Free T3 (FT3) and free T4 (FT4) levels are slightly lower in the second and third trimesters. Thyroid-stimulating hormone (TSH) levels are low-normal in the first trimester, with normalization by the second trimester.

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include post thrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation.

Low molecular weight heparin (LMWH) is the preferred agent for prophylaxis and treatment of DVT during pregnancy. A disadvantage of LMWH over unfractionated heparin (UFH) is its longer half-life, which may be a problem at the time of delivery.

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

This patient presents with secondary amenorrhea, most likely caused by Asherman’s syndrome- Secondary amenorrhea is defined as absence of menstruation for – 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- Asherman’s syndrome as the cause of her amenorrhea is suggested by its beginning shortly after undergoing elective abortion. It is an outflow tract obstruction caused by intrauterine synechiae resulting from the procedure.

The best diagnostic test to confirm this diagnosis is hysteroscopy. It can allow visualization of the uterine cavity, the nature and extent of intrauterine synechiae.

→ Progesterone withdrawal test is one of the diagnostic studies done in the early work-up of secondary amenorrhoea- It is usually followed by the estrogen-progesterone challenge test and other tests. Progesterone withdrawal test alone would not confirm Asherman’s syndrome.
→ Pelvic ultrasound is more useful in primary amenorrhea work-up when the presence or absence of the uterus is to be confirmed- It is not very useful in the evaluation of intrauterine adhesions.
→ Brain MRI is useful in confirming the presence of pituitary tumours in patients, who are found to have high levels of prolactin. This patient’s most likely cause of secondary amenorrhea is Asherman’s syndrome.
→ TSH and prolactin levels should be the next step in the work-up of secondary amenorrhea after pregnancy has been ruled out; however, these studies cannot confirm Asherman’s syndrome.

Mitral stenosis is the most common cardiac condition affecting women during pregnancy and is poorly tolerated due to the increased intravascular volume, cardiac output and resting heart rate that predictably occur during pregnancy.

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension.

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.

Normal labour is characterized by spontaneous onset, rhythmical uterine contractions along with vertex presentation. Cervical dilatation starts from the 1st stage of labour and intensity of the uterine contractions increases with passing time. Bleeding occurs after the child is expelled and the average loss is about 250-500 ml in a normal vaginal delivery.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

Ultrasound has emerged as the more accurate method of assessing fetal gestational age, especially in the first trimester. Both transvaginal and transabdominal probe assessments are used to obtain a more accurate measurement of gestational age. Transvaginal is more helpful in first trimester pregnancies.

A transvaginal ultrasound exam should not be performed in a pregnant patient with vaginal bleeding and known placenta previa, a pregnant patient with premature rupture of membranes, and a patient who refuses exam despite informed discussion.

Sonographic assessment within the first 13 weeks and 6 days will provide the most accurate estimate of gestational age. Both transvaginal and transabdominal approaches may be used. However, the transvaginal approach may provide a more clear and accurate view of early embryonic structures. Although the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate with gestational age.

The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Patient mentioned above is a known case of type 2 diabetes which makes her at high risk of having neural tube defects. She should be advised to start taking a high dose of (5mg) folic acid supplement daily for at least 1-month prior to conception and it should be continued upto 12 weeks of her pregnancy.

Folate, which is a water-soluble B vitamin, is usually obtained from diet or through supplementation. For those patients with a history of type 2 diabetes mellitus, who are planning for pregnancy, high doses are recommended to prevent any possible neural tube defects.

Vitamin A is not safe and should be avoided in pregnancy due to chances for toxicity.

Vitamin C and iron are not considered as essential vitamins to be taken during pregnancy.

First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

The finding of ketonuria in this patient indicates profound dehydration and electrolyte loss. Immediate investigation with baseline serum electrolytes, urea, and creatinine is recommended for aid In intravenous resuscitation and rehydration.

All other assessments listed are appropriate, however, baseline electrolyte concentration is important before initiating intravenous resuscitation.

