Woman in Early Pregnancy Requests An Abortion — Free SCA Practice Case
Woman in early pregnancy requests an abortion
Station Timer
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
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
Full Name
Jessica Cole
Age
26 years
Consultation Type
VideoAge
26
Reason for Encounter
"Patient reports a positive home pregnancy test and wishes to discuss termination."
Medical Records
- ●PMH: Nil significant.
- ●Medications: None. (Previously on the Combined Pill, stopped 6 months ago).
- ●Allergies: NKDA.
Recent Notes
- ●2 Years Ago: Routine cervical smear (Normal). No recent GP attendances.
Patient Script
For the friend playing the patient role
Character Overview: You are Jessica. You are 26 and work as a retail manager. You found out you are pregnant yesterday and are absolutely terrified, but completely resolute in your decision not to continue the pregnancy. You are hiding a dark reality: your partner, Mark, has become increasingly controlling over the last year. He has been pressuring you to have a baby to "prove your commitment" and recently, you suspect he intentionally tampered with your condoms (reproductive coercion). You are secretly planning to leave him next month. You are terrified he will find out about this pregnancy and the abortion. You need this to be handled quickly and with absolute secrecy. You will not volunteer the coercion or your fear of Mark unless the doctor explicitly asks about your home situation, your relationship, or why you seem so anxious about confidentiality.
Consultation Flow & Responses:
- ●The Opening
- ●If the doctor asks an open question: "Hi Doctor. I took a pregnancy test yesterday and it was positive. I can't keep it. I need to arrange an abortion as soon as possible. Can you sort that out for me today?"
- ●Data Gathering
- ●Layer 1: Dating the Pregnancy & Ectopic Screen (The Medical Basics):
- ●"My last period started about 6 weeks ago."
- ●"My breasts are quite sore and I feel a bit sick in the mornings, but that's it."
- ●"No, I haven't had any bleeding at all. No tummy pain or pain in my shoulders."
- ●Certainty & Support:
- ●"I am 100% certain. There is no doubt in my mind. I cannot have a child right now."
- ●If asked who is supporting her: "Just my best friend, Sarah. She's the only one who knows."
- ●Layer 3: ICE & Safeguarding (The Core Revelation) - ONLY REVEAL IF ASKED:
- ●If the doctor asks: "Does your partner know?" or "Are you safe at home?" or "You seem very anxious about the speed of this, is everything okay?"
- ●Reaction (The Reveal): Your voice drops to a whisper. "No, Mark doesn't know. And he can never know. He's been trying to trap me into having a baby. I think he poked holes in the condoms. He checks my phone and my bank statements. I'm trying to save up to leave him. If he finds out I'm pregnant and getting rid of it, he will go crazy. I need to know how to do this without him finding out."
- ●Layer 4: Method Preference & Expectations:
- ●If asked how she wants to proceed: "Sarah said you can just take a pill at home and it feels like a heavy period. Can I do that? I can just tell Mark it's my time of the month."
ICE — Ideas, Concerns, Expectations
(Actor guidance: Jessica does not raise these unprompted. These surface only when the candidate directly explores her perspective.)
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Ideas: Jessica does not have a clear idea about how the pregnancy happened beyond suspecting Mark tampered with the condoms. She is not confused about the pregnancy itself — she simply sees it as a consequence of Mark's coercion and wants it dealt with. If asked what she thinks happened: "I was using condoms every time. I think Mark must have done something to them — I noticed one looked a bit off but I didn't think much of it at the time."
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Concerns: Her overriding concern is secrecy and safety — she is terrified Mark will discover the pregnancy and the termination. Beyond that, she is worried about the process being painful or taking too long, and about anything showing up on her medical records or bank statements that Mark could find. If asked what worries her most: "Honestly? That Mark finds out. That's all I can think about. I'm also a bit scared about what it'll actually be like — the pain and the bleeding and all that."
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Expectations: She wants a fast, discreet resolution — ideally medical abortion at home with pills, arranged as quickly as possible, with no trace Mark could find. If asked what she's hoping for from today: "I just want you to tell me how to get this sorted quickly and quietly. I don't want a big thing — I just want it done so I can focus on getting out."
