Clinical manifestations and diagnosis of early pregnancy

Authors
Lori A Bastian, MD
Haywood L Brown, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG
Disclosures: Lori A Bastian, MD Nothing to disclose. Haywood L Brown, MD Nothing to disclose. Charles J
Lockwood, MD, MHCM Consultant/Advisory Boards: Celula [Aneuploidy screening (Prenatal and cancer DNA
screening tests in development)]. Vanessa A Barss, MD, FACOG Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jul 2015. | This topic last updated: Dec 09, 2014.
INTRODUCTION — Diagnosis of pregnancy and knowledge of normal findings associated with
early pregnancy are common issues in the medical care of reproductive-age women.
The diagnosis of early pregnancy is based primarily upon laboratory assessment of human
chorionic gonadotropin (hCG) in urine or blood. History and physical examination are not highly
sensitive methods for early diagnosis, but knowledge of the characteristic findings of a normal
pregnancy can be helpful in alerting the clinician to the possibility of an abnormal pregnancy,
such as ectopic pregnancy, or the presence of coexistent disorders.
PHYSIOLOGY OF NORMAL PREGNANCY — Most of the clinical findings associated with
normal pregnancy can be attributed to end-organ effects of hormonal and mechanical changes
associated with pregnancy. These pathophysiological changes are described in detail
separately:
●(See "The skin, hair, nails, and mucous membranes during pregnancy".)
●(See "Maternal cardiovascular and hemodynamic adaptations to pregnancy".)
●(See "Respiratory tract changes during pregnancy".)
●(See "Renal and urinary tract physiology in normal pregnancy".)
●(See "Maternal gastrointestinal tract adaptation to pregnancy".)
●(See "Breast development and morphology", section on 'Pregnancy and lactation'.)
●(See "Maternal endocrine and metabolic adaptation to pregnancy".)
●(See "Musculoskeletal changes and pain during pregnancy and postpartum".)
●(See "Hematologic changes in pregnancy".)
●(See "Immunology of the maternal-fetal interface".)
CLINICAL MANIFESTATIONS OF EARLY PREGNANCY
Signs and symptoms — Amenorrhea is the cardinal sign of early pregnancy. Pregnancy
should be suspected whenever a woman in her childbearing years misses a menstrual period:
ie, she notes that a week or more has passed without the onset of an expected menses. Clinical
suspicion is increased if she also reports any sexual activity while not using contraception or
with inconsistent use of contraception. Even women who report consistent use of contraception

2]. Findings on physical examination ●The uterus is enlarged and globular. The correlation between uterine size and gestational age is often described in terms of fruit (eg. linea alba. Their symptoms tended to develop abruptly and occur daily. 14/151 women (9 percent) experienced at least one day of vaginal bleeding during the first eight weeks of pregnancy [2]. However. 60 percent of women experienced some signs or symptoms of pregnancy as early as five to six weeks of gestation (ie. Furthermore.to 8-week size = small pear. areola) In a study that prospectively collected data on the onset of pregnancy symptoms in 221 women attempting to conceive. vaginal bleeding/spotting is relatively common in early normal pregnancy. (See"Overview of the etiology and evaluation of vaginal bleeding in pregnant women". . In one prospective study. the top four "often" reported symptoms are urinary frequency (52 percent). 8. feeling tired (46 percent). section on 'First trimester bleeding'. Cessation of menses can be a difficult symptom to evaluate because some women have irregular menstrual cycles and many women have occasional prolongation of a cycle. and 90 percent were symptomatic by eight weeks [3]. Bleeding tended to occur around the time they expected their period to occur and was typically light (requiring only one or two pads or tampons in 24 hours). poor sleep (28 percent). 6. and often occurs at or near the time that a menstrual period would be expected [1. In surveys of pregnant women in all three trimesters.) The most common signs and symptoms of early pregnancy are: ●Amenorrhea ●Nausea with or without vomiting ●Breast enlargement and tenderness ●Increased frequency of urination without dysuria ●Fatigue Additional signs and symptoms include: ●Mild uterine cramping/discomfort without bleeding ●Abdominal bloating ●Constipation ●Heartburn ●Nasal congestion ●Shortness of breath ●Food cravings and aversions ●Mood changes ●Lightheadedness ●Spider angiomas ●Palmar erythema ●Increased skin pigmentation (face.may become pregnant because of user issues and because no method is 100 percent effective (table 1). increasing in size by about 1 cm per week after four weeks of gestation.to 10-week size = orange. and back pain (20 percent) [4]. five to six weeks after the first day of their last menstrual period [LMP]). the symptoms were nonspecific: they also occurred in 9 percent of nonpregnant cycles.

