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