What to do when a patient presents with a complaint of pregnancy?

Initial Management When a Patient Presents Complaining of Pregnancy

Immediately perform a urine pregnancy test to confirm pregnancy status, then proceed with comprehensive risk assessment, essential laboratory testing, and early pregnancy counseling—all during the same visit whenever possible. 1, 2

Step 1: Confirm Pregnancy Status

• Perform a qualitative urine pregnancy test as the first-line diagnostic tool, which is sufficient in most cases 1
• Consider quantitative serum β-hCG testing if exact hormone levels would help with diagnosis and management, particularly if ectopic pregnancy is suspected 1, 3
• Do not delay care waiting for laboratory results if the clinical situation is urgent—a drop of whole blood can be applied to a urine pregnancy test strip if the patient cannot provide urine 4

Step 2: Assess Gestational Age and Rule Out Complications

If Pregnancy Test is Positive:

• Estimate gestational age immediately by asking about the last normal menstrual period 1
• Perform pelvic examination if the patient is uncertain about dates to help assess gestational age 1
• Screen for ectopic pregnancy warning signs: abdominal pain, vaginal bleeding, hemodynamic instability, or risk factors 3
• If ectopic pregnancy is suspected, obtain quantitative β-hCG and transvaginal ultrasound immediately—do not defer ultrasound based on β-hCG levels 3
• Counsel on normal signs and symptoms of early pregnancy and instruct the patient to report any concerns immediately 1

Step 3: Initiate Essential Interventions During This Visit

Immediate Medication Review and Adjustments:

• Discontinue FDA pregnancy category X medications immediately and review category D medications 2
• Review all current medications with the patient, as some may be contraindicated in pregnancy 1

Start Prenatal Vitamins:

• Prescribe daily prenatal vitamin containing folic acid immediately to reduce neural tube defects 1, 2, 5
• Standard folic acid dosing is 0.4 mg daily for most women 5

Lifestyle Counseling:

• Counsel to avoid smoking, alcohol, and illicit drugs immediately 1, 2
• Screen for tobacco, alcohol, and drug use using validated tools like CAGE or T-ACE questionnaires 1, 2
• Advise avoiding fish with high mercury levels 1

Step 4: Order Essential Laboratory Testing

Obtain baseline laboratory tests during this visit or arrange them urgently: 1, 2

• Complete blood count
• Blood type and Rh screen (critical for determining need for RhoGAM) 3
• Rubella immunity status
• Syphilis screening
• Hepatitis B surface antigen
• HIV testing
• Gonorrhea and chlamydia screening
• Urinalysis
• Consider thyroid-stimulating hormone levels 1
• Cervical cytology if due 1

Step 5: Comprehensive Risk Assessment

Medical History:

• Screen for pre-existing conditions requiring immediate management: diabetes (needs tight glycemic control immediately), hypothyroidism (may need medication adjustment), hypertension (review medication safety) 2

Psychosocial Screening:

• Screen for depression, anxiety, domestic violence, and major psychosocial stressors 1, 2
• This is particularly important as approximately 50% of pregnancies are unintended 1, 2

Physical Examination:

• Measure blood pressure 1, 2
• Perform focused physical examination including thyroid, cardiac, breast, and pelvic examination as clinically indicated 2
• Document body mass index 1, 2

Reproductive History:

• Review previous adverse pregnancy outcomes and family history for genetic disorder risk 2
• Discuss carrier screening for cystic fibrosis and other genetic disorders based on ethnicity 2

Step 6: Provide Options Counseling and Arrange Follow-Up

Options Counseling:

• Present test results followed by discussion of all options in accordance with ACOG and AAP recommendations 1
• Maintain confidentiality even if the patient chooses not to involve her partner 1

For Patients Continuing Pregnancy:

• Make expedited referral to prenatal care provider (obstetrician or midwife) 1
• Provide resource listing or directory of providers 1
• Consider making the appointment for the patient or calling the referral site directly 1
• If delays in obtaining prenatal care are anticipated, provide or refer for STD screening and needed vaccinations during this visit 1

For Patients Not Continuing Pregnancy:

• Provide appropriate referrals for pregnancy termination services or adoption counseling as requested 1

Step 7: Document and Schedule Follow-Up

• Document patient understanding of pregnancy status, options discussed, and individualized follow-up plan 1
• Schedule concrete follow-up within 24-48 hours if any concerns about ectopic pregnancy or pregnancy complications 3
• Ensure all referrals are expedited and followed through 1

If Pregnancy Test is Negative:

• Explore why the patient thought she was pregnant and assess contraceptive needs 1
• Offer contraceptive services during the same visit, as patients may not return later 1
• Discuss reproductive life planning 1
• If the patient is trying to become pregnant, offer preconception health services and basic infertility counseling 1

Critical Pitfalls to Avoid:

• Never defer ultrasound based solely on low β-hCG levels if ectopic pregnancy is suspected—up to 36% of ectopic pregnancies present with β-hCG <1,000 mIU/mL 3
• Do not perform digital bimanual examination before ultrasound in patients beyond first trimester until placenta previa is excluded 3
• Do not delay folic acid supplementation—neural tube defects occur in the first 28 days of pregnancy, often before women know they are pregnant 2, 5
• Avoid giving folic acid doses >0.4 mg daily without ruling out pernicious anemia first 5