000 int.7]. units/L at that time. the median hCG concentration on the first day of expected but missed menses was 239 milli-int. ●The breasts become fuller and tender. intrauterine pregnancy. units/mL (interquartile range 98) [10].000 int. hCG levels decline. maternal weight accounts for some of the variation throughout pregnancy [23. ectopic. Laboratory findings Human chorionic gonadotropin — Detection of human chorionic gonadotropin (hCG) in blood or urine is the basis of all pregnancy tests (table 2) (see 'Detection of hCG' below). The uterus remains a pelvic organ until approximately 12 weeks of gestation.000 int. underwent embryo transfer two to three days after egg retrieval. One diagnostically important change is an increase in the neutrophil count. units/L or more). except in the first one to three weeks post-conception [20. section on 'Uterine size'. and had at least one viable embryo at 8 weeks of gestation: the median hCG concentration on day 12 after embryo transfer was 118 milli int. This is the earliest that hCG can be detected with an ultrasensitive test. At 16 weeks. section on 'Human chorionic gonadotropin'. Late implantation has been associated with an increased risk of pregnancy loss [6. a slower rise is suggestive of an abnormal pregnancy (eg. and postnatal loss'.10. The hCG concentration doubles every 29 to 53 hours during the first 30 days after implantation of a viable.) ●The cervix and uterus soften. and cervix become congested. section on 'Risk of early. when it becomes sufficiently large to palpate abdominally just above the symphysis pubis. reaching a median concentration of about 12.9]. early embryonic death).21] (see'Detection of hCG' below). (See "Ectopic pregnancy: Clinical manifestations and diagnosis". hCG levels are not useful for estimating gestational age [11-19]. HCG concentration stays relatively constant from about the 20th week until term. units/mL in a spot urine. but again the range of normal is quite wide (5000 to 150. The concentration of hCG peaks at 8 to 10 weeks of gestation. late.) Other laboratory findings — Numerous physiological changes occur during pregnancy. again with a wide range of normal: 2000 to 50. units/L at 20 weeks. which begins in the second month of . units/mL in serum and 49 milli-int. The mucous membranes of the vulva. beginning at about 8 to 12 weeks of gestation. averaging 60. The factors accounting for the wide variation in interindividual hCG levels have not been studied extensively in accurately dated pregnancies. the uterine fundus is palpable midway between the symphysis pubis and umbilicus. In the next 10 weeks.to 12-week size = grapefruit). sometimes accompanied by changes in laboratory test values (table 3). The areola darkens and the veins under the breast skin become more visible.6].24]. an unrecognized vanishing twin affects the hCG level [25]. thus. vagina. The range of hCG values was narrower in a study of over 4400 women who conceived by IVF.) In a study of women with normal menstrual cycles who were attempting to conceive. ●Fetal heart activity can usually be detected by handheld Doppler devices at 10 to 12 weeks of gestation. which occurs 6 to 12 days after ovulation [5.000 int. HCG is secreted into the maternal circulation after implantation. unless the woman is obese. but there was a wide range among individuals [8. units/L or more [22].000 to 90. beginning at about six weeks of gestation. and sometimes earlier if the woman is thin and the clinician is persistent. In some cases. (See "Twin pregnancy: Prenatal issues". (See "Prenatal assessment of gestational age and estimated date of delivery".