Other causes that can lead to vomiting in early pregnancy include normal pregnancy, multiple pregnancies, molar pregnancies, or urinary tract infection. Urine culture is necessary to exclude urinary tract infection, pelvic ultrasound to confirm singleton or multiple pregnancy and rule out a molar pregnancy.

An erect abdominal Xray may help to rule out an organic intestinal obstruction in this patient. Her history of an appendectomy predisposes this patient to adhesions leading to small bowel obstruction. However, it is not the immediate assessment in this case.

Before the advent of ultrasound, a quantitative hCG analysis was indicated to assess the presence of molar pregnancy. However, ultrasound is now preferred to confirm this diagnosis.

Shoulder dystocia occurs when the bisacromial diameter, which is the breadth of the shoulders, exceed the diameter of pelvic inlet. This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis, instead of an arrest at the pelvic inlet. Brachial plexus palsies including Erb’s palsy is the most common foetal injury associated with shoulder dystocia.

It is not hyper-extension but the hyper-flexion of maternal legs tightly on her abdomen, called as McRoberts manoeuvre, which facilitates delivery during shoulder dystocia. This technique is effective as it increases the mobility of sacroiliac joint during pregnancy, which allows the rotation of pelvis and thereby facilitating the release of fetal shoulder.
If this manoeuvre does not succeed, another technique called suprapubic pressure is done where an assistant applies pressure on the lower abdomen and gently pulls the delivered head. This technique is useful in about 42% of cases with shoulder dystocia.

Maternal diabetes mellitus and foetal macrosomia both are a risk factor for shoulder dystocia.

Administration of epidural anaesthesia during labour increases the possibility of shoulder dystocia.

Risk of shoulder dystocia may increase with Oxytocin augmentation also.

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

Magnesium Sulphate is the drug of choice in eclamptic patients. A loading dose of 4g magnesium sulphate in 100mL 0.9% saline IVI over 5min followed by maintenance IVI of 1g/h for 24h. Signs of toxicity include respiratory depression and jerky tendon reflexes. In recurrent fits additional 2g can be given. Magnesium should be stopped when the respiratory rate is <14/min, absent tendon reflexes, or urine output is <20mL/h.

Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Amniocentesis is a prenatal procedure performed on a pregnant woman to withdraw a small amount of amniotic fluid from the sac surrounding the foetus.
The goal of amniocentesis is to examine a small amount of this fluid to obtain information about the baby, including its sex, and to detect physical abnormalities such as Down syndrome or spina bifida.
Amniocentesis is only performed on women thought to be at higher risk of delivering a child with a birth defect.

Amniocentesis is performed between 16 and 20 weeks into the pregnancy. By around this time, the developing baby is suspended in about 130ml of amniotic fluid, which the baby constantly swallows and excretes. A thin needle is used to withdraw a small amount of this fluid from the sac surrounding the foetus.

In the given case, the patient should be treated with Augmentin.
Asymptomatic bacteriuria occurs in about 2 % to 10 % of all pregnancies and if left untreated, about 30% of this will develop acute cystitis and the other 50% will develop acute pyelonephritis.

Escherichia coli is the most common pathogen associated with asymptomatic bacteriuria, which consists more than 80% of the isolate and Staphylococcus Saprophyticus accounts for about 5-10% of isolates associated with uncomplicated UTI. Escherichia coli is a very common normal flora found in the gastrointestinal tract and Staphylococcus Saprophyticus is a commonly found normal flora in genital tract and perineum.

Asymptomatic bacteriuria has found to be associated with low birth weight and preterm birth, and it is found that a short term antibiotic treatment will help in improving the fetal outcomes in cases of asymptomatic bacteriuria or uncomplicated UTI. Hence, all cases of asymptomatic bacteriuria and uncomplicated UTI during pregnancy are recommended to be treated with a five day course of oral antibiotics as this is normally sufficient in pregnant women.

