Iranian Council for graduate Medical Education. Board and pre-board Exam questions for obs and Gyn. 2001-2006



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Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006

  • Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006

  • Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India 2002

  • Pritchard JA, MacDonald PC, Gant NF. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005.

  • Tan T and Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142

  • emedicine e-journal:

  • Butler J. postterm delivery. emedicine. June 19. 2006

  • Gaufberg S. Abruptio placenta. emedicine. Aug 29. 2006

  • Gibson P. HTN in Pregnancy. emedicine. DEC 13 2007

  • Hernandez E . GTN. emedicine. Jan 26, 2007

  • Marinnan G. Placenta Previa. emedicine. Aug 26. 2005

  • Ross M. preterm. emedicine. 31 may 2007

  • Pictures and material of multiple pregnancy are adapted with permission from:

  • Zach T. multiple pregnancy.emedicine. Oct 2. 2007





Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies.

  • Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies.

  • HTN is classified into 4 categories

  • 1) chronic hypertension,

  • 2) preeclampsia-eclampsia,

  • 3) preeclampsia superimposed on chronic hypertension

  • 4) gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy).



blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. It persists after 12 wks postpartum.

  • blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. It persists after 12 wks postpartum.



New-onset or worsening hypertension after 20 weeks' gestation should lead to a careful evaluation for manifestations of preeclampsia.

    • New-onset or worsening hypertension after 20 weeks' gestation should lead to a careful evaluation for manifestations of preeclampsia.
    • The diagnosis of severe hypertension or preeclampsia in the first or early second trimester necessitates exclusion of GTD and/or molar pregnancy.




    • Multiple gestations
    • Hydrops fetalis
    • Gestational trophoblastic disease
    • Triploidy


    • Blood pressure should be measured in the sitting position, with the cuff at the level of the heart.
    • Women should be allowed to sit quietly for 5-10 minutes before each blood pressure measurement.
    • Korotkoff sounds I (the first sound) and V (the disappearance of sound) should be used to denote the systolic blood pressure (SBP) and DBP, respectively.




Platelet counts less than 100,000/µL suggest preeclampsia or ITP.

      • Platelet counts less than 100,000/µL suggest preeclampsia or ITP.
      • Hemoglobin levels greater than 13 g/dL suggest hemoconcentration.
      • Low Hbg levels may be due to microangiopathic hemolysis or iron deficiency.


    • Trace levels to +1 proteinuria are acceptable, but levels of +2 or greater are abnormal and should be quantified with a 24-hour urine collection or spot urine protein:creatinine ratio.
    • In a 24-hour urine collection, the reference range for protein excretion in pregnancy is up to 300 mg/d.


Creatinine clearance increases approximately 50% during pregnancy, and levels less than 100 mL/min suggest renal dysfunction that is either chronic or due to preeclampsia.

  • Creatinine clearance increases approximately 50% during pregnancy, and levels less than 100 mL/min suggest renal dysfunction that is either chronic or due to preeclampsia.

    • protein:Cr ratios appear to be more accurate than urinalysis, although an abnormal result should still be confirmed with a 24-hour urine collection.


LDH,

    • LDH,
    • bilirubin,
    • haptoglobin,
    • fibrinogen,
    • D-dimers
    • If:
    • PT/INR/aPTT results are abnormal,
    • thrombocytopenia is present,
    • the hemoglobin level is dropping


Alternate a biophysical profile with a fetal NST twice each week.

    • Alternate a biophysical profile with a fetal NST twice each week.
    • Ask for Serial fetal ultrasound starting at 18 weeks.






Seizures

    • Seizures
    • Cerebral hemorrhage
    • Pulmonary edema
    • Acute renal failure
    • DIC
    • HELLP syndrome
    • Hepatic infarction/rupture and subcapsular hematoma


General: condition/position/diet =low salt,high prot

  • General: condition/position/diet =low salt,high prot

  • Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr, PT,PTT,Fib, ALT,AST,Al P, Bil (T, D)

  • reserve of 2 units of PC

  • IV :Ringer at heparin lock

  • OTHER: Control of vital sign q4hrs, control of FHR, FAD chart , NST, sono OB, daily weight inform if BP>160/110, blurred vision, head ache, epigastric pain, seizure



General: condition/position/diet =NPO

  • General: condition/position/diet =NPO

  • Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D)

  • prep 2 units of PC

  • IV :Ringer 1000cc +10 u of oxytocin

  • if BP>160/110,blurred vision, head ache, epigastric pain, seizure then amp hydralazine 5 mg iv prn

  • MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im in each buttock then 5 gr im q4h

  • If platelet is below 100000 then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR, DTR, prep CPR set with 2 gr 20% MgSO4 ready) +Amp Dexa 6 mg bid for 4 doses

  • OTHER: Control of vital sign q15 min , control of FHR, fix foley,





Preterm labor is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk).

