Academe Learn
CBME Curriculum Preview

Page 29 of 29

OG2.1,OG3.1,OG4.1,OG5.1-2,OG6.1,OG7.1 | Foundations of Reproduction and Pregnancy — PBL Case

CLINICAL SETTING

Priya, a 22-year-old unmarried final-year engineering student, presents to the emergency department at 9 PM with a 6-hour history of right-sided lower abdominal pain, rated 7/10, constant, with one episode of vomiting. She appears anxious and asks to speak only to the female doctor on duty. Her last menstrual period was 7 weeks ago, which she attributes to 'stress from exams'. She initially denies any sexual activity but, when seen alone, discloses that she has been in a relationship for 8 months. She has not used any contraception. Her general examination shows a heart rate of 104 bpm, blood pressure 102/68 mmHg, and temperature 37.2°C. Abdominal examination reveals guarding in the right iliac fossa. A pelvic examination has not yet been performed.

Trigger 1: Initial Assessment and Pregnancy Testing

The duty doctor performs a urine pregnancy test, which returns POSITIVE. Priya is visibly distressed. She says she cannot be pregnant and asks if the test could be wrong. Vital signs remain: HR 104 bpm, BP 102/68 mmHg. A blood sample is sent; serum beta-hCG returns at 3,200 mIU/mL.

DISCUSSION POINTS

  • What is the classification of pregnancy signs, and which category does a positive urine hCG test fall into? Why is this classification clinically useful rather than merely academic?
  • What is the 'discriminatory zone' for serum beta-hCG, and what does it mean in Priya's case? What would you expect to see on transvaginal ultrasound at this hCG level if the pregnancy is intrauterine?
  • How does hCG production begin, and why is it detectable so early in pregnancy? What is the physiological role of hCG in the first trimester beyond pregnancy diagnosis?
Click to reveal Trigger 2: Ultrasound Findings and Urgent Diagnosis (discuss previous trigger first!)

Trigger 2: Ultrasound Findings and Urgent Diagnosis

Transvaginal ultrasound is performed. The uterus is anteverted, 8 × 5 cm, with normal endometrium. No intrauterine gestational sac is visible. A 3.5 cm heterogeneous mass is seen adjacent to the right ovary. There is free fluid in the pouch of Douglas (approx. 200 mL). Priya's BP has fallen to 94/60 mmHg. The gynaecology registrar is called.

DISCUSSION POINTS

  • Synthesise the clinical findings (beta-hCG 3,200 mIU/mL + no intrauterine sac + right adnexal mass + haemoperitoneum). What is the most likely diagnosis, and why is immediate action required?
  • The fallopian tube is the most common site for ectopic implantation. Using your knowledge of fertilisation and transport of the conceptus (OG3.1), explain the pathophysiological sequence that leads from fertilisation to tubal ectopic and then to tubal rupture.
  • What does 'free fluid in the pouch of Douglas' signify anatomically? Name the anatomical structure and its boundaries, and explain why blood collects there first in intraperitoneal haemorrhage.
Click to reveal Trigger 3: Cardiovascular Compensation and Interpretation of Vital Signs (discuss previous trigger first!)

Trigger 3: Cardiovascular Compensation and Interpretation of Vital Signs

Priya is moved to a resuscitation bay. Two large-bore IV lines are placed. Her haemoglobin is 9.8 g/dL. The anaesthetist notes that her BP was recorded as '110/70' at triage (1 hour ago) and has now fallen to 94/60 mmHg. She is tachycardic at 110 bpm. The anaesthetist asks whether the haemoglobin of 9.8 g/dL is anaemia or physiological.

DISCUSSION POINTS

  • In early pregnancy, cardiac output increases due to both increased heart rate and increased stroke volume. Systemic vascular resistance falls. How do these changes affect the interpretation of Priya's vital signs? At what point does tachycardia and falling blood pressure indicate decompensation in a previously healthy young woman?
  • The haemoglobin of 9.8 g/dL is borderline. What is the WHO definition of anaemia in pregnancy (by trimester), and how does the physiological plasma volume expansion of early pregnancy affect haemoglobin concentration? Is 9.8 g/dL at 7 weeks likely to be physiological?
  • Why might haemoglobin underestimate acute blood loss in the early phase of haemorrhage? Which vital sign trend is more sensitive for detecting significant early haemorrhage in a young person?
Click to reveal Trigger 4: Post-operative Counselling and Preconception Planning (discuss previous trigger first!)

