Miscarriage — structured oral station (12 minutes)

Opening prompt — "She is waiting. Tell her."

Model response — the shape matters more than the words: ^[4][6]

• Set up. Sit down, at her level, door closed, phone away. Ask if she would like anyone with her or on the phone. Use her name.
• Warning shot, then the news, then stop. "I am afraid the scan has not shown what we hoped. I am very sorry — the pregnancy has stopped growing and there is no heartbeat. Your baby has died."
• Silence. Let it sit. Do not fill it with information.
• Then the two sentences she needs: "Nothing you did caused this, and nothing you could have done would have changed it." "You do not have to decide anything today."
• Only then move to what happens next, and offer it in writing with a number to call.^[4][6]

Examiner is listening for: warning shot, the actual word, silence, absolution, and no jargon. Candidates who launch into management options in the first thirty seconds lose the rapport and communication domains regardless of the medicine. ^[6]

Probe 1 — "How certain are you of the diagnosis?"

• "The crown-rump length is 14 mm, which is above the 7.0 mm transvaginal threshold, and there is no heartbeat. That meets the criterion for a non-viable pregnancy."^[2]
• "But I would not act on a single scan. I would obtain a second opinion on viability, or repeat the scan a minimum of 7 days after the first, and I would say that to her explicitly — that we will confirm before we do anything."^[2][22]
• "I would not use her last menstrual period to decide whether a heartbeat should be visible, and I would not measure serum hCG, because we have already located an intrauterine pregnancy."^[2][22]

Probe 2 — "She asks what happens now. Talk her through the choices."

• Expectant: "We can wait and let it happen naturally, usually over the next one to two weeks. Many complete without further treatment, but the bleeding can be heavy and unpredictable, and unplanned admission or surgery is substantially commoner than going straight to surgery."^[3][22]
• Medical: "We can give you tablets. A tablet called mifepristone first, then a second medicine called misoprostol a day or two later, which brings on cramping and bleeding — like a heavy, painful period."^[1][21]
• Surgical: "We can do a small procedure to empty the womb — either awake with local anaesthetic in the clinic, or asleep in theatre. It is the quickest and the most predictable."^[3]
• The honest comparison: "The MIST trial showed the infection rate is low and the same for all three, around two to three per cent — but expectant and medical management lead to more unplanned admissions and more unplanned procedures than going straight to surgery."^[3]

Probe 3 — "She chooses medical management. Write the prescription out loud."

• "Mifepristone 200 mg orally, then 24 to 48 hours later misoprostol 600 micrograms sublingually or buccally, or 800 micrograms vaginally, buccally or sublingually. If bleeding has not started 24 to 48 hours after that first misoprostol dose, a repeat dose of misoprostol 400 micrograms."^[1][21]
• "Analgesia and an antiemetic to take home. Written information on how heavy the bleeding will be and how long it lasts. A number to ring if bleeding has not started within 48 hours, or if she is soaking through sanitary pads hour after hour, or if she feels unwell or feverish."^[1][22]
• "A home urine pregnancy test at 3 weeks, and instructions to return if it is still positive."^[22]
• If pushed on the evidence: "MifeMiso showed adding mifepristone cut the need for surgery from 25 per cent to 17 per cent, which is why we give both rather than misoprostol alone."^[1]

Probe 4 — "She is rhesus D negative. What do you do?"

• "Crown-rump length 14 mm is well before 10 weeks. Under RANZCOG C-Gyn 38 from March 2025, routine rhesus D testing followed by anti-D is no longer recommended for threatened miscarriage or miscarriage before 10 weeks. NICE draws the line at up to and including 11+6 weeks."^[21][22]
• "If she were at 12+0 to 12+6 weeks and having medical or surgical management, NICE would offer at least 250 IU. C-Gyn 38 does not issue a separate offer recommendation at that window; if anti-D is given, ANZ dosing is 250 IU up to 12 weeks and 625 IU beyond 12 weeks. I would document the decision either way."^[21][22]

Probe 5 — "What happens after she goes home?"

• Safety-netting and follow-up: home urine pregnancy test at 3 weeks, contact triggers for heavy bleeding, pain or fever, and a named person who will telephone her with the histology result — pre-evacuation ultrasound misses many moles, so tissue goes for histology.^[5][22]
• Psychological follow-up is not optional: "Around 29 per cent of women meet criteria for post-traumatic stress a month after early pregnancy loss and 18 per cent still do at nine months. I would offer written information, a support organisation, and a review at which I actively ask about mood — and I would offer her partner the same."^[4]
• Future pregnancy: "A single sporadic loss is common and does not by itself trigger recurrent-loss investigation. There is no single mandated interval in the guidance — try when you feel ready, once bleeding has settled. If you bleed in a later pregnancy after two or more miscarriages, RANZCOG recommends vaginal micronised progesterone 400 mg twice daily to 16 weeks; NICE offers it after a single previous miscarriage."^[21][22]
• When to investigate: "Two or more confirmed intrauterine losses is the referral threshold in Australia and New Zealand — not three."^[21]