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BackgroundThis report describes a patient counseling approach, conservative and surgical management (cervical cerclage) of a dichorionic-diamniotic twin pregnancy, where delivery of the second twin followed the delivery of the first by 104 days.Case presentationA 35-year-old Indian lady, with 10 years of primary infertility, conceived twins, following ovulation induction with gonadotropin therapy. At 19 weeks and 4 days gestation, she aborted a female fetus of 410 gm. Tocolytic therapy was initiated; the placenta remainedin situand the umbilical cord of twin A was ligated high and McDonald's cerclage was placed and prophylactic antibiotics initiated. But since the patient's uterus continued to be irritable and the cerclage appeared to be under tension, at 20 weeks 6 days the stitch was taken out and all conservative treatment stopped for 24 hours, but reinitiated after this period, since the uterus remained quiescent. After 3 weeks of uterine inactivity, at 23 weeks 6 days gestation, McDonald's suture was reapplied following which conservative management was offered after counseling for possible risks associated with maternal sepsis, coagulopathy, need for extended hospitalization and potential for hysterectomy. Reassuring fetal status was observed for twin B without evidence of contractions or chorioamnionitis. A viable male infant (1,800 gm) was delivered vaginally at 34 weeks and 4 days gestation.ConclusionThis report outlines a counseling approach useful for patients with premature delivery of one twin, and presents application of conservative obstetrical management principles for the aftercoming twin, even when delivery interval is extreme.How to cite this articleSingh TA, Majumdar A. Successful Obstetrical Management of Over 100-day Interval between the First and Second Twin Delivery in an Infertility-Treated Patient: Counseling and Management Approach to Extreme Asynchronous Twin. Int J Infertility Fetal Med 2012;3(3): 97-101.

Background This report describes a patient counseling approach, conservative and surgical management (cervical cerclage) of a dichorionic-diamniotic twin pregnancy, where delivery of the second twin followed the delivery of the first by 104 days. Case presentation A 35-year-old Indian lady, with 10 years of primary infertility, conceived twins, following ovulation induction with gonadotropin therapy. At 19 weeks and 4 days gestation, she aborted a female fetus of 410 gm. Tocolytic therapy was initiated; the placenta remained in situ and the umbilical cord of twin A was ligated high and McDonald's cerclage was placed and prophylactic antibiotics initiated. But since the patient's uterus continued to be irritable and the cerclage appeared to be under tension, at 20 weeks 6 days the stitch was taken out and all conservative treatment stopped for 24 hours, but reinitiated after this period, since the uterus remained quiescent. After 3 weeks of uterine inactivity, at 23 weeks 6 days gestation, McDonald's suture was reapplied following which conservative management was offered after counseling for possible risks associated with maternal sepsis, coagulopathy, need for extended hospitalization and potential for hysterectomy. Reassuring fetal status was observed for twin B without evidence of contractions or chorioamnionitis. A viable male infant (1800 gm) was delivered vaginally at 34 weeks and 4 days gestation. Conclusion This report outlines a counseling approach useful for patients with premature delivery of one twin, and presents application of conservative obstetrical management principles for the aftercoming twin, even when delivery interval is extreme.

Aims: To study the prevalence of clinical manifestations in obese and lean polycystic ovarian syndrome (PCOS) women and their health hazards. Settings and Design: This prospective study was carried out in a tertiary care infertility clinic from 1.7.2005 till 31.12.2007. Materials and Methods: These women were diagnosed to have PCOS by the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine, Rotterdam 2003 criteria. They were further divided into two groups according to their body mass index (BMI): Group A (n = 300), overweight and obese with BMI >23 and Group B (n = 150), normal weight and lean with BMI ≤23. Stastical Analysis and Results: The prevalence of menstrual irregularities [79.2% vs. 44%, P = 0.000, 95% confidence interval (CI) = 0.26-0.44)] and clinical hyperandrogenism (74.2% vs. 50.6%, P = 0.000, 95% CI=0.14-0.32) was signifi cantly higher in the obese group, whereas android central obesity (waist to hip ratio >0.85) was similar in both groups, irrespective of body weight (47.7% vs. 38%, P = 0.056, 95% CI=0.06 to +0.18). Comparative data of various health manifestations in lean vs. obese women with POCS [Table 4]. Of the health risk manifestations, hypertension occurred in both groups with a similar frequency (41% vs. 35.5%, P = 0.261, 95% CI=0.03 to +0.15). Group A showed an increased prevalence of IGT (25% vs. 10%, P = 0.000, 95% CI= 0.13-0.29) and type two diabetes mellitus (11.7% vs. 6%, P = 0.000, 95% CI= 0.13-0.29) as compared with group B. endometrial hyperplasia (EH) also showed an increase prevalence in Group A compared with Group B (5.6% vs. 2%, P = 0.055, 95% CI= 0.01-0.08), although not statistically significant. Conclusion: PCOS emerges as a clinically heterogeneous condition with increased prevalence of health risks such as hypertension, diabetes and EH. Of these, diabetes and EH appear to be more prevalent in the obese, putting them at a greater risk of morbid problems at a much younger age than the lean ones.

A rare case of severe menorrhagia in a young girl with polycystic ovarian syndrome (PCOS) is presented. On thorough investigations (blood tests and ultrasound) nothing substantial came up, hence ultimately pelvic examination under anesthesia was undertaken, which uncovered a cervical polyp 2.5 × 2.5 × 1.5 cm size, with a intracervical broad base, presenting at the external os but not protruding into the vagina. The growth was electrocauterized at its base, resected and a thorough curettage was done. Histopathology revealed a myomatous polyp and secretory endometrium. Though always a dilemma, in adolescent menorrhagia, a pelvic examination may be lifesaving in certain cases, if diagnosis is unclear. The importance of doing a thorough local examination in spite of absent history of sexual activity is highlighted by the following case.