Pregnancy of unknown location — structured oral station (12 minutes)

Opening prompt — "You have just taken over. Tell me what you are thinking."

Model response — lead with the label and the risk, not with a list. ^[1][2]

• "This is a pregnancy of unknown location — a positive pregnancy test with no intrauterine and no extrauterine pregnancy seen on transvaginal ultrasound. In her case it is a high-risk one, because she has had a previous ectopic pregnancy and a salpingectomy, which is among the strongest risk factors there is."^[2][4]
• "She is currently stable, so I have time to be systematic — but I would not leave her unreviewed. I want a focused abdominal examination for peritonism, a repeat set of observations, group and antibody screen, full blood count and a serum hCG, and I would tell the consultant about her today rather than tomorrow."^[1]
• "The small amount of anechoic fluid in the Pouch of Douglas is not by itself diagnostic, but in this woman it lowers my threshold for early senior review."^[1]

Examiner is listening for: the correct label, recognition that this is a high-risk PUL, and early consultant involvement rather than routine outpatient booking. ^[2][4]

Probe 1 — "Her hCG is 2100. Does that not put her above the discriminatory zone, so you can call this an ectopic?"

This is the trap of the station. Refuse it, and say why. ^[1][3]

• "No. I do not use a single hCG to determine the location of a pregnancy, and I do not use a discriminatory level to exclude one. NICE is explicit about that."^[1]
• "The data support it. Among women with a pregnancy of unknown location and an hCG above 3000 IU/L, 39 of 358 — about 11% — still had a viable intrauterine pregnancy. A single cut-off would have led me to treat some of those women."^[3]
• "What the level does change is my urgency. At 2100 IU/L with her history, I want senior review and a plan today, and I would consider an earlier repeat scan by an experienced operator rather than waiting a fortnight."^[1]

Probe 2 — "How will you use the hCG then?"

• "Two measurements, as close as possible to 48 hours apart and no earlier. Only two initially — any further sampling goes through a senior clinician, because open-ended serial testing is how women drift."^[1]
• "Then I act on the change. A rise greater than 63% suggests a developing intrauterine pregnancy and earns a locating scan in 7 to 14 days, or sooner if the hCG is at or above 1500. A fall greater than 50% suggests the pregnancy will not continue, and she does a urine pregnancy test 14 days after the second sample. Anything in between — a fall of less than 50% or a rise of less than 63% — is clinical review within 24 hours."^[1]
• "I would also say out loud that the intermediate band is where ectopic pregnancies live, so I treat it as an escalation and not as a repeat blood test."^[1]

Probe 3 — "Two days later her hCG is 2300 and she has more pain. Now what?"

• "That is a rise of about 10% — well inside the intermediate band, and her symptoms have worsened. Both of those independently mandate review, so she comes in now, not to clinic."^[1]
• "I would reassess her: observations, abdominal examination for peritonism, repeat transvaginal ultrasound by an experienced operator specifically looking for an adnexal mass with a sliding sign and for increasing or echogenic free fluid, and I would take a full blood count and crossmatch."^[1]
• "I would involve the consultant now and consent her for the possibility of laparoscopy. If at any point she becomes unstable, she goes to theatre on clinical grounds — I do not need a scan or an hCG to make that decision."^[1]

Probe 4 — "She is upset. She says 'you keep taking blood and nobody will tell me what is happening.' What do you say?"

This is a scored domain. Demonstrate it out loud, in the words you would use. ^[1][6]

• Sit down, at her eye level, and use her name. "You are right that this is frustrating, and I am sorry it feels that way. Let me tell you exactly where we are."
• "You are definitely pregnant. What we cannot yet tell is where the pregnancy is sitting. Most of the time it turns out to be in the womb and simply too small to see. But because you have had an ectopic pregnancy before, I am not willing to assume that, and that is why we are being careful rather than slow."
• "Here is the plan and here is when you will hear from me." Then commit to a named person and a time.
• Acknowledge the loss she may be facing, and offer written information and support contacts. Nearly a third of women meet criteria for post-traumatic stress a month after early pregnancy loss, and how this conversation goes is part of that.^[6]

Examiner is listening for: plain language, no jargon, an explicit plan with a time, and the offer of support without being asked for it. ^[6]

Probe 5 — "Suppose instead her hCG had halved and she felt better. Would you discharge her?"

• "I would discharge her from the acute pathway, but not from follow-up. A fall of more than 50% means the pregnancy is unlikely to continue, but it is not confirmed and it does not tell me where it was."^[1]
• "So: written information and support contacts, a urine pregnancy test 14 days after the second serum sample, negative means no further action, positive means she returns for review within 24 hours."^[1]
• "And I would still give her the 24-hour number and the return criteria, because a tube can rupture while the hormone is falling."^[1]

Probe 6 — "Your unit wants to reduce follow-up visits. Is that safe?"

• "It can be, if it is protocolised rather than informal. The two-step protocol using initial progesterone and then the M6 model classified 1445 of 2625 pregnancies of unknown location — 55% — as low risk, of whom only 15, that is 1%, were ectopic. Importantly, none of those ruptured or came to significant clinical harm."^[5]
• "So the saving comes from validated triage, not from doing less. And I would still apply clinical override: this woman has a previous ectopic pregnancy and pain, so I would manage her as high risk whatever a model said."^[5][4]