Week 3 DP Response

Table 1: Standard Levels of hCG During Pregnancy

Table 2: hCG Trends in Various Pregnancy Scenarios

Table 3: Common Complaints During Pregnancy

GA Weeks (LMP) hCG Level (mIU/mL)

3 weeks LMP 5 – 50

4 weeks LMP 5 – 426

5 weeks LMP 18 – 7,340

6 weeks LMP 1,080 – 56,500

7–8 weeks LMP 7,650 – 229,000

9–12 weeks LMP 25,700 – 288,000

13–16 weeks LMP 13,300 – 254,000

17–24 weeks LMP 4,060 – 165,400

25–40 weeks LMP 3,640 – 117,000

Non-pregnant < 5

Scenario Beta hCG Level Expected to...

Normal ongoing pregnancy Increase by 66% or more in 48–72 hours

Spontaneous abortion (miscarriage)

Decrease by 21–35% or more in 48–72 hours

Ectopic pregnancy Increase slowly, plateau, or decrease

Gestational trophoblastic pregnancy Increase excessively/highly elevated

Sympt om

Definition and Cause

Presentation & Possible DDX Treatment Education

Consti pation

Progesterone relaxes bowel muscles; slowed GI motility

Infrequent, hard stools; bloating; DDX: bowel obstruction, hypothyroidism

High fiber diet, hydration, physical activity; docusate or psyllium as needed

Avoid stimulant laxatives; increase water and fiber intake

Back Pain

Postural changes, weight gain, ligament laxity

Lumbar pain, worse at end of day; DDX: UTI, kidney stones

Heat, stretching, massage, acetaminophen

Posture support, avoid heavy lifting, supportive shoes

GERD

Relaxation of LES due to progesterone; enlarged uterus compresses stomach

Heartburn, sour taste; DDX: PUD, cardiac chest pain

Small meals, antacids, H2 blockers or PPIs if needed

Elevate head of bed, avoid spicy/ fatty foods, don’t lie flat after meals

Fatigu e

Hormonal changes, increased energy demands

General tiredness; DDX: anemia, hypothyroidism, depression

Rest, naps, iron supplements if anemic

Normalize fatigue; encourage sleep and balanced nutrition

Heart Palpita tions

Increased blood volume and cardiac output

Sensation of fluttering; DDX: arrhythmia, anemia, hyperthyroidism

Reassurance, EKG if abnormal or symptomatic

Usually benign; report if associated with SOB, dizziness, or chest pain

Urinar y Freque ncy

Uterine pressure on bladder, increased renal perfusion

Frequent urination without pain; DDX: UTI

Rule out infection; otherwise reassurance

Void regularly, stay hydrated, report burning or urgency

Nause a and Vomiti ng

hCG and estrogen effects on GI system

Typically 1st trimester; DDX: gastroenteritis, hyperemesis gravidarum

Vitamin B6, doxylamine, small bland meals, antiemetics if severe

Often resolves by 2nd trimester; eat small meals, avoid triggers

Subjective

• Bleeding began 3 days ago as spotting and has since become light period-like bleeding. It is ongoing.

• She denies any pain. No specific mention of other symptoms; these should be clarified during the visit.

• No prior pregnancies, miscarriages, or abortions

• The patient had unprotected intercourse two days prior

• No traumas or strenuous activity

• Denies any nausea, vomiting, breast tenderness, or fatigue 
 


Other Medical History Questions

• Menstrual history: amenorrhea x2 months with positive pregnancy test. STI and Pap history: none

• No chronic medical conditions

• No medication/food/environmental allergies

Round Ligam ent Pain

Stretching of uterine ligaments as uterus enlarges

Sharp, brief pain in groin/lower abdomen; DDX: appendicitis, ovarian torsion

Reassurance, position changes, acetaminophen

Normal; avoid sudden movements; use warm compress

Hyper pigme ntation

Hormonal stimulation of melanocytes (e.g., melasma, linea nigra)

