Bleeding in Pregnancy OSCE - Ectopic Pregnancy | Free OSCE Practice

Case Overview

Age/Sex: 27-year-old female
Occupation: Office administrator
Setting: Emergency department, brought by friend after collapse at work
Chief complaint: "Vaginal bleeding during pregnancy"

Patient Script

Who I Am

I'm 27, I work full time in an office, and I try to keep up with everything even when I'm stressed.

What Brings Me In

"I started spotting this morning and then I got terrible belly pain and felt faint — I came because I'm pregnant and I started bleeding and now I'm really scared."

My Story

I found out I was pregnant about six weeks ago after a positive home test. This morning I had a little brown spotting that I thought might be normal. About 3 hours ago the pain got much worse — it became a sharp, stabbing pain on my right lower abdomen, so bad I had to sit down. The bleeding increased from spotting to heavier bleeding with some dark clots over the last few hours. Then I felt dizzy and sweaty and collapsed briefly at my desk; a colleague brought me in. I also started getting a weird pain under my right shoulder that felt worse when I breathed deeply. I haven't had pregnancy checking with the GP yet.

My Medical Background

Past medical history: treated for chlamydia about 4 years ago (completed antibiotics)
Surgical history: none
Medications: occasional ibuprofen for headaches; stopped taking oral contraceptive pills about 2 months ago when trying to conceive
Allergies: none known
Social: non-smoker, drinks alcohol rarely, lives with partner, works long hours and is feeling stressed at work
Family: mother healthy, no family history of clotting disorders

What I Think & Worry About

I think something is wrong with the pregnancy and I'm terrified I might be losing it.
I'm worried this could mean I can't have children later.
I'm scared I might be dying because I felt faint and now feel really weak.

If You Ask Me About Other Symptoms...

"Pain — it's mainly on the right side of my lower belly and it comes in sharp waves."
"I felt faint and sweaty when I collapsed — I didn't actually pass out for long."
"I started getting this sore feeling under my right shoulder about an hour after the belly pain started."
"I've had no fever or chills, no cough."
"I felt a bit sick but I haven't vomited much."
"I had a bit of urinary burning a few weeks ago, but it got better with a single course of antibiotics from my GP (I thought it was a UTI)." (red herring)
"I had a heavy lifting day at work two days ago but I wouldn't say I hurt myself — just a lot of backache from moving boxes." (red herring)
"I have been under a lot of stress at work lately and haven't slept well." (distractor)

Clinical Summary

Examination

General: pale, sweaty, appears anxious, oriented
Airway: patent
Breathing: RR 22/min, shallow, oxygen saturation 98% on room air
Circulation: HR 118 bpm (sinus tachycardia), BP 88/56 mmHg (hypotensive), capillary refill 4 seconds
Temperature: 36.6 °C
Abdominal exam: abdominal distension, marked tenderness in the right lower quadrant with guarding and rebound; generalized lower abdominal tenderness worse on the right
Pelvic/speculum: moderate vaginal bleeding, blood present on speculum; cervical os closed
Bimanual exam: uterine size consistent with ~6 weeks, marked right adnexal tenderness and a palpable fullness on the right
Neurological: no focal deficit

Investigations

Urine pregnancy test: positive (qualitative)
Serum quantitative β-hCG: 1,800 IU/L (lower than expected for an intrauterine pregnancy at 6 weeks; below usual transvaginal ultrasound discriminatory zone or borderline)
Full blood count: Hb 82 g/L (reduced), WCC 12.5 x10^9/L (mildly raised), platelets 250 x10^9/L (normal)
Group and save (or crossmatch): pending/prepare blood (assign RhD status)
Coagulation: INR 1.0, APTT within normal limits
Transvaginal pelvic ultrasound: empty uterine cavity, right adnexal complex mass ~3.5 cm, moderate-to-large amount of free fluid in the pelvis and Morrison's pouch (suggestive of hemoperitoneum)
ECG: sinus tachycardia

Diagnosis

Primary diagnosis: Ruptured ectopic pregnancy with hemoperitoneum leading to hemodynamic instability
- Evidence: positive pregnancy test with 6-week history, severe unilateral lower abdominal pain, shoulder tip pain (referred diaphragmatic irritation), hypotension and tachycardia, falling hemoglobin, transvaginal ultrasound showing an adnexal mass and free intraperitoneal fluid with an empty uterus.
Differential diagnoses (with reasoning):
- Threatened/inevitable miscarriage: would have vaginal bleeding but usually intrauterine contents visible on ultrasound; does not explain shoulder tip pain or large free fluid.
- Ruptured ovarian cyst: can cause acute pain and free fluid but less likely to cause positive pregnancy test and adnexal mass consistent with ectopic.
- Acute appendicitis with secondary pelvic bleeding: appendicitis causes RLQ pain and mild systemic signs but not positive pregnancy test or adnexal mass and usually not hemoperitoneum causing hypotension.
- Trophoblastic disease (molar pregnancy): usually very high β-hCG and characteristic uterine ultrasound appearance, not isolated adnexal mass.
- Pelvic inflammatory disease with tubo-ovarian abscess: usually febrile, more subacute, and less likely to cause acute massive intraperitoneal bleeding.

Management

Immediate resuscitation: secure airway, high-flow oxygen as needed, large-bore IV access x2, start warmed crystalloid bolus while preparing blood products
Transfuse packed red blood cells urgently given Hb 82 g/L and hemodynamic instability; crossmatch and give O negative or matched blood as per protocol
Urgent obstetrics/gynecology consult for emergency surgical management (likely laparoscopic or open exploration and salpingectomy depending on stability and findings)
Prepare for theatre: NPO, IV analgesia, prophylactic antiemetic, consent for possible salpingectomy and blood transfusion
Do not offer methotrexate (contraindicated in unstable/ruptured ectopic)
Give anti-D immunoglobulin if the patient is RhD negative
Start broad-spectrum IV antibiotics perioperatively as per local protocols if concern for infection or to cover contamination during surgery
Counseling: explain diagnosis, need for emergency surgery, risks including blood transfusion and potential loss of the pregnancy and future fertility implications; arrange partner/family contact
Plan for post-op follow-up: monitor β-hCG to confirm resolution, discuss contraception and future fertility counseling, offer STI screening and partner notification if appropriate

Key Learning Points

Shoulder tip pain in a pregnant patient with abdominal pain suggests diaphragmatic irritation from intraperitoneal blood and should raise concern for a ruptured ectopic pregnancy.
In a hemodynamically unstable patient with suspected ectopic pregnancy and free fluid on ultrasound, urgent resuscitation and surgical management take priority over medical options like methotrexate.
Use a combination of history (unilateral pain, bleeding), examination (hemodynamic instability, adnexal tenderness), β-hCG trends, and transvaginal ultrasound to distinguish ectopic pregnancy from other causes of early pregnancy bleeding.