prophylactic encerclage for multiple pregnancy is always debated.in this presentation cerclage for MFG is favored as there was a debate in recently held KSOGA conference at manipal on 3-11-11.
prophylactic encerclage for multiple pregnancy is always debated.in this presentation cerclage for MFG is favored as there was a debate in recently held KSOGA conference at manipal on 3-11-11.
Review “Abortion ” from “William Obstetrics ”
Viriya Lekprasert
Department of Obstetric and Gynaecology , Vichaiyut Hospital , Bangkok , Thailand
" Every pregnant women should know the fact !!. "
Investigations for iufd & sb, how to select?Wafaa Benjamin
Foetal loss is a distressing situation for the lady ,family and medical staff as well.
Investigating the cause of death has many benefits .
Meticulous history taking and clinical assessment is of at most importance.
There are routine standard tests & others arte selective directed by clinical scenarios.
Researches & recording are required to estimate main causes of foetal death at local level, so, investigations could be directed.
In presence of lack of resources, selection of investigations should be prioritized by most relevant and most informative ones.
Post-mortem examination should be re-included at least external examination & placental histopathology.
The incidence of multiple gestation continues to increase, and now accounting for more than 3% of all live births.
Twin pregnancies and higher-order multiple births comprise an increasing proportion of the total pregnancies in the developed world due to the expanded use of fertility treatments and older maternal age at childbirth.
Multiple gestation is associated with:
Increase in neonatal morbidity and mortality rates.
Increase in maternal complications at least two folds.
The number of triplet, quadruplet, and higher-order multiple births peaked in 1998 and has dropped slightly recently, most likely because of limits in the number of embryos transferred and because of the availability and acceptance of multifetal pregnancy reduction (MFPR) procedures.
Prematurity, monochorionicity, and growth restriction pose the main risks to fetuses and neonates in multiple gestations.
The mean duration of pregnancy is 35.3 weeks for twin gestations, 31.9 weeks for triplets, and 29.5 weeks for quadruplets.
Stillbirth rates increase from 6.8 /1000 for singletons to 16.1 for twins and to 21.5 for triplets, and infant mortality rates increase from 5 to 23.4 and to 51.2 /1000 births, respectively.
Infants of multiple gestations comprise almost one quarter of very-low-birth-weight infants.
The incidence of severe handicap among neonatal survivors of multiple gestation is also increased: 34.0 and 57.5 /1000 twin and triplet survivors, respectively, compared with 19.7 /1000 singleton survivors.
Maternal morbidity is significantly increased in mothers with multiple gestations and is apparently related to the number of fetuses.
Multiple gestations are associated with significantly higher risks for:
Hypertension
Placental abruption
Preterm labor (78%)
Preeclampsia (26%);
HELLP syndrome (9%) (hemolysis, elevated liver enzymes, low platelets)
Anemia (24%)
Preterm premature rupture of membranes (pPROM) (24%)
Gestational diabetes (14%)
Acute fatty liver (4%)
Chorioendometritis (16%)
Postpartum hemorrhage (9%)
Twins can be dizygotic (DZ), resulting from the fertilization of two separate ova during a single ovulatory cycle.
DZ twins have dichorionic-diamniotic (DCDA) placentas, although these may fuse during pregnancy.
Monozygotic (MZ), resulting from a single fertilized ovum that subsequently divides into two separate individuals.
In MZ twins, the timing of egg division determines placentation (تكون المشيمة):
Diamniotic, dichorionic (DCDA) placentation occurs with division prior to the morula stage (within 3 days post fertilization).
Diamniotic, monochorionic (MCDA) placentation occurs with division between 4-8 days postfertilization.
Monoamniotic, monochorionic (MCMA) placentation occurs with division between 8-12 days postfertilization.
Division at or after day 13 results in conjoined twins.
Review “Abortion ” from “William Obstetrics ”
Viriya Lekprasert
Department of Obstetric and Gynaecology , Vichaiyut Hospital , Bangkok , Thailand
" Every pregnant women should know the fact !!. "
Investigations for iufd & sb, how to select?Wafaa Benjamin
Foetal loss is a distressing situation for the lady ,family and medical staff as well.
Investigating the cause of death has many benefits .
Meticulous history taking and clinical assessment is of at most importance.
There are routine standard tests & others arte selective directed by clinical scenarios.
Researches & recording are required to estimate main causes of foetal death at local level, so, investigations could be directed.
In presence of lack of resources, selection of investigations should be prioritized by most relevant and most informative ones.
Post-mortem examination should be re-included at least external examination & placental histopathology.
The incidence of multiple gestation continues to increase, and now accounting for more than 3% of all live births.
Twin pregnancies and higher-order multiple births comprise an increasing proportion of the total pregnancies in the developed world due to the expanded use of fertility treatments and older maternal age at childbirth.
Multiple gestation is associated with:
Increase in neonatal morbidity and mortality rates.