  • Preterm labor is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk).

  • It is the leading cause of neonatal mortality.



decidual hemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios),

  • decidual hemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios),

  • cervical incompetence (eg, trauma, cone biopsy),

  • uterine distortion (eg, müllerian duct abnormalities, fibroid uterus),

  • cervical inflammation (bacterial vaginosis [BV], trichomonas),

  • maternal inflammation/fever (eg, urinary tract infection),

  • hormonal changes (eg, mediated by maternal or fetal stress),

  • Uteroplacental insufficiency (eg, hypertension, insulin-dependent diabetes, drug abuse, smoking, alcohol).



Demographic factors for preterm labor include nonwhite race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low prepregnancy weight.

  • Demographic factors for preterm labor include nonwhite race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low prepregnancy weight.

  • Preterm labor and birth can be associated with stressful life situations (eg, domestic violence; close family death; insecurity over food, home, or partner; work and home environment)

  • Previous preterm delivery



home uterine activity monitoring (HUAM)

  • home uterine activity monitoring (HUAM)

  • salivary estriol : DHEA increases before the onset of labor. This results in an increase of maternal estriol.

  • FFN is a basement membrane protein that helps bind placental membranes to the decidua. FFN has a predictive value in identifying patients who will or will not deliver within the subsequent 1-2 weeks.

  • A short cervical length in the early or late second trimester has been associated with a markedly increased risk of preterm labor and delivery.



1-Fetal growth restriction 2-Oligohydramnios 3-Nonreactive NST,Positive CST 4-Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow 5-Repetitive severe variable decelerations 6-Significant vaginal bleeding consistent with abruption.

  • 1-Fetal growth restriction 2-Oligohydramnios 3-Nonreactive NST,Positive CST 4-Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow 5-Repetitive severe variable decelerations 6-Significant vaginal bleeding consistent with abruption.



A temperature greater than 38.0°C (100.0°F) and 2 of the 5 following signs:

  • A temperature greater than 38.0°C (100.0°F) and 2 of the 5 following signs:

  • 1-WBC > 15,000 cells/mm3 2-Maternal HR> 100 (bpm)

  • 3- Fetal HR> 160 bpm 4-Tender uterus 5-Foul-smelling discharge



General: condition/position/diet=NPO

  • General: condition/position/diet=NPO

  • Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr

  • IV : 1000cc Ringer +10 units of oxytocin start at

  • 2 drops /min, add 2 drops every 15 min if FHR and contractions are normal

    • Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then 60 mg TDS
    • AMP clindamycin 900 mg iv TDS for allergic women to penicillin(continue antibiotics after delivery until the mother is a febrile
  • OTHER: Control of vital sign hourly





General: condition/position/diet

  • General: condition/position/diet

  • Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC

  • IV :

  • 1-1000cc Ringer free

  • 2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure)

  • 3-Amp pethidine 25 mg iv 25 mg im

  • 4-Amp ampicillin 2 gr IV qid

  • 5-Amp erythromicin 400 mg QID

  • 6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below 34 wks

  • OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS or FHR



Maternal

  • Maternal

  • cardiac disease

  • Diabetes

  • Thyrotoxicosis

  • HTN



Hypocalcemia

  • Hypocalcemia

  • Myasthenia gravis

  • Renal failure



50-100 mcg/min increase by 50 mcg/min every 10 min

  • 50-100 mcg/min increase by 50 mcg/min every 10 min

  • max dose:350mcg/min

  • If labor is arrested continue the infusion for at least 12 hrs

  • SC:

  • 250 mcg q3-4 hrs



Twin=36 wks

  • Twin=36 wks

  • Triplets=33.5 wks

  • Quadruplets=31 wks





Postterm pregnancies define pregnancies extending up to or after 42 weeks.

