What are the initial steps to take when a pregnancy is suspected?

Initial Management of Suspected Pregnancy

When pregnancy is suspected, immediately perform a urine pregnancy test (or blood test if urine unavailable) to confirm pregnancy status, then proceed with comprehensive preconception/early pregnancy risk assessment and counseling. 1

Immediate Confirmation of Pregnancy Status

Pregnancy Testing

• Perform a urine pregnancy test as the first-line diagnostic tool to detect human chorionic gonadotropin (hCG), which becomes detectable shortly after implantation 2
• If the patient cannot provide a urine sample (due to dehydration, instability, or urgency), whole blood can be applied directly to a standard urine pregnancy test with 95.8% sensitivity and 100% specificity 3
• Serum quantitative hCG testing provides definitive confirmation and is useful when urine results are equivocal or when quantification is needed for clinical decision-making 4, 2

Important caveat: A negative urine pregnancy test does not definitively rule out pregnancy, particularly in very early gestation. If clinical suspicion remains high despite negative urine testing, obtain serum hCG levels 4

Clinical Assessment Without Requiring Pregnancy Test

You can be reasonably certain a patient is NOT pregnant (99-100% negative predictive value) if she has no signs/symptoms of pregnancy AND meets at least one of these criteria: 1

• Is ≤7 days after start of normal menses
• Has not had intercourse since last normal menses
• Has been correctly using reliable contraception
• Is ≤7 days after spontaneous/induced abortion
• Is within 4 weeks postpartum
• Is fully/nearly fully breastfeeding, amenorrheic, and <6 months postpartum

Once Pregnancy is Confirmed or Highly Suspected

Immediate Risk Assessment and Counseling

Begin comprehensive preconception care components immediately, as approximately 50% of pregnancies are unintended and early intervention optimizes maternal and fetal outcomes 1

Critical Medication Review

• Immediately discontinue FDA pregnancy category X medications and review category D medications unless maternal benefits clearly outweigh fetal risks 1
• Review all over-the-counter medications, herbal supplements, and vitamins 1
• Common teratogens requiring immediate cessation include: isotretinoin, warfarin, certain antiseizure medications 1

Substance Use Screening

• Screen for tobacco, alcohol, and illicit drug use using validated tools (CAGE or T-ACE questionnaires) 1
• Counsel on immediate cessation, as these substances significantly impact fetal development 1

Folic Acid Supplementation

• Initiate daily multivitamin containing folic acid immediately if not already taking, to reduce neural tube defects 1

Essential Laboratory Testing

Obtain the following baseline tests: 1

• Complete blood count (assess for anemia)
• Urinalysis
• Blood type and screen
• Rubella immunity status
• Syphilis screening
• Hepatitis B surface antigen
• HIV testing (with appropriate counseling)
• Gonorrhea and chlamydia screening (if indicated by risk factors or symptoms)
• Consider thyroid-stimulating hormone level

Medical History Assessment

Evaluate for conditions requiring immediate management: 1

• Pre-existing diabetes: Requires tight glycemic control immediately to reduce congenital anomalies 1
• Hypothyroidism: Requires careful management and potential medication adjustment 1
• Hypertension: Review current medications for pregnancy safety 1
• Autoimmune diseases, thromboembolism history, rheumatic heart disease: Require specialist consultation 1

Reproductive and Genetic History

• Review previous adverse pregnancy outcomes (fetal loss, birth defects, preterm birth, low birth weight) 1
• Assess family history and ethnic background for genetic disorder risk 1
• Offer carrier screening (cystic fibrosis, others as indicated by ethnicity) 1

Infection Screening and Immunization Status

• Screen for periodontal, urogenital, and sexually transmitted infections 1
• Update immunizations as needed BEFORE pregnancy progresses: hepatitis B, rubella, varicella (if not immune), Tdap, influenza 1
• Note: Live vaccines (rubella, varicella) are contraindicated during pregnancy but should be given if non-immune and pregnancy not yet confirmed 1
• Counsel on preventing TORCH infections (Toxoplasmosis, Other viruses, Rubella, Cytomegalovirus, Herpes) 1

Psychosocial Screening

• Screen for depression, anxiety, domestic violence, and major psychosocial stressors 1
• If intimate partner violence is suspected, provide appropriate safety referrals 1

Physical Examination

Focus on: 1

• Blood pressure measurement (essential baseline)
• Periodontal examination
• Thyroid examination
• Cardiac examination
• Breast examination
• Pelvic examination (if clinically indicated)

Nutritional Assessment

• Assess body mass index (ideal prepregnancy BMI: 19.8-26.0 kg/m²) 1
• Evaluate dietary intake and promote "five-a-day" (2 fruits, 3 vegetables) 1
• Screen for anemia and other nutritional deficiencies 1

Environmental and Occupational Exposure Assessment

• Counsel about toxins and teratogenic agents at home, neighborhood, and workplace (heavy metals, solvents, pesticides, endocrine disruptors) 1

Special Considerations

Gestational Diabetes Screening Timing

• High-risk patients (marked obesity, personal history of GDM, glycosuria, strong family history of diabetes) should undergo glucose testing as soon as pregnancy is confirmed 1
• Average-risk patients should be tested at 24-28 weeks gestation 1

When Pregnancy Status Remains Uncertain

• If pregnancy cannot be definitively confirmed or excluded and clinical management requires certainty, serial serum hCG measurements 48-72 hours apart can help distinguish viable intrauterine pregnancy from ectopic pregnancy or early pregnancy loss 2