Increase in maternal complications at least two folds.
The number of triplet, quadruplet, and higher-order multiple births peaked in 1998 and has dropped slightly recently, most likely because of limits in the number of embryos transferred and because of the availability and acceptance of multifetal pregnancy reduction (MFPR) procedures.
Prematurity, monochorionicity, and growth restriction pose the main risks to fetuses and neonates in multiple gestations.
The mean duration of pregnancy is 35.3 weeks for twin gestations, 31.9 weeks for triplets, and 29.5 weeks for quadruplets.
Stillbirth rates increase from 6.8 /1000 for singletons to 16.1 for twins and to 21.5 for triplets, and infant mortality rates increase from 5 to 23.4 and to 51.2 /1000 births, respectively.
Infants of multiple gestations comprise almost one quarter of very-low-birth-weight infants.
The incidence of severe handicap among neonatal survivors of multiple gestation is also increased: 34.0 and 57.5 /1000 twin and triplet survivors, respectively, compared with 19.7 /1000 singleton survivors.
Maternal morbidity is significantly increased in mothers with multiple gestations and is apparently related to the number of fetuses.
Multiple gestations are associated with significantly higher risks for:
Hypertension
Placental abruption
Preterm labor (78%)
Preeclampsia (26%);
HELLP syndrome (9%) (hemolysis, elevated liver enzymes, low platelets)
Anemia (24%)
Preterm premature rupture of membranes (pPROM) (24%)
Gestational diabetes (14%)
Acute fatty liver (4%)
Chorioendometritis (16%)
Postpartum hemorrhage (9%)
Twins can be dizygotic (DZ), resulting from the fertilization of two separate ova during a single ovulatory cycle.
DZ twins have dichorionic-diamniotic (DCDA) placentas, although these may fuse during pregnancy.
Monozygotic (MZ), resulting from a single fertilized ovum that subsequently divides into two separate individuals.
In MZ twins, the timing of egg division determines placentation (تكون المشيمة):
Diamniotic, dichorionic (DCDA) placentation occurs with division prior to the morula stage (within 3 days post fertilization).
Diamniotic, monochorionic (MCDA) placentation occurs with division between 4-8 days postfertilization.
Monoamniotic, monochorionic (MCMA) placentation occurs with division between 8-12 days postfertilization.
Division at or after day 13 results in conjoined twins.
Preterm labor is defined as the onset of labor before 37 weeks of gestation. It is a leading cause of neonatal morbidity and mortality, and can lead to long-term health problems for the baby. Risk factors for preterm labor include a history of preterm labor or delivery, multiple gestations, cervical incompetence, uterine anomalies, and infections.
Symptoms of preterm labor can include regular contractions, pelvic pressure or pain, backache, vaginal bleeding or discharge, and a change in vaginal discharge. If preterm labor is suspected, immediate medical attention is required. Treatment may include medications to stop or slow down labor, steroid injections to help speed up fetal lung development, and bed rest.
Prevention of preterm labor can be achieved through good prenatal care, including regular prenatal visits, proper nutrition, and management of underlying medical conditions. Avoiding certain risk factors, such as smoking and substance abuse, can also help reduce the risk of preterm labor.
In cases where preterm labor cannot be prevented, the goal is to delay delivery as long as possible to give the baby the best chance of survival and good health. This may involve hospitalization for bed rest, medication, and close monitoring of the mother and baby.
Preterm labor is a serious and potentially life-threatening complication of pregnancy, but with appropriate management and early intervention, the risk of morbidity and mortality can be minimized.
A multifetal pregnancy is a pregnancy in which there are two or more fetuses in the uterus at the same time. This can include twin pregnancies, triplet pregnancies, and higher-order multiple pregnancies.
The most common type of multifetal pregnancy is twin pregnancy, which can be either fraternal (dizygotic) twins, which are formed from two separate eggs fertilized by two separate sperm, or identical (monozygotic) twins, which are formed when a single fertilized egg splits and develops into two separate embryos.
Risk factors for multifetal pregnancy include:
Advanced maternal age
Assisted reproductive technologies (ART) such as in vitro fertilization (IVF)
A family history of twin pregnancies
Use of ovulation-inducing drugs
The management of multifetal pregnancies can be challenging and requires close monitoring and specialized care. It can include ultrasound monitoring to assess the growth and well-being of each fetus, and to detect any potential complications such as twin-to-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR).
Due to the increased risk of complications, multifetal pregnancies are at a higher risk of preterm labor, cesarean delivery, and perinatal morbidity and mortality.
It's important to note that multifetal pregnancies should be managed by a team of specialists such as obstetricians, perinatologists, and pediatricians with experience in the care of multifetal pregnancies.
Similar to mode of delivery in multiple gestation (20)
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. MODE OF DELIVERY IN
MONOCHRONIC TWIN
PREGNANCY
MARYAM MAJID AL-EZAIREJ
MEDICAL INTERN
OB/GYN DEPARTMENT
2.
