Dear Dr. Nanavaty , Thank you very much for posting a good case for discussion. Agree with Dr. Nisha Bhargava, Dr. M. A. Parveen , Dr. U. S. Sodha and you. Most of the possible causes are discussed already. Just to add few words : - Spontaneous (unprovoked) preterm labor may result from several causes including 1 ) Infection, 2 ) Inflammation, 3 ) Vascular disease (poor blood supply to the uterus and placenta) , 4 ) An overstretched uterus, and 5 ) Abnormalities of the cervix . 6 ) The cause of many preterm births is never found . Prevention of Preterm Labor :- Bedrest, intramuscular and long term use of oral medications to stop contractions (tocolytics) are not recommended for the prevention of preterm labor in multiple pregnancies because these treatments are either ineffective and/or may cause harm. Cervical cerclage is also not recommended in multiple pregnancies except in specific circumstances. However, vaginal progesterone may be effective in reducing bad outcomes in women with a twin pregnancy and a cervical length of 25 mm or less. Cervical pessaries, small ring-shaped devices which are inserted around the cervix, may also be effective in reducing bad outcomes in women with a twin pregnancy and a cervical length of less than 38mm. If there is enough time the babies could be given corticosteroid to help the lungs mature and reduce other complications of being born prematurely. A shortened cervix is a strong predictor of preterm delivery in twin pregnancies . Lastly, with due respect , I hope you won't mind, perhaps you have forgotten to edit the 3rd picture to prevent disclosure of the identity of the mother. And while delivering the breech, I don't understand why the 1st twin is still there , when cord is separated, without wrap, instead of in the hands of a Neonatologist / Paediatrician. What was the Apgar score of 1st and 2nd twin? Are anyone alive still ?
Preterm delivery is common in twins . Timely cervical encirclage should be done. Uti and gest diabetes to be ruled out. Rest and progesterone help to prevent preterm del.
In twin pregnancy preterm delivery is common.Cervical cerclage after doing TIFFA scan at 18wks nd progesterone support up to 36wks will help in twin pregnancy.Cervical incompetence,uncontrolled hypothyroidism,Gest.diabetes, chorioamnionitis are other causes which can cause for early preterm delivery.If the babies wt is more than 500gms can be saved with good NICU facilities .
Both 500+ wt ,both alive. Mother non DM,non hypothyroidism/hyper,no UTI,oncx length was 4.1,no other complaints except she reported late.
As common causes of preterm r ruled out, then it PROM due to infection , chorioamnitis leading to preterm delivery.
Thanks for sharing mam
USG report If cx less than 2.5 cmcx tighten Tab isoxsuprin start
Thanx for sharing of a v. much informative and interesting case.
Thanks for sharing mam..it's helpful
Thanks mam fr sharing this case
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Friends today I am discussing about Nail Abnormalities. What are nail abnormalities? Healthy nails appear smooth and have consistent coloring. As you age, you may develop vertical ridges, or your nails may be a bit more brittle. This is harmless. Spots due to injury should grow out with the nail. Abnormalities — such as spots, discoloration, and nail separation — can result from injuries to the fingers and hands, viral warts (periungual warts), infections (onychomycosis), and some medications, such as those used for chemotherapy. Certain medical conditions can also change the appearance of your fingernails. However, these changes can be difficult to interpret. Your fingernails’ appearance alone isn’t enough to diagnose a specific illness. A doctor will use this information, along with your other symptoms and a physical exam, to make a diagnosis. Abnormalities of the fingernail Some changes in your nails are due to medical conditions that need attention. 