Induction of labor indications and methods US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Induction of labor indications and methods. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Induction of labor indications and methods US Medical PG Question 1: A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management?
- A. Plan for oxytocin administration (Correct Answer)
- B. Perform weekly pelvic ultrasound
- C. Perform dilation and curettage
- D. Perform cesarean delivery
- E. Administer magnesium sulfate
Induction of labor indications and methods Explanation: ***Plan for oxytocin administration***
- The patient is at 26 weeks' gestation with confirmed fetal demise and an effaced, dilated cervix (2 cm long, 3 cm dilated). This indicates the cervix is already preparing for delivery.
- **Oxytocin** is the most appropriate next step to induce labor and facilitate vaginal delivery in cases of **intrauterine fetal demise** (IUFD) after the first trimester, especially when cervical changes have begun.
*Perform weekly pelvic ultrasound*
- The ultrasound has already confirmed **absent fetal cardiac activity**, making repeated ultrasounds unnecessary as the diagnosis of IUFD is already established.
- This option would delay necessary management and exposure to the deceased fetus in utero could increase risks such as **coagulopathy** if prolonged.
*Perform dilation and curettage*
- **Dilation and curettage (D&C)** is generally reserved for termination of pregnancy or management of miscarriage up to **16-18 weeks' gestation**.
- At **26 weeks' gestation**, the size of the fetus and uterus makes D&C a less safe and less effective procedure compared to labor induction.
*Perform cesarean delivery*
- **Cesarean delivery** for IUFD is typically reserved for cases with maternal indications (e.g., prior classical C-section scar, placenta previa obstructing the birth canal) or when labor induction fails.
- There are no maternal or fetal contraindications to vaginal delivery in this scenario, and a C-section would primarily increase maternal morbidity without fetal benefit.
*Administer magnesium sulfate*
- **Magnesium sulfate** is used for **neuroprotection** in preterm deliveries (usually before 32 weeks) and seizure prophylaxis in **preeclampsia/eclampsia**.
- As the fetus is deceased, neuroprotection is not applicable, and there are no signs of preeclampsia, making this intervention inappropriate.
Induction of labor indications and methods US Medical PG Question 2: A 30-year-old G3P0 woman who is 28 weeks pregnant presents for a prenatal care visit. She reports occasionally feeling her baby move but has not kept count over the past couple weeks. She denies any bleeding, loss of fluid, or contractions. Her previous pregnancies resulted in spontaneous abortions at 12 and 14 weeks. She works as a business executive, has been in excellent health, and has had no surgeries. She states that she hired a nutritionist and pregnancy coach to ensure good prospects for this pregnancy. On physical exam, fetal heart tones are not detected. Abdominal ultrasound shows a 24-week fetal demise. The patient requests an autopsy on the fetus and wishes for the fetus to pass "as naturally as possible." What is the best next step in management?
- A. Induction of labor now (Correct Answer)
- B. Dilation and evacuation
- C. Dilation and curettage
- D. Induction of labor at term
- E. Caesarean delivery
Induction of labor indications and methods Explanation: ***Induction of labor now***
- With a confirmed **fetal demise at 28 weeks**, induction of labor is the most appropriate and respectful approach, allowing the patient's request to pass "as naturally as possible" to be honored and initiating the grieving process.
- Delaying labor induction can lead to increased risks of **coagulopathy** (disseminated intravascular coagulation) due to retained fetal tissue, and also prolonged emotional distress for the patient.
*Dilation and evacuation*
- While D&E is a common method for second-trimester termination or fetal demise, it is typically performed earlier in pregnancy (up to 24 weeks) and may not align with the patient's wish for the fetus to pass "as naturally as possible" for a 28-week demise.
- Given the patient's strong emotional investment in this pregnancy and desire for an autopsy, a D&E might be perceived as less respectful or less natural than labor induction.
*Dilation and curettage*
- **Dilation and curettage (D&C)** is primarily used for first-trimester miscarriages or early second-trimester procedures and is not suitable for a 28-week fetal demise due to the size of the fetus.
- Performing a D&C at this gestational age would be technically difficult and carry a higher risk of complications, including uterine perforation.
