Cases/Maternity and Reproductive Health

Spotting and One Sided Pain at Seven Weeks Pregnant — Free SCA Practice Case

Woman at seven weeks with spotting and one sided pain

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Try 5 free cases

Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Shanice Okpara

Age

26 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day urgent line appointment.

Reason for Encounter

"Seven weeks pregnant by my dates. Brown spotting for two days and an ache in my tummy. I'd like some advice."

Medical Records

●PMH: Chlamydia on screening 2 years ago, treated at the sexual health clinic, partner notified. No previous pregnancies. No abdominal or pelvic surgery.
●Medications: Folic acid 400 micrograms daily. Combined oral contraceptive stopped 7 months ago.
●Allergies: NKDA.

Recent Notes

●7 months ago: Pre conception discussion.
●Today: Not booked with a midwife. No scan this pregnancy.

Patient Script

For the friend playing the patient role

Character Overview: You are Shanice Okpara, a 26 year old self employed domestic cleaner, bending and scrubbing most of the day. You live with your partner Kelvin, who drives a van for a parcel firm. You are taking this call on your break, in a client's kitchen while she is out. You are warm, quick talking and a bit apologetic, and you play things down ("it's probably nothing") because you do not want to waste anyone's time. Underneath you are frightened.

You stopped the combined pill about seven months ago and you and Kelvin have been trying for a baby since. This is your first pregnancy. Your last period started seven weeks ago and your cycle is very regular. You have done four positive tests. You have told only Kelvin and your friend Tasha, and plan to tell your parents after the twelve week scan. You have not booked a midwife and have had no scan.

Two mornings ago you saw some brown spotting when you wiped. Since yesterday afternoon you have had a dull, dragging ache low down on the left. Your pregnancy app says light spotting early on is common "implantation bleeding", and you are trying hard to believe that. Tasha told you to ring, and you rang mostly to be told it is normal. You do not volunteer how frightened you are, the rectal pressure, or your past until the doctor asks.

Opening Sentence: "Hi doctor, sorry to bother you, it's probably nothing. I'm about seven weeks pregnant and I've had a bit of brown spotting for a couple of days, and a bit of an ache as well. My friend at work said I should ring up and check."

History if Asked (Data Gathering Phase)

●The spotting: "It's brown, like old blood. I only see it when I wipe, and there was a tiny mark on my liner this morning. Nothing bright red. It started two mornings ago and comes and goes. No clots, no tissue, I haven't needed a pad, and it isn't getting heavier."
●The ache: "It started yesterday afternoon, low down on the left. It's a dull, dragging ache that comes and goes, about three out of ten, worse after bending and scrubbing or if I turn round quickly. It's not like my period pains, which were across the bottom of my tummy. This is more on one side, like a pulling."
●Painkillers: "Two paracetamol this morning helped for a few hours."
●Dates and tests: "My last period started seven weeks ago, every 28 days, so I'm sure about the dates. My first test was about two and a half weeks ago, and three more since, the last this morning. All positive."
●Scan and midwife: "No scan, and I haven't booked in with the midwife."
●Planned, sex and pregnancy symptoms: "We've been trying for about six months. We had sex about four days ago, before any of this started, nothing since. I'm a bit sick in the mornings and my boobs are sore, so that all feels normal."

Ideas, Concerns, Expectations

Gating note: Shanice does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks this is implantation bleeding, and puts the ache down to stretching and all the scrubbing this week. If asked: "My app says spotting's really common this early. Implantation bleeding, isn't it? And I've been scrubbing all week, so I think the ache's just stretching, or my back."
●Concerns: She is embarrassed to be taking up a doctor's time, and underneath she is deeply afraid of losing the baby. If asked what is worrying her: "I keep telling myself it's normal. I don't want to be one of those people who rings up over nothing." If the doctor explores further, more quietly: "We've wanted this for ages. I haven't even told my mum yet. If something's wrong I don't think I want to know yet."
●Expectations: She hoped to be told it is normal and to carry on. If asked whether she was hoping for anything: "Tasha had these pessary things from her doctor when she was spotting and it stopped it. Could I have those?"

If Asked: Medical History and Medications

Gating note: Shanice answers each of these plainly when the doctor asks about it. She is a little embarrassed about the chlamydia.