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Sol.; Natrum muriaticum; Sabadilla; Secal cor..; Senecio aureus; Sepia; Silicea; Thuja.; X-ray. Falling off Brassica napus; Butyric acid; Helleborus faetidus; Helleborus Hangnails Lycopodium; Natrum muriaticum; Sulphur; Upas tiente Hypertrophy (onychauxis) Graphites Inflammation of pulp (onychia) Arnica; Calendula; Fluoricum acidum.; Graphites; Phosphorus; Psorinum; Sarsaparilla; Silicea; Upas tiente Inflammation, under toe nails Sabadilla Ingrowing toe nails Causticum; Magnetis polus austral.; Nitricum acidum; Silicea; Staphysagria; Teucrium; Tetrodymite Softening Plumbum met; Thuja Spots, white on Alumina; Nitricum acidum Trophic changes Radium brom Ulceration Alumina; Garphites; Merc. Sol.; Phosphorus; Sanguinaria; Sarsaparilla; Silicea; Teucrium; Tetrodymite Yellow color Conium maculatumDr. Rajesh Gupta5 Likes7 Answers
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Friends today I am discussing about Avery disgusting problem said to be obesity. What is obesity? Obesity is an epidemic condition puts people at a higher risk for serious diseases, such as type 2 diabetes, heart disease, and cancer. Obesity is defined as having a body mass index (BMI) of 30 or more. BMI is a calculation that takes a person’s weight and height into account. However, BMI does have some limitations. According to the CDC, “Factors such as age, sex, ethnicity, and muscle mass can influence the relationship between BMI and body fat. Also, BMI doesn’t distinguish between excess fat, muscle, or bone mass, nor does it provide any indication of the distribution of fat among individuals.” What causes obesity? Eating more calories than you burn in daily activity and exercise (on a long-term basis) causes obesity. Over time, these extra calories add up and cause you to gain weight. 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THE INVESTIGATION AND TREATMENT OF COUPLES WITH RECURRENT PREGNANCY LOSS. Recurrent pregnancy loss /Recurrent reproductive loss is defined as the loss of three or more consecutive pregnancies. RISK FACTORS. 1)GENETIC FACTORS. PARENTAL CHROMOSOMAL REARRANGEMENTS. In 2-5 % of couples with RPL ,one of the partner carries a balanced chromosomal anomaly. most commonly a balanced reciprocal or robertsonian translocation.These couples are at increased risk of Miscarriage. Live birth with multiple congenital malformation. Mental disability due to unbalanced chromosomal arrangement. EMBRYONIC CHROMOSOMAL ABNORMALITIES. In couples with RPL,chromosomal abnormalities of the embryo account for 30 -60 %of further miscarriages. 2)STRUCTURAL UTERINE MALFORMATIONS. SEPTATE UTERUS. UNICORNUATE UTERUS. BICORNUATE UTERUS. Septate uterus ,unicornuate uterus ,bicornuate uterus are associated with spontaneous abortions mostly in the second trimester. CERVICAL INCOMPETANCE :diagnosis is based on history of second trimester miscarriage preceded by spontaneous rupture of membranes or painless cervical dilatation. 3)ENDOCRINE FACTORS. POORLY CONTROLLED DM. THYROID DYSFUNCTION. PCOS Well controlled diabetes and treated thyroid dysfunction do not increase the risk of abortion . Women with diabetes who have high HbA1C levels in the first trimester are associated with miscarriages and malformations. PCOS :Insulin resistance ,hyperinsulinemia and hyperandrogenaemia lead to increased risk of miscarriage in PCOS. An elevated free androgen index appears to be a prognostic factor for a subsequent miscarriage in women with recurrent miscarriage. 4)ANTI PHOSPHOLIPID ANTIBODY SYNDROME APLA is the most important treatable cause of RPL. APLA refers to association between anti phospho lipid antibodies LAC lupus anti coagulant, ACA anti cardiolipin antibodies . Anti -B2 glycoprotein -1 antibodies and adverse pregnancy outcome Three or more consecutive miscarriages <<10 weeks. One or more morphologically normal fetal losses after 10 weeks. One or more preterm births <<<34 weeks owing to placental disease. Mechanisms by which APLA causes RPL are *Inhibition of trophoblastic function and differentiation *Activation of complement pathways at maternal -fetal interface resulting in a local inflammatory response. *Thrombosis of utero placental vasculature. The effect of APLA on trophoblast function and complement activation is reversed by heparin. 