3. Outcome of monochorionic twin
pregnancy
What is the outcome of monochorionic compared with
dichorionic twin pregnancies ?
Clinicians and women should be aware that monochronic
twin pregnancies have higher fetal loss rates than
dichorionic twin pregnancies, mainly due to second
trimester loss and, overall, may have a higher risk of
associated neurodevelopmental morbidity. This should
form part of the parental counselling
4. MATERNAL COMPLICATION
Antepartum-
Preterm labor , GDM, PIH, Abruptio placentae
Placenta previa
Intrapartum-
Fetal distress, malpresentations, increased incidence of
Caesarean
Post partum-
PPH, Post partum depression
5. FETAL COMPLICATION: MC
Amniotic fluid discordance
Growth discordance ( > 20%)
Unequal placental sharing
Selective intrauterine growth restriction (S-IUGR)
in one fetus
Twin to twin transfusion syndrome (TTTS)
Twin anaemia polycyathemia sequence (TAPS)
Twin reverse arterial perfusion (TRAP)
Anomalies in one fetus
Intrauterine fetal death
Congenital anomaly
Nearly 100% of monochorionic twin placentas have vascular anastomoses but there are marked
variations in the number ,size, and direction
6. TWIN-TWIN TRANSFUSION SYNDROME
Incidence : 4 - 20% of MC twins
o It is characterised by an imbalance
of blood flow between the twins
15 - 20% of perinatal deaths in
twins
Untreated, perinatal loss rates in
the mid trimester approach 80 -
100%
7. TWIN-TWIN TRANSFUSION SYNDROME
TTTS should be managed in conjunction with fetal medicine centres
TTTS presenting before 26 weeks of gestation should be treated by fetoscopic
laser ablation rather than amnioreduction or septostomy.
TOD:
Delivery of monochorionic twin pregnancies previously complicated by TTTS
and treated should be between 34+0and 36+6 weeks of gestation.
8.
9. SELECTIVE IUGR
sIUGR at 18-26 weeks were
classified as:
Type I (UA Doppler with positive
diastolic flow
Type II (persistent absent or
reversed end-diastolic flow
Type III (intermittent absent or
reversed end-diastolic flow
10. MODE OF DELIVERY
sGR in monochorionic twins requires evaluation in a fetal medicine centre
with expertise in the management of such pregnancies.
In type I sGR, planned delivery should be considered by 34–36 weeks of
gestation if there is satisfactory fetal growth velocity and normal umbilical
artery Doppler waveforms.
In type II and III sGR, delivery should be planned by 32 weeks of gestation,
unless fetal growth velocity is significantly abnormal or there is worsening of
the fetal Doppler assessment.
11. monochorionic twin pregnancies
complicated by single twin demise
After a single fetal death in a monochorionic pregnancy, clinicians should be
aware that the risks to the surviving twin of death or neurological abnormality
are of the order of 15% and 26%,respectively.
Single fetal death in a monochorionic pregnancy should be referred and
assessed in a fetal medicine centre, with multidisciplinary expertise to
manage these cases
Rapid delivery is usually unwise, unless at term
12. UNCOMPLICATED MONOCHORIONIC
PREGNANCIES
For uncomplicated monochorionic pregnancies there may be a higher risk of
unexplained fetal demise despite intensive fetal surveillance
Women with monochorionic twins should have timing of birth discussed and
be offered elective delivery from 36+0weeks with the administration of
antenatal steroids, unless there is an indication to deliver earlier.
It is appropriate to aim for vaginal birth of monochorionic diamniotic twins
unless there are other specific clinical indications for caesarean section.
13. UNCOMPLICATED MONOCHORIONIC
PREGNANCIES
planned caesarean section delivery did not significantly decrease (or increase)
the risks of fetal or neonatal death, or serious newborn morbidity as
compared with vaginal delivery
As with all pregnancies, parental views will also be important in reaching a
conclusion about the best, individualized method of monochorionic twin
delivery, including opting for caesarean section.
In addition to the complexities of twin delivery (i.e. malpresentation) there is
a small risk of acute feto–fetal transfusional events during labour and this is
one of the reasons why continuous electronic fetal monitoring during labour is
recommended
14. MCMA
MCMA twins have a high risk of fetal death and should be delivered by
caesarean section between 32+0 - 34+0 weeks
Related complication:
Cord entanglement
Cord accidents
Stuck twin during delivery
16. References
Management of Monochorionic Twin
Pregnancy, Green-top Guideline
No. 51, November 2016, RCOG, UK
A classification system for
selective intrauterine growth
restriction in monochorionic
pregnancies according to
umbilical artery Doppler flow in
the smaller twin,
https://www.ncbi.nlm.nih.gov/pub
med/17542039
Beckmann’s Obstetrics and
Gynecology-7th Edition
