OBGYN Station 5

 

Station 5

 

Some concerning bleeding

Candidate Instructions

Setting:

You are a Foundation Year doctor working on the Antenatal Unit. This patient is 28+2 weeks pregnant and has presented with vaginal bleeding.


Laura Renning


Tasks:

1. Take a history from the patient.

2. Inform the examiner of your main diagnosis, plus two differentials.

3. State which investigations you would like to the examiner.

4. Explain your management plan to the patient.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: Placenta Praevia - vaginal bleed

You are Laura Renning .
You have presented to the antenatal unit with vaginal bleeding.

Appearance and Behaviour

Throughout the consultation you should act anxious, worried about your pregnancy..

Opening statement

“I’m really worried doctor. I noticed some blood on the toilet paper when wiping this morning and I'm really worried something is wrong with my baby”.

Information to Give Freely

You are 28+2 weeks pregnant. You are very anxious because you have never had bleeding like this before.

Presenting Complaint

Site – vaginal bleeding.
Onset – since around 9am this morning, you noticed after you went to the toilet to pass urine. You have also been experiencing spotting for the last week or so, however nothing as bad as this.
Character – bright red blood, no clots. No vaginal discharge. You put a sanitary pad in your underwear when you noticed the bleed this morning, you’ve replaced it twice since due to blood soaking the pads.
Radiation – No abdominal contractions.
Associated symptoms – no pain.
Associated symptoms – No anaemia Sx - no SOB, pallor, dizziness, collapse or palpitations. No bleeding from anywhere else in the body.
Associated symptoms – No change/reduction in foetal movements baby was last felt moving 5 minutes ago.
Timing – bleeding was constant since it started but has stopped around 1 hour ago. You were bleeding for about 2 hours in total.
Exacerbating/relieving factors - nothing, it just stopped by itself. You can’t think of anything that triggered the bleeding. There is no history of trauma.
Severity – you were worried about the quantity of blood so had to use a pad to avoid any leaking.

Current Pregnancy

28+2 weeks’ gestation.
Planned pregnancy.
No abnormalities found on scans so far. You missed your second scan and forgot to re-schedule. If asked, you do not know the position of the placenta.
All pregnancy screening tests were normal.
No reduced foetal movements.

Gynae History

Last menstrual period - can’t remember when it was. You remember you missed your period before you found out you were pregnant and did a test to confirm it.
Age of menarche and menopause - menarche aged 12 years. Menopause n/a.
Relevant sexual history/current status- currently sexually active with your partner. No previous STIs or pelvic inflammatory disease (PID).
Smear status - last cervical smear 2 years ago. All previous smears were normal.

Obstetric History

Last menstrual period - can’t remember when it was. You remember you missed your period before you found out you were pregnant and did a test to confirm it.
Age of menarche and menopause - menarche aged 12 years. Menopause n/a.
Relevant sexual history/current status- currently sexually active with your partner. No previous STIs or pelvic inflammatory disease (PID).
Smear status - last cervical smear 2 years ago. All previous smears were normal.

Past Medical History

Previous similar episodes - Slight PV spotting for the past week.
Other medical conditions - Asthma (well-controlled). Never seen a gynaecologist before.
Previous surgeries - previous C-Section (2 years ago, non-classical). No other surgeries.

Drug History

Prescribed medications - nil.
Over the counter - took folic acid & vitamin supplements for the first 12 weeks of pregnancy.
Allergies - NKDA.
Contraceptive methods used - condoms.

Family History

Nil significant.

Social History

Smoking history - used to smoke 15 cigarettes/day but cut down to around 1-2/day when you first found out you were pregnant.
Alcohol - have since stopped drinking since becoming pregnant.
Illicit drugs - none.
Home - 3 bedroom house. No concerns about domestic violence in the home. Lives with partner and daughter (aged 2).
ADLs - fully independent

Systems Review

Neuro - NO loss of consciousness or confusion
Resp - Nil, NO haemoptysis
Cardio - Nil
GI - Nil
GU - Nil, including NO UTI symptoms
Skin - Nil

Ideas / Concerns / Expectation

Ideas - you think you may have lost your baby.
Concerns - you’re concerned about the implications for your pregnancy.
Expectations - you’d really like someone to scan your baby and listen to their heartbeat to check that they’re ok.

Discussion / Questions

After the history is complete the doctor will discuss a preferred diagnosis and further tests with the examiner, they will then come back to you to discuss the management.

Start the Timer and Begin

Intro

 

Presenting complaint

 
  • When it started - around 9am this morning when wiping with toilet paper after passing urine
  • Quantity - enough to fill 2 pads in around 2 hours
  • Colour - bright red blood, clots - no clots

Gynae History

 

Obstetric History

 

Past Medical History

 

Drug History

 

Family History

 

Social History

 

Systems Review

 

Ideas, Concerns, Expectations

 

Diagnosis

 

Explaining Skills & Management

 

Assessment

Explanation and Further Management

  • Placenta Praevia means the placenta is lying low in the uterus
  • Bleeding comes from seperation of the placenta itself as the lower segment of the uterus forms or from cervical dilation later in pregnancy
  • Blood usually comes from the maternal blood supply
  • It is a serious medical condition and requires close monitoring
  • Emergency delivery (if mother or baby is in haemodynamic distress)
  • Re-scan with elective caesarean section if the placenta remains low
  • Consultant led monitoring, likely as an inpatient due to bleed

Summary

(Grab a coffee…there’s a lot to discuss 👀)

 

Laura was admitted for monitoring due to the volume of her bleed. She remained cardiovascularly stable and CTG readings remained normal. As a result emergency delivery was not indicated. She suffered 1 further bleed whilst straining to lift a chair in her room at 30 weeks. This was treated with successful resusitation and there were no signs of foetal or maternal compromise. Laura remained an inpatient and delivered a healthy baby boy at 37 weeks via semi-elective caesarian section. 

  • Note that a FBC Haemaglobin will not immediately reflect acute blood loss. This is why a history seeking symptoms of anaemia is a key part of any obstetric bleeding history (and in fact, any acute bleeding history). This is especially true as concealed bleeding commonly occurs in obstetric emergencies so true blood loss may be worse than first resported.

  • Estimating blood loss in ml is notoriously difficult so asking about the volume of soiled clothing/bedding/pads can be useful. 

  • In high tension stations like this it is easy to offer false reassurance, remember, you are an FY1. You often won’t know the prognosis of these presentations especially because you will be moving every 4 months on rotations. No doubt a worried actor will ask you if their baby will be okay during the ideas/concerns/expectations section of your history. A good stock sentence when asked “is my baby going to be okay” is something along the lines of “you are in the right place and we are going to take the best care of both you and your baby”. Clearly in real scenarios it is more complex than this, but in an OSCE scenarios this should satisfy the examiners. As a general rule do not be tempted to offer prognosis unless specifically asked in the prompt or you are confident about the answer (e.g. a station about stroke outcomes).

  • Laura (the mother) is Rh+ so a kleihauer test is not required, but this is worth knowing for MCQs. Any rhesus negative (Rh -) mother who has suffered a faetal bleed should receive Anti rhesus D immunoglobulins to stop Rhesus Disease (the kleihauer test helps identify the quantity of Anti-Rh-D-Immunoglobulin required) 

For more information on other labour complications check out this website! Labour Complications

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Tags | OBGYN | vaginal bleeding | placenta | placenta praevia

 Station Written by: Dr Emily Smith

Peer Reviewed by: Dr Benjamin Armstrong

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