PLAB 2 Miscarriage Station: How to Approach, Mark Scheme & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Threatened miscarriage
  Bleeding with a closed cervical os and a viable intrauterine pregnancy on scan. Around half settle and the pregnancy continues - which is why you never pronounce a miscarriage before the ultrasound result.
• Inevitable or incomplete miscarriage
  Bleeding with an open cervical os; in incomplete miscarriage some pregnancy tissue has passed but some remains. Typically heavier bleeding with clots and crampy pain - the picture most PLAB 2 stations paint.
• Complete miscarriage
  All pregnancy tissue has passed, the bleeding and pain are settling and the uterus is empty on scan. Needs follow-up confirmation but usually no further intervention.
• Missed miscarriage
  The pregnancy has stopped developing but there has been little or no bleeding - often found when the scan shows a fetal pole with no heartbeat. Breaking this news gently is the heart of the station when it appears.
• Ectopic pregnancy
  The diagnosis you cannot afford to miss. Unilateral lower abdominal pain, shoulder-tip pain, dizziness or collapse, often with lighter bleeding than a miscarriage. Screen for it in every early-pregnancy bleed and exclude it with a transvaginal scan and serum beta-hCG.
• Molar pregnancy
  Rare - bleeding with a uterus large for dates, exaggerated pregnancy symptoms and a very high beta-hCG. The scan makes the diagnosis; it matters because it needs specialist follow-up.
• Cervical or local causes, including implantation bleeding
  Cervical ectropion, polyps or infection can bleed, especially after intercourse, and light spotting around the time of the missed period may be implantation bleeding. Ask about smear history and recent intercourse, but never let a benign explanation stop you excluding ectopic pregnancy first.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open with warmth and acknowledge the fear

   She is frightened before you say a word. The first thirty seconds set the tone for every interpersonal mark that follows.

   • Wash hands, greet, introduce yourself with name and grade, confirm her name and date of birth.
   • Acknowledge the distress early and explicitly: "I can see how frightening this is. I'm going to look after you."
   • Ask who is with her and whether she would like them present - offering to bring a partner in from the waiting room is a scored item.
   • Signpost gently: you need to ask some questions, then examine and arrange a scan, and you will explain everything as you go.

2. 2. Characterise the bleeding and pain

   The bleeding history drives the working diagnosis and the urgency. Ask specifically - vague questions leave marks on the table.

   • When did the bleeding start and is it getting heavier?
   • Amount - number of pads used and whether they are soaking through. This is weighted.
   • Clots or passage of tissue - ask directly, in plain words.
   • Pain - site, character, severity out of 10. Crampy central-suprapubic pain fits miscarriage; unilateral pain should raise ectopic.
   • Fever or offensive discharge - screening for infection.

3. 3. Date the pregnancy and take the obstetric history

   Gestation changes everything - the differential, the scan approach and the management options.

   • Last menstrual period, usual cycle length and regularity, and gestation by dates.
   • When the pregnancy test was positive and whether she has had a scan yet.
   • Previous pregnancies, miscarriages or terminations - asked sensitively, this is weighted.
   • How long they were trying to conceive - a two-year journey changes the emotional weight of this consultation, and candidates who never learn it sound tone-deaf later.
   • Smear history, STI screening, past medical and surgical history, medications including folic acid, allergies, blood group and Rhesus status, smoking and alcohol.

4. 4. Screen for ectopic red flags

   This is the first safety-critical block. Ask each question explicitly - do not assume the answers.

   • Shoulder-tip pain - referred diaphragmatic irritation from intraperitoneal blood.
   • Dizziness, lightheadedness or fainting - haemodynamic compromise.
   • One-sided lower abdominal pain.
   • Risk factors if time allows - previous ectopic, pelvic infection, tubal surgery.
   • State out loud that you want to rule out a pregnancy outside the womb - naming the differential is scored.

5. 5. Explore ideas, concerns and her emotional response

   At some point she will ask "did I do something wrong?" or "is the baby okay?". How you respond is worth more than any single clinical question.

