History Taking · Foundation · O&G

Vaginal Bleeding in Early Pregnancy

Practise this PLAB 2 history taking station on Miscarriage. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Kirsty Quigley, a 34-year-old woman with a planned pregnancy, has come in with vaginal bleeding at eight weeks gestation. She is distressed and anxious. Please take a focused history and explain the different types of miscarriage and management options.

Background notes: PMH: Migraines (managed with paracetamol), First pregnancy - planned and very much wanted

What this station tests

  • Not all first trimester bleeding is miscarriage: 50% go on to healthy pregnancy
  • USS before confirming: do not diagnose miscarriage without scan evidence
  • Three management options for confirmed miscarriage: expectant, medical, surgical with patient choice
  • Anti-D for Rh-negative women if over 12 weeks or surgical management
  • Acknowledging the loss: 'it is okay to grieve' validates the experience

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Vaginal bleeding in early pregnancy is devastating for a woman with a planned, wanted pregnancy. The candidate must assess the clinical situation while providing compassionate care. Mrs Quigley is 34, 8 weeks pregnant (planned), bleeding since yesterday, devastated. Open with: 'Mrs Quigley, I can see how distressed you are. Tell me about the bleeding and how you are feeling.'

Core approach

Assess the bleeding. Amount: spotting, moderate, or heavy (soaking pads)? Passage of tissue or clots? Pain: cramping (suggests cervix is opening)? Duration: since yesterday. She is 8 weeks by dates. She is certain of her dates. She thinks she is losing the baby and is certain it is a miscarriage. She may be right, but not all first trimester bleeding is miscarriage: approximately 50% of women who bleed in early pregnancy go on to have a healthy pregnancy.

Assess haemodynamic stability: is the bleeding heavy enough to cause hypovolaemia? If moderate bleeding with cramping: likely miscarriage in progress. If spotting without pain: may be threatened miscarriage (viable pregnancy).

She needs urgent USS to determine viability. Refer to EPAU for transvaginal scan. Do not confirm or deny miscarriage without USS evidence. Bloods: beta-hCG (serial levels help if USS inconclusive), blood group (anti-D if Rh negative and over 12 weeks or surgical management), FBC.

Closing and safety netting

Communicate with compassion. 'I know this is incredibly frightening. Bleeding in early pregnancy is actually quite common, and it does not always mean you are losing the baby. We need an ultrasound scan to see what is happening.' Provide realistic hope without false reassurance.

If miscarriage is confirmed on USS: discuss management options. Expectant (wait for natural process), medical (misoprostol to complete the process), or surgical (manual vacuum aspiration). Her preference matters. Acknowledge the grief: 'This is a loss, and it is okay to grieve.'

Regardless of outcome: offer early pregnancy assessment unit follow-up, support from the Miscarriage Association, and a follow-up GP appointment. Safety net: 'If the bleeding becomes very heavy (soaking more than a pad per hour), you feel faint, or you develop a fever, go to A&E.' She may need time off work: offer a certificate.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for miscarriage. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Bleeding assessed (amount, pain, tissue). Haemodynamic stability checked. USS arranged before diagnosing. Blood group checked for anti-D. Serial hCG if needed.

Costs marks: Diagnosing miscarriage without USS. Not checking stability. Not checking blood group.

Domain 2 (Primary focus)

Scores well: EPAU referral. Three management options presented with choice. Anti-D if indicated. Miscarriage Association signposted. Sick certificate offered.

Costs marks: No EPAU referral. No management options. No support resources.

Domain 3 (Primary focus)

Scores well: Compassionate throughout. Acknowledging grief. Providing realistic hope without false reassurance. Giving her time to process.

Costs marks: Clinical detachment. Premature certainty. Not acknowledging the emotional impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Confirming miscarriage without USS: bleeding does not always mean miscarriage, and premature diagnosis causes unnecessary devastation
  2. Being clinically detached: this is a deeply emotional situation requiring compassionate communication
  3. Not discussing management options: the patient should be offered choices (expectant, medical, surgical) not told what will happen

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the miscarriage history in this PLAB 2 station?

Vaginal bleeding in early pregnancy is devastating for a woman with a planned, wanted pregnancy. The candidate must assess the clinical situation while providing compassionate care. Mrs Quigley is 34, 8 weeks pregnant (planned), bleeding since yesterday, devastated.

What are examiners marking in this miscarriage station?

Marks are won for: Bleeding assessed (amount, pain, tissue). Haemodynamic stability checked. USS arranged before diagnosing. Blood group checked for anti-D. Serial hCG if needed. Marks are lost for: Diagnosing miscarriage without USS. Not checking stability. Not checking blood group.

What is the most common mistake candidates make in this miscarriage station?

Confirming miscarriage without USS: bleeding does not always mean miscarriage, and premature diagnosis causes unnecessary devastation.

How do I prepare for this station if I have not managed miscarriage in clinical practice?

Structure beats experience here. Focus on uSS before confirming: do not diagnose miscarriage without scan evidence. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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