Obstetrics: Antenatal Care

• Pregnancy basics: How the Body Changes in Pregnancy | Diagnosing and Dating Pregnancy | Before Pregnancy | Lifestyle Advice in Pregnancy | Vaccines in Pregnancy
• Antenatal care: The Antenatal Care Schedule | Blood and Infection Screening | Screening for Fetal Conditions | CVS and Amniocentesis
• Early pregnancy problems: Nausea, Vomiting and Hyperemesis | Bleeding or Pain in Early Pregnancy | Pregnancy of Unknown Location | Miscarriage | Recurrent Miscarriage | Ectopic Pregnancy | Molar Pregnancy | Abortion (Termination of Pregnancy)
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🤰 Early pregnancy and antenatal care — most pregnancies are healthy, and good antenatal care is about prevention and screening: folic acid, vaccines, blood pressure and urine checks, and offering screening for fetal conditions. Early pregnancy problems are common. About 1 in 5 known pregnancies miscarry, and ectopic pregnancy remains an important cause of maternal death — so any woman of reproductive age with abdominal pain or collapse needs a pregnancy test.
Your four questions for every patient: Could she be pregnant (do a pregnancy test)? How many weeks is she, and where is the pregnancy (intrauterine, ectopic, unknown)? Is she haemodynamically stable? What is her blood group — does she need anti-D?

How the Body Changes in Pregnancy

• Heart and circulation:
  • Cardiac output rises by 30–50% (heart rate up 10–20 beats/min; stroke volume up).
  • BP falls in the first and second trimesters, then returns to normal by term.
  • Blood volume rises by about 40–50%; red cells rise less, so Hb falls (physiological anaemia).
  • Flow murmurs and mild ankle oedema are common.
  • Aortocaval compression — after about 20 weeks, the womb presses on the vena cava when lying flat (low BP, fainting). Use a left lateral tilt.
• Breathing: Tidal volume rises — mild respiratory alkalosis (lower pCO2); feeling breathless is common.
• Kidneys: GFR rises by about 50%, so creatinine and urea fall; mild hydronephrosis (more on the right); glucose in urine can be normal.
• Blood clotting: Hypercoagulable — more clotting factors and fibrinogen; VTE risk rises (highest after birth).
• Gut: Reflux, constipation; raised ALP (from the placenta).
• Hormones:
  • hCG — peaks at 8–12 weeks (can stimulate the thyroid).
  • Insulin resistance rises in the second half (gestational diabetes).
  • Thyroid-binding globulin rises (total T4 rises; use free T4 and trimester ranges).
  • Prolactin rises; the pituitary enlarges.
• Skin: Linea nigra, melasma, stretch marks, spider naevi, palmar erythema.

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Diagnosing and Dating Pregnancy

• Symptoms: Missed period, nausea, breast tenderness, urinary frequency, tiredness.
• Pregnancy tests detect hCG:
  • Urine tests are positive from around the day of the missed period.
  • Serum hCG is quantitative — used in pregnancy of unknown location and ectopic pregnancy.
  • Urine tests can stay positive for weeks after a miscarriage or termination.
• Gestational age is counted from the first day of the last menstrual period (LMP) — about 2 weeks before conception.
  • Naegele's rule — estimated date of delivery = LMP + 1 year − 3 months + 7 days (for a 28-day cycle).
  • Dating scan (11+2 to 14+1 weeks) — crown–rump length is more accurate than the LMP and is used to set the due date.
• Terms:
  • First trimester — up to 13+6 weeks; second — 14 to 27+6; third — 28 weeks to birth.
  • Term — 37+0 to 41+6 weeks; preterm — before 37+0; post-term — 42+0 or more.
  • Gravidity — number of pregnancies (including this one). Parity — number of births at 24 weeks or more (live or stillborn). e.g. G3 P1+1 = third pregnancy, one birth, one loss before 24 weeks.
  • Viability — legally 24 weeks in the UK (survival is possible from about 22–23 weeks with intensive care).

