An ultrasound of the foetal spine at 16-18 weeks of gestation is the most appropriate assessment (correct answer).

Ultrasound performed at 11-12 weeks of gestation can diagnose anencephaly, another neural tube defect, however; any vertebral column defect is unlikely to be detected.

In most cases of neural tube defects in the foetus, elevations will be noted in maternal alpha-fetoprotein levels at 12 to 15 weeks. However, it may not be possible to detect all such abnormalities and a confirmed diagnosis cannot be made.

Additionally, elevations in alpha-fetoprotein levels do not always correlate to the presence of foetal neural tube defects.

Nuchal translucency scans do not detect neural tube defects. They are performed to identify the risk of chromosomal abnormalities in the foetus.

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.

In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.

– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue.

There is a significant increase in oxygen demand during pregnancy due to a 15% increase in the metabolic rate and a 20% increased consumption of oxygen. There is a 40–50% increase in minute ventilation, mostly due to an increase in tidal volume, rather than in the respiratory rate. In a healthy, young human adult, tidal volume is approximately 500 mL per inspiration

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.

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).

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

The Australasian Diabetes in Pregnancy Society recommends a 50 or 75 g glucose challenge at 26–28 weeks in all pregnant women. An OGTT should be performed if the test result is abnormal: 1 hour values after a 50 or 75 g glucose challenge exceeding 7.8 or 8.0 mmol/L respectively.

If a woman has had gestational diabetes, a repeat OGTT is recommended at 6–8 weeks and 12 weeks after delivery. If the results are normal, repeat testing is recommended between 1 and 3 years depending on the clinical circumstances.

Expectant management has been reported with unpredictable success rate ranging from 25–76%. Waiting for spontaneous expulsion of the products of conception would waste much time, during which women may suffer uncertainty and anxiety. However, when additional surgical evacuation is needed owing to failure, they may suffer from an emotional breakdown. It is thus not recommended for missed early miscarriage due to the risks of emergency surgical treatment and blood transfusion.

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.