If Asked — Medical History and Medications
(Actor guidance: Jessica confirms details only when directly asked. She does not volunteer medical history unprompted.)
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If asked about previous contraception / the pill: "I was on the combined pill for years — since I was about 18. I stopped it about six months ago because Mark kept going on about how it was 'unnatural' and said we should just use condoms instead. Looking back, I think that was part of his plan."
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If asked about periods since stopping the pill: "They came back pretty normally after a couple of months. Every 28 days or so, fairly regular, until now obviously."
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If asked about her last smear test: "Yeah, I had one a couple of years ago. It was normal. I got the letter saying everything was fine."
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If asked about any other medical problems: "No, nothing. I've always been pretty healthy. I don't take any medications or anything."
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If asked about allergies: "No, no allergies to anything."
Social History and Lifestyle Impact
(Actor guidance: Jessica may mention work and daily life naturally in conversation, particularly when explaining the urgency or the secrecy required.)
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Occupation and daily life: Jessica is a retail manager at a high-street clothing store. She works long shifts, often including weekends. The job gives her some financial independence from Mark, though he monitors her earnings closely. She has been quietly setting aside small amounts of cash from her wages to fund leaving him.
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Lifestyle impact of the situation: The pregnancy and the need for secrecy are consuming her. She has been unable to concentrate at work and nearly broke down in front of a colleague yesterday. She is terrified of the morning sickness getting worse because Mark will notice. If she mentions work: "I nearly lost it at work yesterday — had to lock myself in the stockroom for ten minutes. I can't eat breakfast because I feel sick and Mark's already asking why I look 'off.' If this goes on much longer he's going to work it out. I need this sorted before the sickness gets any worse."
If Asked — Associated Symptoms
(Actor guidance: Jessica answers these only if the doctor asks directly. Keep responses brief and natural.)
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If asked about vaginal bleeding or spotting: "No, nothing at all. No bleeding."
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If asked about abdominal or pelvic pain: "No pain, no. Just the sore boobs and the nausea."
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If asked about shoulder tip pain: "No, nothing like that."
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If asked about dizziness or fainting: "No, I haven't fainted or felt dizzy."
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If asked about urinary symptoms (frequency, burning, blood): "I'm going to the toilet a bit more often than usual, but no pain or blood or anything like that."
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If asked about vaginal discharge: "Nothing unusual, no."
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If asked about fever or feeling unwell: "No, I feel fine apart from the sickness in the mornings."
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If asked about mood / how she is coping emotionally: "I'm not sleeping. I lie there next to him going over it all in my head. I feel trapped. But I'm not going to hurt myself or anything like that — I just need to get through this."
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If asked about appetite or weight change: "I can't really face food in the mornings. I haven't noticed any weight change — it's only been a few weeks."
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If asked about previous pregnancies: "No, I've never been pregnant before. This is the first time."
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If asked about smoking, alcohol, or recreational drugs: "I don't smoke. I have a glass of wine now and then but I haven't touched anything since the test. No drugs."
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Negotiation & Collaborative Management Plan
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If the Doctor is judgmental or tries to persuade you to "think about it":
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Reaction: Defensive and angry. "I have thought about it. It's my body and my life. Are you going to help me or do I need to find another doctor?"
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If the Doctor suggests referring her to the local hospital:
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Reaction: Panics. "No! Mark's sister is a receptionist in the ultrasound department there. I can't go to the local hospital. Isn't there an independent clinic?" (Doctor must offer BPAS/MSI self-referral).
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If the Doctor explains the "Pills by Post" (Telemedicine) option:
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Reaction: "That sounds perfect. But what if the package comes when Mark is in? Can I get it delivered to Sarah's house, or pick it up from a clinic?"
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If the Doctor asks about future contraception:
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Reaction: "I need something he can't see or tamper with. Maybe that implant in the arm? Or a coil? But I need it done on the same day."