these historical factors are not sufficiently reliable to diagnose or exclude pregnancy. (See "Prenatal assessment of gestational age and estimated date of delivery". a gestational sac or intrauterine fluid collection compatible with pregnancy is usually visible at 4. but absence of these signs does not rule out pregnancy.5 to 5 weeks of gestation (three to four weeks after ovulation). duration of pregnancy) and delivery date. and thus the timing of ovulation. Very early in gestation. Although a report of delayed menses. Biometric measurements (eg. (See "The gynecologic history and pelvic examination". a fetal pole (image 2) with cardiac activity is first detected at 5. hCG levels are generally not useful for estimating gestational age [11-19]. However. The likelihood of pregnancy increases if signs of pregnancy are present.32.) Detection of hCG — When a pregnancy test becomes positive (the number of days after the last menstrual period [LMP]) depends on several factors.5 to 6 weeks. hCG has been detected in urine on day 16 of the cycle [35. the rise in hCG titers is similar among women with viable pregnancies and allows estimation of pregnancy duration [20. A study using a home-based device (Clearblue Advanced Pregnancy Test with Weeks Estimator) was able to estimate time . biparietal diameter. Obviously. As discussed above (see 'Human chorionic gonadotropin' above). Only a few studies have examined the value of physical examination for diagnosing early pregnancy (table 4) [27. The yolk sac appears at five to six weeks (image 1) and remains until approximately 10 weeks. sexual activity with imperfect use of contraception. increases the likelihood of pregnancy. the ability to detect physical signs of pregnancy is highly dependent upon the experience of the examiner.37. but some women do not experience these symptoms or merely have not experienced them before being tested. except in the first one to three weeks postconception. gestational sac size. threshold for a positive test) ●The hCG assay’s combination of antibodies to hCG isoforms Ovulation can occur as early as eight days after the first day of the last menstrual period. in such patients. crown-rump length. femur length) are used to estimate the gestational age (ie.33]. if present.38].) DIAGNOSIS — The diagnosis of pregnancy is based on the presence of any of the following: ●Detection of human chorionic gonadotropin (hCG) in blood or urine ●Identification of pregnancy by ultrasound examination ●Identification of fetal cardiac activity by Doppler ultrasound Several studies have examined the value of patient history for diagnosing early pregnancy (table 4) [26-33]. the normal range for hCG concentration across most of the first trimester is quite wide. These structures are observed slightly later with the transabdominal approach.36].21]. varies by three to five days or more from cycle to cycle ●The hCG assay’s sensitivity (ie. and patient suspicion of pregnancy are predictive that a pregnancy test will be positive.) Ultrasound examination — On transvaginal ultrasound examination. (See "Normal reference ranges for laboratory values in pregnancy". Nausea with or without vomiting. pregnancy tests are most likely to be positive at the time of the expected period [39]. including [5. HCG has been detected in serum six to eight days after the presumed day of conception [18. which varies because the length of the follicular phase.34]: ●Cycle length. thus.pregnancy and should not be mistaken for the leukocytosis associated with inflammation/infection.

