Pregestational diabetes — structured oral station (12 minutes)

Opening prompt — "What do you do at this first visit?"

Model response — three buckets, said out loud in order: ^[1][4]

• Medications: "Stop perindopril today — ACE inhibitors cause fetopathy. Substitute labetalol, nifedipine or methyldopa if she needs cover. Continue metformin and insulin. Start folic acid 5 mg daily and iodine 150 micrograms daily. Start aspirin 100 to 150 mg at night now, before 16 weeks, for preeclampsia prophylaxis."
• Baseline assessment: "Dilated retinal screening now and again at 28 weeks. Creatinine with eGFR and a urine albumin-to-creatinine ratio. Dating scan, and book a detailed anatomy scan at 18 to 20 weeks with fetal echocardiography."
• Glycaemic plan: "Intensify insulin toward an HbA1c as close to below 6.5 percent as she can tolerate, with the diabetes educator, and set up glucose monitoring she can actually do from home."^[7][1]

Examiner is listening for: perindopril stopped at this visit, folate at 5 mg not 500 micrograms, aspirin with a gestational deadline, and a surveillance plan with two organ systems plus the fetus. ^[1][4]

Probe 1 — "Her HbA1c is 8.6 percent at 12 weeks. What do you tell her about the baby?"

• "The window that determines structural anomalies has already closed, and I would not pretend otherwise. Population data from England, Wales and Northern Ireland showed roughly four times the perinatal mortality and roughly double the major anomaly rate in women with type 1 or type 2 diabetes."^[6]
• "What we can still change is a great deal: macrosomia, stillbirth, preterm birth, preeclampsia and neonatal hypoglycaemia all improve with better control from now."^[7]
• "Victorian population data are useful here — pre-existing diabetes carried a stillbirth relative risk of 2.68, and about four in fetuses above the 97th centile. Given her last baby was 4.4 kg, that is directly relevant to how closely we watch this one."^[5]

Probe 2 — "She is already on metformin. Is that right in type 2 diabetes in pregnancy?"

• "The MiTy trial randomised 502 women with type 2 diabetes on insulin to metformin 1 g twice daily or placebo. The composite neonatal outcome was identical at 40 percent in both arms."^[3]
• "Metformin improved the maternal side: HbA1c at 34 weeks 5.90 versus 6.10 percent, insulin 1.1 versus 1.5 units per kilogram per day, weight gain 7.2 versus 9.0 kg, and caesarean 53 versus 63 percent."^[3]
• "The catch is the fetal size distribution. Metformin-exposed babies were lighter — mean 3156 versus 3375 g — with fewer above the 97th centile, but more small-for-gestational-age infants. So I continue it in her, given a 4.4 kg previous baby and a BMI of 38, and I watch growth carefully in both directions."^[3]

Probe 3 — "She lives three hours away. How does that change your plan?"

This is the discriminating probe. A candidate who ignores the geography fails the practicality test. ^[1]

• "I would build the plan around what is deliverable, not around what a metropolitan protocol says. Shared care with the local Aboriginal Community Controlled Health Service and the regional hospital, with telehealth reviews between face-to-face visits."
• "Cluster her appointments: retinal photography, bloods, ultrasound and the diabetes educator on the same day when she travels."
• "Point-of-care HbA1c locally, and glucose data uploaded from home so I can titrate insulin remotely between visits."
• "Agree the gestation at which she relocates or is transferred for birth, and who pays for and organises that travel. Naming the logistics is part of the clinical plan."^[1]
• "And I would say plainly that the higher rates of diabetes in pregnancy in Aboriginal and Torres Strait Islander women reflect access and the determinants of health, not personal failure."^[1]

Probe 4 — "At 31 weeks she has threatened preterm labour and gets betamethasone. What happens to her glucose?"

• "It will rise substantially for about 72 hours, and I escalate insulin proactively rather than reacting to readings."^[9]
• "An Australian prospective cohort using an intensified protocol still found median insulin requirement increases of 50 percent on day 1, 106 percent on day 2 and 133 percent on day 3 — well above the 25 percent bump many older protocols use. Only about a third of readings were in target even with that protocol."^[9]
• "I would monitor hourly to two-hourly, keep her basal insulin running, check ketones, and convert to a variable-rate intravenous insulin infusion if she is persistently out of range. And I would warn the neonatal team."^[9][1]

Probe 5 — "When and how will she give birth?"

• "For well-controlled pre-existing diabetes without vasculopathy and with normal growth, I plan birth at 37+0 to 38+6 weeks. Earlier if there is nephropathy, hypertension, poor control, growth restriction or macrosomia."^[7][8]
• "I would be transparent that the Cochrane review of planned birth in pre-existing diabetes found very limited randomised evidence, so this is consensus and risk-based rather than trial-proven."^[8]
• "Mode of birth is individualised. With a previous 4.4 kg baby I would discuss shoulder dystocia and the option of caesarean at high estimated fetal weight, stating the ultrasound error margin honestly."^[7]
• "In labour: variable-rate intravenous insulin with dextrose, hourly glucose, target 4 to 7 mmol/L."^[1]

Probe 6 — "The baby is born. What are the first two things you change?"

• "Insulin down immediately — to approximately her pre-pregnancy dose, or about half her late-pregnancy dose. The hormonal drive disappears with the placenta and she will be hypoglycaemic within hours if I leave it."^[1][7]
• "And the baby's glucose — she has a previous baby with neonatal hypoglycaemia, so early feeding and protocol glucose monitoring, with buccal dextrose gel rather than reflexive separation."^[7]
• "Then contraception before discharge, and a plan for restarting perindopril once breastfeeding decisions are made."^[1]

Probe 7 — communication: "She says 'you people always say my sugar is bad'. Respond."

Rapport and respect are two of the eight scored domains. Say the words. ^[1]

• Pause, sit back, and acknowledge it: "That sounds like it has happened a lot, and I am sorry. I am not here to tell you off."
• Reframe: "The number is information about the pregnancy, not a verdict about you. My job is to make the plan fit your life, not the other way round."
• Ask permission before advising, offer an Aboriginal Health Worker or liaison officer, and ask who she wants in the room.
• Use teach-back rather than "does that make sense?", and write the plan down in plain language for her to take home.^[1]