Breaking Bad News OSCE - Miscarriage Diagnosis

Case Overview

• Age/Sex: 30-year-old female
• Occupation: Primary school teacher
• Setting: Emergency gynaecology clinic / early pregnancy assessment unit
• Chief complaint: "Here for test results"

Patient Script

Who I Am

I am 30, I teach young kids, and I’m about halfway through my pregnancy.

What Brings Me In

I was asked to come back today for results, but I’ve also been bleeding a lot and feeling faint.

My Story

I found out I was pregnant about 18 weeks ago. I had a routine scan two days ago and they said they would send some test results today. Then about 6 hours ago I started getting really bad crampy pains low in my tummy and noticed heavy vaginal bleeding — lots of blood and some big clots. I felt dizzy and shaky so my partner brought me in. The pain has been getting worse and I felt like I almost fainted once. I also remember passing something that looked like a dark lump. I had a bit of spotting a couple of weeks ago that settled on its own. I don’t smoke, I drink no alcohol in pregnancy, and I haven’t taken any medicines except a multivitamin recently.

My Medical Background

• Past medical history: one previous first‑trimester miscarriage 4 years ago
• Medications: prenatal multivitamin (folic acid + iron), occasional paracetamol for headaches
• Allergies: none known
• Social history: lives with partner, non-smoker, denies alcohol in pregnancy, works full time
• Sexual history: monogamous relationship, no new partners
• Family history: mother had two uncomplicated pregnancies
• Red herrings / distractors: had a cough and mild fever last week that settled; travelled briefly to visit family 3 weeks ago; had heavy periods as a teenager

What I Think & Worry About

• I’m terrified I might be losing the baby and I want to know if that’s what the results mean.
• I’m worried about what this means for having children in the future.
• I’m scared because I felt faint — I worry I might need a blood transfusion or that something serious is happening now.

If You Ask Me About Other Symptoms...

• Abdominal pain: "It’s really crampy and I’d rate it 8/10 now; it comes in waves and is lower down."
• Vaginal discharge: "It’s bright red blood now; earlier there were darker clots and something like tissue."
• Fever/chills: "I had a mild cough and a bit of fever last week but I feel about normal now, no high fever today."
• Urinary symptoms: "No burning, no frequency."
• Bowel symptoms: "A little constipated but nothing big."
• Contraception history (if asked): "No IUD now — I had one years ago but it was removed before I got pregnant."
• Last menstrual period: "I think my dates were regular, but I’m not 100% sure — I was told the pregnancy is about 18 weeks."
• Emotions/support: "I’m really upset and I want my partner here; I want to know what happens next."

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Clinical Summary

Examination

• General: alert but anxious; pale appearance
• Vitals: HR 118 bpm, BP 88/56 mmHg, RR 20/min, Temp 36.7°C, O2 sat 98% on air
• Abdomen: lower abdominal tenderness, suprapubic guarding, uterus palpable consistent with ~18 weeks gestation
• Speculum / vaginal: active fresh bleeding from the os
• Bimanual: cervix dilated approximately 3–4 cm with felt products in the cervical canal; uterus soft but tender

Investigations

• Urine pregnancy test: positive (qualitative)
• Full blood count: Hb 7.8 g/dL (low, significant acute blood loss), WBC 14.2 x10^9/L, Platelets 220 x10^9/L
• Group & save / crossmatch: O negative (patient blood group O negative) (requires urgent confirmation and availability)
• Beta-hCG: 24,000 IU/L (in pregnancy range but not informative for viability at this stage)
• Transvaginal/transabdominal ultrasound: intrauterine pregnancy with absent fetal cardiac activity; products of conception seen within the cervical canal and lower uterine segment consistent with ongoing incomplete second‑trimester miscarriage
• Coagulation screen: INR 1.0, aPTT normal (no coagulopathy on initial testing)

Diagnosis

Primary diagnosis:

• Second‑trimester miscarriage (inevitable/incomplete spontaneous abortion) with significant vaginal haemorrhage and hemodynamic compromise (hypovolaemic shock features).

Supporting evidence:

• Acute heavy vaginal bleeding and passage of tissue
• Cervical dilation with products in the canal on examination
• Ultrasound confirmation of intrauterine pregnancy with absent fetal cardiac activity
• Low hemoglobin and hypotension/tachycardia consistent with acute blood loss

Differential diagnoses (brief reasoning):

• Placental abruption: less likely at 18 weeks with products present in cervix and ultrasound showing non‑viable fetus; abruption usually presents with painful firm uterus and fetal distress rather than passage of products.
• Cervical pathology (polyp): unlikely to explain large clots, systemic signs, and ultrasound findings.
• Septic abortion: consider if fever, foul‑smelling discharge, systemic toxicity — currently no high fever, though WBC mildly raised; monitor.
• Ectopic pregnancy: unlikely given ultrasound demonstrating intrauterine pregnancy and second‑trimester presentation.

Management

• Immediate resuscitation: IV access with two large bore cannulas, crystalloid bolus, continuous monitoring of vitals
• Urgent obstetrics/gynaecology review and escalation to theatre if ongoing heavy bleeding or hemodynamic instability
• Blood products: crossmatch and transfuse packed red blood cells as indicated (Hb 7.8 g/dL with hemodynamic instability) — have O negative available until full crossmatch
• Analgesia and antiemetics as needed
• Uterotonics: IV oxytocin infusion and consider additional uterotonic agents in conjunction with obstetrics
• Definitive management of retained products: plan for prompt surgical evacuation (dilation and evacuation under appropriate anaesthesia) given second‑trimester gestation and incomplete expulsion
• Rh prophylaxis: urgent anti‑D immunoglobulin (for Rh‑negative mother) after discussion and recording of administration
• Infection prophylaxis / treatment: start antibiotics if signs of sepsis or per local protocol (e.g., broad‑spectrum IV antibiotics) and culture where appropriate
• Post‑procedure care: counselling, arrange follow‑up, offer bereavement support, discuss future fertility and recurrence risk

Key Learning Points

• Recognise and promptly manage obstetric haemorrhage: stabilise ABCs, establish IV access, and call for senior obstetric help early.
• In any pregnancy with vaginal bleeding, assess cervical status and perform ultrasound to differentiate types of miscarriage and confirm intrauterine location; management differs if there are retained products and hemodynamic compromise.
• Ensure Rh‑negative women receive anti‑D immunoglobulin after any pregnancy loss to prevent alloimmunisation; consider blood transfusion and psychological support as part of holistic care.