see attachment
Case Scenario 1
Table 1: Standard levels of HCG during pregnancy
(Alexander et al., 2024)
Table 2: Scenarios
GA weeks HCG level
3 weeks LMP 5-50 mIU/mL
4 weeks LMP 5-426 mIU/mL
5 weeks LMP 18-7,340 mIU/mL
6 weeks LMP 1,080-56,500 mIU/mL
7-8 weeks LMP 7,650-229,000 mIU/mL
9-12 weeks LMP 25,700-288,000 mIU/mL
13-16 weeks LMP 13,000-254,000 mIU/mL
17-24 weeks LMP 4,060-165,400 mIU/mL
25-40 weeks LMP 3,640-117,000 mIU/mL
Non pregnant <5 mIU/mL
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to
double within 48-72 hours.
During a spontaneous abortion (miscarriage), the expectation for the beta
HCG level is to decrease by at least 36-50% within 48-72 hours.
(Alexander et al., 2024)
Table 3: Common complaints during pregnancy
During an ectopic pregnancy, the expectation for the beta HCG level is to
increase slowly, plateau, or decrease (does not double) within 48-72 hours.
During a gestational trophoblastic pregnancy, the expectation for the beta
HCG level is to increase rapidly (often by more than double) and remain
elevated within 48-72 hour.
Definition
and Cause
Presentation
(include possible
DDX)
Treatment Education
Constipation
Slower
digestion and
passage of
stool due to
changes in
hormones
and pressure
from the
growing
uterus on the
intestinal
tract.
Delayed gastric
motility, hard
stools, painful
bowel movements
bloating,
discomfort. May
develop
hemorrhoids or
anal fissures.
Increased intake of
dietary fiber and
water, gentle
exercise, stool
softeners if
necessary.
Educate
regarding dietary
and lifestyle
measures to
reduce
constipation,
such as
increasing
dietary sources
of fiber and
hydrating.
Advise when to
seek medical
attention for
severe
constipation and
to avoid straining
during bowel
movement to
Back pain
A shifting
center of
gravity and
hormonal
changes
cause strain
on the back
muscles.
Dull or sharp
lower back pain or
discomfort.
Physical therapy
(pelvic tilts, Kegel
maneuvers to
support pelvic
muscles), back
support, upright
posture, and mild
exercise such as
swimming or
yoga.
Educate
regarding posture
correction,
exercise
techniques, and
appropriate pain
management.
GERD
Acid reflux
occurs as a
result of
relaxation of
the lower
esophageal
sphincter,
caused by
hormonal
changes.
Heartburn,
regurgitation of
food contents.
Antacids, dietary
modifications and
food avoidance;
sleeping with the
head elevated.
Educate the
patient on
lifestyle/diet
modifications,
how to sleep to
avoid acid reflux,
appropriate
medication
management, and
when to seek
attention with a
heath provider.
Fatigue
Decreased
energy
related to
increased
metabolism,
sedative
effects of
progesterone,
and changes
to sleeping
patterns
including
reduced
REM sleep
during the
last trimester
of pregnancy.
Low energy,
drowsiness,
daytime napping.
May also present
as changes to
memory, attention,
mood, and
concentration.
Sleep hygiene and
lifestyle
modifications;
relaxation
techniques such as
yoga, massage, or
acupuncture; sleep
medications as
needed.
Discuss the
expected pattern
of insomnia/sleep
disturbances
during the later
trimesters;
educate on
relaxation
techniques and
proper sleep
hygiene before
trialing
medications.
Heart palpitations
Increased
heart rate or
extra heart
sounds
secondary to
increased
plasma
volume and
cardiac
output.
Fast beating heart,
extra heart sound
or murmur (grade
II systolic ejection
murmur is normal
in pregnancy).
Adequate rest,
balanced diet, and
light physical
activity. Manage
stress and anxiety
with relaxation
techniques.
Reassure the
patient that these
changes are
expected and
should subside
after delivery.
Educate the
patient on rest,
dietary, and
activity
recommendation
s to reduce stress
and help them
relax.
Urinary frequency
Increased
urinary
frequency
caused by
structural
changes in
the renal
system,
increased
renal plasma
flow and
glomerular
filtration rate,
and the
weight of the
growing
uterus
pressing on
the uterus.
