Case ID: EPRH-APS-001
Case Name: Olivia Thompson
Age: 30 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: W78 (Pregnancy), B82 (Antiphospholipid Syndrome), W84 (Miscarriage)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a patient-centred approach 1.2 Uses active listening and questioning skills 1.4 Demonstrates empathy and sensitivity
2. Clinical Information Gathering and Interpretation	2.1 Gathers a relevant and focused history 2.2 Identifies red flags and risk factors
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates appropriate differential diagnoses 3.3 Considers common and serious conditions
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Uses shared decision-making in treatment options
5. Preventive and Population Health	5.1 Provides education on pregnancy care and miscarriage risk 5.3 Discusses strategies to prevent complications
6. Professionalism	6.2 Demonstrates a professional and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.2 Understands early pregnancy and Rh-negative management
8. Procedural Skills	8.1 Recognises the need for Rh immunoglobulin administration
9. Managing Uncertainty	9.1 Identifies when referral to an obstetrician is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as pregnancy loss or thrombotic risks

CASE FEATURES

Complex medication management, including the use of low-dose aspirin and anticoagulation therapy (e.g., enoxaparin or heparin).
Early pregnancy (6–8 weeks gestation) in a high-risk patient.
Previous miscarriages are likely related to antiphospholipid syndrome (APS).
Rh-negative blood type, requiring Rhesus (Rh) immunoglobulin if sensitisation occurs.
Maternal anxiety and concerns about pregnancy viability.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Formulate a differential diagnosis.
Develop a management plan.
Address the patient’s concerns.

SCENARIO

Olivia Thompson, a 30-year-old woman, presents to your clinic for early pregnancy confirmation after a positive home pregnancy test. She is approximately 6 weeks pregnant, based on her last menstrual period. She expresses excitement but also significant anxiety, as she has had two previous miscarriages (at 9 and 10 weeks gestation).

She has a history of antiphospholipid syndrome (APS), which was diagnosed following investigations after her second miscarriage. She is Rh-negative and is aware that this requires monitoring in pregnancy. She is currently taking low-dose aspirin but is unsure whether she needs additional medications.

She wants to know how this pregnancy can be managed differently to reduce the risk of another loss.

PATIENT RECORD SUMMARY

Patient Details

Name: Olivia Thompson
Age: 30 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Low-dose aspirin 100mg daily

Past Obstetric and Gynaecological History

Two previous miscarriages (both at 9-10 weeks gestation)
No living children
No history of ectopic pregnancy or gestational diabetes
Regular menstrual cycles

Medical History

Antiphospholipid Syndrome (APS)
Rh-negative blood type
No history of hypertension, diabetes, or thyroid disease

Family History

Mother had recurrent miscarriages but no formal diagnosis
No family history of clotting disorders or autoimmune conditions

Social History

Works as a teacher
Non-smoker, no alcohol or drug use

Vaccination and Preventative Activities

Up to date with routine vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line:

“I just found out I’m pregnant, and I’m really nervous. I’ve had two miscarriages before, and I don’t want to go through that again.”

General Information

(Freely Given if Asked Open-Ended Questions):

You are Olivia Thompson, a 30-year-old woman who has just found out you are pregnant. You are feeling excited but extremely anxious because you have had two previous miscarriages at around 9–10 weeks. After your second miscarriage, you underwent investigations for recurrent pregnancy loss, and your doctor diagnosed you with antiphospholipid syndrome (APS).

Specific Information

(Only Given If Asked Directly):

Background Information

You were told this increases your risk of miscarriage and that you might need extra medications in pregnancy, but you’re unsure what that means now that you are actually pregnant. You also know that you are Rh-negative, but you don’t remember exactly how that affects pregnancy. You received an injection after your previous miscarriages, but you’re not sure if you need one now or later.

Pregnancy Symptoms:

You have mild nausea but no vomiting.
You feel more tired than usual, but you’re not sure if it’s because of pregnancy or stress.
No abdominal pain, cramping, or vaginal bleeding at this stage.