   • Pause. Let her speak. Silence while she is upset is a scored skill, not dead air.
   • Do not answer "is the baby okay?" with false reassurance - be honest that you need the scan before you can say.
   • Acknowledge the guilt directly when it surfaces: nothing she did - lifting shopping, a glass of wine before she knew - caused this.
   • Never rush this section to get back to your checklist. The examiner is watching for exactly that.

6. 6. Request examination, observations and investigations from the examiner

   Tell the examiner what you would examine and order - findings are only given when you ask for them.

   • Vital signs first - blood pressure, heart rate, temperature, oxygen saturation. Tachycardia or hypotension changes this into a resuscitation priority.
   • General and abdominal examination - pallor, tenderness, peritonism.
   • Speculum examination, gently and with a chaperone - is the cervical os open or closed, is tissue visible?
   • Bimanual examination - uterine size, adnexal tenderness or mass, cervical excitation.
   • Urgent transvaginal ultrasound - the investigation that makes the diagnosis and excludes ectopic pregnancy.
   • Serum beta-hCG, full blood count and group and save. If she is Rhesus negative, mention anti-D per guideline criteria - surgical management, or bleeding after 12 weeks.

7. 7. Break the news honestly and gently

   If the scan confirms a miscarriage, this becomes a breaking-bad-news station. Plain words, delivered kindly, score; euphemisms confuse and cost marks.

   • Warn first: "I'm afraid the scan has not shown what we were hoping for."
   • Say it clearly: "I'm so sorry - the scan shows that the pregnancy has not survived. You are having a miscarriage." Then stop and let it land.
   • Use "baby" or "pregnancy", never "products of conception" or "failed pregnancy" to her face.
   • Explicitly state it is not her fault - miscarriage is common, usually caused by a chromosomal problem in the developing pregnancy, and nothing she did or did not do caused it. Failing to say this is a common way to fail the station.
   • Reassure about the future when she is ready to hear it: most miscarriages are one-off events and most women go on to have healthy pregnancies.

8. 8. Explain the management options, then support, follow-up and safety-net

   NICE guidance on ectopic pregnancy and miscarriage (NG126) sets out three options for a confirmed miscarriage. Explain each in lay terms and let her choose in her own time.

   • Expectant - wait and let nature take its course over 7 to 14 days, with a follow-up scan or pregnancy test to confirm completion. Usually offered first if she is stable.
   • Medical - a tablet or pessary (misoprostol) that helps the womb pass the pregnancy, usually at home, with follow-up.
   • Surgical - a short procedure to empty the womb, either awake with local anaesthetic (manual vacuum aspiration) or asleep under general anaesthetic.
   • Offer written information and emotional support - counselling and the Miscarriage Association's helpline are specifically credited.
   • Safety-net explicitly: come back immediately for very heavy bleeding (soaking more than one pad an hour), severe pain, fever, feeling faint or shoulder-tip pain.
   • Summarise, invite questions, offer to speak to her partner with her, and close with warmth.

Common pitfalls

• Running a flawless clinical checklist with no warmth - this station fails candidates on tone more than on knowledge.
• Skipping the ectopic screen because the story "sounds like" a miscarriage. Ask about shoulder-tip pain, dizziness and one-sided pain every single time.
• Diagnosing miscarriage on history alone before the ultrasound and beta-hCG - a safety-critical fail.
• Hiding behind euphemisms ("the pregnancy is not viable", "products") that leave her unsure what has actually happened. Kind, plain words score; vagueness confuses.
• Never addressing "did I do something wrong?" - explicitly saying it is not her fault is one of the heaviest single marks in the station.
• Forgetting to ask about her blood group and Rhesus status, and never mentioning anti-D where it applies.
• Not offering support - a leaflet, counselling, the Miscarriage Association, or simply bringing her husband in from the waiting room.
• Closing without safety-netting for heavy bleeding, fever, severe pain or fainting.

Frequently asked questions