Station 4 · Early pregnancy

Candidates: do not open until you have consulted.

Persona and manner

• Amara Osei, 29, a hospitality manager; composed on the surface, guarded, quiet; you glance off-camera as if someone might come in. You are at home; your partner is at work.
• You become tearful only if the doctor asks how you feel about the pregnancy; otherwise you keep to the physical story.

Opening line (verbatim)

• “I did a test two weeks ago and it was positive. I've had some brown spotting since yesterday and a sort of ache low down on the right, and I just wanted to know if that's normal.”

The story

• “The spotting is brown, then a bit pink this morning; a panty-liner's worth; no clots.”
• “The pain is a dull ache low on the right, for two days, like a stitch, worse when I walk. This morning there was a sharp twinge that made me stop.”
• “I feel a bit off: tired, sick in the mornings, my breasts are sore.”
• If asked: the pain is 4 out of 10 now; no shoulder-tip pain; no faintness; no dizziness standing up; no pain opening your bowels; no urinary symptoms.
• No scan this pregnancy; you have not booked with a midwife: “I hadn't decided.”
• The termination at 24 was straightforward and you do not regret it. The chlamydia was treated; your partner at the time was treated too.
• If asked how you feel about the pregnancy: it was not planned. Your partner of 18 months, Marcus, does not know. “He'd be thrilled. That's the problem. I'm not sure I am.” You have talked about children “in a few years”.
• You have not decided whether to continue; you wanted “to know it's a real pregnancy first”. You would want to talk to Marcus before deciding, “but not today”.
• No one else knows. Your best friend is religious about these things.
• Blood group unknown. You smoke two or three cigarettes a day when stressed; no alcohol since the test.

Ideas, concerns and expectations

• Idea: “A miscarriage, or maybe it's just normal.”
• Concern: An ectopic pregnancy: you have read about it because of the chlamydia. Also that a hospital visit will mean Marcus finds out.
• Expectation: To be told whether it is serious, and a scan.

Impact

• Work: you are up for promotion to area manager; a day in hospital is a day you have to explain.
• Family: your mother is unwell in Ghana and you send money home; you are the only one in the family in the UK.
• Home: you share a flat with Marcus; you want to decide in your own time, and in private.

Red flags

• Present: One-sided pain with bleeding in early pregnancy, and a history of chlamydia: the combination that makes an ectopic pregnancy possible until a scan has excluded it.
• Absent: No shoulder-tip pain, no faintness or collapse, no dizziness on standing, no pain on opening the bowels.
• Absent: No heavy bleeding, no clots, no tissue passed.
• Absent: No fever, no vaginal discharge, no urinary symptoms.

Hidden facts and their triggers

• You are not sure you want to be pregnant, and Marcus does not know — released only if the doctor asks how you feel about the pregnancy; a question that assumes it is wanted gets “I suppose”
• Your mother's illness in Ghana and being the only one here — released only if asked about family or support
• The promotion and what a hospital visit would mean at work — released only if asked about work
• The two or three cigarettes a day — released only if asked directly about smoking
• Whether the hospital will tell your partner — released only you ask it yourself at minute six if confidentiality has not been mentioned

Behaviour

• Minute 1: glance off-camera — “Sorry, I'm just checking no one's home.”
• Minute 3: “I hadn't really decided anything yet.” Quiet, looking down.
• Minute 6: “If I have to go to the hospital, do they tell my partner?”
• If the doctor recognises the possibility of an ectopic pregnancy, arranges same-day assessment at the early pregnancy unit with a clear explanation, gives the 999 triggers, asks how you feel about the pregnancy without judgement, assures you of confidentiality, and offers a conversation about your options whatever the scan shows: cry briefly, then thank them and ask, “Will I be able to decide afterwards?”
• If the doctor reassures you that spotting is common and suggests waiting: “OK… and the pain on the right?” Accept it if dismissed again.
• If the doctor moves straight to antenatal booking and folic acid without asking how you feel: go quiet; answer “I suppose” to everything.
• If the doctor asks about Marcus in a way that assumes he should be told: “That's my decision.”