*Induction of labor at term*
- Waiting until term for a known fetal demise at 28 weeks is medically inappropriate and dangerous due to the significant risk of **disseminated intravascular coagulation (DIC)** developing from retained fetal tissue.
- Prolonged retention of a deceased fetus also significantly increases the emotional and psychological burden on the patient.
*Caesarean delivery*
- **Caesarean delivery** is generally reserved for live births where there is a medical indication for surgical delivery or in cases of an intact dilation and extraction procedure which is not typically first line for fetal demise at this gestation.
- Performing a C-section for a fetal demise offers no benefit to the fetus and carries unnecessary surgical risks for the mother, including infection, hemorrhage, and complications in future pregnancies.
Induction of labor indications and methods US Medical PG Question 3: A student health coordinator plans on leading a campus-wide HIV screening program that will be free for the entire undergraduate student body. The goal is to capture as many correct HIV diagnoses as possible with the fewest false positives. The coordinator consults with the hospital to see which tests are available to use for this program. Test A has a sensitivity of 0.92 and a specificity of 0.99. Test B has a sensitivity of 0.95 and a specificity of 0.96. Test C has a sensitivity of 0.98 and a specificity of 0.93. Which of the following testing schemes should the coordinator pursue?
- A. Test A on the entire student body followed by Test B on those who are positive
- B. Test A on the entire student body followed by Test C on those who are positive
- C. Test C on the entire student body followed by Test B on those who are positive
- D. Test C on the entire student body followed by Test A on those who are positive (Correct Answer)
- E. Test B on the entire student body followed by Test A on those who are positive
Induction of labor indications and methods Explanation: ***Test C on the entire student body followed by Test A on those who are positive***
- To "capture as many correct HIV diagnoses as possible" (maximize true positives), the initial screening test should have the **highest sensitivity**. Test C has the highest sensitivity (0.98).
- To "capture as few false positives as possible" (maximize true negatives and confirm diagnoses), the confirmatory test should have the **highest specificity**. Test A has the highest specificity (0.99).
*Test A on the entire student body followed by Test B on those who are positive*
- Starting with Test A (sensitivity 0.92) would miss more true positive cases than starting with Test C (sensitivity 0.98), failing the goal of **capturing as many cases as possible**.
- Following with Test B (specificity 0.96) would result in more false positives than following with Test A (specificity 0.99).
*Test A on the entire student body followed by Test C on those who are positive*
- This scheme would miss many true positive cases initially due to Test A's lower sensitivity compared to Test C.
- Following with Test C would introduce more false positives than necessary, as it has a lower specificity (0.93) than Test A (0.99).
*Test C on the entire student body followed by Test B on those who are positive*
- While Test C is a good initial screen for its high sensitivity, following it with Test B (specificity 0.96) is less optimal than Test A (specificity 0.99) for minimizing false positives in the confirmation step.
- This combination would therefore yield more false positives in the confirmatory stage than using Test A.
*Test B on the entire student body followed by Test A on those who are positive*
- Test B has a sensitivity of 0.95, which is lower than Test C's sensitivity of 0.98, meaning it would miss more true positive cases at the initial screening stage.
- While Test A provides excellent specificity for confirmation, the initial screening step is suboptimal for the goal of capturing as many diagnoses as possible.
Induction of labor indications and methods US Medical PG Question 4: A 25-year-old G1P0 at 20 weeks of gestation woman arrives at a prenatal appointment complaining of pelvic pressure. She has had an uncomplicated pregnancy thus far. She takes prenatal vitamins and eats a well-balanced diet. Her medical history is significant for major depressive disorder that has been well-controlled on citalopram. Her mother had gestational diabetes with each of her 3 pregnancies. On physical exam, the cervix is soft and closed with minimal effacement. There is white vaginal discharge within the vagina and vaginal vault without malodor. Vaginal pH is 4.3. A transvaginal ultrasound measures the length of the cervix as 20 mm. Which of the following is most likely to prevent preterm birth in this patient?
