In the absence of evidence-based therapeutic options for the majority of couples with recurrent pregnancy loss (RPL) it is considered significant to offer supportive care, including reliable counseling regarding the prognosis of subsequent pregnancies. Currently, various prediction models are available, with a focus on couples with unexplained RPL. All of them having drawbacks like substantial risk of bias, lack of performance measures and applicability. A new prediction model, using more predictors, such as male predictors and focusing on cumulative live birth rates over a reasonable time period is currently needed. In addition, this model should have the ability to provide reliable predictions at later time points, a so-called dynamic prediction model.

Gonococcal infection is the second most commonly reported bacterial infection. Untreated infection predisposes individuals to disseminated disease, which can result in dermatitis, tenosynovitis, migratory polyarthritis, or the “arthritis-dermatitis syndrome.” Disseminated gonococcal infection has a predilection for women and pregnancy is another risk factor. Suspect disseminated gonococcal infection in any sexually active woman (pregnant or otherwise) with septic arthritis. A history and physical examination usually lead to the working diagnosis; blood cultures, specimens from exposed mucosal surfaces, and affected synovial joint fluid aspirates help to confirm the diagnosis. Intravenous ceftriaxone is the mainstay of treatment, and complete resolution of symptoms without sequelae is the norm.

Hemoglobinopathies are vast grouping of inherited disorders of the hemoglobin chain genes that affect over 270 million people globally. The most common hemoglobinopathies include sickle cell, alpha- thalassemia, and beta-thalassemia. Each of these diseases has numerous phenotypes and thus presentation and management of each will vary. Generally, the carrier or asymptomatic states have pregnancy outcomes that mirror the general population. Patients with clinically significant disease are at increased risk for numerous maternal and fetal complications. All patients desiring pregnancy and those that are currently pregnant should be screened for hemoglobinopathy and those found to have one provided with genetic counseling regarding any potential maternal or fetal risks.

Fibroids are found in up to 10% of pregnant individuals and have been linked with multiple pregnancy complications. Most individuals will not experience fibroid-related pregnancy complications, but complications are more likely with larger and multiple fibroids. The risks of fibroids in pregnancy include preterm labor and delivery, fetal malpresentation, hemorrhage, and increased risk of cesarean delivery. Pregnant individuals should be counseled on these risks both during their antenatal care and upon admission to labor and delivery.

Hypothyroidism during pregnancy occurs when there is an increase in TSH levels. If the T4 levels are low, it is considered overt hypothyroidism; if the T4 levels are normal, it is subclinical hypothyroidism. The most common cause of hypothyroidism during pregnancy is Hashimoto’s disease, characterized by anti-thyroid peroxidase antibodies. Pregnant women with a history of thyroid disease, type 1 diabetes, or those experiencing symptoms such as fatigue, constipation, cold intolerance, dry skin, hair loss, and weight gain should be evaluated for thyroid disease. Uncontrolled hypothyroidism can lead to various complications such as spontaneous abortion, preterm birth, preeclampsia, abruptio placentae, stillbirth, low birth weight, and impaired neuropsychological development of the newborn. Treatment with levothyroxine (LT4) should be initiated when TSH levels are above 4 mU/L at a dose of 1–2 µg/kg/day or 100 µg/day. Adjust the dose every 4 weeks to maintain TSH concentrations at or below 2.5 mU/L. No additional fetal surveillance during pregnancy is recommended. If a patient is being treated for hypothyroidism, consider increasing the LT4 dose by 25% upon pregnancy confirmation. During postpartum, decrease LT4 to pre-pregnancy level. If LT4 was started during pregnancy, maintain the exact dosage to prevent the disease progression and support lactation.

The workup of urolithiasis during pregnancy often requires a multidisciplinary approach. This case examines the physical and anatomical changes in pregnancy that can lead to urolithiasis and the pathophysiology of the disease. Through a patient case, the physical findings, laboratory tests, and imaging studies needed to establish a diagnosis of urolithiasis in pregnancy is reviewed. Treatment options for urolithiasis and special considerations in the pregnant population are then discussed in detail, covering both conservative management and invasive procedures. Specific guidance is provided as to when additional imaging tests or consultation with interventional radiology or urology is warranted.