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Before Pregnancy

• Folic acid (prevents neural tube defects) — from before conception until 12 weeks:
  • 400 micrograms daily for everyone.
  • 5 mg daily for higher risk:
    • Previous neural tube defect (either partner or a previous baby).
    • Diabetes.
    • Antiepileptic drugs.
    • BMI 30 or more.
    • Sickle cell disease or thalassaemia.
    • Coeliac disease or other malabsorption.
• Vitamin D 10 micrograms daily throughout pregnancy and breastfeeding.
• Review medicines — stop or switch teratogenic drugs (e.g. valproate, isotretinoin, warfarin, ACE inhibitors, methotrexate, mycophenolate); don't stop essential drugs suddenly without advice.
• Optimise long-term conditions — diabetes (HbA1c under 48 mmol/mol), epilepsy, thyroid, hypertension, mental health, kidney and heart disease.
• Lifestyle — stop smoking, no alcohol, healthy weight.
• Vaccines — check MMR status (rubella) and chickenpox immunity; give live vaccines before pregnancy (avoid pregnancy for 1 month after).
• Genetic risk — family history, consanguinity, carrier screening (e.g. sickle cell, Tay–Sachs).

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Lifestyle Advice in Pregnancy

• Alcohol — none is safest (fetal alcohol spectrum disorder).
• Smoking — carbon monoxide testing at booking; referral to stop-smoking services. Raises risk of miscarriage, growth restriction, stillbirth, preterm birth and sudden infant death. Nicotine replacement is safer than smoking.
• Food:
  • Avoid unpasteurised milk and soft mould-ripened or blue cheeses, pâté, raw or undercooked meat and eggs (unless British Lion eggs) — listeria, toxoplasma, salmonella.
  • Avoid liver and vitamin A supplements (vitamin A is teratogenic).
  • Limit oily fish to 2 portions a week; avoid shark, swordfish and marlin (mercury).
  • Caffeine under 200 mg a day (about 2 mugs of instant coffee).
  • Wash hands after handling cat litter and soil (toxoplasma).
• Exercise — continue moderate exercise; avoid contact sports, scuba diving, and lying flat on the back after 16 weeks during exercise.
• Weight — no "eating for two"; healthy diet.
• Travel — VTE risk on long flights (hydration, mobilise, stockings); avoid Zika areas; airlines may restrict travel after 36 weeks.
• Sleep — going to sleep on the side in the third trimester is linked to lower stillbirth risk.
• Work — maternity rights; risk assessment.
• Domestic abuse — often starts or worsens in pregnancy; ask everyone, alone, at least once.

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Vaccines in Pregnancy

• Whooping cough (pertussis) — offered from 16 weeks (ideally by 32 weeks) in every pregnancy. Antibodies cross the placenta and protect the baby until its own vaccines.
• RSV vaccine — offered from 28 weeks in every pregnancy (UK programme since 2024), to protect the baby from bronchiolitis in the first months.
• Influenza — inactivated vaccine at any stage, in flu season.
• COVID-19 — as per the current programme.
• Avoid live vaccines in pregnancy — MMR, varicella, BCG, yellow fever (unless the risk is very high). If MMR is given by mistake, reassure (no harm has been shown).
• Postnatal MMR for women who are not immune to rubella.

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The Antenatal Care Schedule

NICE NG201 — about 10 appointments for a first pregnancy (nulliparous) and 7 for later uncomplicated pregnancies.

• At every visit — BP and urine for protein; ask about fetal movements (from about 24 weeks), mental health and wellbeing.
• Fundal height — measured from 24 weeks and plotted on a customised or standard growth chart; a small or falling measurement triggers a growth scan.
• Higher-risk pregnancies (e.g. diabetes, hypertension, previous complications) have consultant-led care with extra scans and visits.

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Blood and Infection Screening

• Offered at booking:
  • FBC — anaemia (repeat at 28 weeks).
  • Blood group and red cell antibodies — RhD status and antibodies that could cause haemolytic disease of the fetus (repeat at 28 weeks).
  • Infectious diseases — HIV, hepatitis B, syphilis (all can be treated or the baby protected).
  • Sickle cell and thalassaemia — blood test for all in high-prevalence areas, or a family origin questionnaire in low-prevalence areas; test the father if the mother is a carrier.
  • Urine culture — asymptomatic bacteriuria (treat in pregnancy).
• Not routinely screened in the UK: Rubella (stopped in 2016), group B streptococcus, toxoplasma, CMV, hepatitis C (offer if risk factors).
• Gestational diabetes — risk-factor based OGTT (see the Medical Problems in Pregnancy chapter).
• Mental health — ask at booking and throughout (past history, current symptoms).

