CKD Stage 3 in pregnancy — structured oral station (12 minutes)

Opening prompt — "Tell me how you assess this woman at booking."

Model response — say it in this order: ^[1][3]

• "Her creatinine of 92 is abnormal in pregnancy — pregnancy normally lowers creatinine to roughly 44-60 micromol/L, so 92 means she has Stage 3 CKD on top of her IgA disease."
• "Her PCR of 60 mg/mmol is abnormal — above the 30 mg/mmol threshold."
• "Her blood pressure of 142/90 is chronic hypertension — the single strongest predictor of delivery before 34 weeks in CKD Stage 3-5."
• "She is at high risk of superimposed preeclampsia, fetal growth restriction and preterm delivery. I would manage her jointly with the renal-obstetric clinic."

Examiner is listening for: the haemodynamic reasoning (75 is abnormal), staging, modifier recognition, and joint clinic. ^[1]

Probe 1 — "She stopped ramipril 3 weeks ago, when she found out she was pregnant at 8 weeks. What is the risk to the fetus and what do you do now?"

• "Ramipril is an ACE inhibitor and is teratogenic in pregnancy — fetal renal dysplasia, oligohydramnios, skull defects. The risk is highest in the second and third trimesters."
• "Stopping at 8 weeks is later than ideal — I would counsel that she needs a detailed fetal anatomy scan at 18-20 weeks, including renal anatomy and amniotic fluid volume, and serial growth scans."
• "I will not restart an ACE inhibitor during pregnancy; I will start labetalol or nifedipine MR for her blood pressure now, and plan to restart ACE/ARB postpartum if not breastfeeding."
• "Pre-conception counselling would have been the correct setting for the switch — this is a missed opportunity, not a fatal error, but I will document the conversation and offer enhanced fetal surveillance."^[1]

Probe 2 — "What surveillance will you put in place?"

• "Joint renal-obstetric clinic every 4 weeks: serum creatinine and eGFR, electrolytes, blood pressure, proteinuria quantification (PCR or ACR)."
• "Plasma PlGF every 4 weeks from 20 weeks — a PlGF below 150 pg/mL predicts superimposed preeclampsia within 14 days with NPV 97%."
• "Serial growth scans with umbilical artery Doppler every 4 weeks from 24 weeks."
• "Aspirin 150 mg nocte from now until 36 weeks; calcium supplementation if her intake is low."^[3][7]

Probe 3 — "At 28 weeks her PlGF is 95 pg/mL and her BP is 156/98 with new headache and epigastric pain. What do you do?"

• "This is severe superimposed preeclampsia. I admit her, give magnesium sulphate for seizure prophylaxis (4 g IV loading then 1 g/h maintenance), control blood pressure with IV labetalol or hydralazine to keep under 160/110, send FBC, coagulation, U&E, urate, and lactate, and assess the fetus with CTG and ultrasound."
• "Give a course of corticosteroids for fetal lung maturity — 28 weeks is within the window where they benefit the neonate — if delivery is anticipated and there is time."^[1]
• "Plan delivery after maternal stabilisation — vaginal induction if she is stable, caesarean if maternal or fetal compromise. The decision is by the consultant in conjunction with neonatology."^[3]

Probe 4 — "She is terrified and asks what this means for her kidney long-term. What do you say?"

This is a scored communication domain. Demonstrate it out loud: ^[1][3]

• Sit down, use her name, acknowledge the fear: "I can see this is frightening. Let me explain what we know and what we are doing."
• "Your kidney disease means pregnancy does put extra strain on the kidney. In women with CKD Stage 3-5, pregnancy advances the need for dialysis or transplant by about 2.5 years on average — that is the average, and your individual risk depends on how your function behaves."
• "We will recheck your kidney function after birth and at 6-12 weeks to see whether there has been any permanent change. If so, your nephrologist will work with you on slowing that down."
• "Avoid jargon, allocate a staff member to support her and her partner, and commit to a debrief afterwards."

Probe 5 — "She wants to know about future pregnancies."

• "Future pregnancies carry the same or higher risk. Pre-conception counselling with the renal team is essential — optimise blood pressure, confirm we are on pregnancy-safe medications, and consider whether function is good enough."
• "Contraception between pregnancies — a progesterone-only method or intrauterine device, since oestrogen-containing combined pills add thrombosis and hypertension risk."^[3][18]