St Emlyn’s Lesson Plans
Pain and bleeding in early pregnancy
Separate urgent ectopic-pregnancy concern from stable bleeding, while explaining uncertainty and organising dependable follow-up.
Medical Students · 45-minute session
For learners
Before: Allow about 15 minutes in total.
When we meet: We will compare stable bleeding with collapse and pelvic pain, practising both urgent escalation and a sensitive explanation of uncertain findings.
For facilitators
Send: the learner preparation link before teaching.
Bring: Current referral pathway and a fictional scan report; no intimate examination practice required.
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 ectopic pregnancy and miscarriage · About 12 minutes
From the recommendations, read the initial recognition and referral advice for suspected ectopic pregnancy, the first six recommendations under pregnancy of unknown location, and the short anti-D prophylaxis section. Focus on who needs urgent help, what remains uncertain after an inconclusive scan and the current gestational limits for anti-D. Leave the treatment regimens for later.
https://www.nice.org.uk/guidance/ng126
Think about (allow 3 minutes): How would you answer a patient who asks whether bleeding means they have miscarried before the pregnancy’s location is known?
Picture the scene
A 24-year-old who recently found out they are pregnant has started spotting. They ask whether the pregnancy will be all right.
By the end of the session
- Identify symptoms or instability requiring urgent ectopic-pregnancy assessment.
- Explain why a single test or an early scan may not establish location and viability.
- Give sensitive, specific follow-up and emergency advice.
After the session
- Rehearse one sentence that acknowledges uncertainty and distress without using false reassurance.
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.
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
- Locate the current early-pregnancy referral route and out-of-hours gynaecology contact.
- Check the June 2026 NG126 anti-D update against local policy before teaching; replace old local leaflets where necessary.
Equipment: Current referral pathway and a fictional scan report; no intimate examination practice required.
Setup: Pairs practise both emergency escalation and a compassionate uncertainty explanation. Invite learners to pass on personal pregnancy-related discussion.
If the preparation has not been completed
Use five minutes instead of “Establish the essentials”. Display the NICE referral advice and the two cases. Spend two minutes separating the stable and unstable presentations, two rehearsing a sentence that acknowledges fear without diagnosing miscarriage, and one identifying the local urgent gynaecology route. Keep pregnancy-of-unknown-location follow-up for case 1.
Suggested session plan
- 0–5 min — Explore. Ask what information is needed before answering the patient’s question.
- 5–10 min — Establish the essentials. Identify stable versus urgent pathways.
- 10–32 min — Discuss & Apply. Spend 12 minutes on communication/follow-up and 10 on collapse.
- 32–40 min — Consolidate. Ask pairs to explain pregnancy of unknown location, give the local follow-up contact and describe symptoms requiring urgent care.
- 40–45 min — Reflect & Transfer. Give learners a minute to practise an explanation that acknowledges distress and uncertainty while setting out the next step.
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.
Spotting at approximately six weeks
A 28-year-old with a previous pregnancy loss reports light vaginal bleeding. The last menstrual period was about 6 weeks ago; observations are stable and they currently have no significant abdominal pain.
Add this information as the discussion develops:
- They ask whether they caused the bleeding by working a long shift.
- An initial ultrasound does not yet establish the pregnancy’s location.
Ask the group:
- What symptoms, history and examination change urgency?
- What can you honestly say about outcome today?
- What follow-up must be arranged for a pregnancy of unknown location?
Discussion notes
Points to draw out:
- Ask about pain, amount of bleeding, collapse, shoulder-tip pain, relevant history and the person’s concerns. Explain tests and seek consent; do not rely on the absence of risk factors.
- Do not diagnose miscarriage from bleeding alone. Explain what is known, what is uncertain and the next assessment.
- A pregnancy of unknown location may be ectopic until the location is resolved. Follow the early-pregnancy service plan; changing symptoms take precedence over an apparently reassuring prior hCG trend.
- Offer compassionate reassurance that the person should not blame themselves, while avoiding promises about viability.
Common misconceptions:
- Treating a single hCG value as proof of location.
- Calling a nondiagnostic early scan ‘normal’.
- Using universal statements that pelvic examination is never useful.
For a more experienced group: Ask the supervisor to explain when progesterone is relevant under NG126, including scan confirmation and prior miscarriage, without making it an automatic treatment for all bleeding.
Collapse with pelvic pain
A 29-year-old reports transient loss of consciousness after severe lower abdominal pain. They use contraception and believe pregnancy is unlikely.
Add this information as the discussion develops:
- They become pale and hypotensive; a pregnancy test is positive.
- A trained clinician identifies free intraperitoneal fluid on bedside ultrasound.
Ask the group:
- What should happen before a detailed outpatient work-up?
- How do you explain pregnancy testing respectfully?
- What must not be delayed while waiting for imaging or laboratory results?
Discussion notes
Points to draw out:
- Call senior EM and gynaecology help, assess ABC and treat possible haemorrhagic shock using the local emergency pathway.
- Contraception reduces pregnancy risk but does not exclude it. Explain why a pregnancy test helps assess the current emergency; avoid implying dishonesty.
- A negative bedside scan would not exclude ectopic pregnancy. In a deteriorating person, urgent specialist assessment and definitive management take priority over routine serial testing.
- Use validated laboratory or point-of-care tests as intended; do not put blood on a urine-only kit or catheterise solely to obtain a screening urine sample.
Common misconceptions:
- Accepting perceived low pregnancy risk as exclusion.
- Waiting for a numerical hCG before calling for help.
- Offering outpatient follow-up to an unstable patient.
For a more experienced group: Practise a shared EM/gynaecology handover focused on shock, symptoms and what has already been done.
Important clinical points
- Collapse, significant pain or haemodynamic compromise requires urgent assessment for ectopic pregnancy and other causes.
- NICE's June 2026 update does not recommend anti-D for miscarriage or ectopic pregnancy through 11 weeks + 6 days. Use the current NG126 recommendations for later gestations and the specific clinical situation; check that local policy reflects the update.
- Ensure a specific route for worsening pain, heavy bleeding, dizziness or collapse; do not offer vague ‘see your GP if worried’ advice.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Explain pregnancy of unknown location without claiming it is a diagnosis of miscarriage.
- Give an emergency handover for the collapse case.
- State the exact local follow-up contact and what symptoms should bypass it for urgent care.
Key teaching points:
- Assess immediate safety before discussing the likely outcome.
- Location and viability may need more than one assessment.
- Explain follow-up and how worsening symptoms change the plan.
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 pregnancy often remains diagnostically uncertain after the first visit. The plan must explain who will resolve that uncertainty and how worsening symptoms change it.
If the discussion drifts
What do we know today, what remains uncertain, and what will happen next?
For a more experienced group
Discuss the difference between a reassuring trend and a confirmed intrauterine pregnancy.
A 30-minute version
30 minutes: opening 3, pathway 5, collapse 10, communication 7, consolidation 3, reflection 2.
Evidence and guidance
- NICE NG126 — Current early-pregnancy guidance including 2026 anti-D update.https://www.nice.org.uk/guidance/ng126
- NICE 2026 resource impact statement — Confirms changed anti-D recommendations; exact gestational-band implementation needs local alignment.https://www.nice.org.uk/guidance/ng126/resources/resource-impact-statement-pdf-8779033659589
- NICE NG126: management of miscarriage — Selected progesterone recommendations; use the live guidance and local early-pregnancy pathway.https://www.nice.org.uk/guidance/ng126/chapter/management-of-miscarriage
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Ectopic pregnancy; miscarriage and communication
Students recognise risk and explain the plan without exceeding diagnostic certainty.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Iain Beardsell.