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Screening for Fetal Conditions

Screening is a choice — it gives a chance, not a diagnosis. Women should get balanced information and can decline.

• Down (T21), Edwards (T18) and Patau (T13) syndromes:
  • Combined test (11+2 to 14+1 weeks) — nuchal translucency (NT) on scan + blood PAPP-A and hCG, plus maternal age.
    • Down syndrome: high hCG, low PAPP-A, thick NT.
    • Edwards and Patau: low hCG and low PAPP-A.
  • Quadruple test (14+2 to 20+0 weeks) — if too late for the combined test: AFP, hCG, oestriol and inhibin-A (Down syndrome only).
  • Result — "higher chance" if 1 in 150 or more.
  • Higher chance — offer:
    • NIPT (non-invasive prenatal testing) — cell-free fetal DNA in the mother's blood; very accurate for T21 but still a screening test; no miscarriage risk. Offered in the NHS as a second-line ("contingent") test.
    • Or a diagnostic test (CVS or amniocentesis).
    • Or no further testing.
• Anomaly scan (18+0 to 20+6 weeks) — looks for 11 conditions including spina bifida, anencephaly, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious heart defects, kidney problems, and some skeletal dysplasias. Also checks placental position (low-lying placenta — rescan at 32 weeks).
• Raised AFP — neural tube defects, abdominal wall defects, multiple pregnancy, wrong dates.
• Soft markers (e.g. echogenic bowel, mild kidney pelvis dilatation) — may need further assessment.

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CVS and Amniocentesis

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Nausea, Vomiting and Hyperemesis

• Nausea and vomiting of pregnancy — very common (up to 80%), starting at 4–7 weeks, peaking at 9–12 weeks, usually settling by 16–20 weeks.
• Hyperemesis gravidarum (about 1–3%) — severe, prolonged vomiting with:
  • Weight loss of more than 5%.
  • Dehydration (ketones in urine).
  • Electrolyte imbalance (low potassium and sodium).
• Risk factors — multiple pregnancy, molar pregnancy, previous hyperemesis, first pregnancy, family history.
• Exclude other causes — UTI, gastroenteritis, hepatitis, pancreatitis, DKA, thyrotoxicosis, Addison's, raised intracranial pressure. Vomiting starting after 10–12 weeks suggests another cause.
• Assessment: PUQE score (severity); weight; hydration; urine ketones; U&E; LFTs (mildly raised in hyperemesis); TFTs (often a low TSH from hCG — gestational thyrotoxicosis, usually doesn't need treatment); ultrasound (twins, molar pregnancy).
• Treatment (RCOG):
  • Mild — small, frequent, bland meals; ginger; rest.
  • First-line antiemetics — cyclizine, promethazine, prochlorperazine, chlorphenamine, or doxylamine with pyridoxine (Xonvea).
  • Second-line — ondansetron (very small increase in cleft lip risk if used in the first trimester — discuss), metoclopramide (up to 5 days — risk of extrapyramidal effects).
  • Third-line — corticosteroids (hydrocortisone IV then prednisolone) under specialist care.
  • Ambulatory or inpatient care if unable to keep fluids down:
    • IV 0.9% sodium chloride with potassium chloride; avoid dextrose-only fluids at first.
    • Thiamine (oral or IV) — to prevent Wernicke's encephalopathy.
    • LMWH (VTE prophylaxis) while dehydrated or admitted.
    • Treat reflux (PPI or H2 blocker) and constipation.
• Mental health — hyperemesis is very distressing; some women consider termination. Support and validate.

⚠️ Safety Pearl: In hyperemesis, give thiamine before glucose-containing fluids, and replace potassium. Wernicke's encephalopathy (confusion, ataxia, eye movement problems) is a preventable complication.

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Bleeding or Pain in Early Pregnancy

