Updated: 2/29/2020

Diagnosis of Pregnancy

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  • Snapshot
    • A 24-year-old G0P0 comes to clinic for 9 weeks of amenorrhea, nausea, and bloating. She does not endorse spotting. She has no medical history. Menarche began at age 12, and she typically has her menstrual cycle every 28-35 days. She is sexually active with her boyfriend and uses barrier protection inconsistently. Her temperature is 98.6°F, blood pressure is 114/78, pulse is 70/min, and respirations are 14/min. A serum hCG test is positive and a transvaginal ultrasound demonstrates a gestational sac.
  • Introduction
    • Overview
      • diagnosis of pregnancy is made based on any one of the following
        • human chorionic gonadotropin (hCG) detection
          • urine or blood
        • ultrasound examination
        • Doppler ultrasound exam (detect fetal cardiac activity)
  • Presentation
    • History
      • sexual activity without adequate and consistent contraception
      • patient thinks she may be pregnant
      • positive home pregnancy test
    • Symptoms
      • most common
        • amenorrhea
        • breast tenderness and enlargement
        • nausea +/- vomiting
        • fatigue
        • increased urinary frequency
    • Physical exam
      • globular and enlarged uterus
        • 6-8 weeks
          • size of a small pear
        • 8-10 weeks
          • size of an orange
        • 10-12 weeks
          • size of a grapefruit
        • 12 weeks
          • uterus can be palpated abdominally
        • 16 weeks
          • uterus palpable halfway between symphysis pubis and umbilicus
      • cervical softening
        • 6 weeks
      • bluish mucous membranes (Chadwick sign)
        • 8-12 weeks
      • larger and tender breasts
      • darker aereolas
      • linea nigra
  • Imaging
    • Ultrasound
      • indications
        • diagnosis of pregnancy
        • confirmation of intrauterine pregnancy
      • views
        • transvaginal
      • findings
        • 4.5-5 weeks
          • gestational sac
        • 5-6 weeks
          • yolk sac
        • 5.5-6 weeks
          • fetal pole
        • 10-12 weeks
          • fetal cardiac activity
      • sensitivity and specificity
        • presence of gestational sac on ultrasound
          • ~53% sensitivity and 98% specificity
    • Doppler ultrasound exam
      • indications
        • detect fetal cardiac activity
        • identify early fetal malformations
      • views
        • transabdominal
      • findings
        • hypervascular rim around corpus luteum
        • changes in uterine artery pulsatility index
  • Studies
    • Serum labs
      • human chorionic gonadotropin (hCG)
        • more sensitive than urine test
          • preferred when menstrual period ≤ 1 week late
        • earliest detection 6 days after ovulation
        • cannot use to estimate gestational age beyond 3 weeks
    • Urine labs
      • urine hCG
        • earliest detection 12-15 days after ovulation
    • Home pregnancy test
      • highly accurate but should be confirmed with imaging or medical-grade hCG test
  • Differential
    • Uterine fibroid
      • key distinguishing factor
        • asymmetric uterus
    • Pseudocyesis
      • key distinguishing factor
        • unshakable belief of pregnancy in spite of medical evidence
    • Molar pregnancy
      • key distinguishing factor
        • absent or malformed fetal tissue on ultrasound
  • Complications
    • Ectopic pregnancy
      • incidence
        • approximately 2% of all pregnancies
      • risk factors
        • history of ectopic pregnancy
        • damage to fallopian tubes
        • pelvic infection
      • treatment
        • methotrexate
        • surgery
    • Hyperemesis gravidarum
      • incidence
        • approximately 3% of pregnancies
      • risk factors
        • multiple pregnancy
        • history of nausea and vomiting of pregnancy
        • history of motion sickness
        • history of migraines
      • treatment
        • lifestyle changes
        • vitamin B6 and doxylamine
        • antiemetic drugs
    • Spontaneous abortion
      • incidence
        • approximately 10% of pregnancies
      • risk factors
        • advanced maternal age
        • history of early pregnancy loss
      • treatment
        • expectant management
        • vaginal misoprostol/mifepristone
        • surgical uterine evacuation

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