O&G SAQs · Antenatal care — preconception
Pre-pregnancy counselling — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on pre-pregnancy optimisation of a woman with type 1 diabetes on an ACE inhibitor, statin and 400 microgram folate: risk factors, folate/iodine/lifestyle advice, the teratogen medication swap, and the glycaemic-contraceptive-plan bundle. Per-sub-part marking rubric included.
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Prompt
A 33-year-old woman with type 1 diabetes for 18 years attends pre-pregnancy counselling. She takes insulin (basal-bolus), ramipril 10 mg, atorvastatin 20 mg, and a multivitamin containing 400 micrograms of folate. She smokes 8 cigarettes a day and drinks alcohol socially. Her HbA1c is 7.9% (63 mmol/mol), BMI is 31, blood pressure 138/86. She had laser therapy for retinopathy two years ago. (a) List her pre-pregnancy risk factors and the single most important safety priority. (3 marks) (b) Outline her folate, iodine and lifestyle advice with specific doses. (4 marks) (c) Detail the medication changes you will make before she conceives and why. (4 marks) (d) State the glycaemic and contraceptive plan, and the further assessments needed before she is cleared to conceive. (4 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. Marks come from specifics: dose, target, contraindication, time window, named drug swap. Write in short labelled points. Answer the sub-part you are asked. [1]
Reveal model answer and mark schemeShowHide
(a) Risk factors and safety priority (3 marks)
One mark per risk factor (max three), one further mark for naming the safety priority. [1]
- Risk factors: type 1 diabetes with HbA1c 7.9% (above the 6.5% target); BMI 31; hypertension 138/86; previous retinopathy (renal and retinal risk); ramipril and atorvastatin (teratogenic); smoking; alcohol; folate dose too low (400 micrograms, needs 5 mg).[1][5]
- Single most important safety priority: maintain reliable contraception until HbA1c is at target, medications are swapped, and retinal/renal status is assessed — so she does not conceive in a high-anomaly-risk state.[5]
(b) Folate, iodine and lifestyle advice (4 marks)
One mark for folate with dose, one for iodine, one for weight/BMI, one for smoking/alcohol. [1]
- Folate 5 mg daily (diabetes is a high-risk indication), at least four weeks before conception, continued to 12 weeks.[1]
- Iodine 150 micrograms daily through preconception, pregnancy and breastfeeding.[1]
- Weight: aim BMI 18.5 to 24.9; structured weight-reduction; non-stigmatising counselling.[1]
- Smoking: structured cessation (behavioural support plus pharmacotherapy); alcohol: no known safe level — advise abstinence.[1][2]
(c) Medication changes before conception (4 marks)
One mark per correct swap with rationale. [5][8]
- Ramipril (ACE inhibitor): switch to labetalol, methyldopa or nifedipine — ACE inhibitors cause fetal renal dysgenesis and oligohydramnios.[8]
- Atorvastatin: stop — statins are avoided in pregnancy on teratogenicity grounds.[8]
- Insulin: continue basal-bolus; optimise regimen for tight control; review for insulin pump or closed-loop if appropriate.[5]
- Confirm no sodium valproate, warfarin, retinoid or methotrexate; (valproate, if present, would be transitioned to lamotrigine or levetiracetam with neurology).[7]
(d) Glycaemic and contraceptive plan, further assessments (4 marks)
One mark each for the glycaemic target, the contraceptive plan, retinal/renal assessment, and thyroid/other. [5]
- Glycaemic target: HbA1c below 6.5% (48 mmol/mol) before conception, achievable without problematic hypoglycaemia.[2][5]
- Contraception: continue a reliable method until HbA1c and medications are optimised.[5]
- Retinal and renal assessment before conception (retinal photography, urine albumin-to-creatinine ratio, eGFR); pregnancy and rapid tightening can worsen both.[5]
- Further: check TSH, blood group and antibodies, rubella/varicella/hepatitis B immunity, HIV and syphilis; offer carrier screening (C-Obs 63); refer to a multidisciplinary pre-pregnancy diabetes clinic.[1]
References5ShowHide
- [1]Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Pre-pregnancy counselling (C-Obs 3a), Version 13.1 RANZCOG Clinical Guideline, 2024.Source
- [2]Cooper KM, Szymanski LM, David PS, et al. Prepregnancy Care and Counseling: A Review JAMA, 2026.PMID 42008245
- [5]American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics ACOG Practice Bulletin No. 201: Pregestational Diabetes Mellitus Obstet Gynecol, 2018.PMID 30461693
- [8]Adam MP, Polifka JE, Friedman JM Evolving knowledge of the teratogenicity of medications in human pregnancy Am J Med Genet C Semin Med Genet, 2011.PMID 21766440
- [7]Christensen J, Grønborg TK, Sørensen MJ, et al. Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism JAMA, 2013.PMID 23613074