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You are an FY1 doctor working in the obstetric and gynaecology department. Leigh Jonella is a 29 year old lady who has presented with a problem with her pregnancy. This is her first pregnancy, and therefore she is quite worried about this presentation.

Please take an obstetric history and explore Leigh’s concerns about this presentation. You will be asked to perform the appropriate examination and discuss the case with the examiner.

HPC: You are Leigh Jonella, a 29 year old lady presenting with vaginal bleeding. You are 32 weeks pregnant and this is your first pregnancy. You have been feeling increasingly dizzy since this morning, when you first noticed the bleeding. You have severe abdominal pain which suddenly started this morning and has been gradually getting worse over the past couple of hours. You are quite excited about the pregnancy. You can feel the baby kicking! However, you are becoming increasingly worried about losing the baby. You can’t put your finger on why: it’s just a sense of trepidation that you can’t explain. You don’t have any visual disturbances and you don’t feel nauseous. You don’t have any abnormal urinary or bowel symptoms. You feel lethargic and little short of breath but put this down to being pregnant. You have attended both the 12 and 20 week scans which have been normal however a recent growth scan did suggest the pregnancy was small for dates. Other than that, it has been an uncomplicated pregnancy but you have been advised to stop smoking and lose weight.

ICE: You are very happy about the pregnancy, you and your partner had been trying to get pregnant for at least 6 months and you feel like your hopes and dreams of having a family are finally materialising. You aren’t that concerned about your symptoms as you have had migraines in the past that have resolved but your partner thought you should be seen by a doctor.

Past obstetric history: You’ve never been pregnant before. Isn’t this exciting!

Past gynae history: You have never had any sexually transmitted infections in the past and have regularly attended your cervical smear tests that have all come back negative. You used to have the copper coil however recently have been using barrier methods only.

PMH: You have asthma and a snazzy blood problem called factor V leiden thrombophilia. You get lots of points for that on scrabble!

DH: Salbutamol and Betamethasone inhalers. No drug allergies.

FH: Your mother has high blood pressure and your dad unfortunately died of a stroke last year.

SH: You live with your partner who has been very supportive during the pregnancy. You are unemployed and your husband is a sales assistant. You stopped drinking alcohol during the pregnancy but continue to smoke 5-10 cigarettes/day.

The student should take a thorough history of the presenting pregnancy problem and perform an obstetric examination. They should elicit Leigh’s concerns, particularly around her fears of losing the baby.

An appropriate differential diagnosis should discuss different causes of bleeding during pregnancy, including placenta praevia and placental abruption.

Topics for discussion may include:

  • What is the definition of antepartum haemorrhage?
  • What are the risk factors for placental abruption?
  • How would you manage an antepartum haemorrhage? How would you manage shock?
  • What is fetal distress? How is it determined in pregnancy?