see attachment Table 1: Standard Levels of hCG During PregnancyTable 2: hCG Trends in Various Pregnancy ScenariosTable 3: Common Complaints

Table 1: Standard Levels of hCG During Pregnancy

Table 2: hCG Trends in Various Pregnancy Scenarios

Table 3: Common Complaints During Pregnancy

GA Weeks (LMP) hCG Level (mIU/mL)

3 weeks LMP 5 – 50

4 weeks LMP 5 – 426

5 weeks LMP 18 – 7,340

6 weeks LMP 1,080 – 56,500

7–8 weeks LMP 7,650 – 229,000

9–12 weeks LMP 25,700 – 288,000

13–16 weeks LMP 13,300 – 254,000

17–24 weeks LMP 4,060 – 165,400

25–40 weeks LMP 3,640 – 117,000

Non-pregnant < 5

Scenario Beta hCG Level Expected to…

Normal ongoing pregnancy Increase by 66% or more in 48–72 hours

Spontaneous abortion
(miscarriage)

Decrease by 21–35% or more in 48–72
hours

Ectopic pregnancy Increase slowly, plateau, or decrease

Gestational trophoblastic
pregnancy Increase excessively/highly elevated

Sympt
om

Definition and
Cause

Presentation &
Possible DDX Treatment Education

Consti
pation

Progesterone
relaxes bowel
muscles; slowed
GI motility

Infrequent, hard
stools; bloating;
DDX: bowel
obstruction,
hypothyroidism

High fiber diet,
hydration,
physical activity;
docusate or
psyllium as
needed

Avoid stimulant
laxatives;
increase water
and fiber intake

Back
Pain

Postural changes,
weight gain,
ligament laxity

Lumbar pain,
worse at end of
day; DDX: UTI,
kidney stones

Heat, stretching,
massage,
acetaminophen

Posture support,
avoid heavy
lifting, supportive
shoes

GERD

Relaxation of LES
due to
progesterone;
enlarged uterus
compresses
stomach

Heartburn, sour
taste; DDX: PUD,
cardiac chest pain

Small meals,
antacids, H2
blockers or PPIs
if needed

Elevate head of
bed, avoid spicy/
fatty foods, don’t
lie flat after
meals

Fatigu
e

Hormonal
changes,
increased energy
demands

General
tiredness; DDX:
anemia,
hypothyroidism,
depression

Rest, naps, iron
supplements if
anemic

Normalize
fatigue;
encourage sleep
and balanced
nutrition

Heart
Palpita
tions

Increased blood
volume and
cardiac output

Sensation of
fluttering; DDX:
arrhythmia,
anemia,
hyperthyroidism

Reassurance,
EKG if abnormal
or symptomatic

Usually benign;
report if
associated with
SOB, dizziness,
or chest pain

Urinar
y
Freque
ncy

Uterine pressure
on bladder,
increased renal
perfusion

Frequent urination
without pain;
DDX: UTI

Rule out infection;
otherwise
reassurance

Void regularly,
stay hydrated,
report burning or
urgency

Nause
a and
Vomiti
ng

hCG and estrogen
effects on GI
system

Typically 1st
trimester; DDX:
gastroenteritis,
hyperemesis
gravidarum

Vitamin B6,
doxylamine, small
bland meals,
antiemetics if
severe

Often resolves
by 2nd trimester;
eat small meals,
avoid triggers

Subjective

• Bleeding began 3 days ago as spotting and has since become light period-like bleeding. It is
ongoing.

• She denies any pain. No specific mention of other symptoms; these should be clarified
during the visit.

• No prior pregnancies, miscarriages, or abortions

• The patient had unprotected intercourse two days prior

• No traumas or strenuous activity

• Denies any nausea, vomiting, breast tenderness, or fatigue 




Other Medical History Questions

• Menstrual history: amenorrhea x2 months with positive pregnancy test. STI and Pap history:
none

• No chronic medical conditions

• No medication/food/environmental allergies

Round
Ligam
ent
Pain

Stretching of
uterine ligaments
as uterus enlarges

Sharp, brief pain
in groin/lower
abdomen; DDX:
appendicitis,
ovarian torsion

Reassurance,
position changes,
acetaminophen

Normal; avoid
sudden
movements; use
warm compress

Hyper
pigme
ntation

Hormonal
stimulation of
melanocytes (e.g.,
melasma, linea
nigra)

