St Emlyn’s Lesson Plans

Pain and bleeding in early pregnancy

Discuss possible ectopic pregnancy, uncertain early scan findings and sensitive explanations with reliable follow-up.

New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 15 minutes in total.

When we meet: We will discuss bleeding in a stable patient and the urgent care of someone who collapses with abdominal pain.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Local referral and follow-up contact sheet. Use the written pregnancy-of-unknown-location report in case one; no separate ultrasound image or report is needed.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 15 minutes in total.

Core preparation

NICE NG126: Early pregnancy complications · About 8 minutes

Read NG126’s assessment and diagnosis sections, focusing on ultrasound and pregnancy of unknown location. Note who needs urgent assessment and what follow-up is required.

https://www.nice.org.uk/guidance/ng126

NICE NG126: June 2026 anti-D update · About 4 minutes

Read the final June 2026 anti-D update summary. Note the change so you can compare it with the local policy during the session.

https://www.nice.org.uk/guidance/ng126/resources/resource-impact-statement-pdf-8779033659589

Think about (allow 3 minutes): How would you explain a pregnancy of unknown location without giving false reassurance?

Picture the scene

A 24-year-old who has recently learned they are pregnant has started bleeding. They and their partner want to know whether the pregnancy will be all right.

By the end of the session

Identify features needing immediate resuscitation or urgent gynaecological assessment.
Explain what pregnancy testing and ultrasound can and cannot establish.
Give an empathetic explanation and a clear plan for review and deterioration.

After the session

Check whether your written discharge advice names a service the patient can actually reach.
Ask an early-pregnancy colleague how uncertain results are tracked locally.

Optional further learning

You do not need to complete this before attending. The listening time is additional to the core preparation above.

Optional listening · 26 min 59 sec

St Emlyn’s Podcast: Ep 55 - Communicating (not Breaking) Bad News with Liz Crowe

Practise listening and responding to fear while a diagnosis remains uncertain.

Listen to the episode

Search for this episode by title in MedPod Learn if you want to record your listening there.

Use this 2015 conversation to prepare two sentences acknowledging fear and uncertainty, then invite the patient’s priorities. Adapt to individual and cultural preferences. Bleeding alone does not confirm miscarriage or exclude ectopic pregnancy; use current NICE guidance for investigation and treatment.

https://www.stemlynspodcast.org/e/breaking-bad-news-with-liz-crowe-at-stemlyns/

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 15 minutes in total.

Before learners arrive

Confirm same-day and out-of-hours early-pregnancy access and who reviews serial results.
Bring current pregnancy-testing and anti-D policies; check the June 2026 change with gynaecology.
Find patient information and a 24-hour return contact.

Equipment: Local referral and follow-up contact sheet. Use the written pregnancy-of-unknown-location report in case one; no separate ultrasound image or report is needed.

Setup: Pairs practise answering the patient’s question in the stable case. One plays the patient and the other explains what is known and what happens next. Discuss the collapse case together, starting with immediate actions.

If the preparation has not been completed

Replace the patient-question opening and preparation check (12 minutes). Read the linked assessment and diagnosis guidance for eight minutes, with the local early-pregnancy contact sheet supplied by the facilitator. Use four minutes to practise explaining why the first scan may leave uncertainty. Begin the cases at minute 12. For the 30-minute version, replace the first eight minutes with a five-minute shared read and three-minute explanation in pairs.

Suggested session plan

0–5 min — Start with the patient’s question. Ask learners to answer without false reassurance.
5–12 min — Preparation check. Agree what a positive pregnancy test and one scan can establish.
12–35 min — Two cases. Spend most time on uncertainty, reliable follow-up and the deteriorating patient.
35–40 min — Safety-net rehearsal. Pairs explain return symptoms and where to get help.
40–45 min — Choose a follow-up action. Choose one communication phrase to improve.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Bleeding does not yet establish a diagnosis

A stable 28-year-old reports spotting at about six weeks, with one previous birth and a previous miscarriage. Pregnancy location has not been confirmed.