• Causes:
  • Miscarriage (threatened, inevitable, incomplete, complete, missed).
  • Ectopic pregnancy.
  • Molar pregnancy.
  • Implantation bleeding; cervical causes (ectropion, polyps, infection).
  • Subchorionic haematoma.
  • Non-pregnancy causes of pain — UTI, appendicitis, ovarian cyst accident (torsion, rupture).
• Assessment:
  • Pregnancy test in every woman of reproductive age with abdominal pain or bleeding.
  • Observations — signs of shock (pallor, tachycardia, low BP), shoulder tip pain (blood under the diaphragm), collapse.
  • Abdominal and speculum examination — cervical os open or closed; products of conception in the os (cervical shock — bradycardia and low BP; remove with forceps).
• Referral (NICE NG126):
  • Immediate (A&E or gynaecology) if haemodynamically unstable or severe pain.
  • Early pregnancy assessment unit (EPAU) if pregnant and pain, or bleeding at 6 weeks or more, or bleeding with pain or tenderness at any stage.
  • Bleeding without pain under 6 weeks — manage expectantly; repeat urine pregnancy test after 7–14 days; return if pain or bleeding worsens.
• Transvaginal ultrasound — locates the pregnancy and checks viability.
• Anti-D — see the Miscarriage and Ectopic sections.

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Pregnancy of Unknown Location

• What it is: A positive pregnancy test with no pregnancy seen in the womb or tubes on transvaginal scan. It may be a very early intrauterine pregnancy, a failing pregnancy, or an ectopic.
• Two serum hCG levels 48 hours apart (NICE NG126):
  • Rise of more than 63% — likely a developing intrauterine pregnancy (an ectopic is still possible). Rescan in 7–14 days, or sooner once hCG is 1,500 IU/L or more.
  • Fall of more than 50% — likely a failing pregnancy. Urine pregnancy test after 14 days.
  • In between — review in EPAU within 24 hours (suspicious of ectopic).
• Safety-net — return immediately with pain, shoulder tip pain, dizziness or heavy bleeding.

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Miscarriage

• What it is: Loss of a pregnancy before 24 weeks. Most are early (first trimester), mostly from chromosomal abnormalities. Risk rises with maternal age.
• Types:

• Scan criteria for miscarriage — no heartbeat with a crown–rump length of 7 mm or more, or a gestational sac of 25 mm or more with no fetal pole (repeat the scan if below these sizes).
• Management options (NICE NG126):
  • Expectant — first line for 7–14 days (unless high risk of bleeding, previous traumatic experience, infection, or her choice). Repeat pregnancy test after 3 weeks.
  • Medical:
    • Missed miscarriage — mifepristone 200 mg orally, then misoprostol 800 micrograms (vaginal, oral or sublingual) 48 hours later.
    • Incomplete miscarriage — misoprostol 600 micrograms.
    • Pain relief and antiemetics; urine pregnancy test after 3 weeks.
  • Surgical — manual vacuum aspiration under local anaesthetic, or surgical management under general anaesthetic. Risks: bleeding, infection, retained tissue, uterine perforation, Asherman's syndrome (rare).
• Anti-D (RhD-negative women) — after surgical management, or any miscarriage at 12 weeks or more. Not needed for medical management of miscarriage under 12 weeks, or threatened miscarriage under 12 weeks (unless heavy bleeding with pain).
• Threatened miscarriage with a previous miscarriage — offer vaginal micronised progesterone 400 mg twice daily until 16 weeks (reduces loss).
• Emotional care — grief, anxiety and post-traumatic stress are common; offer support and follow-up; options for the remains (sensitive disposal).

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Recurrent Miscarriage

• Definition: Now usually defined (RCOG) as two or more pregnancy losses before 24 weeks (previously three).
• Causes and investigations:
  • Antiphospholipid syndrome — lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein antibodies (on two occasions 12 weeks apart). The most treatable cause.
  • Parental chromosome rearrangements (balanced translocation) — karyotype of pregnancy tissue first.
  • Uterine abnormalities — septate womb, fibroids, Asherman's syndrome (pelvic ultrasound).
  • Cervical weakness — second-trimester losses.
  • Thyroid disease (TSH, thyroid antibodies); poorly controlled diabetes.
  • Older age, obesity, smoking, alcohol.
• Treatment:
  • Antiphospholipid syndrome — aspirin 75 mg from a positive test plus prophylactic LMWH from when a heartbeat is seen.
  • Progesterone in a future pregnancy if bleeding.
  • Surgery for a uterine septum (selected).
  • Early scan and support in a future pregnancy (supportive care improves outcomes).
  • Many couples have no cause found, and the chance of a future successful pregnancy is still good.

