Six "I didn't know I was pregnant!" Curveballs to Know for your Exam
By Dr. Simon Moore MD CCFP Pregnancy is something you should never miss in clinic or on the exam. Be ready to hand out pregnancy tests to ANY patient you see. Here are SIX scenarios to be extra vigilant on, so you don’t miss a pregnant patient: 1. I took Plan B, but… The effectiveness of Plan B (Levonorgestrel up to 3 days after unprotected intercourse (UPI)) declines as body mass index (BMI) increases. If your patient’s BMI is ≥ 30 kg/m2, be sure to offer more effective options such as copper IUD or levonorgestrel IUS (new for 2021) up to 7 days after UPI, or oral ulipristal acetate (up to 5 days after UPI). 2. I have Anorexia Nervosa Even though up to 90% of patients with Anorexia Nervosa have amenorrhea (it used to be a part of the diagnostic criteria until the DSM-5), their fertility rates are similar to those of the general population. 3. I’m breastfeeding Lactational amenorrhea is up to 98% effective for up to 6 months, but requires exclusive breastfeeding. However, be warned that fertility can return before menstruation occurs. 4. I’m on the minipill Patients who are taking the progesterone-only pill for contraception have higher rates of pregnancy than other contraceptive methods. 5. I’m menopausal Though menstruation becomes less regular and less frequent during perimenopause, fertility may still be preserved. 6. I’m already pregnant The rate of ectopic & intrauterine pregnancy is 1:30,000: rare but don’t miss it.
Here are 2 ways to ensure you don't miss a pregnancy:
1. Have a low index of suspicion - use the sheep trick you learned at The Review Course in Family Medicine
2. Counsel appropriately - discuss with your patients the risk of pregnancy at every opportunity References: https://pubmed.ncbi.nlm.nih.gov/9678098/ https://www.jogc.com/article/S1701-2163(16)39372-0/fulltext https://www.nejm.org/doi/full/10.1056/NEJMoa2022141