Pregnant women who contract the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) face an elevated risk of preterm birth, and their newborns are more prone to stillbirth or admission to a neonatal unit. Despite the World Health Organization declaring the end of the coronavirus disease 2019 (COVID-19) pandemic as a global health emergency in May 2023, pregnant women continue to contract SARS-CoV-2. Limited information is available on the impact of SARS-CoV-2 infection in early pregnancy on pregnancy outcomes. Additionally, understanding the safety of vaccination is crucial. Current evidence suggests that SARS-CoV-2 infection in early pregnancy does not seem to heighten the risk of miscarriages. Moreover, vaccinations have demonstrated efficacy in safeguarding both pregnant women and their pregnancies

Transvaginal ultrasound scan is the mainstay of diagnosis of miscarriage. Evidence based criteria should be fulfilled in all cases, with interval scans as needed to avoid inadvertent interventions when the pregnancy may be viable. Incomplete, inevitable and complete miscarriages have specific ultrasound findings. Several ultrasound factors, including slow embryonic heart rate, small embryo or gestation sac size and an enlarged yolk sac, alone or in combination, help predict impending pregnancy loss. Uterine factors such as fibroids, adenomyosis and adhesions after previous caesarean birth may make ultrasound assessment for early pregnancy more challenging.

This chapter discusses the common occurrence of miscarriage in pregnancy and reviews the current genetic methodologies, from cytogenetics to genomics, available to aid individuals and families suffering from pregnancy loss. While often unexplored, a genetics evaluation should be offered in all cases of pregnancy loss given the high diagnostic yield and therapeutic value of providing families with answers. This chapter walks the reader through the available technologies to evaluate chromosome content, which provide an explanation for approximately half of pregnancy losses, as well as current and future genetic and genomic evaluations that can be used to further increase diagnostic yield and identify couples at increased risk of recurrence.

Core outcome sets are an agreed, standardised set of outcomes based on what key stakeholders consider the important outcomes in the management or prevention of a condition. They are crucial to unifying research data from different trials, allowing outcomes to be combined and compared. Core outcome sets in miscarriage prevention and management and ectopic pregnancy have been produced. The final outcomes for miscarriage management are: efficacy of miscarriage treatment, heavy vaginal bleeding, pelvic infection, maternal death, procedural related complications and patient satisfaction. The final outcomes for miscarriage prevention are: pregnancy loss, live birth, congenital abnormalities, fetal growth restriction, gestation at birth, pre-term birth, neonatal or infant death, maternal complications, compliance with intervention, patient satisfaction, maternal hospitalisation and neonatal or infant hospitalisation. The final outcomes for ectopic pregnancy are: treatment success, resolution time of EP, number of additional interventions, adverse events, mortality and severe morbidity and treatment satisfaction.

Obesity is a worsening global epidemic that is detrimentally affecting women’s reproductive health. Being obese not only decreases fertility, but also increases miscarriage rates and other pregnancy complications. Perhaps even more significant is the increasing evidence demonstrating associations between maternal obesity and long-term risks of obesity and metabolic disturbances in the offspring.

The mechanisms mediating the effects of obesity on early pregnancy are likely multifactorial, involving oocyte quality, embryo competence, endometrial receptivity, and fetal development. Early pregnancy is a critical time that strongly influences the fate of the pregnancy as well as the health of the next generation.

Progesterone is an endogenous hormone which is derived from cholesterol steroids. It is secreted in women principally by the corpus luteum in the ovaries during normal menstrual cycles. Progesterone exerts a number of essential effects vital for the support and maintenance of a pregnancy. The role of progesterone in threatened and recurrent miscarriage was a matter of debate for many decades, until the findings of the PROMISE and PRISM trials. Vaginal micronized progesterone may increase the live birth rate for women with a history of one or more previous miscarriages and early pregnancy bleeding, with likely no difference in adverse events. There remains an uncertainty over the effectiveness and safety of alternative progestogen treatments for threatened and recurrent miscarriage.

The term “molar pregnancy” is commonly used to describe disorders of the villous anatomy which results from a lack, maldevelopment or regression of the villous vasculature that make the drainage of fluid supplied by the trophoblast impossible. When these changes are associated trophoblastic hyperplasia on histology they are described as hydatidiform moles (HM) which are classified into either complete hydatidiform moles (CHM) where the trophoblastic hyperplasia is diffuse, fetal development is absent and the morphological changes are generalised, or partial hydatidiform moles (PHM) which characteristically display trophoblastic hyperplasia with focal villous hydropic changes and evidence of fetal development. The vast majority of CHM and triploid PHM miscarry spontaneously during the first three months of pregnancy. Following uterine evacuation, around 15% and between 0.5-5.6% of patients with a CHM and PHM develop gestational trophoblastic neoplasia (GTN) requiring chemotherapy and thus it is essential that patients with HM are diagnosed early in pregnancy and provided with follow-up. The molar transformation of the placental tissue in HM is a progressive phenomenon secondary to the oedema of the villous mesenchyme and the typical cystic molar changes found on ultrasound are often not visible before 9 weeks of gestation. Most patients with HM are likely to be first seen in an early pregnancy unit.