Frequent need to
urinate, minor
accidents when
going to the
bathroom.
Limiting caffeine
and fluids before
bed, hydrating
during the day
with water,
physical therapy to
strengthen pelvic
floor muscles,
bladder training.
Educate
regarding fluid
intake, exercises
and training
options to help
with urinary
frequency.
Nausea and
Vomiting
Rapid rises in
hormone
concentration
, delayed or
dysrhythmic
gastric
motility, and
genetic
factors cause
nausea and
vomiting in
pregnancy.
Morning sickness,
nausea, gagging,
retching, dry
heaving, emesis,
odor or food
aversion.
Dietary changes,
avoidance of
nausea triggers
and spicy, acidic,
or high-fat foods,
alternative
therapies. May use
medications as
necessary (e.g.,
promethazine or
diphenhydramine).
Educate the
patient on
identifying and
avoiding
triggering foods,
building a diet
around tolerable
foods, and trying
alternative
medicine
techniques, such
as acupressure.
Round ligament
pain
Pain in the
connective
tissues that
support the
growing
uterus
secondary to
stretching of
the nerve
fibers and
ligaments
surrounding
this area.
Sharp pain in the
lower abdomen,
pain in the grown
area with sudden
movement. May
mimic pain of
ectopic pregnancy,
preterm labor,
hernias, or
appendicitis.
Avoidance of
quick movements,
supporting
garments, warm
compress.
Educate patient
regarding the
normalcy of
round ligament
pain, but to seek
medical attention
if pain persists or
worsens. Discuss
lifestyle
measures to
avoid this type of
pain.
Hyperpigmentatio
n
Darkening of
the skin as a
result of
increased
production of
melanocyte-
stimulating
hormone
(MSH),
stimulated by
estrogen and
progesterone
production.
Hyperpigmentatio
n of the areolae,
genital skin,
axillae, inner
thighs; the linea
alba becomes the
linea nigra;
freckles and moles
also darken. Some
women present
with melasma,
which is a patch of
hyperpigmentation
spread across the
forehead, cheeks,
and bridge of the
nose.
Routine use of
sunscreen and
limiting sun
exposure can
decrease the
degree of
hyperpigmentation
. The discoloration
should subside
after delivery but
may persist for
months to years.
Educate the
patient on the
routine use of
sunscreen and
limiting sun
exposure during
pregnancy.
(Alexander et al., 2024; Jordan et al., 2019).
Case Study
Case: “Tonia is an 18-year-old female who presents to your office complaining of two months
of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She
reports she has had some bleeding for the past 3 days, that started as spotting, but has continued
to be a light period-like bleeding today. She denies any pain. She indicates plans to continue the
pregnancy.”
S: Subjective
CC: “I have missed my period for two months and now have some light bleeding.”
HPI: Tonia is an 18-year-old female who presents today with two months of amenorrhea. She
reports that she has missed her period for the past two months, though she was having regular
periods prior to then. She also reports intermittent vaginal bleeding that began three days ago
with gradual onset. The bleeding initially began as spotting but has progressively increased to
light, “period-like” bleeding today. The blood is dark red in color and without clots. She
associates symptoms of nausea, fatigue, and mild breast tenderness with the amenorrhea. She
Sleep disturbance
Interrupted
sleep related
to sleep
disorders
(e.g., sleep
apnea or
snoring) or
psychologic
changes in
pregnancy,
including
weight gain,
an enlarging
uterus,
swelling of
mucous
membranes
caused by
estrogen, and
decreased
lung
expansion.
May present as
restless leg
syndrome, sleep
deprivation and
fatigue during
waking hours;
insomnia may
present as daytime
sleepiness,
decreased energy
levels, adverse
moods, irritability.
Treat underlying
sleep disorder
(e.g., CPAP for
OSA, nasal strips
for upper airway
resistance). Other
techniques include
regulation of
weight gain,
elevating the head
while sleeping,
avoiding the
supine position
while sleeping,
and limiting the
use of sedatives
and alcohol.
Proper sleep
hygiene and
lifestyle changes
should be
employed to
manage insomnia.