Dark patches on face, abdomen; DDX: Addison’s disease

Usually no treatment needed

Common and benign; usually fades postpartum

Sleep Distur bance

Hormonal changes, discomfort, anxiety, nocturia

Trouble falling or staying asleep; DDX: depression, restless legs syndrome

Sleep hygiene, relaxation techniques, left side sleeping

Avoid caffeine, screens; use pillows for support; maintain sleep schedule

• Vaccinations are up to date for her age, COVID vaccine received (no boosters)

• Mental Health Screening Complete: No risk

Other Social History Questions

• Denies substance use (tobacco, alcohol, drugs

• Social support system: Mother, Father, Partner, Best Friends

• Intimate partner violence screening: Denies

• Senior Year in High-school

• Stable home environment

Objective

a. Head-to-toe assessment:

• Vital Signs:

o Temperature: 98.4°F (36.9°C)

o Heart Rate (HR): 84 beats per minute

o Respiratory Rate (RR): 16 breaths per minute

o Blood Pressure (BP): 110/68 mmHg

o Oxygen Saturation (SpO₂): 98% on room air

o Weight: 132 lbs (59.9 kg)

o BMI: 22 – Normal weight range

• HEENT: Hydration status

• Cardiac/Respiratory: Baseline function

• Abdomen: Palpation for tenderness, guarding, masses

• Pelvic exam:

o External genitalia inspection

o Speculum exam: check for active bleeding, source of bleeding (cervix vs vaginal)

o Bimanual exam: uterine size, adnexal masses/tenderness, cervical motion tenderness

b. Tests and rationale:

• Quantitative beta-hCG: Monitor pregnancy progression or loss (Doubling every 48–72h is expected in viable pregnancy)

• Transvaginal ultrasound: Confirm intrauterine pregnancy or assess for ectopic (TVUS can detect gestational sac at hCG ≥1500–2000 mIU/mL)

• CBC: Evaluate for anemia or infection

• Type and screen: Determine Rh status (important if Rh-negative and bleeding)

• STI screening: Chlamydia, gonorrhea, HIV, syphilis, Hep B/C

• Pap smear (if due)

Assessment / Diagnosis

a. Presumptive diagnosis:

• Threatened abortion (vaginal bleeding with closed cervix and viable intrauterine pregnancy)

Differential diagnoses:

• Early intrauterine pregnancy with normal implantation bleeding

• Ectopic pregnancy

• Spontaneous abortion (inevitable, incomplete, or missed)

• Molar pregnancy (less likely with current hCG levels)

b. Additional differentials:

• Cervical pathology (polyps, ectropion)

• Coagulopathy or bleeding disorder

c. HCG results interpretation:

• Day 1 hCG: 1200 mIU/mL

• Day 3 hCG: 550 mIU/mL → Significant decline (>50%)

Diagnosis:

• Spontaneous abortion (miscarriage) 
 This is supported by a falling hCG level, which indicates a nonviable pregnancy.

4. Plan

a. Explaining hCG results:

• “Your hCG level has dropped significantly, which indicates that the pregnancy is no longer progressing. This means that you are likely having a miscarriage.”

b. Treatment & follow-up:

Options:

1. Expectant management – allow natural passage of tissue.

2. Medical management – misoprostol to induce expulsion.

3. Surgical management – uterine aspiration/D&C if heavy bleeding, infection, or incomplete passage.

Medications:

• Misoprostol (600–800 mcg vaginally or orally)

o Side effects: cramping, bleeding, nausea, diarrhea

o Success rate: ~80-90% in early pregnancy loss (ACOG, 2018)

Partner notification:

• Not typically required unless STI is suspected.

Follow-up:

• Repeat hCG until <5 mIU/mL

• Monitor for signs of infection or retained products

• Ultrasound if bleeding persists or incomplete passage is suspected

c. Patient education:

• Emotional support: Normalize grief response, provide reassurance

• Sexual activity: Wait until bleeding stops and no signs of infection (usually 1–2 weeks)

• Contraception: Discuss short-term options if not ready to conceive

• Trying to conceive again: Safe to try after 1 normal menstrual cycle; ACOG supports early attempts if emotionally ready

• Red flags: heavy bleeding, foul-smelling discharge, fever, severe pain → return immediately