  • Postterm pregnancies define pregnancies extending up to or after 42 weeks.

  • The reported frequency is 3-12%.



The most frequent cause of postterm pregnancy is inaccurate dating criteria

  • The most frequent cause of postterm pregnancy is inaccurate dating criteria

  • primiparity,

  • prior postterm pregnancy,

  • male gender of the fetus,

  • genetic factors



Macrosomia complications like shoulder dystocia,

  • Macrosomia complications like shoulder dystocia,

  • CPD and Maternal risks like an increase in labor dystocia, perineal injuries, and cesarean deliveries.

  • dysmaturity syndrome: affects 20% of postterm fetuses and is thought to be caused by chronic uteroplacental insufficiency resulting in oligohydramnios, meconium aspiration, and reversible neonatal complications.



NST and AFI 2 times per week for pregnancies continuing past 41 weeks.

  • NST and AFI 2 times per week for pregnancies continuing past 41 weeks.





Intrauterine growth restriction (IUGR) occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The fetus is affected by a pathologic restriction in its ability to grow.

  • Intrauterine growth restriction (IUGR) occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The fetus is affected by a pathologic restriction in its ability to grow.





Idiopathic- In a majority of cases (40%)

  • Idiopathic- In a majority of cases (40%)



Has had a previous baby with IUGR

  • Has had a previous baby with IUGR

  • Extremes of age

  • Small mothers (Ht & Wt)

  • poor weight gain and malnutrition during preg.

  • socially deprived

  • Substance abuse (like tobacco,narcotics, alcohol)

  • low total blood volume during early pregnancy



Multiple pregnancy

  • Multiple pregnancy

  • Living in High altitude locations

  • Drugs like anticoagulants, anticonvulsants

  • Cardio-vascular disease:preeclampsia, HTN, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions

  • Chronic kidney disease

  • Chronic infection- UTI, Malaria, TB, genital infections

  • Antibody abnormality like antiphospholipid antibody syndrome, SLE



Intrauterine infection:German measles (rubella), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19.

  • Intrauterine infection:German measles (rubella), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19.

  • Birth defect (cardiovascular, renal, anencephally, limb defect, etc).

  • Chromosome defect(trisomy-18 (Edwards’ syndrome),21(Down’s syndrome), 16, 13, xo (turner’s syndrome.)

  • Primary disorder of bone or cartilage.

  • Chronic lack of oxygen during development (hypoxia).

  • Developed outside of the uterus.

  • Placenta or umbilical cord defects.



Uteroplacental insufficiency:

  • Uteroplacental insufficiency:

    • Improper / inadequate trophoblastic invasion and placentation in the first trimester.
    • Lateral insertion of placenta.
    • Reduced maternal blood flow to the placental bed.
  • Fetoplacetal insufficiency due to:

    • Vascular anomalies of placenta and cord
    • Decreased placental functioning mass:
      • Small placenta, abruptio placenta, placenta previa, post term pregnancy.


US fetal biometry: HC- BPD- AC

  • US fetal biometry: HC- BPD- AC

  • Uterine Doppler studies (Doppler Velocimetry): bilateral notches and a mean resistance index of at least 0.55

  • Or

  • Unilateral notches and a mean resistance index of at least 0.65 at 20 weeks.

  • Biochemistry: CRH level at 33 weeks



Low ponderal index (Wt./Fl).

  • Low ponderal index (Wt./Fl).

  • Decreased subcutaneous fat.

  • Presence / appearance of –

    • Hypoglycemia,
    • Hyperbilirubinemia,
    • Necrotizing enterocolitis,
    • Hyper viscosity syndrome


Strong evidence of benefit only for the following interventions:

  • Strong evidence of benefit only for the following interventions:

    • balanced protein/energy supplementation,
    • strategies to reduce maternal smoking,
    • antibiotic administration to prevent urinary tract infections
    • antimalarial prophylaxis.






Bed rest

  • Bed rest

  • Aspirin before 20 wk GA

  • Nutritional supplementation: zinc , fish oil, hormones

  • Oxygen therapy.



