Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

Elements of the Apgar score include colour, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression or apnoea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.

Nutrition in pregnancy
Weight gain must be:
– In patients <18.5 kg/m2, there should be an increase of 12.7 - 18 kg (28-40 lb)
– In patients 18.5 – 24.9 kg/m2 there should be an increase of 11.4 – 15.9 kg (25-35 lb)
– In patients 25 – 29.9 kg/m2 there should be an increase of 6.8 – 11.4 kg (15-25 lb)
– In patients ≥30 kg/m2 there should be an increase of 5 – 9 kg (11-20 lb)

Supplementation required:
– Intake of daily prenatal vitamin
– Additional specific supplements as indicated
– Avoidance of harmful substances like drugs, alcohol, etc
– Substance abuse counseling
– Avoidance of fish with high mercury levels
– Moderating caffeine intake

Food safety:
– Avoid undercooked meat, fish & eggs
– Clean raw fruits & vegetables before consuming
– Avoid unpasteurized dairy products

Nutrition in pregnancy is addressed at the initial prenatal visit based on pre-pregnancy BMI. Appropriate weight gain for a women with a normal pre-pregnancy BMI of 18.5 – 24.9 kg/m2 should be 11.4 – 15.9 kg (25-35 lb) during pregnancy. This weight gain is equivalent to the increasing caloric intake of 350 kcal/day during the second and 450 kcal/day during the third trimesters.  Patients following any specific diets like veganism can continue their usual diet throughout pregnancy as long as it contains a well-balanced quantity of protein, carbohydrates and fats.

Vitamin and mineral supplementation during pregnancy is a single, daily prenatal vitamin recommended for majority of pregnant women as it helps to fulfill most of the daily vitamin and mineral supplementation requirements. In case of patients with vitamin or mineral deficiencies like iron, calcium, etc, a specific supplementation of the deficit vitamin/mineral only is required rather than multiple prenatal vitamins to avoid consuming harmful amounts of other vitamins like vitamin A.  Vegans, who are at risk for some vitamin and mineral deficiencies like vitamin B12, calcium, iron, etc, secondary to lack of meat consumption, may require supplementation.

Pregnant women are counselled on avoidance of harmful substances like alcohol, drugs, etc and substances like fish with high mercury levels.  Although high caffeine intake during pregnancy can be harmful, a moderate intake ie, 1 or 2 cups of coffee a day is thought to be safe.

Safe handling of food is important because some food products are found to result in congenital infection and intrauterine fetal demise. Patients are also counselled to avoid undercooked meat, fish, and eggs; to thoroughly clean raw fruits and vegetables and to avoid consumption of unpasteurized dairy products.

By maintaining a proper maternal nutrition during pregnancy, patients are provide appropriate nutrition to the fetal and thereby reducing the risk of pregnancy related complications like low birth weight, preterm delivery, etc.

Pregnant patients are counseled to avoid exercises like contact sports, downhill skiing, etc which increases the risk of abdominal trauma resulting in increased risk of placental abruption. But those patients with an uncomplicated pregnancy, who are already accustomed with long-duration, high-intensity exercise like running 5 miles/day, as in the given case, can continue with their regimen if tolerated.

Proper nutrition in pregnancy includes appropriate weight gain, supplementation of vitamins and minerals, avoidance of any harmful substances, and safe handling of food. Patients with a normal pre-pregnancy BMI should gain around 11.4-15.9 kg (25-35 lb) during pregnancy by increasing their caloric intake by 350 kcal/day in the second and 450 kcal/day in the third trimesters.

Rubella infection during pregnancy may lead to miscarriage, intrauterine fetal demise, premature labour, intrauterine growth retardation, and congenital rubella syndrome. The risk of developing complications is highest if the infection is contracted within the first 12 weeks of gestation.

In those cases in which a pregnant woman has been exposed to a suspected rubella case, a specimen of blood should be tested as soon as possible for the measurement of rubella-specific IgG antibodies. If it is positive, then the woman was likely to be immune and could be reassured. If it is negative, a determination rubella-specific IgG and rubella-specific IgM antibodies should be obtained in 3 weeks to exclude an asymptomatic primary rubella infection.

Stillbirth has many causes: intrapartum complications, hypertension, diabetes, infection, congenital and genetic abnormalities, placental dysfunction, and pregnancy continuing beyond forty weeks.