Qualitative serum pregnancy tests typically detect hCG levels of 5 to 10 int. unless the test used has a high threshold for hCG positivity [46. convenience. but because samples are typically processed in batches. sonographic visualization of the pregnancy).since ovulation (one to two weeks. Doppler confirmation of fetal cardiac activity. . Because urine tests are slightly less sensitive than serum tests. Women choose to use home pregnancy test (HPT) kits because of the speed of obtaining results and the convenience of testing at home. By contrast. Types of pregnancy tests — Pregnancy tests can be performed on urine or serum. the most sensitive method for detecting hCG in early pregnancy is a serum pregnancy test. while a high-sensitivity. units/L. and take only one to five minutes to perform. while a negative test only shows one band/line (eg. It takes about 15 minutes to complete a test. ‘ll’ or ‘+’). urine pregnancy tests may not be positive when serum beta hCG is positive [42]. Standard urine pregnancy tests used in clinical practice have a urine hCG threshold of 20 to 50 int. especially when exclusion of pregnancy is an important factor in patient care. A random urine sample can be used for testing because hCG production is not circadian [43-45] and a low urine specific gravity does not appear to alter the sensitivity of detecting hCG. Because the urine beta hCG concentration can be much lower than in serum. therefore. Tests on urine are adequate for diagnosis of a suspected pregnancy in women who have missed a menstrual period. early in pregnancy. Home pregnancy test — Positive results on a home-based test should always be confirmed with an office-based hCG test or another definitive test (eg. Urine pregnancy test — Urine pregnancy testing is the most common method for diagnosing pregnancy in the office setting. ‘l’ or ‘-’). such as before administering a potentially teratogenic agent. units/L. Manual tests are interpreted by noting the number of color bands/lines in the window of the device a few minutes after dipping it in urine for several seconds. quantitative serum beta-hCG assay can measure hCG values as low as 1 to 2 int. it may take much longer to obtain a result. The median hCG concentration is higher in serum than in urine [17. units/L.47] or the urine specimen is extremely dilute. two to three weeks. therefore. units/L. especially when there is time to follow an initial negative test with a second test a week later. The performance of HPTs is affected by the users' technique and interpretation [48]. Some devices have a digital display that shows “yes” or “no” or “pregnant” or “not pregnant” on an LCD screen. They detect hCG in the urine using immunometric assay methods [9].40]. serum tests are preferable when the patient’s menstrual period is less than a week late. The only potential advantage of a qualitative serum pregnancy test over a quantitative test is that the qualitative test can usually be performed more rapidly [41]. a serum pregnancy test may be positive while the urine pregnancy test is still negative. detecting hCG beginning at a level of 20 to 50 int. Many brands of HPT kits are available. Factors that influence the choice of a urine or serum pregnancy test include duration of missed menses. need for accuracy. the urine pregnancy test is less sensitive. The quantitative test procedure requires use of dedicated automated measurement equipment and may be processed only in a commercial or hospital-based laboratory. three or more weeks) in singleton viable pregnancies with an accuracy of 93 percent when compared with standard reference methods [20]. and cost. A positive test will show two band/lines (eg. Serum pregnancy test — In clinical practice. a urine test may be negative and the serum test positive around the time of missed menses. A variety of affordable and reliable urine tests are available for use in office practices.

Although manufacturers claim these kits are 99 percent accurate. the test should be repeated in one week. In urine.and betasubunits [39].5 int. This variability was demonstrated by a blinded in vitro sensitivity analysis of six commonly used HPT kits that found [49]: ●"First Response manual” and “First Response Gold digital devices" were the most sensitive HPT kits with analytical sensitivity 5. both the capture and tracer antibodies used in immunoradiometric assays become saturated. it will not be sensitive enough to diagnose pregnancy in women who have recently missed a menstrual period. preventing the binding of the two to create a sandwich. on the first day of a missed period. Many HPT kits make this recommendation and provide an extra kit for this purpose. and production of sufficient hCG for detection by a HPT are variable. •“EPT” manual and digital devices detected of 54 percent and 67 percent of pregnancies. The intervals between the first day of the LMP. If pregnancy is suspected despite a negative test. units/L. on the first day of a missed period. a large proportion of hCG is a metabolic fragment of the hormone known as the beta-core. Causes of a false negative test — The most common cause of a false negative result is performing the test too soon after conception (table 2). HPT kits vary in sensitivity for detection of hCG. ●The next tier of tests had analytical sensitivity 11 to 22 int. units/L. Waiting a week or two after a missed period before performing a urine pregnancy test not only minimizes false negatives. hCG levels are generally lower in normal pregnancies. and first day of the missed menstrual period) occurred later than expected [50. the test should be repeated in one week. Practitioners can use these data to advise their patients on selection of HPT kits and their limitations. respectively. ovulation. This is most commonly seen with the very high hCG levels associated with gestational trophoblastic disease. Almost all hCG in blood is in the form of the intact hormone (alpha and beta dimer). An assay’s inability to recognize specific isoforms of hCG can . Rarely. Women with irregular cycles or an uncertain LMP generally should wait at least 14 days from a sexual act before obtaining a pregnancy test. but also decreases the tendency to perform a serum hCG test to exclude or confirm very early pregnancy after a negative urine test. •"Clearblue Easy” manual and digital devices detected 64 percent and 54 percent of pregnancies. false negative results are due to a “hook effect” [52]. with only small amounts of the free alpha. In many cases. Over 97 percent of pregnancies could be detected on the first day of a missed period. When a very high hCG concentration is present and the sample is tested without prior dilution. this claim is based upon the ability of the test to detect an arbitrary amount of intact hCG added to nonpregnant urine samples in vitro. respectively. Since the non-sandwiched tracer antibodies are washed away with the excess material. If pregnancy is suspected despite a negative test.) False negative results caused by limited or no detection of hCG isoforms can cause misdiagnosis in cases of very early pregnancy. however. section on 'False negative test (hook effect)'. The test is negative because ovulation (and thus fertilization. implantation. implantation. (See "Human chorionic gonadotropin: Testing in pregnancy and gestational trophoblastic disease and causes of low persistent levels". The most common problem with HPT kits is a negative result because the test was performed too soon after the expected onset of menses. fertilization.51]. the test result will be negative.