Corticosteroids with a delay in delivery for 2.4 days

  • Corticosteroids with a delay in delivery for 2.4 days

  • Mode of delivery depends on the bishop score and IUGR severity

  • For dichorionic twins : injection of KCl into the heart of the weaker fetus ( in most cases management is expectant)

  • For monochorionic twins photocoagulation of anastomoses or diathermy in cases of TTTS and AAA





Fetal Death

  • Fetal Death

  • low blood sugar

  • low body temperature

  • abnormal development of the nervous system

  • Adulthood aftermath :

  • CAD

  • HTN

  • Diabetes II

  • Dyslipidemia

  • Stroke

  • Depression

  • Suicide attempts





Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation.

  • Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation.

  • Abruptio placentae occurs in about 1% of all pregnancies.



Vaginal bleeding - 80%

    • Vaginal bleeding - 80%
    • Abdominal or back pain and uterine tenderness - 70%
    • Fetal distress - 60%
    • Abnormal uterine contractions (eg, hypertonic, high frequency) - 35%
    • Idiopathic premature labor - 25%
    • Fetal death - 15%


extent of separation (ie, partial vs complete)

  • extent of separation (ie, partial vs complete)

  • location of separation (ie, marginal vs central)

  • Clinical





Maternal HTN(44% of all cases)

  • Maternal HTN(44% of all cases)

  • Maternal trauma

  • Cigarette smoking

  • Alcohol consumption

  • Cocaine use

  • Advanced maternal age



Short umbilical cord

  • Short umbilical cord

  • Sudden decompression of the uterus (eg, PROM, delivery of first twin)

  • Retroplacental fibromyoma

  • postamniocentesis

  • Idiopathic (probable abnormalities of uterine blood vessels and decidua)



Ultrasonography is not very useful in diagnosing placental abruption.

  • Ultrasonography is not very useful in diagnosing placental abruption.

    • Retroplacental hematoma may be recognized in 2-25% of all abruptions.
    • Recognition of retroplacental hematoma depends on the degree of hematoma and on the operator's skill level.


Condition/position/diet:NPO

  • Condition/position/diet:NPO

  • Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer-

  • Prep 4 units of crossmatched packed red blood cells

  • Prep 5 units of platelets, prep 10 units of FFP

  • Continuous high-flow supplemental oxygen

  • One or 2 large-bore IV lines with normal saline (NS) or lactated Ringer (LR) solution+10 units of oxytocin in 1 lit of ringer start at 2 drops/min add 2 drops every 15 min if fetal heart rate and uterine contractions are favorable.

  • perform amniotomy

  • Closely observe the patient. Monitor vital signs and urine output, fetal heart rate and uterine height measurement.

  • Prepare OR for emergent C/S





(1) complete or total: the placenta covers 360° of the internal cervical os;

  • (1) complete or total: the placenta covers 360° of the internal cervical os;

  • (2) incomplete or partial: 0°-360° of the internal cervical os is covered by placental tissue;

  • (3) marginal: the placental tissue does not cover the internal cervical os;

  • (4) low lying: the edge of the placenta lies abnormally close to but does not abut the internal cervical os.



  • prior placenta previa,

  • prior cesarean delivery,

  • increased maternal age,

  • large placentae (eg, multiple gestations or erythroblastosis),

  • maternal history of smoking.



1 in 200 deliveries

  • 1 in 200 deliveries



painless vaginal bleeding during the second half of pregnancy (70%).

  • painless vaginal bleeding during the second half of pregnancy (70%).

  • It can occur without an inciting cause, although pelvic examination, intercourse, or labor may provoke it.

  • The average gestational age at presentation is 32 weeks.

  • Hemorrhage recurs, and, in nearly all cases, it is more severe the second time.



Patients are treated expectantly, with:

  • Patients are treated expectantly, with:

  • volume replacement,

  • transfusions,

  • tocolytics,

  • emergent cesarean delivery

  • Without endangering the life of the mother, all attempts are made to delay delivery until the fetal lungs mature.



Physical examination should be performed only with a fetus that has achieved pulmonary maturity and only in a fully staffed operating room.

  • Physical examination should be performed only with a fetus that has achieved pulmonary maturity and only in a fully staffed operating room.



TA sonography is the test of choice to confirm placenta previa.

  • TA sonography is the test of choice to confirm placenta previa.