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Safety Netting / Follow-up
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If the Doctor offers domestic abuse support (e.g., Women's Aid):
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Reaction: "I have a plan to leave, I just need to get through this first. But if you have a number I can hide in my phone under a fake name, I'll take it."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
The Legal Framework for Abortion in England and Wales
Under the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990), abortion is legally permitted up to 24 weeks gestation provided two registered medical practitioners agree that one of the statutory grounds is met. The vast majority (>98%) are certified under Ground C: that continuation of the pregnancy would involve a greater risk of injury to the physical or mental health of the pregnant woman than if the pregnancy were terminated.
Abortion beyond 24 weeks is lawful only in exceptional circumstances — for example, where there is a substantial risk of serious fetal abnormality (Ground E) or where continuation poses a risk to the life of the woman (Ground A).
Both doctors sign the HSA1 form (previously HSA4, updated 2024). Crucially, the GP does not need to be one of the signatories. The independent abortion provider arranges both signatures. A GP who holds a conscientious objection must not obstruct access: they are obliged to refer the patient promptly to a colleague or inform her of self-referral options without delay.
There is no mandatory waiting period or reflection period in UK law, and no requirement for the woman to justify her reasons. The decision belongs to the patient.
Referral Pathways and Self-Referral
Patients can self-refer directly to NHS-commissioned independent providers without seeing a GP:
- ●BPAS (British Pregnancy Advisory Service) — 0345 730 4030
- ●MSI Reproductive Choices (formerly Marie Stopes) — 0345 300 8090
- ●NUPAS (National Unplanned Pregnancy Advisory Service) — 0333 004 6666
The GP's role is not gatekeeping but facilitation: confirming approximate gestation, excluding ectopic pregnancy on history, identifying safeguarding concerns, providing emotional support, and signposting. In cases involving domestic abuse, the GP adds particular value by recognising coercion, offering a safe referral pathway (e.g., directing pills to a safe address), and initiating a safety plan — tasks that may not emerge through self-referral alone.
NHS England mandates that patients should be seen by an abortion provider within 5 working days of referral. Delays increase gestation and reduce available options, making timely signposting essential.
Ectopic Pregnancy Exclusion on History
Before any discussion of abortion method, the GP must take a focused history to exclude symptoms suggestive of ectopic pregnancy, which occurs in approximately 1 in 80 pregnancies:
- ●Unilateral pelvic or lower abdominal pain — constant or intermittent
- ●Vaginal bleeding — often scanty, dark, or "prune-juice" in character
- ●Shoulder tip pain — a red flag for intraperitoneal bleeding from rupture
- ●Dizziness, syncope, or haemodynamic instability — suggests rupture
Risk factors include previous ectopic, pelvic inflammatory disease, tubal surgery, IUD in situ, and assisted conception. In this case, Jessica reports no pain, bleeding, or shoulder tip pain, and her symptoms are consistent with an intrauterine pregnancy at approximately 6 weeks. A formal ultrasound to confirm intrauterine location is arranged by the abortion provider as part of their standard pathway.
Early Medical Abortion (EMA)
EMA is the most common method of abortion in England and Wales, accounting for over 85% of all procedures. It is available up to 9 weeks + 6 days gestation (NICE NG140; RCOG guideline).
Regimen:
- ●Mifepristone 200 mg orally — a progesterone receptor antagonist that destabilises the decidua and sensitises the myometrium to prostaglandins
- ●Misoprostol 800 micrograms (buccal, vaginal, or sublingual) — administered 24–48 hours later; a prostaglandin E1 analogue causing uterine contractions and cervical softening
What to expect: Heavy, crampy bleeding — typically heavier than a normal period — beginning 1–4 hours after misoprostol. Clots and pregnancy tissue may be visible. Bleeding gradually lightens over 1–2 weeks. Nausea, vomiting, diarrhoea, and transient fever can occur as prostaglandin side-effects. Analgesia (ibuprofen ± codeine) and an anti-emetic should be supplied or advised.
Red flags to return or call: soaking more than two pads per hour for two consecutive hours, fever persisting beyond 24 hours, offensive vaginal discharge, or no bleeding at all (suggesting failed expulsion).
