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OG5.1-2 | Preconception Counselling — SDL Guide (Part 3)
Self-Assessment
You have now covered the full scope of preconception counselling — from identifying who needs it and why, through the principles of risk stratification, to the detailed management of individual conditions, medications, immunisations, and nutritional interventions. The three scenarios below require you to synthesise knowledge across multiple domains simultaneously, exactly as clinical practice demands. Do not approach them as recall exercises — approach them as clinical consultations where you are the most senior person in the room and the woman in front of you is relying on your advice to make one of the most consequential decisions of her life. A wrong answer in a preconception consultation — failing to identify a teratogenic drug, under-dosing folic acid, or missing a WHO class IV cardiac contraindication — does not produce an error in an examination; it produces a preventable birth defect, a maternal death, or a recurrent miscarriage. This module has given you the knowledge to prevent those outcomes. These scenarios are the bridge between knowledge and clinical action.
- A 25-year-old woman with SLE currently on hydroxychloroquine + mycophenolate mofetil presents for preconception counselling. Her SLEDAI score is 8 (moderately active disease). What are the two most urgent changes you would recommend before she attempts conception?
- A 29-year-old primigravida at 6 weeks' gestation discloses she has been taking isotretinoin for acne for the past 3 months. What is the most important information to provide, and what further management is required?
- A 32-year-old woman with rheumatic heart disease has mitral stenosis with valve area 0.9 cm² (severe mitral stenosis). She asks about pregnancy. Using the WHO Maternal Cardiovascular Risk Classification, how would you classify her risk, and what would your counselling be?
SELF-CHECK
A 30-year-old woman with CKD stage 4 (eGFR 22 mL/min/1.73m²) asks about pregnancy planning. What is the most appropriate initial response?
A. Advise that CKD stage 4 is compatible with pregnancy and refer for standard antenatal care
B. Advise that pregnancy is absolutely contraindicated in CKD and offer sterilisation
C. Refer to a nephrologist and maternal-fetal medicine specialist for detailed counselling about the risks of further permanent renal function decline, pre-eclampsia, and preterm birth; explore whether renal transplantation should be considered first
D. Prescribe folic acid and ASA and advise her to proceed with a planned pregnancy
Reveal Answer
Answer: C. Refer to a nephrologist and maternal-fetal medicine specialist for detailed counselling about the risks of further permanent renal function decline, pre-eclampsia, and preterm birth; explore whether renal transplantation should be considered first
CKD stage 4 (eGFR 15–29 mL/min/1.73m²) is associated with a high risk of accelerated renal function decline, pre-eclampsia, preterm birth, and intrauterine growth restriction. Pregnancy is not absolutely contraindicated but requires a multidisciplinary specialist decision — nephrologist + maternal-fetal medicine — that weighs the maternal risks against the patient's wishes. For eGFR <15, transplantation before pregnancy is generally recommended. Neither dismissive reassurance nor blanket prohibition is appropriate.