●General health, operations, previous pregnancies: "Nothing, I've always been healthy. No operations. This is my first pregnancy, no miscarriages or terminations."
●Chlamydia: Her voice goes small. "Oh. Yes. About two years ago a postal test came back positive. I had a week of tablets from the sexual health clinic and they told my ex. A test when I got together with Kelvin was clear." If asked about pain or spread: "No, I never had any pain. Nobody said anything about my tubes." She adds: "Is that relevant? I did everything they told me."
●Contraception and fertility: "The combined pill from 18 until seven months ago. Never a coil or an implant. No fertility help."
●Smoking, alcohol and drugs: "About five a day, down from ten before we started trying. I know I should stop. No alcohol since we started trying, and no drugs."
●Medicines and allergies: "Folic acid, and two paracetamol this morning. No allergies."

Social History and Lifestyle Impact

Gating note: Shanice mentions these naturally when the conversation turns to her day, her work or getting anywhere.

●Work: Two more houses this afternoon, the next at one o'clock and the last finishing about half past five. The lady at the last house is 85 and relies on her. "I'm self employed, so if I don't clean I don't get paid. I'd hate to let them down."
●Getting about: She does not drive and gets buses between clients. "The hospital's about half an hour on the bus. I haven't got a car."
●Support: Kelvin is out in his van but only twenty minutes away and would come straight away if she rang. Tasha is working across town.

If Asked: Associated Symptoms

Gating note: Shanice answers direct questions about associated symptoms briefly, in one or two sentences.

●Dizziness, faintness, shoulder tip pain, palpitations, breathlessness, fever, heavy bleeding, discharge, diarrhoea or vomiting: "No, not at all. I feel fine in myself." She feels sick in the mornings but has not been sick.
●Pressure or pain opening her bowels: "Now you say it, there was a bit of pressure at the back when I went this morning. I've been a bit bunged up this week so I thought that was it."
●Urinary symptoms: "No burning. I'm going a bit more than usual, but that's the pregnancy, isn't it?"
●Mood and eating today: "A bit on edge. I had breakfast and a cup of tea."

Responses to Management (The Negotiation Phase)

●
If the doctor says it sounds like implantation bleeding or a threatened miscarriage, and advises rest and waiting:
- ●Reaction: Relieved. "Oh, thank goodness. So I can carry on working?" If told implantation bleeding is not the usual explanation at seven weeks, especially with a one sided ache: taken aback. "Oh. I thought that's what it was. So what do you think it is?"
●
If the doctor explains that the pregnancy could be growing outside the womb and has to be ruled out, or asks about the chlamydia:
- ●Reaction: About the pregnancy: goes quiet. "Outside the womb? Is that dangerous? Could I lose the baby?" She steadies if told it is uncommon but needs checking promptly, and that only a scan can say more. About the chlamydia: embarrassed and defensive. "That was ages ago and I took all the tablets. Is it my fault?" She softens if told it is common, was treated, and is not her fault.
●
If the doctor says she needs to be seen at an early pregnancy unit today, or first thing tomorrow:
- ●Reaction: Alarmed and practical. "Today? I've got two more houses this afternoon. If I cancel I don't get paid. Can I not go after work, or tomorrow?" She agrees once the doctor explains calmly why waiting is not safe and helps her cancel: "Okay. If you think it's that important, I'll ring my clients." If offered tomorrow morning: "So can I still do my houses this afternoon? What would make it an emergency tonight?" If the doctor will phone the unit: "Oh, thank you. Will they know I'm coming?" If told to dial 999 now: "An ambulance? I'm sat here with a cup of tea."
●
If the doctor explains the scan and blood tests, or mentions treatment such as her friend's pessaries:
- ●Reaction: Anxious. "Is it the scan inside? Do I have to have that? Could they do it on my tummy?" If told the internal scan is clearer this early but she can say no: "Okay. I'll see how I feel when I'm there." If told she may need repeat bloods: "So I might go all that way and still not know?" About the pessaries: "Is there anything I can take in the meantime?" If told they are not for her until after the scan: "Okay, that makes sense."
●
If the doctor gives safety netting:
- ●Reaction: To vague netting such as "come back if it gets worse": "Worse how? It already aches. How would I know when it's an emergency?" To specific netting: "So very bad pain, my shoulder hurting, feeling faint or soaking a pad means 999 and don't wait? Can you say that again so I can put it in my phone?"
●
If the doctor asks how she is feeling, or offers follow up whatever the scan shows:
- ●Reaction: Opens up. "I'm scared, to be honest. We've wanted this for so long." If the doctor responds kindly: "Thank you. I just wanted someone to say it's okay to be worried." About follow up: "Will someone ring me after, or should I ring you?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●A woman with a positive pregnancy test, bleeding and pain on one side has an ectopic pregnancy (implanted outside the uterine cavity, most often in a fallopian tube) until the pregnancy has been located. NICE Clinical Knowledge Summaries (CKS) gives about 11 in 1000 pregnancies, and tubal rupture can be life threatening if treatment is delayed.
●Implantation bleeding and threatened miscarriage are diagnoses made after the pregnancy has been located, not before. Ectopic pregnancy often presents atypically (NICE NG126 1.4.2), and mild pain, light spotting and a well looking woman do not make it unlikely. Symptoms usually appear 6 to 8 weeks after the last period, which is exactly where Shanice is.
●Model answer: history by phone including risk factors and instability, explain honestly that ectopic pregnancy must be excluded, arrange assessment at an early pregnancy assessment service (EPAS) today with a scan and a blood test for the pregnancy hormone hCG, phone ahead, deal with work and travel, give specific safety netting and arrange follow up.
●Also acceptable for a woman the call has shown to be stable: a first appointment the next morning that the doctor arranges, with a clear plan for A&E or 999 tonight; same day attendance at A&E or a gynaecology ward if EPAS is closed; or a same day check in person at the surgery that does not delay onward referral.

