Abortion — structured oral station (12 minutes)

Opening prompt — "What is your differential, and what do you do first?"

Model response: ^[1][2]

• "My lead diagnosis is septic abortion with retained products — fever, pain, foul discharge and bleeding five days after a medical abortion. I'm also considering uterine perforation (less likely with a medical method), an ectopic that was missed if she had a pregnancy of unknown location, and a coincident urinary or genital infection."
• "First I'd recognise she is septic and possibly in shock — pulse 118, blood pressure 96 over 58 — and call for help: senior gynaecologist, anaesthetics, nursing coordinator. Two large-bore cannulae, fluids, oxygen, bloods including lactate and crossmatch, and blood cultures before antibiotics."^[1]

Probe 1 — "She is septic. Walk me through source control."

• "Broad-spectrum intravenous antibiotics within the first hour — ampicillin, gentamicin and clindamycin or metronidazole per local protocol — and urgent examination under anaesthesia with suction evacuation. The retained tissue is both the sepsis source and the bleeding source; removing it is the single most effective intervention."^[1][3]
• "If she's haemorrhaging I'd add uterotonics — oxytocin, ergometrine 0.5 mg intramuscularly if no hypertension, misoprostol 800 micrograms per rectum — and activate the massive-haemorrhage protocol." I'd watch for the rare case where evacuation doesn't control bleeding and she needs to proceed to laparotomy.^[1]

Probe 2 — "What's the regimen if she were stable and wanted to avoid theatre?"

• "For incomplete abortion managed medically, the RANZCOG regimen is misoprostol 800 micrograms buccally, followed by 400 micrograms after four hours if tissue hasn't passed. Ultrasound is not required beforehand. But in a septic, unstable patient, surgical evacuation is the answer — this regimen is for the well patient."^[1]

Probe 3 — "She mentions her first doctor seemed reluctant to refer her. What's the law around that?"

• "A clinician with a conscientious objection is legally entitled to decline to provide abortion in Australia and New Zealand — but the right carries duties. They must tell the woman of the objection, and inform her how to access the closest provider within a clinically reasonable time, without imposing delay, distress or health consequences."
• "An Australian qualitative study by Merner and Keogh found that in practice objection runs on a spectrum from partial provision to refusal without referral — and refusal without referral fails the duty."^[1][5]

Probe 4 — "She asks whether what happened to her is a common complication."

• "Reassure her honestly: serious complications after early abortion are uncommon. The systematic review by White found major complications — transfusion-requiring haemorrhage or perforation needing repair — in 0.1 percent or fewer of first-trimester aspiration procedures, and repeat aspiration in 3 percent or fewer. What she experienced is real and serious, but rare."
• "I'd debrief her, offer contraception before she leaves — a long-acting method can be placed now to prevent rapid repeat pregnancy — and arrange follow-up for both physical and psychological recovery."^[1][2]

Probe 5 — "You mentioned pregnancy of unknown location. Why does that matter here?"

• "Because if she originally had no visible intrauterine pregnancy on scan, she had a pregnancy of unknown location, and the Society of Family Planning tells us that among abortion seekers with a pregnancy of unknown location the ectopic rate is 4 to 8 percent. Some post-abortion 'complications' are actually a missed ectopic — which is why unilateral pain or a rising hCG after an abortion must be investigated, not dismissed."^[4]

Probe 6 — "Name the gestational threshold for two-doctor involvement in your state."

Know your jurisdiction: "In New South Wales and Queensland the threshold is 22 weeks; in Victoria and the Northern Territory it's 24 weeks; in Western Australia 23 weeks; in Tasmania 16 weeks; South Australia 22 weeks and 6 days; the ACT has no gestational limit; and in Aotearoa New Zealand it's 20 weeks, with the Abortion Legislation Act 2020 allowing a qualified health practitioner to approve a later abortion if clinically justified."^[1]