- A. Pessary
- B. Vaginal progesterone (Correct Answer)
- C. Metformin
- D. Metronidazole
- E. Prednisone
Induction of labor indications and methods Explanation: ***Vaginal progesterone***
- This patient has a **short cervical length** (20 mm at 20 weeks gestation), and **vaginal progesterone** has been shown to reduce the risk of **spontaneous preterm birth** in women with a singleton pregnancy and a short cervix.
- While she has subjective pelvic pressure, the physical exam shows a closed cervix, making her a candidate for prophylactic intervention rather than immediate treatment for active labor.
*Pessary*
- A **cervical pessary** can be used to prevent **preterm birth** in women with a short cervix, but evidence suggests **vaginal progesterone** is often preferred as a first-line intervention in singleton pregnancies due to ease of use and good evidence base.
- While it's an option, it's generally considered secondary to progesterone in this specific scenario.
*Metformin*
- **Metformin** is used to treat **gestational diabetes** or **type 2 diabetes** and is not indicated for the prevention of preterm birth.
- While her mother had gestational diabetes, this patient has not been diagnosed with it, nor is prevention of preterm birth an indication for metformin use.
*Metronidazole*
- **Metronidazole** is an antibiotic used to treat **bacterial vaginosis** or **trichomoniasis**.
- While she has vaginal discharge, the pH of 4.3 and lack of malodor do not suggest bacterial vaginosis or trichomoniasis, and metronidazole does not prevent preterm birth.
*Prednisone*
- **Prednisone** is a corticosteroid used to manage inflammatory conditions or to promote **fetal lung maturity** in cases of threatened preterm labor.
- It is not used to prevent preterm birth and would not be indicated for this patient whose cervix is closed and appears to be experiencing benign pelvic pressure rather than active labor.
Induction of labor indications and methods US Medical PG Question 5: A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?
- A. Vibroacoustic stimulation
- B. Routine monitoring (Correct Answer)
- C. Administer tocolytics
- D. Emergent cesarean delivery
- E. Placement of fetal scalp electrode
Induction of labor indications and methods Explanation: ***Routine monitoring***
- The presented FHR tracing exhibits a **normal baseline rate** (145/min), **moderate variability** (≥15/min), and the presence of **accelerations**, indicating a reassuring fetal status.
- The described decelerations are **variable decelerations** due to their sudden onset, nadir within 30 seconds, and variable relationship to contractions, which are generally benign unless prolonged, deep, or repetitive. Given the otherwise reassuring status, continued routine monitoring is appropriate.
*Vibroacoustic stimulation*
- This intervention is used to elicit **fetal accelerations** or movement during non-stress tests (NSTs) when the fetus is quiet or shows a non-reactive pattern.
- In this case, the fetus is already showing **accelerations** and moderate variability, so stimulation is not needed to assess fetal well-being.
*Administer tocolytics*
- **Tocolytics** are used to stop or slow down labor, typically in cases of preterm labor or uterine tachysystole causing fetal distress.
- This patient is at **38 weeks' gestation** and in active labor, and there are no signs of fetal distress warranting the cessation of contractions.
*Emergent cesarean delivery*
- **Emergent cesarean delivery** is indicated for acute fetal distress, such as prolonged decelerations, significant bradycardia, or absent variability in conjunction with other concerning FHR patterns.
- The FHR tracing described is largely reassuring with moderate variability and accelerations, and the variable decelerations are not indicative of immediate threat, making emergent delivery unnecessary.
*Placement of fetal scalp electrode*
- A **fetal scalp electrode** provides a more accurate and continuous measure of the FHR, often used when external monitoring is difficult or when there are concerns about the reliability of the tracing.
- While it can be useful in some situations, the current tracing is **interpretable as reassuring**, making invasive monitoring currently unnecessary.
Induction of labor indications and methods US Medical PG Question 6: A 29-year-old G2P1 at 35 weeks gestation presents to the obstetric emergency room with vaginal bleeding and severe lower back pain. She reports the acute onset of these symptoms 1 hour ago while she was outside playing with her 4-year-old son. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She received appropriate prenatal care during both pregnancies. She has a history of myomectomy for uterine fibroids. Her past medical history is notable for diabetes mellitus. She takes metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 104/68 mmHg, pulse is 120/min, and respirations are 20/min. On physical examination, the patient is in moderate distress. Large blood clots are removed from the vaginal vault. Contractions are occurring every 2 minutes. Delayed decelerations are noted on fetal heart monitoring. Which of the following is the most likely cause of this patient's symptoms?