  • When the internal cervical os cannot be visualized or when the results are inconclusive, transperineal or transvaginal sonography is recommended as an adjunct.

  • No increased risk of hemorrhage has been associated with transvaginal or transperineal sonography in this clinical setting.









Pictures and material of multiple pregnancy are adapted from:

  • Pictures and material of multiple pregnancy are adapted from:

  • Zach T. multiple pregnancy. emedicine. Oct 2. 2007

  • with permission



Dizygotic twins(fraternal) are produced when 2 sperm fertilize 2 ova. Separate amnions, chorions, and placentas are formed in dizygotic twins. The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth.

  • Dizygotic twins(fraternal) are produced when 2 sperm fertilize 2 ova. Separate amnions, chorions, and placentas are formed in dizygotic twins. The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth.

  • Monozygotic twins (Identical)develop when a single fertilized ovum splits during the first 2 weeks after conception. An early splitting (ie, within the first 2 d after fertilization-30%) of monozygotic twins produces separate chorions and amnions. These dichorionic twins have different placentas that can be separate or fused.





Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation .

  • Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation .

  • Approximately 70% of monozygotic twins are monochorionic/diamniotic.





If splitting occurs even later (ie, during 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs .

  • If splitting occurs even later (ie, during 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs .

  • Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of placentation.





Monochorionic/monoamniotic twins have a common placenta with vascular communications between the 2 circulations.

  • Monochorionic/monoamniotic twins have a common placenta with vascular communications between the 2 circulations.



Trizygotic triplets occur when 3 sperm fertilize 3 ova.

  • Trizygotic triplets occur when 3 sperm fertilize 3 ova.

  • Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from a different zygote.

  • Finally, 2 consecutive zygotic splittings with one split results in a vanished fetus and monozygotic triplets.



The birth rate of monozygotic twins is constant worldwide (approximately 4 per 1000 births).

  • The birth rate of monozygotic twins is constant worldwide (approximately 4 per 1000 births).

  • Birth rates of dizygotic twins vary by race. (Highest in Africans and lowerest in Asians)



low birth weight infants( due to prematurity and (IUGR)

  • low birth weight infants( due to prematurity and (IUGR)

  • congenital anomalies,

  • placenta previa, abruptio placenta,

  • preeclampsia,

  • cord accidents,

  • malpresentations,

  • asphyxia/perinatal depression,

  • group B streptococcal (GBS) infections,

  • hyaline membrane disease (HMD),

  • TTTS.



excessive weight gain,

  • excessive weight gain,

  • hyperemesis gravidarum,

  • sensation of more than one moving fetus

  • use of ovulation-inducing drugs

  • family history of dizygotic twins



CBC count: In TTTS, the donor twin is frequently anemic at birth. The recipient twin is polycythemic at birth.

  • CBC count: In TTTS, the donor twin is frequently anemic at birth. The recipient twin is polycythemic at birth.

  • Calcium level: Hypocalcemia is common in premature infants, especially the donor twin in TTTS.

  • Glucose level: Hypoglycemia is common in premature infants, especially if TTTS is present.

  • Bilirubin level: Hyperbilirubinemia due to TTTS may develop in polycythemic infants.



Twin reversed arterial perfusion (TRAP) sequence occurs when an acardiac twin receives all of the blood supply from the normal "pump" twin. This only occurs in monochorionic twins.

  • Twin reversed arterial perfusion (TRAP) sequence occurs when an acardiac twin receives all of the blood supply from the normal "pump" twin. This only occurs in monochorionic twins.



Occurs in monochorionic/monoamniotic or monochorionic/diamniotic twins. Vascular anastomoses in the monochorionic placenta result in transfusion of blood from one twin (ie, donor) to the other twin (ie, recipient). Polyhydramnios develops in the sac of the recipient twin and oligohydramnios develops in the sac of the donor twin.

  • Occurs in monochorionic/monoamniotic or monochorionic/diamniotic twins. Vascular anastomoses in the monochorionic placenta result in transfusion of blood from one twin (ie, donor) to the other twin (ie, recipient). Polyhydramnios develops in the sac of the recipient twin and oligohydramnios develops in the sac of the donor twin.



Incomplete late division of monozygotic twins produces conjoined twins.