Placenta previa is a common and potentially life-threatening complication of pregnancy. Transvaginal ultrasound is the best method for diagnosis, and delivery should be via cesarean delivery. Women with uncomplicated placenta previa should be delivered at 36–37 weeks. Antepartum bleeding is a common presentation, during which maternal stabilization is paramount, followed by a decision for delivery based on the maternal and fetal clinical statuses. Placenta previa is also a risk factor for placenta accreta syndrome and should be considered at time of delivery. Postpartum hemorrhage is also common in these deliveries, and various techniques can be employed to diminish the blood loss, including uterotonics, uterine artery embolization, intrauterine balloon, and hysterectomy. Proper identification of blood loss at every stage and proper utilization of blood products is essential to good outcomes.

Sexual health is an important component of a person’s overall well-being. Physiologic, psychologic, anatomic, and hormonal changes inherent to pregnancy negatively affect sexual function. Sexual frequency and satisfaction progressively decline over the course of pregnancy, worsening in the third trimester. Initiating a discussion regarding sexuality during pre- and post-natal care can lessen the degree of sexual dysfunction. It is imperative for providers to counsel pregnant patients that the alterations in sexual function that occur during this time are normal and are seen in most antepartum patients. Additional management strategies include relationship nurturing, stress management, and addressing physical limitations that commonly arise with advancing gestation.

Velamentous umbilical cord insertion and vasa previa are rare ultrasound findings during pregnancy but carry an extremely high morbidity and mortality without prenatal diagnosis. Increased risk is associated with in vitro fertilization, multiple gestation, velamentous umbilical cord insertion, and vasa previa. At present, the recommendations continue to be based on a risk approach with ultrasound as the gold standard for diagnosis. The evaluation is improved with the addition of transvaginal ultrasound and Doppler flow. With known diagnosis, fetal growth surveillance is recommended due to increased risk for growth restriction. Current recommendations for vasa previa are cesarean delivery between 34 and 37 weeks. Inpatient management with known vasa previa is still unclear and a patient centered decision.

Cervical and endometrial polyps are benign masses that can cause abnormal uterine bleeding. In this case we discuss the etiology of these polyps and how they may be approached in pregnancy. Polyps are present in 2–5% of the general population. In pregnancy, polyps and their removal have been associated with vaginal bleeding and preterm labor. Management of polyps found during pregnancy is based on the presence or absence of symptoms and the site of origin of the polyp. Removal of decidual polyps are more likely to lead to complications such as preterm labor compared to those polyps that arise from the cervix. Ultrasound may help to distinguish the origin of symptomatic polyps to determine patient counseling and management.

Gestational diabetes mellitus (GDM) is defined as hyperglycemia first detected during the second or third trimester of pregnancy. It is diagnosed with an oral glucose tolerance test (OGTT), administered at 24–28 weeks’ gestation and universal screening is recommended for all pregnant women. Earlier testing in the first trimester is encouraged for women with risk factors for diabetes. Screening for GDM starts with a 1-hour, 50 g nonfasting screening test followed by a 3-hour, 100 g OGTT if the screening test is positive. Upon diagnosis, women should receive nutritional and exercise education and begin blood glucose monitoring. Women should target glucose levels below 95 mg/dL fasting and below 140 mg/dL at 1 hour or 120 mg/dL at 2 hours postprandially. Treatment of GDM reduces the risk of many of its complications. If glucose levels are not at target with lifestyle modifications, medical management should be initiated. Weight-based insulin is the recommend first-line therapy. However, metformin, an oral antidiabetic agent, can be considered in some cases. Gestational diabetes is an antecedent to type 2 diabetes and all women with GDM should be tested for underlying diabetes with a 2-hour 75 g OGTT at 4–12 weeks postpartum.