- A. Premature separation of a normally implanted placenta (Correct Answer)
- B. Amniotic sac rupture prior to the start of uterine contractions
- C. Placental implantation over internal cervical os
- D. Chorionic villi attaching to the myometrium
- E. Chorionic villi attaching to the decidua basalis
Induction of labor indications and methods Explanation: ***Premature separation of a normally implanted placenta***
- The acute onset of **vaginal bleeding**, **severe lower back pain**, frequent uterine contractions, and **fetal decelerations** in a patient with risk factors like a prior cesarean section and diabetes mellitus are highly suggestive of **abruptio placentae**.
- **Uterine tenderness** and a **firm, rigid uterus** (though not explicitly stated, implied by contractions and pain) are also characteristic findings.
*Amniotic sac rupture prior to the start of uterine contractions*
- This condition presents with a gush of fluid from the vagina, often without significant bleeding or severe pain unless associated with other complications.
- While it can lead to preterm labor, it doesn't directly cause the severe back pain, heavy bleeding with clots, and fetal distress seen here.
*Placental implantation over internal cervical os*
- This describes **placenta previa**, which typically presents with **painless vaginal bleeding**, often bright red, without severe abdominal or back pain.
- The presence of severe abdominal pain and uterine contractions makes placenta previa less likely.
*Chorionic villi attaching to the myometrium*
- This describes **placenta accreta**, a condition where the placenta abnormally adheres to the myometrium. It is typically diagnosed postnatally with **difficulty in placental separation** and severe hemorrhage.
- While a prior C-section is a risk factor, the acute presentation of pain and bleeding in the antepartum period is not the classic presentation of accreta alone.
*Chorionic villi attaching to the decidua basalis*
- This describes the **normal implantation** of the placenta into the decidua basalis of the uterus.
- This is the physiological process of pregnancy and would not cause the symptoms of vaginal bleeding, severe pain, and fetal distress described.
Induction of labor indications and methods US Medical PG Question 7: A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?
- A. Uterine inertia
- B. Amniotic fluid embolism
- C. Uterine rupture (Correct Answer)
- D. Vasa previa
- E. Abruptio placentae
Induction of labor indications and methods Explanation: ***Uterine rupture***
- The patient's history of a prior **cesarean section**, sudden onset of **vaginal bleeding** and **severe abdominal pain**, resolution of contractions, and signs of **hypovolemic shock** (tachycardia, hypotension) coupled with fetal distress (variable decelerations) are highly indicative of uterine rupture.
- Diffuse abdominal tenderness without rebound or guarding, and no palpable contractions, are also consistent with rupture.
*Uterine inertia*
- This condition is characterized by **weak or uncoordinated uterine contractions** leading to prolonged labor, but it does not typically present with acute vaginal bleeding, sudden severe abdominal pain, or hypovolemic shock.
- Fetal distress in uterine inertia would more likely be due to prolonged labor rather than acute compromise following a sudden event.
*Amniotic fluid embolism*
- This is a rare, life-threatening obstetric emergency characterized by sudden **cardiovascular collapse, respiratory distress**, and **coagulopathy**, often occurring during labor or immediately postpartum.
- While it can cause fetal distress, vaginal bleeding and severe abdominal pain are not primary presenting symptoms.
*Vasa previa*
- Characterized by **painless vaginal bleeding** when fetal vessels within the membranes cross the internal cervical os, making them vulnerable to rupture during cervical dilation or amniotomy.
- The bleeding is typically fetal blood, and fetal distress occurs rapidly, but the mother would not experience severe abdominal pain or signs of hypovolemic shock unless the bleeding is substantial and prolonged.
*Abruptio placentae*
- This involves the **premature separation of the placenta**, causing painful vaginal bleeding, uterine tenderness, and frequent, strong contractions.
- While it can cause hypovolemic shock and fetal distress, the description of contractions stopping after bleeding started, along with a previous C-section scar, points more specifically to uterine rupture rather than an abruption.