5)IMMUNOLOGICAL FACTORS No clear evidence. just hypothetical. Natural killer cells are found in peripheral blood and uterine mucosa.Peripheral blood NK cells are phenotypically and morphologically different from uterine NK ceels (uNK cells ) uNK cells play a role in Trophoblast invasion. Angiogenesis. Important component of local maternal immune response to patjogens. This remains a research field and testing for peripheral blood NK cells or uNK cells SHOULD NOT BE OFFERED routinely in the investigation of RPL. Cytokines are immune molecules that control both immune and other cells.cytokine resposes are generally characterised as T -helper -1 cells (Th-1 ) produces pro inflammatory Cytokines. They are Interleukin 2 . Interferon. Tumour necrosis factor alpha (TNF ) T-helper -2 cells (Th-2 ) produces anti inflammatory cytokines .They are Interleukin 4 Interleukin 6 Interleukin 10. Normal pregnancy is the result of predominantly Th-2 cytokine response. Women with RPL have more of Th -1 cytokine response. Routine cytokine tests are NOT RECOMMENDED. 6)INFECTIONS. Any severe infection that leads to bacteremia or viraemia can cause sporadic miscarriage. The role of infection in RPL is unclear. For an infective agent to cause RPL ,it must be Capable of persistence in the genital tract and avoiding detection. Must cause insufficient symptoms to disturb the women. Toxoplasmosis .cytomegalovirus ,rubella ,herpes and Listeria infections do not fulfill these criteria and ROUTINE TORCH SCREENING SHOULD BE ABANDONED. 7)INHERITED THROMBOPHILIC DEFECTS. Inherited thrombophilias have been implicated as a possible cause of RPL 8)EPIDEMIOLOGICAL FACTORS. Advanced maternal and paternal age are risk factors for RPL. Maternal cigarette smoking and heavy alcohol consumption also increases the risk of miscarriage. INVESTIGATIONS. 1) APLA -to check for LAC and ACA.To diagnose APLA , it is mandatory that the women has TWO POSITIVE TESTS 12 weeks apart for LAC and ACA antibodies of immunoglobulin G and immunoglobulin M with titres >>>40 g/L. 2) CYTOGENETIC ANALYSIS. Cytogenetic analysis should be performed on products of conception. When testing of products of conception reports an unbalanced structural chromosomal abnormality, PARENTAL PERIPHERAL BLOOD KARYOTYPING OF BOTH PARTNERS should be performed in couples with RPL. ROUTINE KARYOTYPING OF COUPLES WITH RPL CANNOT BE JUSTIFIED. SELECTIVE PARENTAL KARYOTYPING MAY BE MORE APPROPRIATE WHEN AN UNBALANCED CHROMOSOMAL ABNORMALITY IS IDENTIFIED IN POC (PRODUCTS OF CONCEPTION ) 3) FOR UTERINE ANOMALIES. Two dimensional ultrasound and HSG are used as initial screening tests. Combined hysteroscopy and laparoscopy and three dimensional ultrasound are used for definitive diagnosis. 4)INHERITED THROMBOPHILIAS. Factor V Leiden , Factor II (prothrombin )gene mutation. Protein S deficiency. TREATMENT OPTIONS. 1) Low dose aspirin and low molecular heparin in APLA. NEITHER CORTICOSTEROIDS OR INTRAVENOUS IMMUNOGLOBULIN THERAPY IMPROVE THE LIVE BIRTH RATE IN WOMEN WITH RPL ASSOCIATED WITH APLA.THEIR USE MAY PROVOKE SIGNIFICANT MATERNAL AND FETAL MORBIDITY. 2)Abnormal parental karyotype.offer Genetic counseling. Pre implantation genetic diagnosis. 3)Transcervical hysteroscopic resection of uterine septum. THERE IS NO CONCLUSIVE EVIDENCE THAT PROPHYLACTIC CERCLAGE REDUCES THE RISK OF PREGNANCY LOSS AND PRETERM DELIVERY IN THOSE WITH CERVICAL FACTORS. In women with RPL and short cervical length <<<2.5 cms on transvaginal ultrasound ,cerclage is beneficial. Transabdominal cerclage is advocated i selected women with Previous failed transvaginal cerclage. Very short and scarred cervix. 5)THERE IS INSUFFICIENT EVIDENCE TO EVALUATE THE EFFECT OF PROGESTERONE SUPPLEMENTATION DURING PREGNANCY IN WOMEN WITH RPL. THERE IS INSUFFICIENT EVIDENCE TO EVALUATE THE EFFECT OF HUMAN CHORIONIC GONADOTROPHIN.Dr. Suvarchala Pratap21 Likes20 Answers