Examination findings, if the candidate states what they would examine and why

• Video: no examination possible. If the candidate states what they would examine and why: you look well; you can stand and walk across the room; if asked to count your pulse it is 84; you have no fever that you know of.
• Abdominal and pelvic examination will be done at the unit; the candidate should say so.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Reassuring that spotting is common and suggesting she waits, without ever asking about the right-sided pain and the chlamydia (statement D6)
• Moving straight to antenatal booking and folic acid without asking how she feels, so that she withdraws to “I suppose” (statement R2)
• Leaving “do they tell my partner?” unanswered or answered wrongly (statement R4)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: pain and bleeding in early pregnancy with an ectopic pregnancy possible until a scan excludes it. The examiner is listening for: the same-day referral and what the unit will do; the 999 triggers named (severe or shoulder-tip pain, fainting, heavy bleeding); the plain answer on confidentiality; the options kept open whatever the scan shows, with a follow-up conversation booked; and a check of understanding in her words, including when she would call 999.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Refer women with a positive pregnancy test and pain and abdominal tenderness, pelvic tenderness or cervical motion tenderness to an early pregnancy assessment service (or out of hours to A&E) immediately; refer women with bleeding or other symptoms of early pregnancy complications who have pain, or a pregnancy of six weeks or more, or of uncertain gestation, to an early pregnancy assessment service. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.3, symptoms and signs of ectopic pregnancy and initial assessment, 2019, last updated August 2023, checked 10 Oct 2026
2. Be aware that ectopic pregnancy can present with a range of symptoms (abdominal or pelvic pain, amenorrhoea or a missed period, vaginal bleeding, breast tenderness, gastrointestinal symptoms, dizziness or fainting, shoulder-tip pain, urinary symptoms, passage of tissue, rectal pressure or pain on defecation) and signs, and that symptoms alone cannot distinguish it from miscarriage. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.3, symptoms and signs of ectopic pregnancy, 2019, last updated August 2023, checked 10 Oct 2026
3. Risk factors for ectopic pregnancy include previous pelvic inflammatory disease or chlamydia, previous ectopic pregnancy, tubal surgery, an intrauterine device in situ, assisted conception and smoking; a woman with no risk factors can still have an ectopic pregnancy. NICE CKS — Ectopic pregnancy, background information: risk factors, current online version, checked 10 Oct 2026
4. Offer anti-D immunoglobulin to rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage; do not offer it for a threatened miscarriage, a complete miscarriage, or a pregnancy of unknown location managed medically or expectantly. Blood group is established at the unit. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.8, anti-D rhesus prophylaxis, 2019, last updated August 2023, checked 10 Oct 2026
5. Women requesting an abortion can self-refer to an abortion service without seeing a GP; services should offer an appointment within one week of the request and the procedure within one week of the assessment; a woman's decision is her own and information is given without judgement. NICE — NG140 Abortion care, section 1.1, service organisation; section 1.2, information and support, September 2019, checked 10 Oct 2026
6. Patients have a right to expect that information about them will be held in confidence; disclosure to a partner or family member requires the patient's consent unless a disclosure is required by law or justified in the public interest; an adult's pregnancy is not disclosed to a partner without her agreement. GMC — Confidentiality: good practice in handling patient information, paragraphs 9 to 17, using and disclosing patient information, 2017 (updated 2018), checked 10 Oct 2026
7. Women who smoke in pregnancy are offered referral to stop-smoking support at every opportunity; the offer is made without judgement and framed around the woman's own goals. NICE — NG209 Tobacco: preventing uptake, promoting quitting and treating dependence, section 1.17, pregnant women who smoke, 2021, last updated January 2025, checked 10 Oct 2026
8. If a transvaginal ultrasound shows neither an intrauterine nor an ectopic pregnancy, the pregnancy is of unknown location and the woman is at risk of an ectopic pregnancy until the location is known. Two serum hCG measurements 48 hours apart guide what follows: a rise of more than 63% suggests a developing intrauterine pregnancy, a fall of more than 50% suggests a failing pregnancy, and a change between those values needs clinical review within 24 hours. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.4, diagnosis of viable intrauterine pregnancy and ectopic pregnancy: pregnancy of unknown location, 2019, last updated August 2023, checked 10 Oct 2026
9. A woman with bleeding but no pain, with a pregnancy of under six weeks, can be managed expectantly: she repeats a urine pregnancy test after 7 to 10 days and returns if it is positive, or if bleeding or pain continues or worsens; a negative test means the pregnancy has miscarried. Pain, a gestation of six weeks or more, or an uncertain gestation takes her to the early pregnancy assessment service instead. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.3, symptoms and signs of ectopic pregnancy and initial assessment: expectant management under six weeks, 2019, last updated August 2023, checked 10 Oct 2026
10. At the unit, an ectopic pregnancy with no significant pain, an adnexal mass under 35 mm with no visible heartbeat, a serum hCG below 1500 IU/L and no intrauterine pregnancy may be treated with methotrexate. Surgery (laparoscopic salpingectomy, or salpingotomy if the other tube is damaged) is offered with significant pain, a mass of 35 mm or more, a fetal heartbeat, or an hCG of 5000 IU/L or more. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.6, management of ectopic pregnancy, 2019, last updated August 2023, checked 10 Oct 2026
11. A confirmed miscarriage is managed expectantly for 7 to 14 days as the first option, unless the woman is at increased risk of haemorrhage or has had a previous distressing pregnancy experience. Medical management is mifepristone followed 48 hours later by misoprostol (the August 2023 update); surgical management is manual vacuum aspiration under local anaesthetic or surgery under general anaesthetic. A urine pregnancy test three weeks after medical management confirms completion. NICE — NG126 Ectopic pregnancy and miscarriage: diagnosis and initial management, section 1.5, management of miscarriage, 2019, last updated August 2023, checked 10 Oct 2026
12. If she continues the pregnancy, the booking appointment should take place ideally before 10 weeks, with the dating scan between 10 and 14 weeks. Folic acid 400 micrograms daily is advised until 12 weeks and vitamin D 10 micrograms daily throughout. At booking the woman is asked about smoking, with a carbon monoxide test offered, and about domestic abuse, in private. NICE — NG201 Antenatal care, section 1.1, organisation of antenatal care: the booking appointment; section 1.3, interventions and information, August 2021, checked 10 Oct 2026
13. Health professionals trained to do so should ask about domestic violence and abuse where there are indicators, in a private setting with no partner or other family member present, and respond to a disclosure by assessing immediate safety, giving information about specialist services, and recording what was said. NICE — PH50 Domestic violence and abuse: multi-agency working, recommendations on creating an environment for disclosure and responding to it, February 2014, checked 10 Oct 2026
14. The Topic Guide 'Maternity and reproductive health' expects the GP to recognise and act on the complications of early pregnancy, including ectopic pregnancy and miscarriage, through the local early pregnancy pathway; to support a woman with an unplanned pregnancy without judgement, with balanced information on continuing, adoption and abortion; and to maintain confidentiality while asking about safety at home. RCGP — GP curriculum: Maternity and reproductive health, early pregnancy problems; unplanned pregnancy and abortion, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

14 statements, 782 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

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