Induction of labor indications and methods US Medical PG Question 8: A 37-year-old woman, gravida 2, para 1, at 35 weeks' gestation is brought to the emergency department for the evaluation of continuous, dark, vaginal bleeding and abdominal pain for one hour. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. The patient has a history of hypertension and has been noncompliant with her hypertensive regimen. Her medications include methyldopa, folic acid, and a multivitamin. Her pulse is 90/min, respirations are 16/min, and blood pressure is 145/90 mm Hg. The abdomen is tender, and hypertonic contractions can be felt. There is blood on the vulva, the introitus, and on the medial aspect of both thighs. The fetus is in a breech presentation. The fetal heart rate is 180/min with recurrent decelerations. Which of the following is the cause of fetal compromise?
- A. Rupture of the uterus
- B. Placental tissue covering the cervical os
- C. Rupture of aberrant fetal vessels
- D. Abnormal position of the fetus
- E. Detachment of the placenta (Correct Answer)
Induction of labor indications and methods Explanation: ***Detachment of the placenta***
- The presentation of **continuous, dark vaginal bleeding**, **abdominal pain**, and **hypertonic contractions** in a pregnant woman with hypertension strongly indicates **placental abruption**.
- **Fetal compromise**, evidenced by a fetal heart rate of 180/min with recurrent decelerations, results from the compromised oxygen and nutrient exchange due to placental detachment.
*Rupture of the uterus*
- Uterine rupture typically presents with **sudden sharp abdominal pain**, **vaginal bleeding**, and often **cessation of uterine contractions**, which is contradicted by hypertonic contractions.
- A previous C-section scar is a risk factor, but the clinical picture with continuous dark bleeding and hypertonic contractions points more strongly to abruption.
*Placental tissue covering the cervical os*
- This describes **placenta previa**, which typically causes **painless, bright red vaginal bleeding** and usually does not present with abdominal pain or hypertonic contractions.
- The characteristics of pain and dark bleeding make placenta previa less likely.
*Rupture of aberrant fetal vessels*
- This condition, known as **vasa previa**, involves the rupture of fetal blood vessels, leading to **fetal blood loss** and rapid fetal compromise.
- However, the presenting symptoms usually include **sudden onset of bleeding with concurrent fetal bradycardia** or distress, and the vaginal bleeding is typically bright red fetal blood, not dark maternal blood as described.
*Abnormal position of the fetus*
- An abnormal fetal position, such as **breech presentation**, can complicate delivery but does not directly cause dark vaginal bleeding, abdominal pain, or hypertonic uterine contractions.
- While the fetus is breech, this finding does not explain the acute maternal symptoms or the signs of placental compromise.
Induction of labor indications and methods US Medical PG Question 9: A 34-year-old G3P2 is admitted to the hospital after being physically assaulted by her husband. She developed severe vaginal bleeding and abdominal pain. She is at 30 weeks gestation. Her previous pregnancies were uncomplicated, as has been the course of the current pregnancy. The vital signs are as follows: blood pressure, 80/50 mmHg; heart rate, 117/min and irregular; respiratory rate, 20/min; and temperature, 36.2℃ (97.1). The fetal heart rate is 103/min. On physical examination, the patient is pale and lethargic. Abdominal palpation reveals severe uterine tenderness and tetanic contractions. The perineum is grossly bloody. There are no vaginal or cervical lesions. There is active heavy bleeding with blood clots passing through the cervix. An ultrasound shows a retroplacental hematoma with a volume of approximately 400 ml.
Laboratory workup shows the following findings:
Red blood cells count: 3.0 millions/mL
Hb%: 7.2 g/dL
Platelet count: 61,000/mm3
Prothrombin time: 310 seconds (control 20 seconds)
Partial prothrombin time: 420 seconds
Serum fibrinogen: 16 mg/dL
Elevated levels of which of the following laboratory markers is characteristic for this patient’s complication?