In 5% of normal-appearing stillborns, a chromosomal abnormality will be detectable. With an autopsy and a chromosomal study, up to 35% of stillborns are found to have a major structural pathology, and 8% have abnormal chromosomes. After a complete evaluation, term stillbirth remains unexplained about 30% of the time. The chance of finding a cause is impacted by the age of the foetus, the experience of the caregiver, and the thoroughness of the exam. Chromosome testing for aneuploidy should be offered for all stillbirths to confirm or to seek a cause of the stillbirth. Genetic amniocentesis or chorionic villus sampling before delivery offers the highest yield.

Pituitary tumours, the most common pathologic cause of galactorrhoea can result in hyperprolactinemia by producing prolactin or blocking the passage of dopamine from the hypothalamus to the pituitary gland. Approximately 30 percent of patients with chronic renal failure have elevated prolactin levels, possibly because of decreased renal clearance of prolactin. Primary hypothyroidism is a rare cause of galactorrhoea in children and adults. In patients with primary hypothyroidism, there is increased production of thyrotropin-releasing hormone, which may stimulate prolactin release. Nonpituitary malignancies, such as bronchogenic carcinoma, renal adenocarcinoma and Hodgkin’s and T-cell lymphomas, may also release prolactin.

A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.

Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.

In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.

Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.

The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.

Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.

Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.

Placental abnormalities such as placenta previa and placenta accreta are the most common reasons for considering hysterectomy as an inevitable treatment option in postpartum hemorrhage.

Placental villi normally invade only the superficial layers of endometrial deciduas basalis, but when the invasion is too deep into the uterine wall, the condition is termed as placenta accreta, increta or percreta depending on the depth of invasion.
– When the villi invade the deeper layers of the endometrial deciduus basalis, but not the myometrium it is called as Placenta accreta. This is the most common type of decidual invasion and accounts for approximately 75% of the cases.
– When the villi invade the myometrium, but do not reach the uterine serosa or the bladder is called Placenta increta. This type accounts for nearly 15% of cases.
– In cases were the villi invades into the uterine serosa or the bladder is it called as Placenta percreta and this happens in 5% of cases.

Prior uterine surgery is the main risk factor for placenta accreta and the best management is elective cesarean hysterectomy.
postpartum hemorrhage can also be caused by conditions like genital lacerations, uterine atony, retained products of conception and uterine inversion. In most of these above mentioned cases, hysterectomy is not required and remains as the last resort in extremely desperate situations.

NOTE– Though uterine atony is the most common cause of postpartum hemorrhage, it is often manageable medically.

The most common clinical findings in a postpartum women with endometritis are postpartum fever, with tachycardia relative to the rise in temperature, midline lower abdominal pain and uterine tenderness from the 2nd to 10th day of postpartum.

Most common risk factors for the development of postpartum endometritis are:
– Cesarean deliveries are considered as the most important risk factor for postpartum endometritis, especially those performed after the onset of labour.
– Young maternal age.
– Multiple digital cervical examinations.
– Prolonged rupture of membranes.
– Retention of placental products.
– Prolonged labour.
– Chorioamnionitis.
Advanced maternal age is not considered as a risk factor for development of postpartum endometritis.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

Routine ultrasonography at around 18-22 weeks gestation has become the standard of care in many communities. Acceptance is based on many factors, including patient preference, medical-legal pressure, and the perceived benefit by physicians. However, rigorous testing has found little scientific benefit for, or harm from, routine screening ultrasonography.

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.

In pregnancy, the uterus increases in size to accommodate the developing foetus. At 16 weeks gestation, the fundus of the uterus must be palpated at the midpoint between the umbilicus and the pubic symphysis but the patient’s uterus was already palpable at just 11 weeks.

If less than seven weeks pregnant, it’s unlikely to find a heartbeat by ultrasound. Using transvaginal ultrasound, a developing baby’s heartbeat should be clearly visible by the time a woman is seven weeks pregnant. Abdominal ultrasound is considerably less sensitive, so it can take longer for the heartbeat to become visible. If past seven weeks pregnant, seeing no heartbeat may be a sign of miscarriage.

Fetal viability is confirmed by the presence of an embryo that has cardiac activity. Cardiac activity is often present when the embryo itself measures 2 mm or greater during the 6th week of gestation. If cardiac activity is not evident, other sonographic features of early pregnancy can predict viability.

It is recommended that all pregnant women undergo a routine ultrasound at 10 to 13 weeks of gestation to determine an accurate gestational age. Getting an accurate gestational age is highly important and pertinent for the optimal assessment of fetal growth later in pregnancy. Ultrasound is the most reliable method for establishing a true gestational age by measurement of crown-rump length, which can be measured either transabdominally or transvaginally.