Dark patches on
face, abdomen;
DDX: Addison’s
disease

Usually no
treatment needed

Common and
benign; usually
fades postpartum

Sleep
Distur
bance

Hormonal
changes,
discomfort,
anxiety, nocturia

Trouble falling or
staying asleep;
DDX: depression,
restless legs
syndrome

Sleep hygiene,
relaxation
techniques, left
side sleeping

Avoid caffeine,
screens; use
pillows for
support; maintain
sleep schedule

• Vaccinations are up to date for her age, COVID vaccine received (no boosters)

• Mental Health Screening Complete: No risk

Other Social History Questions

• Denies substance use (tobacco, alcohol, drugs

• Social support system: Mother, Father, Partner, Best Friends

• Intimate partner violence screening: Denies

• Senior Year in High-school

• Stable home environment

Objective

a. Head-to-toe assessment:

• Vital Signs:

o Temperature: 98.4°F (36.9°C)

o Heart Rate (HR): 84 beats per minute

o Respiratory Rate (RR): 16 breaths per minute

o Blood Pressure (BP): 110/68 mmHg

o Oxygen Saturation (SpO₂): 98% on room air

o Weight: 132 lbs (59.9 kg)

o BMI: 22 – Normal weight range

• HEENT: Hydration status

• Cardiac/Respiratory: Baseline function

• Abdomen: Palpation for tenderness, guarding, masses

• Pelvic exam:

o External genitalia inspection

o Speculum exam: check for active bleeding, source of bleeding (cervix vs vaginal)

o Bimanual exam: uterine size, adnexal masses/tenderness, cervical motion tenderness

b. Tests and rationale:

• Quantitative beta-hCG: Monitor pregnancy progression or loss (Doubling every 48–72h is
expected in viable pregnancy)

• Transvaginal ultrasound: Confirm intrauterine pregnancy or assess for ectopic (TVUS can
detect gestational sac at hCG ≥1500–2000 mIU/mL)

• CBC: Evaluate for anemia or infection

• Type and screen: Determine Rh status (important if Rh-negative and bleeding)

• STI screening: Chlamydia, gonorrhea, HIV, syphilis, Hep B/C

• Pap smear (if due)

Assessment / Diagnosis

a. Presumptive diagnosis:

• Threatened abortion (vaginal bleeding with closed cervix and viable intrauterine
pregnancy)

Differential diagnoses:

• Early intrauterine pregnancy with normal implantation bleeding

• Ectopic pregnancy

• Spontaneous abortion (inevitable, incomplete, or missed)

• Molar pregnancy (less likely with current hCG levels)

b. Additional differentials:

• Cervical pathology (polyps, ectropion)

• Coagulopathy or bleeding disorder

c. HCG results interpretation:

• Day 1 hCG: 1200 mIU/mL

• Day 3 hCG: 550 mIU/mL → Significant decline (>50%)

Diagnosis:

• Spontaneous abortion (miscarriage) 

This is supported by a falling hCG level, which indicates a nonviable pregnancy.

4. Plan

a. Explaining hCG results:

• “Your hCG level has dropped significantly, which indicates that the pregnancy is no longer
progressing. This means that you are likely having a miscarriage.”

b. Treatment & follow-up:

Options:

1. Expectant management – allow natural passage of tissue.

2. Medical management – misoprostol to induce expulsion.

3. Surgical management – uterine aspiration/D&C if heavy bleeding, infection, or incomplete
passage.

Medications:

• Misoprostol (600–800 mcg vaginally or orally)

o Side effects: cramping, bleeding, nausea, diarrhea

o Success rate: ~80-90% in early pregnancy loss (ACOG, 2018)

Partner notification:

• Not typically required unless STI is suspected.

Follow-up:

• Repeat hCG until <5 mIU/mL

• Monitor for signs of infection or retained products

• Ultrasound if bleeding persists or incomplete passage is suspected

c. Patient education:

• Emotional support: Normalize grief response, provide reassurance

• Sexual activity: Wait until bleeding stops and no signs of infection (usually 1–2 weeks)

• Contraception: Discuss short-term options if not ready to conceive

• Trying to conceive again: Safe to try after 1 normal menstrual cycle; ACOG supports early
attempts if emotionally ready

• Red flags: heavy bleeding, foul-smelling discharge, fever, severe pain → return immediately