Trigger 4: Post-operative Counselling and Preconception Planning

Priya undergoes emergency laparoscopy. A right salpingectomy is performed for a ruptured ectopic pregnancy. She recovers well. Two days post-operatively, she is ready for discharge. She asks: 'What caused this? Could it have been prevented? Can I still have children?' She also mentions that her mother has Type 2 Diabetes, her maternal grandmother had a stroke at 50, and she herself was told her blood pressure was 'borderline high' on a medical check 6 months ago.

DISCUSSION POINTS

  • What are the known risk factors for ectopic pregnancy? Which of these might be relevant to Priya, and what can be modified before her next planned pregnancy? How does this relate to the principles of preconception counselling (OG5.2)?
  • Priya has a family history of Type 2 Diabetes and has borderline hypertension. Using your knowledge of preconception risk assessment (OG5.1 + OG5.2), outline the structured assessment and interventions you would offer her when she plans a future pregnancy. What specific investigations would you request?
  • How would you counsel Priya about future fertility after unilateral salpingectomy? What is the role of the remaining fallopian tube in fertilisation (OG3.1), and what monitoring would you recommend in her next pregnancy given her history of ectopic?
Click to reveal Trigger 5: Reflection — Systems, Ethics, and Communication (discuss previous trigger first!)

Trigger 5: Reflection — Systems, Ethics, and Communication

During the debrief, the team notes that Priya initially did not disclose her sexual history due to social concerns. The diagnosis was delayed by 45 minutes. The senior registrar also notes that Priya's triage blood pressure of 110/70 mmHg was recorded as 'normal' — but in retrospect, in a woman of her age with ruptured ectopic, this represented early haemodynamic compensation.

DISCUSSION POINTS

  • What are the ethical obligations of the clinical team when a young unmarried patient presents with a suspected pregnancy but initially withholds her history? How should confidentiality, non-judgement, and the duty of care be balanced in this scenario?
  • This case illustrates the principle: 'Any woman of reproductive age with pelvic pain must have a pregnancy test before any other diagnosis.' Identify two other clinical scenarios in OG where a failure to test for pregnancy early caused diagnostic delay, and explain the systemic harms.
  • The triage team applied a 'normal' BP threshold without considering that normal BP in young women may represent relative hypotension once acute haemorrhage begins. How does understanding of cardiovascular physiology in pregnancy and non-pregnant young women improve your ability to recognise early haemodynamic compromise?

Group Task Assignments

  • Draw a timeline of events in Priya's case from fertilisation to tubal rupture, annotating each stage with the corresponding embryological or physiological event (OG3.1, OG4.1).
  • Using the clinical information provided, construct a problem list for Priya at the time of presentation and at the time of discharge. For each problem, identify the relevant competency code.
  • Design a structured preconception counselling checklist for a woman with Priya's risk profile (family history of T2DM, borderline hypertension, previous ectopic). Include: investigations, medications to review, vaccinations, lifestyle modifications, and gestational monitoring plan.
  • Role-play: One student takes the role of the junior doctor breaking the news of ectopic pregnancy to Priya (who is distressed and asks if she will be able to have children). Focus on clear communication, empathy, and factual accuracy about future fertility.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG3.1] What is the normal mechanism of fertilisation and transport of the conceptus from the ampulla to the uterine cavity? At what stage does implantation normally occur, and what factors can disrupt transport and cause ectopic implantation?
  2. [OG5.1] What are the preconception implications of borderline hypertension and a first-degree family history of Type 2 Diabetes? What investigations and interventions are indicated before the next pregnancy?
  3. [OG5.2] What is a structured approach to identifying maternal high-risk factors in a preconception consultation? Which risk factors require specialist referral versus primary care counselling?
  4. [OG6.1] What is the clinical and biochemical basis of the discriminatory zone in ectopic pregnancy diagnosis? How does serial beta-hCG monitoring help differentiate a normal IUP, a failing pregnancy, and an ectopic pregnancy?
  5. [OG7.1] How do the physiological cardiovascular changes of early pregnancy — increased cardiac output, reduced SVR, reduced haematocrit — affect the interpretation of vital signs and haematological investigations in a haemodynamically compromised pregnant patient?