Telemedicine pathway (Pills by Post): Since March 2020 (made permanent in 2022 in England), women at ≤9+6 weeks can undergo a telephone or video consultation with a provider and receive both medications by post to a nominated address. This is particularly important for patients like Jessica who need medications delivered to a safe alternative address to avoid detection by an abusive partner.
Surgical methods (for completeness):
- ●Vacuum aspiration — up to 14 weeks; performed under local anaesthetic, conscious sedation, or general anaesthetic
- ●Dilatation and evacuation (D&E) — from 14 weeks onward
At 6 weeks gestation, Jessica is well within the EMA window. Medical abortion avoids any need for a clinic visit for the procedure itself, maximising discretion and safety.
Reproductive Coercion as Domestic Abuse
Reproductive coercion is a pattern of behaviour that interferes with a person's autonomous decision-making about their reproductive health. It is recognised by NICE (PH50; QS116) and the Home Office statutory guidance as a form of controlling and coercive behaviour under the Domestic Abuse Act 2021. Examples include:
- ●Sabotaging contraception — removing condoms ("stealthing"), hiding or discarding contraceptive pills, refusing to allow contraceptive use
- ●Pressuring or forcing pregnancy
- ●Pressuring or forcing abortion
- ●Controlling access to reproductive healthcare
In this case, Mark's insistence that Jessica stop her combined pill, combined with suspected condom tampering, constitutes reproductive coercion. This exists within a broader pattern of controlling behaviour.
Screening in practice: Reproductive coercion rarely presents overtly. It emerges when the clinician asks about the home situation, explores why contraception was stopped, or notices incongruent anxiety (e.g., extreme concern about secrecy disproportionate to the clinical situation). Useful prompts include:
- ●"Is anyone making you feel pressured about this pregnancy or about contraception?"
- ●"Do you feel safe at home?"
- ●"Has anyone ever tried to stop you using contraception or made you feel you had to get pregnant?"
A validated screening tool is available (DASH-RIC — Domestic Abuse, Stalking and Honour-Based Violence Risk Identification Checklist), though in a consultation it is the open, non-judgemental question that unlocks disclosure.
Safeguarding Response and Safety Planning
When a patient discloses domestic abuse, the GP's response must be supportive, validating, and patient-led. The key principles (NICE PH50; RCGP safeguarding toolkit):
Do:
- ●Name the behaviour as abuse — "What you're describing — someone tampering with contraception to control whether you become pregnant — is a form of domestic abuse."
- ●Validate her autonomy — "You've clearly thought about this carefully. I'm here to support you."
- ●Offer specialist resources:
- ●National Domestic Abuse Helpline: 0808 2000 247 (Freephone, 24-hour, run by Refuge)
- ●Women's Aid live chat: womensaid.org.uk
- ●These can be saved in her phone under a cover name at her request
- ●Discuss the 999 silent solution — if she calls 999 and cannot speak, pressing 55 when prompted transfers the call to the police
- ●Support her existing safety plan without overriding it
- ●Offer a MARAC referral (Multi-Agency Risk Assessment Conference) if the risk is assessed as high
Do not:
- ●Breach confidentiality to police without her consent (unless there are children at risk or an immediate threat to life) — forced disclosure can escalate lethality
- ●Insist she leave the relationship — she is the expert on her own safety
- ●Contact the partner for any reason
- ●Document abuse in shared records accessible to the partner (e.g., patient-facing online portals)
Record-keeping: Code the consultation using appropriate clinical codes but ensure any domestic abuse disclosure is recorded in a way that is not visible on patient-facing summaries, online access, or printed summaries that Mark could access. Many GP systems allow confidential entries to be hidden from patient online access. This is essential.
Confidentiality and Covert Care
Jessica's safety depends on Mark not discovering the consultation, the abortion, or the contraception. Practical confidentiality measures include:
- ●No letters to the home address — ensure the provider and GP practice suppress routine correspondence
- ●Telephone contact to a safe number only — confirm which number and safe times to call
- ●Medications posted to a safe address — Jessica has nominated Sarah's address
- ●GP record access — check whether Mark could access her records through proxy access or a shared NHS login; restrict online record visibility for sensitive consultations
- ●Financial traces — if the service is NHS-commissioned (which BPAS, MSI, and NUPAS are for UK residents), there is no direct charge. If a prescription is issued, prepayment certificates or HC2 certificates leave no identifiable trace. No abortion-related charges should appear on bank statements
These measures exemplify the principle of covert care — healthcare delivered without the knowledge of a controlling person. GPs should be familiar with this concept from covert contraception and safeguarding pathways.