Taking the History

●NG126 lists the symptoms: abdominal or pelvic pain, a missed period and vaginal bleeding with or without clots, and less commonly breast tenderness, gastrointestinal symptoms, dizziness or fainting, shoulder tip pain, urinary symptoms, passage of tissue, and rectal pressure or pain on opening the bowels.
●Establish the dates, whether a scan has been done, the pain's side, onset, severity and pattern, and the colour, amount and pattern of bleeding.
●Risk factors: previous ectopic pregnancy, pelvic inflammatory disease or salpingitis, pelvic or tubal surgery, assisted conception, smoking, age over 35 years, and a pregnancy with an intrauterine device in place (CKS). Untreated chlamydia can lead to pelvic inflammatory disease and ectopic pregnancy. Shanice's infection was treated and the sources do not say how much risk that adds, so treat it as a reason for concern, not a calculation.
●About a third of women with an ectopic pregnancy have no known risk factor (NG126 1.4.8), so exclude it even when risk factors are absent.
●Check for instability: dizziness, fainting, shoulder tip pain, palpitations, pallor, and heavy or severe pain or bleeding. Ask about work, transport and support early, because a plan that ignores them will not be followed.

Decision Framework: Which Pathway Applies

●Unstable (pallor, tachycardia, hypotension, collapse) or significant concern about pain or bleeding: A&E (NG126 1.4.1), by 999 if she is unwell or cannot travel safely.
●Pain, or six weeks or more, or uncertain gestation, with bleeding or other symptoms: refer to EPAS, or out of hours gynaecology if EPAS is not available. Urgency depends on the clinical situation (1.4.9). Shanice meets all three triggers.
●A positive test with pain and abdominal, pelvic or cervical motion tenderness on examination: refer immediately (1.4.7). These are examination findings, so a telephone call cannot trigger this, but if she is seen in person and any are found, onward referral must be immediate.
●A repeat urine test after 7 to 10 days applies only to under 6 weeks with bleeding, no pain and no risk factors (1.4.10). It does not apply to Shanice.
●Women with pain or bleeding are assessed by a clinician and referred rather than self referring (1.3.3), so the candidate makes the referral. EPAS should see a woman within 24 hours if the clinical situation warrants it, and if it is unavailable the nearest facility with specialist assessment and scanning is used (1.3.1, 1.3.4).
●Same day assessment is the model answer: she has pain, rectal pressure, past chlamydia and smoking, and a phone call cannot exclude tenderness or instability. NG126 does not require immediate assessment for pain alone, and 1.4.11 and 1.3.4 allow assessment within 24 hours, so next morning is defensible for a stable woman with a plan for tonight. More than 24 hours, or no timing at all, is not.