Previous Pregnancy and APS Management:

Your previous pregnancies were not managed with anticoagulation, as your APS was only diagnosed after the second miscarriage.
In both pregnancies, you had an early scan at 7 weeks, which showed a heartbeat. However, by the time of the 9–10 week scan, there was no heartbeat, and you had missed miscarriages requiring medical management.
You were not on aspirin or blood thinners during those pregnancies.
You have been taking low-dose aspirin (100mg daily) since your APS diagnosis, but you are not on heparin or enoxaparin.
You have read online that some women with APS take blood thinners, and you want to know if you need them.

Family and Medical History:

Your mother had multiple miscarriages, but she was never formally diagnosed with APS or any other condition.
No history of hypertension, diabetes, or thyroid issues.
You have never had blood clots, strokes, or deep vein thrombosis (DVTs) yourself.

Social History and Lifestyle:

You work as a teacher, and your job can be stressful at times.
You don’t smoke, drink alcohol, or use drugs.
You eat a fairly healthy diet but are wondering if you should make any changes.
You try to exercise lightly, but you’ve been afraid to do anything too strenuous since finding out you’re pregnant.

Patient’s Concerns and Expectations:

Concerns About Miscarriage Risk:

You are worried about losing another pregnancy and want to know if there is anything you can do differently to reduce your risk.
You want to know how often you should have check-ups and ultrasounds.
You are unsure if you need extra medications, such as blood thinners or progesterone.

Concerns About APS and Blood Thinners:

You were told APS increases miscarriage risk and have read online that some women take enoxaparin or heparin during pregnancy. You want to know:
- “Do I need blood thinners? If so, when do I start them?”
- “Are they safe for my baby?”
- “Will I need to take them for the whole pregnancy?”
You have read that APS can also increase the risk of pre-eclampsia or stillbirth, and you want to know how those risks can be reduced.

Concerns About Rh-Negative Blood Type:

You remember being told in the past that being Rh-negative means you need injections in pregnancy, but you don’t know when or why.
You want to know:
- “Do I need an injection now, or later?”
- “What happens if I don’t get it?”
- “Could this affect my baby?”

Concerns About Referral to a Specialist:

You are unsure whether you should continue seeing your GP or if you need early referral to an obstetrician or haematologist.
You want to know:
- “When should I see a specialist?”
- “Will I be considered high-risk and need extra scans?”
- “Will I need to give birth early?”

Emotional and Behavioural Cues:

You appear anxious and cautious, frequently asking for reassurance.
You are attentive to medical advice and want a clear plan.
If the doctor provides a structured management plan, you feel relieved and reassured.
If the doctor dismisses your concerns, you may become more anxious or frustrated.
You may become overwhelmed if too much medical jargon is used.

Potential Questions for the Candidate:

“Is there anything I can do to stop another miscarriage?”
“Do I need blood thinners or any extra medications?”
“What does Rh-negative mean for my baby?”
“How often do I need check-ups and ultrasounds?”
“When should I see a specialist?”
“Could my APS cause other problems for the baby?”
“What foods should I avoid? Do I need to change my diet?”
“Can I still exercise, or should I be resting more?”
“What symptoms should I watch for that might mean something is wrong?”
“If I do need blood thinners, will I have to inject myself? How long for?”

Guidance for Role-Player Responses:

If the candidate provides clear explanations about APS and pregnancy management, you should appear reassured and appreciative.
If the candidate does not mention blood thinners, you should directly ask about them.
If the candidate avoids discussing Rh-negative implications, you should express confusion and ask if it is important.
If the candidate provides a vague or unclear plan, you should appear frustrated and ask more questions.
If the candidate offers a structured follow-up plan, you should express relief and trust in their advice.

Key Learning Points for the Candidate:

This case evaluates the candidate’s ability to:

Conduct a comprehensive early pregnancy history, focusing on risk factors, APS, and Rh status.
Provide clear, evidence-based management, including anticoagulation, Rh immunoglobulin, and monitoring.
Address maternal anxiety sensitively, ensuring the patient feels supported.
Identify the need for early referral to an obstetrician and haematologist.
Explain APS-related pregnancy risks, including miscarriage, pre-eclampsia, and stillbirth, while offering reassurance and a clear management plan.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on Olivia’s pregnancy symptoms, previous pregnancy losses, and risk factors.