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Ectopic Pregnancy

• What it is: A pregnancy outside the womb — over 95% in the fallopian tube (usually the ampulla). About 1 in 90 pregnancies.
• Risk factors:
  • Previous ectopic.
  • Previous PID (chlamydia) or tubal surgery.
  • IVF.
  • Pregnancy with an IUD or IUS in place, or after progestogen-only contraception or emergency contraception failure.
  • Endometriosis; smoking; older age.
  • Many have no risk factors.
• Features (usually 6–8 weeks after the LMP):
  • Lower abdominal pain (one-sided) and vaginal bleeding (often dark, light).
  • Shoulder tip pain, pain on passing stool or urine, dizziness, collapse (rupture).
  • Atypical — diarrhoea and vomiting, or no bleeding. Missed diagnoses still contribute to maternal deaths.
  • Adnexal or cervical motion tenderness; peritonism; shock.
• Diagnosis: Transvaginal ultrasound (adnexal mass, empty womb, free fluid) and serum hCG.
• Ruptured ectopic — emergency: ABC, two large-bore cannulas, crossmatch, call senior gynaecologist and anaesthetist, theatre for laparoscopy (laparotomy if very unstable).
• Management of stable ectopic (NICE NG126):

• Methotrexate — single IM dose (50 mg/m²); hCG on days 4 and 7 (should fall by 15% or more); may need a second dose or surgery.
  • Side effects — abdominal pain, nausea, mouth ulcers, raised LFTs.
  • Avoid alcohol, folic acid supplements and NSAIDs during treatment.
  • Avoid pregnancy for at least 3 months afterwards (teratogenic).
• Surgery — laparoscopic salpingectomy (removing the tube) if the other tube is healthy; salpingotomy (opening the tube) if the other tube is damaged (follow up hCG — some tissue may remain).
• Anti-D for RhD-negative women having surgery for an ectopic.
• Other sites — interstitial (cornual — late rupture, severe bleeding), cervical, caesarean scar, ovarian, abdominal; heterotopic (ectopic plus intrauterine — IVF).

⚠️ Safety Pearl: Every woman of reproductive age with abdominal pain, diarrhoea and dizziness, or collapse needs a pregnancy test. A ruptured ectopic can present as "gastroenteritis" or a faint.

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Molar Pregnancy

• Gestational trophoblastic disease — abnormal growth of placental tissue.
• Types:
  • Complete mole — no fetus; all genetic material from the father (an empty egg fertilised); higher risk of becoming cancer.
  • Partial mole — triploid (two sets from the father, one from the mother); may have fetal parts.
  • Gestational trophoblastic neoplasia — invasive mole, choriocarcinoma (can follow any pregnancy; spreads to lungs), placental site trophoblastic tumour.
• Risk factors: Age under 20 or over 40; previous molar pregnancy; Asian ancestry.
• Features:
  • Bleeding in the first trimester.
  • Womb larger than dates.
  • Very high hCG — causing hyperemesis, hyperthyroidism (hCG stimulates the thyroid), and early pre-eclampsia (before 20 weeks).
  • Theca lutein cysts in the ovaries.
  • Scan — "snowstorm" appearance (complete mole).
• Management:
  • Suction evacuation; histology of all pregnancy tissue.
  • Register with a UK specialist centre (Charing Cross in London, Sheffield, or Dundee) for hCG monitoring (blood and urine) until normal and beyond.
  • Avoid pregnancy until monitoring is complete.
  • Persistent or rising hCG — gestational trophoblastic neoplasia: methotrexate (cure rates close to 100%) or combination chemotherapy.

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Abortion (Termination of Pregnancy)

• The law (England, Wales and Scotland):
  • Abortion Act 1967 — legal when two doctors agree in good faith that grounds are met (one doctor in an emergency). The most common ground: continuing the pregnancy would involve greater risk to the woman's physical or mental health than ending it, up to 24 weeks.
  • No time limit — risk to the woman's life, grave permanent injury, or a substantial risk of serious fetal abnormality.
  • England and Wales — the Crime and Policing Act (Royal Assent April 2026) removed women from criminal law for ending their own pregnancy; the Abortion Act framework still governs how clinicians provide abortion.
  • Northern Ireland — different framework (on request to 12 weeks since 2020).
  • Conscientious objection — doctors may decline to take part (not in an emergency), but must refer on without delay.
• Methods (NICE NG140):
  • Medical — mifepristone (oral) then misoprostol 24–48 hours later. Up to 10 weeks, both tablets can be taken at home (including after a telemedicine consultation).
  • Surgical — vacuum aspiration (usually up to about 14 weeks); dilatation and evacuation later.
  • Later medical abortions are done in hospital; feticide is offered from about 21–22 weeks.
• Before the procedure:
  • Confirm gestation (scan if unsure or ectopic suspected).
  • Offer STI testing; discuss contraception (can start immediately, including an IUD at surgical abortion or an implant with mifepristone).
  • Safeguarding (age, coercion, domestic abuse).
• Anti-D — for RhD-negative women at 10+0 weeks or more (medical or surgical).
• Complications: Bleeding, infection, incomplete abortion, continuing pregnancy (rare), uterine perforation or cervical damage (surgical). No increase in breast cancer or future infertility.
• Follow-up — low-sensitivity urine pregnancy test (after medical abortion at home); emotional support.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 29-year-old with type 1 diabetes and BMI 32 is planning a pregnancy.
Answer: Pre-conception care.

