Bleeding in Pregnancy OSCE - Complete Miscarriage

Diagnosis: Complete Miscarriage

Case Overview

  • Age/Sex: 29-year-old female
  • Occupation: Office administrator
  • Setting: Early pregnancy assessment clinic / General practice
  • Chief complaint: "Vaginal bleeding during pregnancy"

Patient Script

Who I Am

I am 29, I work in an office, and I live with my partner — I'm 9 weeks pregnant by my dates.

What Brings Me In

I've had some bleeding and cramping today and I'm really worried about my pregnancy.

My Story

I had my last normal period about 9 weeks ago, and a pregnancy test at home was positive about 6 weeks ago. This morning I woke up with sudden lower abdominal cramps and spotting, which got heavier during the day — I passed what looked like a small dark clot and then the pain eased off. The bleeding was heavier for a few hours but has now calmed to light bleeding. I felt nauseous in the first trimester but that settled a couple of weeks ago. I had a mild sore throat and a low-grade fever two days ago but that went away; I thought it was just a cold. Two years ago I had an early miscarriage around 7 weeks.

My Medical Background

  • Past medical history: One early miscarriage 2 years ago; otherwise healthy
  • Medications: folic acid daily, occasional paracetamol for headaches
  • Allergies: none known
  • Social: drinks one or two glasses of wine on weekends, not smoking, lives with partner, works long hours and feels stressed
  • Sexual: sexually active with same partner, no new partners
  • Family: mother had difficulty conceiving in her 30s (later had successful pregnancy)

What I Think & Worry About

  • I think I might be losing the baby.
  • I'm worried I did something to cause this — maybe stress or the mild fever I had.
  • I'm worried about whether I will be able to get pregnant again.

If You Ask Me About Other Symptoms...

  • Abdominal pain: "I had sharp cramps this morning that got quite bad for an hour, then eased; now it's just mild aching."
  • Vaginal discharge: "No smelly discharge, just blood and a small clot I passed."
  • Fever/systemic: "Felt a bit feverish two days ago with a sore throat, but I'm fine now."
  • Dizziness/fainting: "I felt a bit light-headed when the bleeding was heavier but I didn’t faint."
  • Recent procedures: "I had a smear test six months ago and it was normal." (red herring)
  • Contraception history: "Stopped the pill about 2 months before this pregnancy." (red herring)

Clinical Summary

Examination

  • General: alert, mildly anxious, well appearing
  • Vitals: BP 112/72 mmHg, HR 82 bpm, RR 14/min, T 36.7°C, SpO2 99% on air
  • Abdomen: soft, mild suprapubic tenderness, no guarding or rebound, no palpable masses
  • Pelvic/speculum: small amount of old blood in the vaginal vault, no active heavy bleeding on exam
  • Bimanual: uterus non-tender to moderate palpation, size slightly smaller than expected for 9 weeks (approx consistent with 6 weeks), cervical os closed
  • No adnexal tenderness or palpable masses

Investigations

  • Urine pregnancy test: positive (weakly positive)
  • Serum beta-hCG: 140 IU/L (low for 9 weeks; suggests failing pregnancy)
  • Full blood count: Hb 12.1 g/dL (no anaemia), WCC 6.8 x10^9/L
  • CRP: 2 mg/L
  • Blood group and antibody screen: O positive (no anti-D required)
  • Transvaginal ultrasound: empty uterine cavity, endometrial thickness 18 mm, small amount of intrauterine fluid/debris, no intrauterine gestational sac or fetal pole identified, no adnexal mass or free pelvic fluid

Diagnosis

  • Primary diagnosis: Complete miscarriage

    • Evidence: history of heavy bleeding with passage of tissue and subsequent reduction in bleeding and pain, closed cervical os on exam, very low serum beta-hCG for gestation by dates, and transvaginal ultrasound showing no intrauterine gestational sac and small amount of intrauterine debris consistent with products already expelled.

  • Differential diagnoses:

    • Missed miscarriage: less likely because the patient reports passage of tissue and bleeding has decreased; ultrasound shows no retained gestational sac.
    • Threatened/inevitable miscarriage: less likely as cervix is closed now and ultrasound shows an empty cavity rather than an ongoing viable intrauterine pregnancy.
    • Ectopic pregnancy: less likely given no adnexal mass, minimal pain, and empty uterus with low but declining hCG; however ectopic must be considered when ultrasound is non-diagnostic — low hCG and stable exam make ectopic unlikely here.
    • Molar pregnancy: unlikely given low hCG and ultrasound appearance.

Management

  • Immediate:

    • Confirm hemodynamic stability and reassure patient — she is stable and not bleeding heavily currently.
    • Provide clear explanation that findings are consistent with a complete miscarriage and offer emotional support.
    • No anti-D immunoglobulin required (patient is O positive).
    • Analgesia as needed (paracetamol; consider short course NSAID if no contraindication).

  • Investigations / follow-up:

    • Arrange repeat serum beta-hCG in 48–72 hours to confirm falling trend (expect decline in complete miscarriage).
    • Arrange follow-up in early pregnancy unit / GP in 1–2 weeks to review bleeding and results.

  • Ongoing care and options if concerns arise:

    • If bleeding increases, there is syncope, persistent severe pain, fever, or passage of large clots — advise urgent ED return.
    • If retained products suspected or ongoing significant bleeding, discuss options: expectant management vs medical management (misoprostol) vs surgical management (vacuum aspiration) depending on clinical course and patient preference.

  • Psychosocial:

    • Offer discussion about the previous miscarriage and current feelings; provide written information and offer referral to bereavement or counselling services and local support groups.
    • Discuss future fertility: reassure that most women have successful pregnancies after one miscarriage; offer fertility referral only if recurrent miscarriages occur.

  • Other practical points:

    • Offer contraception advice if desired; discuss timing for future conception (often safe to try after next normal menstrual cycle, tailored to patient preference).
    • Consider STI screening only if clinical suspicion; not routinely indicated here.

Key Learning Points

  • Differentiate complete miscarriage from other early pregnancy complications by combining history (passage of tissue, reduction in bleeding/pain), physical exam (closed cervical os), transvaginal ultrasound (empty uterine cavity), and falling serum beta-hCG.

  • Always assess hemodynamic stability, check blood group and antibody status for possible anti-D, and provide clear safety-netting (return if heavy bleeding, syncope, fever, or worsening pain).

  • Address emotional impact and provide appropriate counselling and follow-up — miscarriage is common and often not predictive of future fertility.

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