Obstetrics Marrow Pg 455-464 (Obstetrics Complications)
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Obstetrics Marrow Pg 455-464 (Obstetrics Complications)

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Questions and Answers

Which condition is NOT associated with bleeding in females at 28 weeks or more?

  • Ectopic pregnancy (correct)
  • Placenta previa
  • Abruptio placenta
  • Uterine rupture

    • In cases of abruptio placenta, the fetal heart sounds are typically abnormal.

    True

    What color is the amniotic fluid when performing an ARM in the case of abruptio placenta?

    Dark red

    In cases of a ruptured uterus, the fetal parts can typically be felt ___ in the peritoneal cavity.

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

    Match the following features to the correct condition:

    <p>Fetal head can be felt = Abruptio placenta Loss of fetal station = Ruptured uterus Tender rigid uterus = Abruptio placenta Uterine contour not felt = Ruptured uterus</p> Signup and view all the answers

    What is the earliest week for assessing gestational age using ultrasound in twin pregnancies?

    <p>7 weeks</p> Signup and view all the answers

    The presence of two placentas is a marker of monochorionicity in twin pregnancies.

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

    What type of conjoined twins are joined at the thorax?

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

    The ideal time for ultrasound in twin pregnancy to determine gestational age is in the ______ trimester.

    <p>1st</p> Signup and view all the answers

    Match the types of conjoined twins with their description:

    <p>Paraphagus = Joined at lower abdomen &amp; pelvis Thoracophagus = Joined at thorax Rachiphagus = Joined at vertebral column Craniophagus = Joined at head</p> Signup and view all the answers

    What distinguishes superfecundation from superfetation?

    <p>Both ova are fertilized in the same cycle.</p> Signup and view all the answers

    Superfetation is a phenomenon that can occur in humans.

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

    What is the term for the type of twins formed when two separate ova are fertilized in the same cycle?

    <p>Dizygotic twins</p> Signup and view all the answers

    Dizygotic twins are typically _____ and _____, meaning each twin has its own amnion and chorion.

    <p>dichorionic, diamniotic</p> Signup and view all the answers

    Match the following risk factors with dizygotic twins:

    <p>Geographical distribution = Influences twin prevalence based on location Increased maternal age = Older mothers are more likely to have twins IVF = A method that increases the chance of twins Ovulation induction drugs = Medications that stimulate multiple ovum release</p> Signup and view all the answers

    What is the characteristic of Grade 2 in the FIGO classification of placenta accreta spectrum?

    <p>Villi infiltrate into myometrium</p> Signup and view all the answers

    Placenta percreta is characterized by villi that are superficially attached to the myometrium.

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

    Name one of the etiological factors leading to placenta accreta spectrum.

    <p>Absent decidua basalis or Absent Nitabuch's layer or Hyper-invasiveness of cytotrophoblast</p> Signup and view all the answers

    The layer that limits the penetration of trophoblastic villi into the decidua is known as the _______.

    <p>Nitabuch's layer</p> Signup and view all the answers

    Match the following terms with their correct descriptions:

    <p>Placenta accreta = Villi superficially attached to myometrium Placenta increta = Villi infiltrate into myometrium Placenta percreta = Villi attached to serosa or pelvis Nitabuch's layer = Limits trophoblastic villi penetration</p> Signup and view all the answers

    What is the recommended action when maternal vitals are unstable and there is fetal distress due to abruptio placenta?

    <p>Immediate C-section</p> Signup and view all the answers

    DIC is classified as a non-emergency condition in cases of abruptio placenta.

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

    What management is required for a patient with abruptio placenta and DIC?

    <p>Manage DIC and perform a C-section</p> Signup and view all the answers

    If the gestational age is less than 34 weeks, the action taken for abruptio placenta is _____ management.

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

    Match the following conditions with their corresponding management actions:

    <p>Abruptio Placenta + Maternal Vitals Stable = Vaginal Delivery Abruptio Placenta + DIC = Manage DIC and C-section Gestational Age ≥ 34 weeks = Induction of Labor Gestational Age &lt; 34 weeks = Expectant Management</p> Signup and view all the answers

    Which of the following is NOT a risk factor for placenta previa?

    <p>Elevated maternal serum hCG</p> Signup and view all the answers

    Maternal serum AFP levels of 2.5 moM or greater indicate an increased risk of PAS.

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

    What imaging technique is the definitive diagnosis for assessing placenta accreta spectrum at 28 weeks?