Pregnancy loss (PL) is a common complication in early pregnancy, occurring in ~25% of recognized pregnancies. Standard medical care after PL traditionally focuses on emptying of the fetus from the uterus. Historically the emotional impact of PL has been overlooked. However, research shows that PL has a negative psychological impact on women’s and their partner’s well-being, and that patients wish for post-PL care that attends to their emotional and psychological needs as well. This chapter summarizes the latest research on the psychological impact of PL, patient preferences for medical and supportive care after PL and in a new pregnancy and provides recommendations for care. Psychological impact and support after ectopic pregnancies and late pregnancy losses > 24 weeks are not specifically addressed in this chapter. Health care staff providing care to those with PL should be educated about the psychological impact of PL including that a first PL can cause emotional distress for both partners and that the psychological burden can increase with multiple losses. Informing patients that their emotional reactions to the PL are normal and to be expected without diminishing their impact is crucial. Information provision and empathic and sensitive communication is valued by patients and their partners. Structural changes are also needed to facilitate continuity in care and follow-up in order to promote overall well-being after PL.

The apparent inefficiency of human Implantation remains perplexing and is the cause of much distress when it occurs in the context of fertility treatments. Many of the prevailing paradigms that have shaped our understanding of implantation have been extrapolated from imperfect animal models, but in recent years in-vitro models have revealed novel insights into the role of the endometrium as an active, rather than passive participant in implantation. Evidence has emerged of the existence of a biosensor function ascribed to the decidualised endometrial stroma which allows for a maternal strategy of rejecting poorly viable embryos. In this chapter, this new understanding of the regulation of implantation and of the aetiology of recurrent miscarriage is addressed and implications for clinical management are considered.

This chapter will discuss the current state of miscarriage gene identification efforts using Chromosome Microarrays (CMA) and Next Generation Sequencing (NGS). CMA is an established clinical test for identifying genetic etiology of miscarriage with tens of thousands of cases reported. This allows finding hot-spots in the genome for copy number changes carrying candidate miscarriage genes as well as focusing on deeper analysis of individual genes within small CNVs. NGS studies for miscarriage candidate gene discovery and diagnosis are still relatively infrequent and include NGS of whole family, miscarriage only, couple only or women with recurrent pregnancy loss. Large scale integration of sequencing and CNV data in a pregnancy loss specific database, accompanied by obstetric and pathology findings is needed to facilitate identification of candidate genes and understanding of their role in adverse pregnancy outcome.

Subchorionic hematoma is a common ultrasound finding in pregnant patients presenting with first-trimester bleeding or found on routine pregnancy ultrasound. Patients may be asymptomatic or have light vaginal bleeding not associated with pain or cramps. On ultrasound, a subchorionic hematoma appears as a crescent-shaped fluid collection between the chorionic membranes and the decidua. Studies show that this finding can be associated with a higher risk of miscarriage and pregnancy loss, preterm delivery, and preterm premature rupture of membranes. No intervention has been shown to reduce this risk. This finding can be associated with stress and anxiety to the expecting parents. The cause is not well understood and most resolve spontaneously by the second trimester. Management for small subchorionic hematomas is conservative with counseling and follow up at routine visits. Larger subchorionic hematomas can be followed more frequently.

Working as a psychiatric trainee, further pregnancy, early loss, acute stress reaction. Back to work, pregnant again, passed Part 1 MRCPsych. Second daughter born.

Genealogical narratives often include a strand of violence and physical effort for women, particularly through childbirth but also through exile, migration for marriage, and establishing an independent life, as the previous chapters show. This chapter explores genealogical transmission and its relationship to violence and women’s action in the context of administrative communication networks in the Middle English Athelston, in which the king kicks his wife, killing his heir, and sentences his pregnant sister to a trial by fire. Drawing on network theory, which emphasizes the “doers” and “doing” of a network, the chapter explores the alignment of the two royal heir-bearers with messengers, which positions the women as key transmitters, not unlike the Virgin Mary at the Annunciation, rather than as wives who simply carry their husbands’ children. In this model of transmission, the women influence succession not only through childbearing but also through royal petitioning, letter writing, and prayer.

Women with uterine fibroids are more likely to have pregnancies complicated by fetal and maternal complications. Women should be counselled that the risks of obstetrical complications are increased with the presence of fibroids in pregnancy. There are still no adequate data on the optimum management strategy of fibroids in pregnancy. In women with prior myomectomy, a plan for labour and vaginal delivery is reasonable in those who did not have extensive myometrial dissection or entry into the endometrial cavity. Alternately, for those who choose an approach of scheduled Caesarean delivery, timing at 37–38 weeks’ gestation is reasonable.

While conception, pregnancy and childbirth are ‘natural’ events for most, for some the process is more complicated, medicalised, and marked by unexpected or difficult events. This chapter examines the experience of pregnancy when high investment is juxtaposed with high risk. The impact of a history of infertility, conception involving ART, pregnancy loss is examined in depth as well as evidence regarding the most effective ways to support parents who experience perinatnal loss.

Data from UK confidential enquiries suggest a declining rate of twin stillbirth in monochorionic (MC) and dichorionic (DC) twin pregnancies with improved outcomes possibly reflecting the establishment of national guidelines for the management of multiple pregnancies. Despite this, twin pregnancies are at greater risk of all pregnancy complications, miscarriage and stillbirth than singleton pregnancies. Monochorionic twins, comprising approximately 20% of twin pregnancies, are at particular risk of fetal loss due to the unique pathological complications of a shared placenta: Twin to Twin Transfusion Syndrome (TTTS), early-onset severe selective growth restriction (sGR) and twin anaemia polycythaemia sequence (TAPS). Furthermore, following single intrauterine fetal demise (sIUFD) surviving monochorionic co-twins are exposed to an increased risk of intrauterine death, neonatal death and neurological disability. This chapter examines single and double fetal loss in DC and MC twin pregnancies, outlining the key facts, and covering the difficult issues and management challenges posed by twin demise.