- A. C-reactive protein
- B. D-dimer (Correct Answer)
- C. Creatinine
- D. Pro-brain natriuretic peptide
- E. Procalcitonin
Induction of labor indications and methods Explanation: *** **D-dimer***
- This patient's presentation with **severe vaginal bleeding**, **abdominal pain**, **uterine tenderness**, **tetanic contractions**, and **fetal distress** following trauma, along with the ultrasound finding of a **retroplacental hematoma**, is highly suggestive of **abruptio placentae**.
- The abnormal coagulation panel (low platelets, prolonged PT/PTT, low fibrinogen) indicates **disseminated intravascular coagulation (DIC)**, a common complication of severe placental abruption due to extensive activation of the coagulation cascade and subsequent breakdown of clots. **D-dimer levels** are characteristically **elevated** in DIC as they are degradation products of **fibrin** from enhanced fibrinolysis.
*C-reactive protein*
- **C-reactive protein (CRP)** is an **acute-phase reactant** primarily elevated in response to **inflammation** or **infection**.
- While trauma could induce some inflammation, very high CRP levels are not specific for **DIC** or the direct complications of **placental abruption** described.
*Creatinine*
- **Creatinine** is a marker of **renal function**. While severe shock and hypoperfusion from significant bleeding could lead to **acute kidney injury** and elevated creatinine, it is not a direct or characteristic marker of the **coagulopathy** or **DIC** seen in this patient.
- The primary issue presented is one of **bleeding and coagulation abnormalities**, not primarily renal dysfunction.
*Pro-brain natriuretic peptide*
- **Pro-brain natriuretic peptide (pro-BNP)** is a biomarker primarily used to assess **cardiac stretch** and **heart failure**.
- There are no clinical signs or symptoms presented that suggest **cardiac dysfunction** as the primary or most characteristic complication in this setting.
*Procalcitonin*
- **Procalcitonin** is a biomarker that is significantly elevated in **bacterial infections** and **sepsis**.
- Although the patient's condition is critical, the clinical picture strongly points towards **hemorrhage** and **DIC** due to **placental abruption** rather than a primary **bacterial infection**.
Induction of labor indications and methods US Medical PG Question 10: A 30-year-old primigravida schedules an appointment with her obstetrician for a regular check-up. She says that everything is fine, although she reports that her baby has stopped moving as much as previously. She is 22 weeks gestation. She denies any pain or vaginal bleeding. The obstetrician performs an ultrasound and also orders routine blood and urine tests. On ultrasound, there is no fetal cardiac activity or movement. The patient is asked to wait for 1 hour, after which the scan is to be repeated. The second scan shows the same findings. Which of the following is the most likely diagnosis?
- A. Missed abortion
- B. Ectopic pregnancy
- C. Complete abortion
- D. Fetal demise (Correct Answer)
- E. Incomplete abortion
Induction of labor indications and methods Explanation: ***Fetal demise***
- The absence of fetal cardiac activity and movement on repeated ultrasound scans at 22 weeks' gestation, after previously reporting fetal movement, is consistent with **fetal demise**.
- **Fetal demise** refers to the death of a fetus in utero at or after 20 weeks of gestation, or when the fetus weighs 350 grams or more.
*Missed abortion*
- **Missed abortion** (or missed miscarriage) is typically defined as a non-viable intrauterine pregnancy with a retained fetus or embryo without cardiac activity before 20 weeks of gestation.
- The patient is 22 weeks gestation, which places the condition beyond the general definition of a missed abortion.
*Ectopic pregnancy*
- In an **ectopic pregnancy**, the fertilized egg implants outside the uterus, most commonly in the fallopian tube, and would not have reached 22 weeks with reported fetal movement.
- An ectopic pregnancy would present with earlier symptoms like **abdominal pain** and **vaginal bleeding**, and an ultrasound would show an empty uterus or evidence of extrauterine pregnancy.
*Complete abortion*
- A **complete abortion** involves the complete expulsion of all products of conception from the uterus.
- This would be characterized by **heavy vaginal bleeding** and the passage of tissue, which the patient denies.
*Incomplete abortion*
- An **incomplete abortion** occurs when some, but not all, products of conception have been expelled from the uterus.
- Similar to complete abortion, an incomplete abortion would typically involve **vaginal bleeding** and retained tissue, accompanied by **cramping**, which are absent in this case.
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