Educate on
available
relaxation
techniques,
adequate sleep
hygiene and
weight
management,
avoidance of
stimulants, and
addressing
underlying sleep
disorders.
denies cramping, abdominal pain, pelvic pain, or passage of tissue. She took a home pregnancy
test which resulted positive and admits desire to continue the pregnancy.
Medications: None.
Allergies: NKDA.
LMP: 3/5/25 (2 months ago).
Gyn/OB history: G1P0; menarche at age 12 with regular cycles every 28-30 days and moderate
flow; no previous pregnancies, STIs or gynecological issues; no Pap smears to date.
PMH: Unremarkable.
Chronic Illness/Major trauma: None.
Family Hx: Noncontributory.
Social Hx: Lives with parents; no tobacco, alcohol, or drug use. Sexual Hx: Currently sexually
active with one male partner, no contraception use.
ROS:
General: Positive for mild fatigue. Patient denies fever, chills, dizziness.
Psych/Neuro: Patient denies changes to mood, behavior, cognition, memory.
Endocrine: Patient denies abnormal hair growth, intolerance to heat or cold, changes to weight
distribution.
Cardiovascular: Patient denies chest pain, palpitations, leg swelling.
Respiratory: Patient denies cough, wheezing, upper respiratory symptoms.
Gastrointestinal: Positive for nausea. Denies abdominal pain or cramping.
Gynecological/Pelvic: Positive for vaginal bleeding and breast tenderness. Denies vaginal
dryness, itchiness, other discharge. Denies pelvic pain, dysmenorrhea, dyspareunia.
Health maintenance: Up to date on immunizations and screenings.
O: Objective Data
General: Patient appears in good health and demonstrates appropriate behavior for age and
situation. Patient is of a healthy weight and fat distribution.
VS: BP 112/68 mmHg, HR 73 bpm, RR 16, T 98.6 F, SpO2 99% RA; Wt: 60 kg (132.27 lb.), Ht:
5’4”, BMI: 22.7 (normal weight)
Physical exam:
Psych/Neuro: Patient is alert, oriented, in no acute distress.
Cardiovascular: S1/S2 auscultated. No murmurs auscultated. No JVD or leg swelling observed.
Respiratory: Normal work of breathing demonstrated. Lung fields clear bilaterally.
Neck: Thyroid palpable and mobile; no tenderness, enlargement, or nodules palpated.
Abdominal: Bowel sounds auscultated in all fields. Abdomen is flat, non-acute, non-tender.
Breast: Breasts of symmetrical size and distribution; no nipple puckering, or nipple discharge
observed. Some breast tenderness to palpation demonstrated.
Pelvic: External exam revealed pink and intact genitalia with typical hair distribution and no
atrophy, ulcerations, or lymphadenopathy observed. Small amount of dark red blood in vaginal
vault. Speculum exam revealed nontender, nulliparous cervix. Bimanual exam revealed
nontender, mobile uterus of expected size and contour for age, adnexa non-palpable.
POCT:
Urine hCG: Positive
Urine NAAT chlamydia/gonorrhea/HPV: Negative
EGA: 5 weeks 6 days (based on LMP)
(Norwitz & Park, 2025)
A: Assessment/Diagnosis
Primary diagnosis: Early intrauterine pregnancy (Z3A.01) with threatened abortion (O20.0)
Pertinent positives: Amenorrhea, sexual activity without contraception, positive urine hCG test,
subjective symptoms of nausea, breast tenderness, and fatigue, and the absence of adnexal pain
suggest an intrauterine pregnancy; vaginal bleeding in the first trimester without other signs of
imminent miscarriage on examination suggests a threatened abortion.
Pertinent negatives: Absence of vaginal spotting or bleeding, which could suggest an
extrauterine pregnancy or miscarriage.
Rationale: Once the patient is confirmed to be pregnant, the absence of heavy bleeding,
lightheadedness, and significant cramping make the diagnoses of ectopic pregnancy or pregnancy
loss much less likely. It is possible that a threatened abortion (meaning fetal activity is present,
though mom continues to have light bleeding) or implantation bleeding are occurring. However,
life-threatening diagnoses cannot be ruled out merely by clinical exam, and diagnostic tests must
be run to better explain the cause of the bleeding (Norwitz & Park, 2025).