The competent candidate should:

Use open-ended questions to gather a comprehensive obstetric history, including:
- Current pregnancy symptoms (nausea, bleeding, cramping).
- Previous pregnancy history (gestation at loss, management, investigations).
- APS diagnosis (when, how it was diagnosed, prior treatments).
- Rh-negative status (previous administration of Rh immunoglobulin).
Assess maternal health and risk factors, including:
- Medications (low-dose aspirin, anticoagulation).
- Family history of clotting disorders or autoimmune disease.
- Lifestyle factors (smoking, alcohol, stress levels).
Explore patient concerns, including miscarriage risk, medication safety, and specialist referral.

Task 2: Formulate a differential diagnosis and justify your reasoning.

The competent candidate should:

Identify the most likely diagnosis: early pregnancy in a high-risk patient due to APS, Rh-negative status, and previous miscarriages.
Consider potential complications:
- Threatened miscarriage – if vaginal bleeding or cramping develops.
- Missed miscarriage – given history of previous early pregnancy losses.
- Ectopic pregnancy – should be ruled out in early pregnancy, especially if risk factors exist.
- Molar pregnancy – if abnormal symptoms such as severe nausea or abnormally high hCG levels arise.
Justify the need for early ultrasound (viability, location) and blood tests (beta-hCG, progesterone, FBC, clotting studies).

Task 3: Develop a management plan, including anticoagulation, Rh immunoglobulin, and early pregnancy monitoring.

The competent candidate should:

Confirm pregnancy viability with serial beta-hCG and early ultrasound (6–7 weeks gestation).
Provide supportive pregnancy care:
- Folic acid (5mg daily) and pregnancy multivitamins.
- Regular antenatal visits with specialist referral to an obstetrician/haematologist.
- Monitor for complications (e.g., bleeding, clotting symptoms, fetal growth restriction).
Initiate thromboprophylaxis:
- Continue low-dose aspirin (100mg daily).
- Start low-molecular-weight heparin (LMWH) (e.g., enoxaparin 40mg daily) if not contraindicated.
Ensure appropriate follow-up:
- Review in 1–2 weeks to assess ultrasound results and response to treatment.
Manage Rh-negative status:
- Administer Rh immunoglobulin (Anti-D) at 28 weeks and after any bleeding episodes.

Task 4: Address the patient’s concerns, particularly regarding miscarriage risk, medication safety, and referral options.

The competent candidate should:

Acknowledge and validate Olivia’s anxiety about pregnancy loss.
Provide reassurance on how APS and Rh-negative status will be managed to improve pregnancy outcomes.
Explain medication safety:
- Aspirin and heparin are safe in pregnancy and reduce miscarriage risk.
- Rh immunoglobulin prevents complications in future pregnancies.
Outline monitoring and specialist referral:
- Regular check-ups and scans will track fetal growth and maternal health.
- Referral to an obstetrician and haematologist ensures expert oversight.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, exploring previous miscarriages, APS, Rh-negative status, and medication use.
Formulates a clear differential diagnosis, considering normal pregnancy, miscarriage, ectopic pregnancy, and clotting-related complications.
Provides an evidence-based management plan, including anticoagulation, early ultrasound, and Rh immunoglobulin administration.
Addresses maternal concerns empathetically, providing clear education and reassurance.
Refers appropriately to specialists, ensuring ongoing monitoring and coordinated care.

PITFALLS

Failing to identify APS as a high-risk factor, leading to delayed anticoagulation initiation.
Not addressing Rh-negative status, missing Anti-D administration if required.
Overlooking the need for early pregnancy ultrasound, delaying confirmation of viability.
Providing incorrect or vague information about anticoagulation and its safety in pregnancy.
Not acknowledging the patient’s emotional distress, reducing trust and engagement.
Failing to arrange timely specialist referral, delaying optimal antenatal care.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a relevant and focused history.
2.2 Identifies red flags and risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates appropriate differential diagnoses.
3.3 Considers common and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Uses shared decision-making in treatment options.

5. Preventive and Population Health

5.1 Provides education on pregnancy care and miscarriage risk.
5.3 Discusses strategies to prevent complications.

6. Professionalism

6.2 Demonstrates a professional and non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.2 Understands appropriate Medicare item numbers for early pregnancy and Rh-negative management.

8. Procedural Skills

8.1 Recognises the need for Rh immunoglobulin administration.

9. Managing Uncertainty

9.1 Identifies when referral to an obstetrician is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as pregnancy loss or thrombotic risks.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD