Pre-pregnancy counselling — structured oral station (12 minutes)

Opening prompt — "Walk me through her pre-pregnancy plan."

Model response — say it in this order: ^[1][4]

• "First, contraception until the plan is in place, because the neural tube closes by day 28."
• "Folate 5 mg daily — she is on an antiseizure medication, which is a high-risk indication — from four weeks before trying to 12 weeks."
• "Iodine 150 micrograms daily, no alcohol, smoking cessation, and weight loss toward a BMI of 18.5 to 24.9."
• "The key decision is her antiseizure medication: I would plan, with her neurologist, to transition her away from sodium valproate to monotherapy with lamotrigine or levetiracetam at the lowest effective dose, well before conception."^[1][6]

Examiner is listening for: the 5 mg dose (not 400 micrograms), the valproate transition named proactively, and contraception-until-ready. ^[1]

Probe 1 — "Why transition off valproate? She is seizure-free on it."

• "Valproate is doubly harmful in pregnancy. It causes neural tube defects, and it causes dose-dependent neurodevelopmental harm — the NEAD cohort showed lower cognitive outcomes at 4.5 years, and a Danish population study linked prenatal valproate to an increased risk of autism spectrum disorder."^[6][7]
• "The aim is monotherapy at the lowest effective dose with a safer agent. I would not stop it abruptly — a generalised seizure in pregnancy is also dangerous — I would transition in advance with neurology, confirming seizure control on the new regimen before she conceives."^[8]

Probe 2 — "What if valproate is genuinely the only drug that controls her seizures?"

• "Then the decision is made explicitly and jointly: the woman, her neurologist and I document that the benefit of seizure control outweighs the fetal risk, she stays on the lowest effective dose, takes 5 mg folate, and has first-trimester screening and a detailed anatomy scan. This is an exception that proves the rule, not the default."^[6][8]

Probe 3 — "She asks whether 400 micrograms of folate from the pharmacy is enough."

• "For her, no. Antiepileptic medication is on the RANZCOG high-risk list, so she needs 5 mg daily. The 400 microgram dose is for women with no risk factors. Starting it before conception matters because the neural tube closes by day 28."^[1][4]

Probe 4 — "Counsel her. She is anxious about harming her baby."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, and validate the fear: "It is completely reasonable to want to get this right, and the fact that you are here a year before trying is already protecting your baby."
• Brief plainly: "We will change one of your tablets to a safer one with your neurologist, start a higher dose of folic acid, and you will stop alcohol and smoking. Once those are in place, your pregnancy will start in the safest possible way."
• Offer a written plan, a follow-up contact, and involvement of her partner. Avoid jargon and avoid a dismissive "don't worry."^[1]

Probe 5 — "What else before she is cleared to conceive?"

• Confirm seizure control on the new regimen for several months; check FBC, ferritin, TSH, blood group, rubella/varicella/hepatitis B immunity, HIV and syphilis; offer reproductive carrier screening (C-Obs 63).^[1]