units/L [56]). typically in perimenopausal women. and thyrotropin. whether in urine or serum. False positive pregnancy tests are rare. and diagnostic evaluation". (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ultrasonography of pregnancy of unknown location". causes. the provider needs to think about the following: ●Is the pregnancy intrauterine or extrauterine? ●If intrauterine.play a role in false negative results [34. and due to: ●Operator error.54]. thus rendering cross-reaction with subunits of other hormones. specifically identify the beta subunit of hCG. section on 'Clinical presentation'. and change in hCG level over time for diagnosis of viable. unlikely. pregnancy loss very soon after implantation). extrauterine pregnancy is excluded by demonstrating an intrauterine pregnancy by transvaginal ultrasound examination [55]. transvaginal ultrasonography is indicated to look for cardiac activity and evaluate the size and appearance of the gestational sac and thereby determine pregnancy viability. absolute hCG level. In these cases. ●Pituitary hCG secretion.53. Exogenous hCG should be cleared by two weeks post-injection.) The pregnancy can be assumed to be viable except in women who report vaginal bleeding with or without suprapubic pain/cramping and/or cessation of symptoms associated with early pregnancy. unless the medication contains hCG or. and ectopic pregnancy is reviewed in detail separately. etiology. ultrasound may not detect an intrauterine pregnancy before five weeks of gestation or at a serum hCG concentration below the discriminatory cut-off (3510 int. nonviable. section on 'Causes and evaluation of persistent low levels of hCG'. (See "Spontaneous abortion: Risk factors. The characteristics. (See "Human chorionic gonadotropin: Testing in pregnancy and gestational trophoblastic disease and causes of low persistent levels". particularly with home pregnancy tests. such as luteinizing hormone. follicle stimulating hormone. Medications do not cause false positive pregnancy tests. or has risk factors for extrauterine pregnancy (table 5). ●HCG secretion from a tumor. rarely. Interference by isoforms is most common in urine tests that measure intact hCG. The correlation between ultrasound findings. is the pregnancy viable? The pregnancy is generally assumed to be intrauterine (98 percent of pregnancies are intrauterine) unless the woman has adnexal pain and/or vaginal spotting/bleeding.) .) POST-PREGNANCY TEST CONSIDERATIONS — When human chorionic gonadotropin (hCG) is initially detected. ●Interference by human antibodies against animal or human antibodies (serum test positive but urine test is usually negative). serum specimens are tested serially to determine the rate of rise of the hCG level. However. In these cases. An abnormally slow rate of rise suggests either an ectopic pregnancy or a pregnancy that will eventually spontaneously abort. ●Biochemical pregnancy (ie. For these women. and evaluation of false positive pregnancy tests are discussed in detail separately. The use of ultrasound examination in this setting is discussed separately. Causes of a false positive test — Modern immunoassays for hCG. ●Interference from hCG administered as part of infertility treatment. clinical manifestations. certain antibodies.