    <p>USG with color Doppler</p> Signup and view all the answers

    The presence of large placental lacunae is indicative of ________ on ultrasound.

    <p>placenta accreta spectrum</p> Signup and view all the answers

    Match the following investigations with their descriptions:

    <p>Maternal serum AFP = Marker for PAS risk Anomaly scan = Screening for congenital anomalies USG with color Doppler = Definitive diagnosis of PAS Maternal serum hCG = Marker for PAS risk</p> Signup and view all the answers

    What is the management of choice for antenatally detected placenta accreta spectrum?

    <p>Elective C-section followed by hysterectomy with placenta in-situ</p> Signup and view all the answers

    Ureteric catheterization before surgery has an increased risk of urinary tract injury.

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

    What procedure is performed when managing postnatally detected placenta accreta spectrum if fertility is desired?

    <p>Leave placenta in situ, ligate cord close to insertion, and perform hysterotomy closure with compression sutures.</p> Signup and view all the answers

    The preferred method of anesthesia for elective C-section in cases of antenatally detected placenta accreta spectrum is ___

    <p>general anesthesia</p> Signup and view all the answers

    Match the following procedures or features with their descriptions:

    <p>Pre-op internal iliac artery catheterization = Decreases blood flow to the pelvis Classical C-section = Done to avoid the placental site Serial β-hCG = Monitoring after leaving placenta in situ Emergency hysterectomy = Management for postnatally detected PAS</p> Signup and view all the answers

    What is the main difference between dizygotic and monozygotic twins?

    <p>Dizygotic twins originate from two separate ova, while monozygotic twins come from one ovum.</p> Signup and view all the answers

    Dizygotic twins are also known as identical twins.

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

    What is the incidence rate of monozygotic twins across the world?

    <p>1 in approximately 250</p> Signup and view all the answers

    If the incidence of twins in a country is 1 in 80, then the incidence of triplets is 1 in ______.

    <p>802</p> Signup and view all the answers

    Match the following characteristics with the correct type of twins:

    <p>Same blood group = Monozygotic Twins Different fingerprints = Dizygotic Twins Same sex = Monozygotic Twins Different blood group = Dizygotic Twins</p> Signup and view all the answers

    What type of twins are formed when the zygote divides less than 4 days after fertilization?

    <p>Dichorionic Diamniotic (DCDA)</p> Signup and view all the answers

    Monochorionic twins have a better prognosis than dichorionic twins.

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

    What condition can occur as a complication in Monochorionic Monoamniotic (MCMA) twins?

    <p>Cord entanglement</p> Signup and view all the answers

    The recommended timing for a cesarean section in twin pregnancies is ___ weeks.

    <p>32-34</p> Signup and view all the answers

    Match the types of twins with their characteristics:

    <p>Dichorionic Diamniotic (DCDA) = Two separate chorions and two separate amniotic sacs Monochorionic Diamniotic (MCDA) = One chorion and two amniotic sacs Monochorionic Monoamniotic (MCMA) = One chorion and one amniotic sac Dizygotic twins = Two separate ova fertilized in the same cycle</p> Signup and view all the answers

    What is the number of layers between twins in Monochorionic Diamniotic (MCDA) pregnancies?

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

    Monochorionic Monoamniotic (MCMA) pregnancies have at least 2 mm thickness of membrane separating the twins.

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

    What type of twin pregnancy is characterized by having two chorions and two amnions?

    <p>Dichorionic Diamniotic (DCDA)</p> Signup and view all the answers

    In a Monochorionic Monoamniotic (MCMA) pregnancy, the number of layers between the twins is _____.

    <p>none</p> Signup and view all the answers

    Match the following types of twin pregnancies with their characteristics:

    <p>DCDA = ≥4 layers between twins, ≥2 mm thickness of membrane MCDA = ≥4 layers between twins, no specified membrane thickness MCMA = No layers between twins, no specified membrane thickness</p> Signup and view all the answers

    Study Notes

    Twin Pregnancy: Part 1

    • Dizygotic twins form when two ova are fertilized by two different sperms, forming two separate zygotes.
    • Monozygotic twins form when a single ovum is fertilized by a single sperm, forming a single zygote that divides into two separate zygotes.
    • The incidence of dizygotic twins varies geographically, with the highest incidence in Nigeria (1 in 20) and the lowest in Japan (1 in 200).
    • The incidence of monozygotic twins is relatively uniform throughout the world (1 in approximately 250).
    • Hellin's Rule states that if the incidence of twins in a country is 1 in 80, then the incidence of triplets is 1 in 802 and the incidence of quadruplets is 1 in 803.