The Limits of a Telephone Assessment

●Nothing said on the phone can locate the pregnancy. In person, CKS advises an abdominal examination and, if there is no abdominal pain and tenderness, a gentle pelvic examination. Transvaginal ultrasound is the diagnostic tool of choice.
●A home test confirms pregnancy only and says nothing about where it is. A woman asked to examine herself cannot give a reliable answer, so the correct step is to arrange to see her.

Explaining the Referral and What to Expect

●NG126 1.4.12 asks you to explain the reasons for referral and what she can expect, which reduces anxiety and avoids her leaving after a long wait with no result.
●At EPAS she should expect a transvaginal ultrasound and an hCG blood test. If a transvaginal scan is not acceptable, a transabdominal scan can be offered with its limits explained.
●If no pregnancy is seen, this is a pregnancy of unknown location and she is treated as possibly ectopic until it is found. Two serum hCG measurements about 48 hours apart guide management, and symptoms matter more than hCG results (NG126 1.8). She should leave with written advice on what to do if symptoms change and how to reach emergency care 24 hours a day.

If an Ectopic Pregnancy Is Confirmed

●Treatment is expectant, medical or surgical, chosen by stability, hCG, pain and her wishes (CKS). Methotrexate is first line for women who can return for follow up, with no significant pain, a mass under 35 mm, no heartbeat and hCG under 1500 IU/L. Surgery is first line with significant pain, a mass of 35 mm or more, a heartbeat, hCG of 5000 IU/L or more, or when follow up is not possible.
●Anti D decisions are made in secondary care (NG126 updated them in June 2026). Afterwards she needs follow up and support, and about a 10% risk of another ectopic pregnancy, so early scans in any future pregnancy.

Progesterone and Other Treatments for Bleeding

●NG126 1.9.2 offers vaginal micronised progesterone 400 mg twice daily to women with a scan confirmed intrauterine pregnancy, bleeding and a previous miscarriage, continued until 16 completed weeks if a heartbeat is confirmed. There is no benefit without a previous miscarriage, and a scan is required first so that an ectopic pregnancy or pregnancy of unknown location is not given progesterone.
●Shanice has no previous miscarriage and no scan, so the answer to her friend's pessaries is no, for now. Prescribing to bridge the wait could mask the problem and delay assessment.

Safety Netting and Travel

●Give an action for each warning sign. Call 999 for severe pain, shoulder pain, feeling faint or dizzy, collapse, or heavy bleeding that soaks a pad soon after putting it on (NHS). For milder worsening, urgent help from the early pregnancy unit, A&E or NHS 111.
●A woman with a possible ectopic pregnancy should not travel alone and should not drive herself if pain is increasing. Shanice needs Kelvin, a friend or a taxi, with her phone on.
●Do not tell a stable woman with mild symptoms to call an ambulance, but make clear the thresholds above mean 999 and not waiting. "Come back if it gets worse" fails, because she already has symptoms and "worse" tells her nothing about when to act.

Communication Points in This Station

●Acknowledge her implantation explanation before explaining why this picture needs a check, since a flat contradiction makes her defensive.
●Be honest about uncertainty: do not say the baby is fine or that she is losing it. Only the scan can answer that. Explain risk factors without blame, since past chlamydia is common and was treated.
●Work with practical barriers. Self employment, lost income and not wanting to make a fuss are the most likely reasons a woman delays. Acknowledge them and still hold the line on timing.
●Explain the scan, including the internal one, and give her a say. She has told almost nobody, so acknowledge what the pregnancy means to her and offer support whatever the scan shows.

Common Candidate Mistakes in This Station

●Agreeing it sounds like implantation bleeding or threatened miscarriage and advising rest, a repeat urine test in 7 to 10 days, or waiting for her midwife booking.
●Failing to ask about shoulder tip pain, dizziness and bowel pressure, or never asking about the past chlamydia and smoking.
●Telling her to ring EPAS or 111 herself, or giving no fallback if the unit cannot see her today.
●Letting her finish her round of clients and attend later, or sending her on the bus alone.
●Prescribing progesterone before a scan has located the pregnancy.
●Safety netting with no specific action, and no plan for how the practice will learn the result.
●Blaming her for the chlamydia, or catastrophising so she cannot take in the plan.

Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.

← Back to Free SCA Practice Cases