see attachment
Week3DPresponse-1.pdf
Table 1: Standard Levels of hCG During Pregnancy
Table 2: hCG Trends in Various Pregnancy Scenarios
Table 3: Common Com
May 31, 2025
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see attachment
Week3DPresponse-1.pdf
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
Table 1: Standard Levels of hCG During Pregnancy
Table 2: hCG Trends in Various Pregnancy Scenarios
Table 3: Common Complaints During Pregnancy
Subjective
Other Medical History Questions
Other Social History Questions
Objective
Vital Signs:
Assessment / Diagnosis
4. Plan
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