy-A

    Cervical Incompetence

    • Cervical incompetence is a condition in which the cervix thins and dilates prematurely during pregnancy, which can lead to miscarriage or premature birth.

    • The definition of a shortened cervix varies but is generally less than 2.5 cm in length.

    • The most common cause of cervical incompetence is unknown.

    Cervical Circlage

    • A surgical procedure done to strengthen the cervix that is performed during pregnancy
    • Procedure involves placing a suture around the cervix to keep it closed.

    Indications

    • History of ≥2 painless abortions (irrespective of USG findings)
    • History of incomplete abortion + Cervical length

    Different Types of Vaginal Circlage

    • McDonald Circlage

      • Purse string in portio vaginalis
      • Dissection of bladder is not done
      • Suture material: Non-absorbable (Propylene)
      • Lower success rate

    • Shirodkar Circlage

      • Continuous
      • Bladder is dissected
      • Suture closes to internal Os
      • Higher success rate
      • Suture material: Mersilene tape

    • Wurms Circlage (Emergency Circlage)

    • Used when cervix is already dilated

    • Places 2 sutures in the anteroposterior direction and 1 in the transverse direction

    • Performed between 14-24 weeks (up to 28 weeks)

    • Suture removal occurs at 37 weeks.

    • Abdominal Circlage

      • Indicated if vaginal circlage fails.
      • Laparoscopic procedure.
      • Outdated procedure, LASH & LASH surgery: removes part of cervix and then applies suture
      • Done in non-pregnant females.

    Hydrops Fetalis

    • A condition where there is excessive fluid accumulation in the fetus.
    • Can be immune or non-immune
    • Immune hydrops fetalis is the most common type of hydrops fetalis.
    • Cause of immune hydrops fetalis:
      • Blood incompatibility
      • Fetal Hb < 4g% +
      • Hematocrit < 15%
    • Non-immune hydrops fetalis can be caused by:
      • Cardiovascular abnormalities
      • Chromosomal abnormalities
      • Parvovirus B19 infection
      • Other TORCH infections
      • Anemia

    Hydrops Fetalis Diagnosis

    • Ultrasound (USG) findings:
    • Pericardial effusion
    • Ascites
    • Pleural effusion
    • Subcutaneous edema
    • "Buddha sign" (scalp subcutaneous edema)

    Recurrent Miscarriage

    • ≥ 2 consecutive pregnancy losses at ≤20wk of gestation
    • Two confirmed pregnancy losses by American Society of Reproductive medicine (ASRM).
    • Confirmation by Histopathological examination (HPE) & USG
    • Most common causes:
      • Maternal:
        • Endocrine:
          • Hypothyroidism
          • Uncontrolled diabetes
        • Uterine:
          • Congenital: Septate uterus > Bicornuate uterus (T2 > Ta)
          • Acquired: - Cervical incompetence (only T abortions) - Submucous fibroid - Ashermann syndrome
      • Chromosomal Abnormalities
        • Can lead to 2 to 5% of recurrent abortions.
        • Most common: Balanced translocation of chromosomes

    Recurrent Miscarriage Investigation

    • Start after 2 abortions:

      • TSH (if endocrine cause suspected)
      • TVS (if uterine cause suspected)
      • Antiphospholipid antibody (APLA) Ab-testing
      • Parental Karyotyping

    • Investigations not done:

      • TORCH (in infections) - Including VDRL test for syphilis.
      • Thrombophilia

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    Description

    This quiz covers essential aspects of tocolytics, their role in preterm labor, and the procedure of cordocentesis for fetal blood analysis. It also addresses the management of Rh negative pregnancies and fetomaternal hemorrhage. Test your knowledge on these critical topics in obstetric care.

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