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

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

Anticoagulant therapy is the standard treatment for deep vein thrombosis (DVT) but is mostly used in non-pregnant patients. In pregnancy, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used. Warfarin therapy is generally avoided in pregnancy because of its fetal toxicity.

Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.

Twin pregnancy is associated with a number of obstetric complications, some of them with serious perinatal consequences, especially for the second twin. The rate of perinatal mortality can be up to six times higher in twin compared to singleton pregnancies, largely due to higher rates of preterm delivery and fetal growth restriction seen in twin pregnancies. Preterm birth and birth weight are also significant determinants of morbidity and mortality into infancy and childhood. More than 50% of twins and almost all triplets are born before 37 weeks of gestation and about 15–20% of admissions to neonatal units are associated with preterm twins and triplets.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

The best treatment option for chlamydial urethritis in pregnancy is Azithromycin 1g as a single dose orally. This is the preferred option as the drug is coming under category B1 in pregnancy.

Tetracycline antibiotics, including doxycycline, should never be used in pregnant or breastfeeding women.

Erythromycin Estolate is contraindicated in pregnancy due to its increased risk for hepatotoxicity. Ciprofloxacin is not commonly used for treating chlamydial urethritis and its use is not safe during pregnancy.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.

The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.

Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

Contraindications to tocolysis in preterm labor are as follows:
– Gestational age > 34 weeks or <24 weeks
– Labor is too advanced with an advanced cervical dilation of >4 cm
– Abnormal CTG suggesting a non-reassuring fetal status
– Lethal fetal anomalies
– Intrauterine fetal demise
– Suspected fetal compromise
– Significant antepartum hemorrhage, such as placental abruption/ active vaginal bleeding with hemodynamic instability
– Any suspected intrauterine infections like chorioamnionitis
– Maternal hypotension
– Pregnancy-induced hypertension/ eclampsia/ pre-eclampsia
– Placenta previa
– Placental insufficiency
– Intrauterine growth retardation
– Maternal allergy to specific tocolytic agents or cases where tocolytics are contraindicated due to specific comorbidities like in case of cardiac disease, were beta agonists cannot be administered.

As there are nonpulmonary morbidities associated with preterm birth, fetal pulmonary maturity, known or suspected, is not an absolute contraindication for tocolysis. These fetuses could potentially benefit from prolongation of pregnancy and from the nonpulmonary benefits of glucocorticoid therapy.

When cervical dilation is greater than 3 cm inhibition of preterm labor is less likely to be successful. In such cases Tocolysis can be considered when the goal is to administer antenatal corticosteroids or to safely transport the mother to a tertiary care center.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication to suppression of labor.

The correct answer is reassurance after thorough examination. Most breast lesions diagnosed during pregnancy and lactation, even some specific ones such as lactation and adenoma galactocele, are benign. The diagnosis of breast cancer, which is difficult to elucidate and is less common among women who are pregnant or lactating than among those of the same age who are not, continues to be a challenge for clinicians.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

The episiotomy is a technique originally designed to reduce the incidence of severe perineal tears (third and fourth-degree) during labour. The general idea is to make a controlled incision in the perineum, for enlargement of the vaginal orifice, to facilitate difficult deliveries.

Below is the classification scale for the definitions of vaginal tears:
First degree involves the vaginal mucosa and perineal skin with no underlying tissue involvement.
Second degree includes underlying subcutaneous tissue and perineal muscles.
Third degree is where the anal sphincter musculature is involved in the tear. The third-degree tear can be further broken down based on the total area of anal sphincter involvement.
Fourth degree is where the tear extends through the rectal muscle into rectal mucosa.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

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.

Patient mentioned in the case has developed severe nausea and vomiting at the initial weeks of pregnancy. If the following clinical features are present, it confirms the diagnosis of hyperemesis gravidarum:
– Weight loss of more than 5% of pre-pregnancy weight
– Moderate to severe dehydration.
– Ketosis
– Electrolyte abnormalities.

Management of hyperemesis gravidarum include:
– Temporary suspension of oral intake, followed by gradual resumption.
– Intravenous fluid resuscitation, beginning with 2 L of Ringer’s lactate infused over 3 hours to maintain a urine output of more than 100 mL/h.
– Use of Antiemetics like metoclopramide, if needed.
– Oral administration of Vitamin B6.
– Replacement of electrolytes if required in the case.

Encouraging oral intake and sending this patient home without any intravenous hydration, is not considered the correct treatment option in this case.