or the pituitary gland. headache. If the pregnancy and IUD are intrauterine. section on 'First trimester bleeding'.) Nausea and vomiting — The onset of nausea and vomiting after about 10 weeks of gestation should prompt an evaluation. a positive pregnancy test is not due to pregnancy. or is associated with any of these symptoms. Alternatively. (See "Overview of the etiology and evaluation of vaginal bleeding in pregnant women". then the patient should . pleurisy. fever. fever or increase in basal heart rate by more than 15 to 20 beats/min). If dyspnea occurs acutely. The evaluation of these patients is discussed separately. of gradual onset. however. pyuria. cough. diarrhea.) Urinary frequency — Cystitis or an upper urinary tract infection should be suspected if pregnancy-related urinary frequency is accompanied by dysuria. but have an abnormal pregnancy or a coexistent medical or surgical disorder. and not associated with other pulmonary signs or symptoms (eg. The approach to evaluation and management of women with bleeding in early pregnancy is discussed in detail separately. because this is after the typical period expected for onset of pregnancy-related nausea and vomiting. fever. section on 'Causes and evaluation of persistent low levels of hCG' and"Human chorionic gonadotropin: Testing in pregnancy and gestational trophoblastic disease and causes of low persistent levels". any amount of bleeding is worrisome. Ultrasound can be useful to distinguish among these entities.) Hyperemesis gravidarum is considered the severe end of the spectrum of nausea and vomiting of pregnancy. (See "Intrauterine contraception: Management of side effects and complications". Vaginal bleeding — Bleeding in early pregnancy that is heavier than spotting or accompanied by any pain may represent an ectopic pregnancy (table 5) or impending miscarriage. a non-trophoblastic malignancy. or it is a false positive.) Dyspnea — Pregnancy-related dyspnea is usually mild. In these cases. hCG is secreted by gestational trophoblastic disease. section on 'Pregnancy'. the diagnosis can be made in women with pregnancy-related vomiting that occurs more than three times per day with weight loss greater than 3 kg or 5 percent of body weight and ketonuria. wheezing. (See "Human chorionic gonadotropin: Testing in pregnancy and gestational trophoblastic disease and causes of low persistent levels". A cause other than pregnancy should be considered if nausea and vomiting are accompanied by pain. a woman may become pregnant with an intrauterine device (IUD) in place. (See "Clinical features and evaluation of nausea and vomiting of pregnancy".) WHEN TO BE CONCERNED ABOUT PREGNANCY SYMPTOMS — Knowledge of the clinical spectrum of normal pregnancy is helpful when evaluating pregnant women who present with one or more similar clinical symptoms. The evaluation and management of pregnancies complicated by an in situ IUD is reviewed separately. hematuria. section on 'Pregnancy'. or flank pain. the IUD should be removed because the risk of pregnancy complications is higher if it is left in place than if it is removed.Rarely. since most pregnancies in this setting are ectopic.) Women with intrauterine devices — Although rare. or rales) or systemic findings (eg. (See "Renal and urinary tract physiology in normal pregnancy" and "Urinary tract infections and asymptomatic bacteriuria in pregnancy". (See "Approach to the adult with nausea and vomiting". as it will not identify a pregnancy and may identify the intrauterine or adnexal tumor that is the source of the hCG. or abdominal distension. vertigo. hemoptysis. and is commonly defined as persistent vomiting accompanied by weight loss exceeding 5 percent of prepregnancy body weight and ketonuria unrelated to other causes. An ultrasound should be performed to determine whether the pregnancy is intrauterine or extrauterine.