    Chorionicity & Amnionicity

    • Dizygotic twins: Always dichorionic and diamniotic (DCDA)
    • Monozygotic twins: Chorionicity and amnionicity depend on the time of division of the zygote.

    Monozygotic Twins: Chorionicity & Amnionicity

    • < 4 days: Dichorionic Diamniotic (DCDA)
    • 4-8 days: Monochorionic Diamniotic (MCDA)
    • 8-12 days: Monochorionic Monoamniotic (MCMA)
    • ≥ 14 days: Conjoined twins (MCMA)

    Types of twins based on chorion and amnion formation:

    • Dichorionic Diamniotic (DCDA): Two separate chorions and two separate amniotic sacs.
    • Monochorionic Diamniotic (MCDA): One chorion and two amniotic sacs.
    • Monochorionic Monoamniotic (MCMA): One chorion and one amniotic sac.

    Complications:

    • Monochorionic Monoamniotic (MCMA): Cord entanglement, Sudden Intrauterine death (IUD) of both twins.
    • Management of MCMA: Corticosteroid for lung maturity, Cesarean section at 32-34 weeks.

    Prognosis:

    • DCDA (Dizygotic twins): Better prognosis.
    • Monozygotic twins: MCDA: Also better prognosis.
    • Monochorionic: Bad prognosis.
    • Dichorionic: Better prognosis.

    Determination of chorionicity:

    • IOC: USG (TVS)
    • Timing: 10 weeks-14 weeks/1st trimester.

    DCDA vs MCDA vs MCMA

    Feature DCDA MCDA MCMA
    No of layers between the twins ≥4 ≥4 -
    Thickness of membrane ≥2 mm
    Placenta 2 Separate Placentas 1 Placenta 1 Placenta

    Conjoined Twins

    • A complication of monoamniotic twins, result from the complete or partial fusion of identical twins.
    • Types:
      • Paraphagus: Joined at lower abdomen & pelvis.
      • Thoracophagus: Joined at thorax.
      • Rachiphagus: Joined at vertebral column.
      • Craniophagus: Joined at the head.

    USG in Twin Pregnancy

    • Significance:
      • Assess gestational age: Earliest 7 weeks, Best 10 weeks.
      • Determine chorionicity.
      • ↑ Nuchal translucency (NT): Suspect twin-to-twin transfusion syndrome.

    Markers of Dichorionicity on USG:

    • ≥ 4 membranes between twins.
    • ≥ 2 mm thickness of membranes.
    • Different sexes on USG.
    • 2 placenta (+).
    • Twin peak sign (+)

    Superfecundation vs Superfetation

    • Superfecundation: Both ova released in the same cycle, fertilized at different times by different acts of coitus.
    • Superfetation: 2 ova released and fertilized in different cycles. Not seen in humans.

    Risk Factors for Twin Pregnancy:

    • Dizygotic Twins:
      • Geographical distribution.
      • Increased maternal age.
      • Increased parity.
      • Maternal family history of twins.
      • IVF.
      • Ovulation induction drugs (Clomiphene citrate, hMG).

    Fetal Membranes

    Type of membrane Outer membrane Inner membrane
    Formation 8 days after fertilization 10 days after fertilization

    Miscellaneous

    • D/D for Bleeding Female ≥28 Weeks:

      • APH:
        • Abruptio placenta
        • Placenta previa
        • Vasa previa
        • Uterine rupture
        • Preterm labor

    • Labour vs Abruptio:

    Feature Labour Abruptio
    Discharge Blood mixed mucus discharge Bleeding
    Cervix Dilation Progressive dilation of cervix -
    FHS Normal Fetal distress

    • ARM in Abruptio:

      • Liquor is dark red in color.
      • Accelerates labor process.
      • Increased bleeding.

    • Abruptio vs Ruptured Uterus:

    Feature Abruptio Ruptured Uterus
    History H/o trauma/PIH H/o previous LSCS
    Presentation Bleeding + Pain in abdomen Bleeding + Pain in abdomen
    P/A
    - Uterus: Tender rigid, Fundal height > POA, Fetal parts are not palpable
    - Uterine contour not felt, Fetal part felt superficially in peritoneal cavity
    P/V Fetal head can be felt Loss of fetal station

    Placenta Accreta Spectrum (PAS)

    • Villi of placenta attaches to/infiltrates the myometrium.
    • Previously known as: Morbidly adherent placenta.