Differential diagnosis:
Viable intrauterine pregnancy with implantation bleeding (light vaginal bleeding is common
around the time of implantation)
Spontaneous abortion (complete or incomplete—pending lab results)
Ectopic pregnancy (less likely in the absence of pelvic or abdominal pain)
Trophoblastic disease (rare)
(Norwitz & Park, 2025)
P: Plan
Diagnostic tests
• Transvaginal ultrasound (to verify intrauterine pregnancy and fetal activity, rule out ectopic
pregnancy): Expect to see a yolk sac and measurable embryo at an EGA of 5.6 weeks.
• Examination of the vagina and cervix
• (Alexander et al., 2024; Norwitz & Park, 2025)
Lab tests
• Serum quantitative beta-hCG now and repeat in 48 hours (to determine viability and
progression of pregnancy): Expecta value between 18-7,340 mIU/mL now with a rise of >
50% in 48 hours if the pregnancy is viable.
• May consider routine screening for initial prenatal visit to determine baseline health and rule
out other infections. This would include CBC, TSH, ABO/Rh, Hepatitis B/C, syphilis,
rubella/varicella titers.
• (Alexander et al., 2024; Norwitz & Park, 2025)
Treatment
• Continue prenatal vitamin, as iron would benefit the patient whether a viable pregnancy or
spontaneous abortion is evident.
• Pending lab and imaging results:
o If fetal activity is present and hCG rises as expected, resume watchful waiting for the
treatment of threatened abortion.
o If hCG does not rise as expected (i.e., hCG drops from 1200 to 550) and a viable pregnancy
is not demonstrated by sonogram, begin treatment for spontaneous abortion.
• (Alexander et al., 2024; Norwitz & Park, 2025)
Medication
• Continue daily prenatal vitamin. Take as indicated on the bottle (OTC).
• If spontaneous abortion is confirmed, the recommendation would be to allow the body to
complete the miscarriage naturally. Would consider secondary intervention with misoprostol
(800 mcg vaginally or buccally once) to aid in the expelling of tissue, per patient
preference.
• Advise pain management with NSAIDs prior to dose of misoprostol, and otherwise as
needed.
• (Prager et al., 2024)
Referrals
• Consider referral to psychiatry or counseling, per patient preference.
• Consider referral to genetic counseling, per patient preference.
Education
• In the event of a viable pregnancy, proceed with prenatal care and counsel the patient on next
steps, genetic testing, and risk reduction.
• In the event of a spontaneous abortion, reassure the patient that miscarriage is very common
and offer grief support.
• Educate the patient on the potential side effects of a spontaneous abortion, including
continued bleeding and cramping. If the patient requires medication (misoprostol), some side
effects may include heavy bleeding, cramping, nausea, and fever.
• Depending on the type of miscarriage, surgical management may be required. Discuss these
options with the patient.
• Offer support to the patient and encourage to share with her partner.
• Advise contraceptive use until ready to try to conceive again.
• (Norwitz & Park, 2025, Prager et al., 2024)
Health Maintenance
• Patient is up to date with immunization, primary care, dental, and vision.
• Pap due at age 21.
• Ensure adequate access to contraceptive care and prenatal vitamins, as applicable.
Follow-up
• The patient should be advised to have her blood drawn in 48 hours then return to clinic to
discuss the results and next steps.
• Instruct the patient to present to the emergency room if symptoms worsen or profuse
bleeding ensues.
• (Norwitz & Park, 2025, Prager et al., 2024)
Prompt Questions
Subjective:
1. What other relevant questions should you ask regarding the HPI?
a. When was your LMP?
b. Have you taken any pregnancy tests at home? What were the results?
c. What are the characteristics of the bleeding? (e.g., Is it continuous or intermittent in timing?