The evaluation of women with chest pain is the same as in nonpregnant women of similar age. The signs of true pregnancy on physical examination are identification of a fetal heart rate that is distinguishable from the maternal heart rate and palpation of fetal parts. it may be due to varicosities. ovarian torsion) should be excluded when the pain is moderate or severe. and diagnostic evaluation"). or other vigorous activity. Lightheadedness is of concern when associated with an abnormal heart rate/rhythm or signs suggestive of a seizure. preterm labor and abruptio placentae should be excluded in women with these symptoms. nausea/vomiting.) Chest pain — Chest pain not due to gastrointestinal reflux is not a normal finding in pregnancy. as the pain is usually mild and self-limited. After 20 weeks of gestation. especially in a warm environment. rarely. etiology.) Lightheadedness — Pregnancy-related lightheadedness typically occurs when the woman has been standing. or endometriosis associated with the ligament. and when it does not resolve in the lateral or head-down position. ruptured ovarian cyst. right lower-quadrant pain.) Pseudocyesis — Pseudocyesis and delusion of pregnancy are rare psychiatric diagnoses applied to women with negative pregnancy tests who believe they are pregnant.) . pathogenesis. suddenly rolling over in bed. but no treatment is necessary. ie. breast tenderness.) Pelvic discomfort — The round ligaments begin near the uterine cornua. Pain in the location of the round ligaments has been termed "round ligament pain. regardless of the stage of pregnancy.) Right lower-quadrant pain is a common symptom of appendicitis. clinical manifestations. which should be excluded. The pain is believed to be caused by irritation of nearby nerve fibers or spasm of the ligament. or accompanied by vaginal bleeding or peritoneal signs.) SUMMARY AND RECOMMENDATIONS ●The most common signs and symptoms of pregnancy are amenorrhea. (See "Dyspnea during pregnancy" and "Treatment of respiratory infections in pregnant women" and "Pulmonary embolism in pregnancy: Epidemiology.) Midline pelvic pain and vaginal bleeding are the cardinal signs of impending or ongoing spontaneous abortion (see "Spontaneous abortion: Risk factors. the most common symptom of appendicitis. (See 'Clinical manifestations of early pregnancy' above. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Adnexal mass in pregnancy". urinary frequency. and diagnosis"." it is common and a diagnosis of exclusion. and fatigue. (See "Pseudocyesis".be evaluated for pulmonary embolism or other cardiopulmonary disease. myomas. It should resolve when she lies on her left side. The pain is typically on the right side of the abdomen/pelvis and often occurs upon waking. occurs close to McBurney's point in the majority of pregnant women. A change in position may alleviate the pain. (See "Maternal cardiovascular and hemodynamic adaptations to pregnancy". These women may have signs and symptoms that mimic those of actual pregnancy and can be quite convincing [57]. Although the location of the appendix migrates a few centimeters cephalad as the uterus enlarges. pass through the abdominal inguinal ring and along the inguinal canal. (See "Acute appendicitis in pregnancy". Adnexal disease (eg. persistent or progressive. (See "Diagnosis of preterm labor and overview of preterm birth" and "Placental abruption: Clinical features and diagnosis". and end in the labia majora. ectopic pregnancy. (See "Diagnostic approach to chest pain in adults".

but sensitivity depends on the gestational age. (See 'Urine pregnancy test' above. (See 'Home pregnancy test' above. (See 'Diagnosis' above and 'Ultrasound examination' above. Doppler confirmation of fetal cardiac activity.) ●Knowledge of the clinical spectrum of normal pregnancy is helpful when evaluating women who present with one or more similar clinical findings. as many as 46 percent of pregnant women will have a negative test.5 to 5 weeks of gestation (table 6).) ●The accuracy of home pregnancy tests is affected by the sensitivity of the specific test kit. but have an abnormal pregnancy or coexistent medical or surgical disorder. sonographic visualization of the pregnancy). Positive results on a home-based test should always be confirmed with an office-based hCG test or another definitive test (eg. Identification of pregnancy by ultrasound examination or identification of fetal cardiac activity by Doppler ultrasound are alternative methods. as well as the user's technique and interpretation.) ●Although the urine pregnancy is less sensitive than the serum test. On the first day after a missed period. Transvaginal ultrasound examination can visualize a gestational sac at 4. (See 'Serum pregnancy test'above.●The diagnosis of early pregnancy is based primarily upon laboratory assessment of human chorionic gonadotropin (hCG).) . almost all pregnant women will have a positive urine pregnancy test one week after the first day of a missed menstrual period. (See 'When to be concerned about pregnancy symptoms' above.) ●The most sensitive method of detecting hCG is a serum pregnancy test.