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Penny Sillin is a 28 year old lady who has presented to the maternity assessment unit with vaginal bleeding at 20 weeks gestation. Her pregnancy had previously been normal and this is her first pregnancy.

Please take a history from Penny and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Penny Sillin, a 28 year old lady who is currently 20 weeks pregnant with her first child. You noticed some vaginal bleeding last night, which you are very worried about.

HPC: You are 20 weeks pregnant with your first child. You had been trying for about a year and you are very happy to be pregnant, you can’t wait to be a mum!

When you woke up this morning, you noticed that there was some blood in your pyjama bottoms and then when you went to the toilet and wiped there was a bit more. This was very worrying! You have not bled previously in your pregnancy and have noticed no abnormal discharge. There was no abdominal pain. You and your partner had sex last night and you think it might be related to that. You are worried that the baby might be hurt.

POH: This is your first pregnancy. At the 12 week scan, the midwife said that everything was normal. She also took your bloods and said that you were Rhesus negative but that everything else was fine. You are due to have your second scan in 2 days but you were very worried about the bleeding and did not want to wait until then to mention it! You have had some morning sickness and have been urinating more often but this was nothing you didn’t expect; you did a lot of research in the run up to getting pregnant! You have begun to get some back pain but you are still able to manage fine; your husband is well-trained and has been giving you back rubs which help!

PGH: You started your periods age 12 and they have been regular, bleeding 6/28. Sometimes they are little heavy and you were previously on the combined pill previously to manage this. You have only had one smear which was normal. You have never had any STIs.

PMH: You had some problems with depression and anxiety when you were in your late teens. This was managed with medication and some counselling and although you have always been a little “highly strung” you have not had any problems since.

DH: You have been taking your folic acid 400mcg since beginning to try for a baby. You have also been taking special pregnancy vitamins from the supermarket. You are allergic to ibuprofen (it gives you an itchy rash).

FH: No relevant family history.

SH: You live with your husband who is a graphic designer. You work at a florist in town. You really enjoy your job and are sure that your boss will be good about maternity leave. You have never smoked and rarely drink; in fact you have not had any alcohol in the past year as you have been trying to get pregnant.

ICE: You think that it might be related to the fact that you and your partner had intercourse last night. You are really worried that the baby might be hurt. You want to find out what is happening and have some reassurance.

Observe the student taking a history from the patient. It would be appropriate to do an obstetric exam on this lady but NOT an internal examination or speculum at this point. Ask the student to summarise their findings and present a differential diagnosis, which should include placenta praevia. It would also be relevant to include placental abruption (although this would normally present with painful bleeding) and cervical pathology.

Points for discussion: • How would you investigate this patient? • What is placenta praevia and how does it commonly present? • What features may help you determine between placenta praevia and placental abruption? • What is the management of placenta praevia and what advice would you give this patient? • What is the relevance of this patient being Rhesus negative and what extra precautions would you take in this pregnancy? • What conditions might this patient be at a higher risk of after the birth, given her past history? How do we manage these conditions?