Add this information as the discussion develops:

They ask: “Have I definitely lost the baby?”
The ultrasound report later describes a pregnancy of unknown location.

Ask the group:

Which symptoms would change urgency?
How will you explain what is still uncertain?
Who will arrange and review the next tests?

Discussion notes

Points to draw out:

Assess pain, bleeding, observations and ectopic risk without assuming absence of risk factors excludes ectopic pregnancy.
Explain that bleeding can have different outcomes and avoid diagnosing completed miscarriage without adequate evidence.
Pregnancy of unknown location needs the agreed early-pregnancy pathway, symptom-led reassessment and reliable follow-up; a single hCG value does not establish location.
Progesterone is for a defined group with scan-confirmed intrauterine pregnancy, bleeding and previous miscarriage, under current NG126 guidance.

Common misconceptions:

Reassuring solely because bleeding is light or a patient appears well.
Providing serial-test advice without an identified service to act on results.

For a more experienced group: Role-play explaining why a repeat scan may be necessary without promising the result.

Collapse with abdominal pain

A 29-year-old has briefly collapsed after severe lower abdominal pain. They use contraception and believe pregnancy is impossible.

Add this information as the discussion develops:

Pulse rises, blood pressure falls and pregnancy testing is positive.

Ask the group:

What must happen before a definitive diagnosis?
How would you discuss pregnancy testing respectfully?
What does a bedside scan add and what can it miss?

Discussion notes

Points to draw out:

Move to an appropriate monitored area, assess and resuscitate, involve senior ED and gynaecology teams urgently and consider haemorrhage.
Explain the clinical reason for testing rather than portraying the patient as unreliable.
Bedside ultrasound may identify free fluid but a negative or indeterminate scan does not exclude ectopic pregnancy; do not delay specialist care for a perfect scan.

Common misconceptions:

Treating contraception or no missed period as exclusion of pregnancy.
Waiting for serial hCG in a deteriorating patient.

For a more experienced group: Discuss the local pathway when immediate specialist ultrasound is unavailable.

Important clinical points

Severe pain, collapse, haemodynamic change or concerning bleeding require urgent reassessment regardless of an earlier reassuring test.
Use validated laboratory or point-of-care pregnancy tests as intended; do not apply blood to a urine-only test.
NICE’s June 2026 update advises no anti-D for miscarriage or ectopic pregnancy through 11+6 weeks; later gestations and specific circumstances require the current full pathway.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Why does a pregnancy of unknown location need follow-up?
What would you do if the patient worsens before their appointment?
How will you explain uncertainty without blaming the patient?

Key teaching points:

Consider ectopic pregnancy even when there are no recognised risk factors.
Act promptly if pain, bleeding or physiology suggests deterioration.
Arrange the next review through an identified service, with clear timing and return advice.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Early ultrasound and hCG often leave uncertainty. Communicate this explicitly; align anti-D prescribing with current national guidance and the locally approved pathway.

If the discussion drifts

What is the risk while we wait, and who is responsible for the next review?

For a more experienced group

Explore discordant hCG and ultrasound findings with an early-pregnancy specialist; avoid turning the induction session into a treatment-protocol lecture.

A 30-minute version

30 minutes: patient question 3; diagnostic limits 5; stable case 10; collapse case 7; consolidation and reflection 5. Omit extended progesterone discussion.

Evidence and guidance

NICE NG126: Early pregnancy complications — Updated June 2026. Diagnosis, follow-up and support.https://www.nice.org.uk/guidance/ng126
NICE NG126: June 2026 anti-D update — Final resource impact statement confirms the June 2026 change; use the full current recommendation for prescribing.https://www.nice.org.uk/guidance/ng126/resources/resource-impact-statement-pdf-8779033659589
NICE NG126: Management of miscarriage — Current threatened-miscarriage guidance including the selected group offered progesterone.https://www.nice.org.uk/guidance/ng126/chapter/management-of-miscarriage