    • Incomplete late division of monozygotic twins produces conjoined twins.
    • Classification:
      • Thoracopagus - Joined at chest (40%)
      • Xiphopagus/omphalopagus - Joined at abdomen (34%)
      • Pygopagus - Joined at buttocks (18%) 
      • Ischiopagus - Joined at ischium (6%) 
      • Craniopagus - Joined at head (2%)


. Birth weight discrepancies of more than 20-25% are considered discordant. Discordant birth weights occur in 10% of twins.

  • . Birth weight discrepancies of more than 20-25% are considered discordant. Discordant birth weights occur in 10% of twins.





hydatidiform mole : is the most common form of gestational trophoblastic neoplasia it can behave in a malignant or benign fashion,

  • hydatidiform mole : is the most common form of gestational trophoblastic neoplasia it can behave in a malignant or benign fashion,

  • invasive mole (chorioadenoma destruens),

  • choriocarcinoma,

  • and placental site trophoblastic tumor (PSTT).



In 80% of patients with a benign hydatidiform mole, serum HCG titers steadily drop to normal within 8-12 weeks after evacuation of the molar pregnancy.

  • In 80% of patients with a benign hydatidiform mole, serum HCG titers steadily drop to normal within 8-12 weeks after evacuation of the molar pregnancy.

  • In the other 20% of patients with a malignant hydatidiform mole, serum HCG titers either rise or plateau.



Stage I – Confined to the uterus

  • Stage I – Confined to the uterus

  • Stage II – Limited to the genital structures

  • Stage III – Lung metastases

  • Stage IV – Other metastases



Age 40 years or older = 1 point

  • Age 40 years or older = 1 point

  • Antecedent pregnancy terminated in abortion = 1 point

  • Antecedent full-term pregnancy = 2 points

  • Interval of 4 months to less than 7 months between antecedent pregnancy and start of chemotherapy = 1 point

  • Interval of 7-12 months between antecedent pregnancy and start of chemotherapy = 2 points

  • Interval of more than 12 months between antecedent pregnancy and start of chemotherapy = 4 points



Beta-HCG level in serum is 1000 mIU/mL but less than 10,000 mIU/mL = 1 point

  • Beta-HCG level in serum is 1000 mIU/mL but less than 10,000 mIU/mL = 1 point

  • Beta-HCG level in serum is 10,000 mIU/mL but less than 100,000 mIU/mL = 2 points

  • Beta-HCG level in serum is 100,000 mIU/mL or greater = 4 points

  • Largest tumor is 3 cm but less than 5 cm = 1 point

  • Largest tumor is 5 cm or greater = 2 points

  • Site of metastases is spleen or kidney = 1 point



Site of metastases is gastrointestinal tract = 2 points

  • Site of metastases is gastrointestinal tract = 2 points

  • Site of metastases is brain or liver = 4 points

  • Number of metastases is 1-4 = 1 point

  • Number of metastases is 5-8 = 2 points

  • Number of metastases is more than 8 = 4 points

  • Prior chemotherapy with single drug = 2 points

  • Prior chemotherapy with multiple drugs = 4 points



Patients with a hydatidiform mole present with signs and symptoms of pregnancy.

  • Patients with a hydatidiform mole present with signs and symptoms of pregnancy.

    • The most frequent symptom of gestational trophoblastic neoplasia (GTN) is abnormal uterine bleeding.
    • Patients have a history of amenorrhea. Occasionally, the typical hydatid vesicles (edematous villi) are passed through the vagina.


Prolonged hyperemesis gravidarum

  • Prolonged hyperemesis gravidarum

  • preeclampsia

  • Hyperthyroidism

  • signs and symptoms associated with the metastatic disease, such as hematuria, hemoptysis, abdominal pain, and neurologic symptoms



a positive pregnancy test result occurs in the absence of a fetus.

  • a positive pregnancy test result occurs in the absence of a fetus.

  • vesicles in the vagina is diagnostic

  • Enlarged ovaries secondary to theca lutein cysts are found in up to 20% of cases.

    • The cysts regress after evacuation of the hydatidiform mole for 12 weeks.


A hydatidiform mole occurs when a haploid sperm fertilizes an egg that has no maternal chromosomes and then duplicates its chromosomal complement.

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