    FIGO CLASSIFICATION OF PAS

    Grades Characteristics
    1 Placenta accreta: villi superficially attached to myometrium
    2 Placenta increta: Villi infiltrate into myometrium
    3 Placenta percreta: Villi attached to serosa
    3a Villi attached to serosa
    3b Villi attached to the bladder
    3c Villi attached to any other pelvic structure

    Etiopathogenesis of PAS

    • 1. Absent decidua basalis/defective decidualization.
      • Nitabuch's layer: Layer of fibrinoid degeneration between trophoblast and decidua basalis. Function: Limits the penetration of trophoblastic villi into decidua. Absence → Deeper penetration of blastocyst.
    • 2. Absent Nitabuch's layer.
    • 3. Hyper-invasiveness of cytotrophoblast.

    Management of Abruptio Placenta

    • Emergency Conditions:

      • Maternal vitals unstable, Fetal distress, DIC, Acute Kidney injury.
      • Action: Immediate C-section.

    • Non-Emergency Conditions (Normal Fetal Heart Sounds):

      • Maternal vitals stable, No DIC.
      • Action: Vaginal delivery.

    • Gestational Age:

      • ≥ 34 weeks: Induction of labor.
      • < 34 weeks: Expectant management.

    Disseminated Intravascular Coagulation (DIC)

    • Aka Consumptive coagulopathy.

    • Obstetric Causes:

      • Abruptio placenta
      • Amniotic fluid embolism
      • Septic abortion
      • Acute fatty liver of pregnancy

    • Management:

      • Cryoprecipitate
      • Fresh frozen plasma (FFP)

    • In abruptio + DIC:

      • Manage DIC
      • C-section.

    • Additional Considerations:

      • Intrauterine death (for ≥ 4 weeks)
      • Rarely in severe Preeclampsia/Eclampsia/HELLP syndrome
      • Blood Transfusion

    Management of Placenta Accreta Spectrum

    • Antenatally Detected PAS:

      • Management of choice: Elective C-section between 34-35 weeks + 6/7 days, followed by hysterectomy (with placenta in-situ).
      • General anesthesia: Preferred.
      • Classical C-section: Done to avoid the placental site.
      • No attempt to separate/deliver the placenta: Uterine incision closed prior to hysterectomy to avoid bleeding.
      • Pre-op ureteric catheterization: Helps in ureteric identification (if bladder invasion present).
      • Pre-op internal iliac artery catheterization: Decreases blood flow to the pelvis, reducing bleeding. Not recommended by ACOG.

    • Postnatally Detected PAS:

      • Clinical features:

        • Intractable postpartum hemorrhage (PPH).
        • Placenta cannot be separated.
        • Hematuria (plus/minus).

      • Management:

        • Emergency hysterectomy.

      • If fertility is desired:

        • Placenta left in situ, with cord ligated close to the placental insertion, followed by hysterotomy incision closure and compression sutures/ tamponade packing to control bleeding.

      • Investigations : Serial ultrasound (USG) and Magnetic Resonance Imaging (MRI).

      • Serial β-hCG: (No role of methotrexate injection).

    • Prognosis: 20% will require hysterectomy ultimately.

    Risk Factors for PAS:

    • 1.Placenta previa (Anterior) in present pregnancy.
      • Previous surgeries:
        • Previous C-section (Risk ↑ with number of C-sections).
        • Myomectomy.
        • Curettage.
        • Endometrial ablation.
    • 2.Previous history of PAS.
    • 3.Risk factors of placenta previa.

    Investigations for PAS

    • Markers (Not routinely done):
      • Maternal serum AFP ≥ 2.5 moM { ↑risk of PAS }
      • Maternal serum hCG ≥ 2.5 moM { ↑risk of PAS }
    • Screening: Anomaly scan (characteristic findings + in T2).
    • Definitive Diagnosis: USG with color Doppler (10c) at 28 weeks.

    Signs of PAS on USG

    • 1.Large placental lacunae/placental lakes (sonolucent areas):

      • Moth-eaten appearance.
      • Color Doppler: Increased vascularity in lacunae.

    • 2.Thinning of retroplacental myometrium: (Distance b/w serosa & myometrium < 1 mm)

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    Description

    Explore the fascinating world of twin pregnancies in this quiz, focusing on the formation, incidence, and classification of dizygotic and monozygotic twins. Learn about the geographical variations in twin occurrences and understand the principles of chorionicity and amnionicity. Test your knowledge about twin pregnancies and their unique characteristics.

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