Breaking the Silence and Handling Domestic Abuse in Early Pregnancy – A PLAB 2 Scenario

Summary:

This scenario involves a 12-week pregnant woman presenting with concerns about vaginal bleeding. During the consultation, signs of possible domestic abuse are identified. The case focuses on empathetic reassurance, safeguarding, and appropriate referral pathways for domestic violence.

Key Points:

Obstetrics:

• Patient is 12 weeks pregnant and reports vaginal bleeding for 1–2 days.

• Ultrasound confirmed a normal early pregnancy.

• No other symptoms (e.g. abdominal pain or hyperemesis) were actively explored but are relevant.

Safeguarding:

• Observed bruising and burn marks inconsistent with accidental injury.

• Patient initially denies abuse, claiming she fell.

• Escalation to safeguarding is required due to visible injuries and presence of a young child at home.

Important Considerations:

• Always confirm safety and well-being of both the patient and the unborn child.

• Early reassurance about fetal health can help build rapport.

• Domestic abuse victims often don’t disclose unless a trusting, confidential environment is created.

• Involve safeguarding when there is a concern for non-accidental injury or vulnerable dependents (e.g., children).

Diagnostic Approach:

1. History:

   • Explore bleeding onset, duration, and quantity.

   • Past obstetric history.

   • Ask about other pregnancy symptoms (pain, vomiting, discharge).

2. Social Assessment:

   • Use open-ended questions to identify household composition and support system.

   • Ask about partner's behaviour using HARK screening (Humiliation, Afraid, Rape, Kick).

3. Physical Signs:

   • Note any unexplained physical injuries or behaviour suggesting fear.

Management:

1. Medical:

   • Confirmed normal ultrasound—no urgent medical treatment required.

2. Safeguarding:

   • Discuss the need to refer to the safeguarding team.

   • Explain the role and scope of safeguarding, ensuring the patient feels supported, not threatened.

3. Referral:

   • Offer contact with social services, domestic violence support, and mental health if appropriate.

   • Encourage development of a crisis plan.

4. Follow-up:

   • Ensure proper documentation and clear handover to the safeguarding team.

Communication Skills:

• Use empathetic, patient-centred language.

• Reassure about confidentiality, but clarify its limits early.

• Avoid overused stock phrases; be natural and sensitive.

• Introduce topics with clarity: “I’d like to ask you some questions about your safety at home…”

Ethical Considerations:

• Confidentiality vs. duty to disclose when others (e.g., children) are at risk.

• Respect patient autonomy—do not force decisions.

• Act in the best interest of both mother and child while respecting legal rights.

Additional Resources:

• GMC Good Medical Practice (2024) – Safeguarding section

• NICE Guideline [NG116] – Domestic violence and abuse

• GMC Ethical Hub – Safeguarding adults and children

• UK Domestic Abuse Referral Pathways