A 32-year-old female complains of crampy abdominal pain. She tells you she is 20 weeks pregnant. She has moderate vaginal bleeding. You should suspect:

• A. Ectopic pregnancy.
• B. Uterine rupture.
• C. Spontaneous abortion.
• D. Severe mittelschmerz.

Answer: (C)

This question tests recognizing miscarriage in mid-pregnancy based on cramping and vaginal bleeding. When a pregnant patient presents with crampy abdominal pain and moderate vaginal bleeding around the mid-gestation period, the most likely explanation is spontaneous abortion. Ectopic pregnancy is typically a first-trimester concern and often presents with unilateral pain and adnexal tenderness rather than mid-pregnancy onset. Uterine rupture usually occurs in the setting of labor or late pregnancy with a prior uterine scar and presents with sudden, severe pain and signs of maternal instability or fetal distress. Severe mittelschmerz is ovulation pain and not something that occurs in the setting of an ongoing pregnancy. Therefore, the presentation fits best with a spontaneous abortion.