Congenital anomalies of the female reproductive tract are the result of deviations from normal embryologic development. While diverse in their clinical presentation and associated medical complications, all congenital genitourinary tract abnormalities can impact reproductive health and pregnancy. Uterine anomalies in pregnancy are associated with increased risk of first-trimester pregnancy loss, preterm birth, fetal malpresentation, and poor fetal growth. The degree of risk varies based on the type of uterine anomaly. Obstetric outcomes are usually good and vaginal birth should be encouraged if the fetus is in cephalic presentation and in the absence of any other indication for cesarean section.

Substance use disorders are a major risk factor for maternal mortality, and opioid overdose is a leading cause of maternal mortality in several states. Pregnant and postpartum patients should be assessed for substance use disorders using a validated screening tool, and if present, should be managed with counseling, initiation of pharmacotherapy, and referral for ongoing treatment. Acute presentations of opioid intoxication and opioid withdrawal should be identified and treated. The recommended treatment of opioid use disorder in pregnancy is pharmacotherapy using an opioid agonist. Either buprenorphine or methadone may be appropriate, depending on patient preferences and available treatment resources. Patients should receive education on recognition and prevention of opioid overdose and a prescription for naloxone for overdose reversal.

Once thought to be on target for eradication, syphilis prevalence is on the rise. Syphilis in pregnancy constitutes a significant risk to the health of mothers and infants. Screening should be performed for all pregnant individuals, though no single definitive laboratory test is widely available. Treponemal and nontreponemal tests are utilized in multistep algorithms to distinguish false from true-positive results and active from past infection. Provider familiarity with these algorithms allows for accurate diagnosis and treatment. Positive test results must be reported to local health officials. Duration of infection and disease sequalae determines categorization into primary, secondary, tertiary, and latent disease. Treatment of syphilis during pregnancy requires the administration of benzathine penicillin G even in penicillin allergic patients. Two or three doses of 2.4 million units intramuscularly are often indicated. Fetal assessment should include detailed ultrasound. Close follow-up is vital to successful risk mitigation and often involves the treatment of partners and infants.

This is a case of a 20-year-old gravida 2 para 0 patient at 14 weeks’ gestation who presents for her initial prenatal care evaluation. The patient has a history of documented genital herpes infections and expresses concern about her condition and how it can affect her pregnancy. The case reviews the pertinent information needed to diagnose, counsel, and manage a pregnant patient with herpes simplex virus (HSV). Patients should be provided with routine prenatal care, including regular prenatal checkups, ultrasounds, and blood tests. Antiviral medications such as acyclovir and valacyclovir can reduce the severity and frequency of herpes outbreaks. The primary goal of diagnosis and treatment of HSV infections in pregnancy is to prevent neonatal herpes. Also, the use of acyclovir and valacyclovir started at 36 weeks as a prophylactic measure with patients with a recurrent history of HSV infection has been shown to reduce the rate of recurrent infections and active viral shedding at the moment of delivery, which are known risk factors for neonatal infection.

Vaccination during pregnancy is an effective route of protecting pregnant individuals, their fetuses, and neonates from morbidity and mortality of vaccine preventable diseases. There is sufficient epidemiologic safety data to support routine administration of influenza vaccine, Tdap, and COVID-19 vaccine, however there are poor rates of vaccine uptake in pregnancy due to low vaccine confidence and barriers to care. Routine inactivated childhood vaccines, travel vaccines, and live attenuated vaccine recommendations are reviewed, and recommendations are made based on weighing the risk of exposure, risk of the vaccination, and necessity of travel.

Chapter 6 employs Welby’s Meaning Triad to investigate whether the boundary for the beginning of girlhood should be clearly identified in the international legal framework. It studies the definitions of child under international law and in the English language to assess whether they establish a beginning point for girlhood. It conducts two case studies concerning, respectively, the practice of prenatal sex selection and the right of young and adolescent girls to a safe abortion, to illustrate the significance for girl children of the current boundary for the beginning of girlhood under international law. It studies the sense, meaning and significance of provisions in the Convention on the Rights of the Child (CRC), the International Covenant on Civil and Political Rights (ICCPR) and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and refers to their respective travaux préparatoires.