What is the color of the blood? Are there any clots?)
d. Do you have any abdominal or pelvic cramping or pain?
e. Have you had any fever, chills, or other vaginal symptoms?
f. Have you experienced nausea, vomiting, breast tenderness, or fatigue?
g. (Alexander et al., 2024; Prabhu & Bastian, 2025)
2. What other medical history questions should you ask?
a. Have you ever been pregnant or had a miscarriage?
b. Do you have a history of infertility issues?
c. Do you have a history of STIs?
d. Do you have any chronic conditions, such as thyroid dysfunction, diabetes, or a clotting
disorder?
e. What medications, vitamins, or supplements are you currently taking?
f. What is your surgical history, if any?
g. (Alexander et al., 2024; Prabhu & Bastian, 2025)
3. What other social history questions should you ask?
a. Are you currently in a monogamous or polyamorous relationship?
b. What is your sexual history and contraceptive use history?
c. Do you feel safe in your relationship and at home?
d. Do you have a support system?
e. What are your diet and exercise regimens like?
f. Do you currently work or attend school?
g. Do you use alcohol, tobacco, or recreational drugs?
h. (Alexander et al, 2024)
Objective:
1. Describe all elements of the head-to-toe assessment you will perform for her initial prenatal
visit.
a. Like a well women exam, the initial prenatal visit should include vital signs, height and
weight metrics, cardiovascular and respiratory exams, a thyroid exam, a gentle breast exam,
an abdominal exam, and a pelvic exam (Alexander et al., 2024).
2. Explain what test(s) you will order and perform and discuss your rationale for ordering and
performing each test.
a. POCT: Urine hCG, for quick verification of pregnancy status, and urine NAAT, to rule out
common STI presentations in a sexually active female without use of contraception.
b. Other testing: Serum quantitative beta-hCG, to determine viability and progression of
pregnancy; transvaginal US, to confirm intrauterine pregnancy and fetal activity; may
consider initial prenatal blood testing/screening (CBC, ABO/Rh, hepatitis B/C, syphilis,
rubella/varicella titers, TSH) if pregnancy is deemed viable.
c. (Alexander et al., 2024; Norwitz & Park, 2025)
Assessment/Diagnosis:
1. What are your presumptive and differential diagnoses, and why?
a. Early intrauterine pregnancy with threatened abortion is the presumptive diagnosis, as the
patient has a positive pregnancy test and vaginal bleeding without cervical dilation on exam.
If hCG results drop dramatically in 48 hours, spontaneous abortion would be suspected
(Norwitz & Park, 2025).
b. Differential diagnosis: Spontaneous abortion (complete or incomplete); ectopic pregnancy
(Norwitz & Park, 2025).
2. Any other diagnosis or differential diagnosis you would like to add?
a. Implantation bleeding or gestational trophoblastic disease (Norwitz & Park, 2025).
3. Assume you ordered an HCG today and the result was 1200. She returns to the clinic in 2
days and her HCG results is 550. What would be her diagnosis?
a. This drop in hCG (which is >50% in 48 hours) suggests a spontaneous abortion (Norwitz &
Park, 2025).
Plan:
1. How will you explain the HCG results to your patient?
a. I would first explain to the patient what hCG levels are and what a dramatic rise or fall in
hCG levels could indicate. If the patient’s hCG were to drop from 1200 to 550 in 48 hours, I
would explain the results as follows: “Tonia, your hCG levels have significantly dropped
instead of going up, which means the pregnancy is not progressing as we would expect. This
means that a miscarriage, or early pregnancy loss, has occurred. I am very sorry. This can be
an emotionally difficult process, and we are here to support you.”
2. Explain treatment guidelines and side effects including any possible side effects of the
medication and treatment(s), partner notification, and follow-up plan of care.
a. Discuss the continuation of a prenatal vitamin for iron supplementation and support of a
future pregnancy, as applicable.
b. Discuss that first-line treatment for spontaneous abortion is allowing the body to naturally
pass pregnancy tissue. However, medical management is available with misoprostol.
c. Discuss misoprostol, which aids in expelling tissue by inducing uterine contractions. Discuss
the common side effects of this medication, including heavy bleeding, cramping, nausea, and
fever.
d. Discuss pain management with NSAIDs.
e. (Prager et al., 2024)
3. What patient education is important to include for this patient? (Consider when the patient
can resume sexual activity, birth control options, when she can resume trying to conceive
again).
a. Discuss avoiding sexual activity until bleeding stops and follow-up care has been provided.
b. Discuss contraception options with the patient and gauge her feelings about future
conception.
c. Discuss the mental health impact and offer resources as applicable.
d. (Alexander et al., 2024; Prager et al., 2024)