• Folic acid 5 mg daily from now until 12 weeks.
• Aim for HbA1c under 48 mmol/mol; retinal and kidney assessment; review medicines (stop statin and ACE inhibitor at conception).
• Plan aspirin from 12 weeks (pre-eclampsia risk); early booking with the joint diabetes antenatal clinic.

2. A 24-year-old at 6 weeks has left iliac fossa pain and light bleeding. She is stable. Scan shows a 25 mm left adnexal mass, no heartbeat, empty womb. hCG is 1,200 IU/L.
Answer: Unruptured tubal ectopic pregnancy suitable for methotrexate (or expectant management if hCG falling and pain-free).

• Methotrexate 50 mg/m² IM; hCG days 4 and 7; safety-net.
• Avoid pregnancy for 3 months.

3. A 33-year-old at 10 weeks has a routine scan showing no heartbeat (CRL 15 mm). She has no symptoms and wants to avoid surgery.
Answer: Missed miscarriage.

• Options: expectant (7–14 days), medical (mifepristone 200 mg, then misoprostol 800 micrograms 48 hours later), or surgical.
• Pregnancy test after 3 weeks; anti-D not needed for medical management under 12 weeks.
• Psychological support.

4. A 21-year-old at 8 weeks has been vomiting for 4 days. She can't keep fluids down, has lost 4 kg, and has ketones 3+.
Answer: Hyperemesis gravidarum.

• Ambulatory or inpatient IV 0.9% saline with potassium; thiamine; antiemetics (cyclizine, then ondansetron or metoclopramide).
• U&E, LFTs, TFTs; ultrasound for twins or molar pregnancy.
• LMWH while dehydrated; mental health support.

5. Combined screening shows a 1 in 40 chance of Down syndrome.
Answer: Higher-chance result.

• Offer NIPT, a diagnostic test (CVS now or amniocentesis from 15 weeks — about 0.5% miscarriage risk), or no further tests.
• Non-directive counselling; support whatever she decides.

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Key Points

• Folic acid 400 micrograms for all (5 mg if high risk) until 12 weeks; vitamin D 10 micrograms.
• Pertussis vaccine from 16 weeks, RSV vaccine from 28 weeks, and flu vaccine in every pregnancy; no live vaccines.
• Booking by 10 weeks; dating scan 11–14 weeks; anomaly scan 18–20+6 weeks; anti-D at 28 weeks if RhD-negative.
• Screening for HIV, hepatitis B, syphilis, blood group, antibodies, anaemia and haemoglobinopathies.
• Combined test: NT, PAPP-A, hCG — "higher chance" at 1 in 150 or more; offer NIPT or CVS/amniocentesis.
• Hyperemesis: weight loss over 5%, dehydration, electrolyte imbalance — fluids with potassium, thiamine, antiemetics, LMWH.
• Pregnancy of unknown location: hCG 48 hours apart — over 63% rise suggests intrauterine; over 50% fall suggests failing.
• Miscarriage: expectant first; mifepristone then misoprostol for missed miscarriage; surgical option.
• Ectopic: pain and bleeding at 6–8 weeks; methotrexate if small, no heartbeat, hCG under 1,500 and pain-free; surgery if hCG 5,000 or more, heartbeat, mass 35 mm or more, or pain.
• Molar pregnancy: very high hCG, hyperemesis, hyperthyroidism, snowstorm scan — evacuate and register for hCG follow-up.
• Abortion: two doctors under the Abortion Act; medical abortion at home up to 10 weeks; anti-D from 10 weeks.

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