Drug of choice in asymptomatic bacteriuria (directed therapy based on sensitivities) in case of E. coli are either:
– Cephalexin 500 mg oral twice a day for 5 days or
– Nitrofurantoin 100 mg orally twice daily for 5 days or
– Trimethoprim 300 mg oral doses daily for 5 days (avoided during first trimester and in those pregnant women with established folate deficiency, low dietary folate intake, or for women taking other folate antagonists).
– Amoxicillin + clavulanate 500 + 125 mg oral, twice daily for 5 days if < 20 weeks of gestation.
Note: In view of childhood outcomes – (ORACLE II trial and 7 year follow-up), which showed an associated increase in necrotising enterocolitis, functional impairment (low), and cerebral palsy, it is recommended that amoxicillin / clavulanate is only used if no alternative treatment is available(if >20 weeks of gestation).

Asymptomatic bacteriuria (directed therapy based on sensitivities ) in case of Staphylococcus saprophyticus infection is as follows:
Cephalexin 500 mg oral doses twice a day for 5 days or Amoxicillin 500mg TDS for 5 days.

Asymptomatic bacteriuria (directed therapy based on sensitivities) in case of infection with Pseudomonas suggest Norfloxacin 400 mg oral twice daily for 5 days, then repeat MSSU 48 hours after the treatment is completed.

In case of Group B streptococcus as a single organism, Penicillin V 500 mg oral twice daily for 5 days. If the patient is hypersensitive to penicillin give Cephalexin 500 mg orally twice a day for 5 days were immediate hypersensitivity is excluded. If immediate hypersensitivity to penicillin is noticed, then Clindamycin 450 mg three times daily for 5 days is advised.

Amoxicillin is found more effective in treating UTIs caused by organisms which are resistant to the drug in vitro because of its high concentrations attainable in urine. However, a study shows that amoxicillin-resistant organisms do not respond to amoxicillin alone but Augmentin [amoxicillin clavulanate] is found to cure urinary tract infection irrespective of the amoxicillin susceptibility of the organism in vitro. Of the patients infected with amoxicillin-resistant organisms, 80% were cured by augmentin and only 10% with infection by amoxicillin-resistant organisms were cured by amoxicillin.

Now a days Amoxicillin is not preferred as the common treatment option for UTI due to increasing incidences of Escherichia coli resistance, which accounts majority of uncomplicated urinary tract infections. Clavulanic acid which is a beta-lactamase inhibitor works synergistically with amoxicillin to extend spectrum antibiotic susceptibility. This makes UTIs less likely to be resistant to the treatment with amoxicillin clavulanate compared to amoxicillin alone.
Ciprofloxacin and Gentamicin which are the other antibiotic choice considered otherwise also should be avoided in pregnancy as they comes under FDA pregnancy Category C.

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity.

Normally, there will be a slight raise in prolactin level throughout pregnancy even despite estrogen stimulating and progesterone inhibiting prolactin secretion.

Serum alkaline phosphatase levels will be increased in pregnancy due to placental ALP.

During the first trimester of pregnancy there is a physiological mechanism by hCG causing cross-stimulation of the TSH receptors and as a result of this the concentration of thyroid stimulating hormone (TSH) normally decreases. During second trimester TSH concentration will again return back to its pre-pregnancy levels and then rises slightly by the third trimester. However, most of the changes still occur within the normal non-pregnant range, and the serum free T3 and T4 concentrations remain unchanged throughout pregnancy. But the total concentrations, which include both free and protein-bound fractions, elevates significantly due to an increase in the circulating binding globulins.

Iron binding capacity reflects transferrin, a protein used for iron transportation, which is a globulin found in the beta band on electrophoresis. To counteract the reduction of plasma iron during pregnancy both transferrin and iron binding capacity are elevated during this period.

When compared to the non-pregnant level, cortisol levels are been elevated up to three times than normal.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.

This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.

Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.

Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.

New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.