Bleeding in Pregnancy OSCE - Threatened Miscarriage

Case Overview

• Age/Sex: 25-year-old female
• Occupation: Retail assistant
• Setting: Early pregnancy assessment clinic / GP urgent appointment
• Chief complaint: "I've had some vaginal bleeding while pregnant"

Patient Script

Who I Am

I'm 25, work part-time in a clothes shop, and this is my second pregnancy.

What Brings Me In

I've had some vaginal bleeding for the last two days and I'm worried about losing the baby.

My Story

I found bright red spotting on my underwear two days ago, which has continued as light bleeding. It started after I had sex with my partner a couple of days before that. The bleeding hasn't been heavy — mostly blood mixed with brown mucus — and I haven't passed any clots or tissue. I have had mild crampy tummy pains on and off since it started, nothing like really bad labour pains. I felt a bit faint once yesterday but only for a moment and I sat down. I am about 14 weeks pregnant (my dating scan at 10 weeks estimated this). I haven't felt the baby move yet. I had one previous early miscarriage two years ago at about 8 weeks, but this pregnancy has otherwise been fine and my first-trimester bloods were normal.

My Medical Background

• Past medical history: one prior early miscarriage at 8 weeks (2 years ago)
• Medications: prenatal folic acid and iron supplement (ferrous fumarate) daily
• Allergies: none known
• Social: non-smoker, drinks an occasional glass of wine socially before I knew I was pregnant; stopped after pregnancy confirmed; lives with partner
• Obstetric: G1P0 for current pregnancy (previous miscarriage not carried to viability)
• Family: mother alive and well, no major hereditary conditions

What I Think & Worry About

• I think I might be losing the baby.
• I'm really worried that this bleeding means the pregnancy won't survive.
• I want to know if there's anything I did to cause this or that I can do to stop it.

If You Ask Me About Other Symptoms...

• Vaginal discharge: "Mostly blood and some brownish sticky stuff; no foul smell."
• Pain: "Mild cramping, like period pain; not continuous and not severe."
• Fever/chills: "No fever, I haven't been hot or cold."
• Urinary symptoms: "No burning or frequency."
• Recent trauma: "No falls or anything like that."
• Recent sexual activity: "Yes, two days ago — it was normal, but I did notice the next day there was some spotting."
• Bleeding history earlier in pregnancy: "I had no bleeding until this week, though I did have some spotting the week before my first miscarriage two years ago."
• Contraception history: "I was on the combined pill before this pregnancy but stopped when I became pregnant."
• STIs: "I was treated for chlamydia 3 years ago and it was cleared — had antibiotics then."

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Clinical Summary

Examination

• General: alert, afebrile
• Vitals: BP 110/70 mmHg, HR 86/min, RR 14/min, O2 sat 99% on air, afebrile
• Abdomen: soft, uterus palpable consistent with 14 weeks' size, mild suprapubic tenderness on palpation but no guarding or rebound
• Speculum exam: cervical os closed; small amount of fresh blood in the vagina, no visible products of conception; no obvious cervical lesions
• Bimanual: cervix closed, no cervical motion tenderness, uterus non-tender aside from mild cramp sensation

Investigations

• Urine pregnancy test: positive (supports ongoing pregnancy)
• Full blood count: Hb 125 g/L (normal), WCC 7.5 x10^9/L (normal), platelets 250 x10^9/L (normal)
• Blood group and antibody screen: O negative (patient is Rh-negative) (important for anti-D decision)
• Serum beta-hCG: 92,000 IU/L (consistent with 14-week gestation)
• Transvaginal ultrasound: single intrauterine pregnancy; fetal heart rate 155 bpm; crown–rump length / fetal biometry consistent with 14 weeks; closed cervical os; small subchorionic hemorrhage (approx. 10 mm) adjacent to gestational sac

Diagnosis

• Primary diagnosis: Threatened miscarriage — evidenced by vaginal bleeding in pregnancy with a closed cervical os and a viable intrauterine pregnancy on ultrasound; presence of a small subchorionic hematoma explains bleeding.

• Differential diagnoses:

  • Inevitable/incomplete miscarriage: less likely because the cervical os is closed and ultrasound confirms a viable pregnancy.
  • Cervical ectropion or cervicitis causing bleeding: possible cause of bleeding after intercourse but speculum exam shows bleeding from the vaginal vault and no obvious cervicitis; prior treated chlamydia is a red herring.
  • Ectopic pregnancy: unlikely given clear intrauterine pregnancy on ultrasound and appropriate hCG level.
  • Placental issues (e.g., placenta previa): unlikely at 14 weeks and ultrasound localised placenta away from os.

Management

• Immediate:

  • Reassure patient that the pregnancy is currently viable and explain the finding of a small subchorionic hematoma that can cause bleeding.
  • Give anti-D immunoglobulin promptly (250 IU IM as per local guideline) because patient is Rh-negative.
  • Arrange observation and analgesia as required (paracetamol for crampy pain; avoid NSAIDs in pregnancy).
  • Send baseline blood tests (completed) and ensure results are filed.

• Further/Follow-up:

  • Arrange repeat transvaginal ultrasound in 1–2 weeks or sooner if bleeding worsens to reassess viability and size of hematoma.
  • Advise pelvic rest (avoid intercourse) and avoid heavy lifting until bleeding settles, acknowledging evidence is limited but this is commonly recommended.
  • Advise return to ED if heavy bleeding, passage of tissue, severe pain, dizziness/syncope, or fever.
  • Offer emotional support and discuss uncertainty — explain that bleeding increases the risk of subsequent miscarriage but many pregnancies with threatened miscarriage continue normally.
  • Provide written information and offer referral to early pregnancy support services or counselling if desired.

Key Learning Points

• Threatened miscarriage is vaginal bleeding before 20 weeks with a closed cervical os and a viable intrauterine pregnancy on ultrasound; management focuses on confirmation with ultrasound and supportive care.

• Always check maternal Rh status in any bleeding pregnancy and administer anti-D immunoglobulin to Rh-negative women after first-trimester bleeding.

• Subchorionic hematomas are a common cause of bleeding in early pregnancy; size and location on ultrasound correlate with risk, and many resolve with conservative management and follow-up imaging.