Contraception After Abortion — Covert LARC
Ovulation can return as early as 5–8 days after an early medical abortion. Contraception must therefore be initiated promptly. NICE CKS (Contraception) and FSRH guidelines recommend that contraception is discussed and ideally provided at the time of the abortion.
In the context of reproductive coercion, the choice of method is clinically critical:
| Method | Suitability in coercion context |
|---|---|
| Subdermal implant (Nexplanon) | Excellent — inserted in the upper arm, impalpable or barely palpable in many patients; effective for up to 5 years. Can be fitted at the time of surgical abortion or during the EMA pathway. Small risk the partner detects it on palpation. |
| IUS (e.g., Mirena) / IUD (copper) | Excellent — completely undetectable externally. Threads can be trimmed short. Fitted at the time of surgical procedure or at a subsequent visit. |
| Combined pill / POP | Inappropriate — packaging can be found, routine disrupted, pills discarded by abuser |
| Condoms | Inappropriate — already being sabotaged |
| Depo-Provera injection | Possible covert option — no physical device, but requires repeat clinic visits every 12 weeks |
Jessica should be offered LARC fitting at the same appointment as her abortion procedure if logistically feasible. The abortion provider clinics routinely offer this. If medical abortion is chosen via Pills by Post, a separate appointment for LARC fitting should be arranged at a clinic — not the GP surgery if there is any risk Mark monitors her appointments.
Emotional Wellbeing and Psychological Support
Most women do not experience lasting psychological harm after abortion. The predominant emotion reported in longitudinal studies is relief. However, the clinical context here involves concurrent domestic abuse and reproductive coercion, which independently increase the risk of anxiety, depression, and post-traumatic stress.
The GP should:
- ●Screen for current mental state — low mood, anxiety, sleep disturbance, suicidal ideation
- ●Acknowledge that the emotional burden here arises from the abuse, not from the abortion decision, which she has made clearly and autonomously
- ●Offer optional counselling — BPAS and MSI provide free pre- and post-abortion counselling, but this is not mandatory and should never be framed as a prerequisite
- ●Arrange follow-up — flexibly, at a time and contact method that is safe for her
Rhesus Status and STI Screening
Anti-D prophylaxis: NICE and RCOG guidance (2024 update) state that anti-D is no longer routinely required for medical abortion under 10 weeks gestation, following evidence review. Rhesus status testing may still be performed by the provider as part of their standard pathway, but anti-D administration at this gestation is no longer standard practice.
STI screening: Given that Jessica's partner has been tampering with barrier contraception, she is at risk of STI exposure. The abortion provider will offer screening (chlamydia and gonorrhoea as minimum) as part of routine care. If this is declined or deferred, the GP should ensure it is revisited.
The GP Consultation — Putting It Together
This case tests the trainee's ability to manage a clinically straightforward request (abortion at 6 weeks) while uncovering and responding to a complex safeguarding situation. The highest-scoring candidates will demonstrate:
- ●A non-directive opening that respects her decision from the outset, rather than exploring ambivalence that does not exist
- ●Systematic ectopic exclusion on history before moving to management
- ●Attunement to incongruence — recognising that her anxiety about secrecy is disproportionate to the clinical scenario, and gently exploring this
- ●Direct but sensitive safeguarding inquiry — the coercion will not emerge unless asked about
- ●Naming the abuse clearly and without hesitation, while following her lead on next steps
- ●Practical, safety-conscious management — safe delivery address, covert LARC, confidential records, helpline numbers stored discreetly
- ●Holistic integration — addressing the pregnancy, the coercion, her emotional state, her contraceptive future, and her safety plan within a single coherent consultation
Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.
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