OSCE 8: Early pregnancy discussion.
A 28 year old female presents to fast track with 2 days of light PV bleeding. She has been referred to you via her GP based on an ultrasound scan that shows an intra uterine pregnancy with a yolk sac and a 6mm gestational sac but there is not foetal heart beat. The GP letter states she is 12 weeks pregnant. The patient is aware of her scan and has come to your ED for ongoing management.
You have seven minutes
- Medical Expertise
- Professionalism and Communication
Advice / framework for an early pregnancy discussion:
- Apologies for any wait and offer analgesia.
- Address concerns.
- Gather information to see what investigations have been done, the timing and if you have a definitive diagnosis or need more follow up. These cases in real life as well as in the OSCE world can be confusing, make sure you understand BHCG levels and the transition zone, what USS results you would expect and what follow up is required. In nearly all cases you will not have a definitive answer at the bedside. Even if you do, explain your impression but also state that you will confirm this with a specialist.
- If there is a possibility of a miscarriage explain that this occurs in 25% of pregnancies, often not discussed and there is nothing the patient has done wrong.
- Check that they have social supports.
- Allow them to ask questions.
- Give a clear follow up and return instructions.
- Summarize your plan.
Additional comments / Resources on this video:
- If you find you have said something awkward, then say so “I’m really sorry that came out wrong, can I rephrase that?”.
- Exploring any pregnancy difficulties you could ask “Was this a natural or assisted conception”.
- An example in the debrief was given: What if you have a PID case and they ask ‘What are the risks?’ and you know they have multiple partners. Answer: “We know there is an increased incidence in people who have multiple partners”.
- QLD guidelines – early pregnancy / RANZCOG guidelines – anti-D.
Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.