Station 40
Sarah Thompson
Age: 25 years old female
Full Case
Patient’s Data
Patient’s Name: Sarah Thompson
Age: 25-year-old female
Past medical history
- Epilepsy diagnosed age 17
Medications/ drug history
- Lamotrigine 200mg OD
- Levetiracetam 500mg BD
Recent consultation
Patient missed second routine appointment for her 3-monthly contraceptive depot medroxyprogesterone acetate injection
Reminder messages sent advising her to contact the surgery as soon as possible
Advised to use condoms in the interim, as contraceptive cover may be compromised
Patient has booked an urgent telephone consultation to discuss concerns
Patient's Story (Role player’s brief)
Patient’s Story
You are Sarah, a 25-year-old woman who has called today to discuss a significant concern. Two days ago, you took a pregnancy test at home, and it came back positive. Since then, you’ve repeated the test twice, and each test has also shown a positive result. You’re particularly worried about whether your antiepileptic medications could harm your baby or affect their development. You want to know whether you should stop taking your medications immediately.
IF ASKED TO DISCUSS FURTHER
You first became suspicious when you noticed breast fullness and increased fatigue. This prompted you to reflect and realise that you had missed your last appointment for your 3-monthly depot contraceptive injection. You had travelled on vacation during that period and, on returning, forgot to rebook the injection.
You took a pregnancy test and discovered you are pregnant.
You are unsure how far gone you might be, as your menstrual periods stopped a few years ago after starting the depot injection. Your last seizure episode was 9 months ago. You have remained seizure-free since then. You would like to continue with this pregnancy.
Social History: You do not smoke or use alcohol or recreational drugs. You work as a sales assistant at Tesco. You live with your boyfriend. You do not drive.
Ideas: You’re unsure what should happen next regarding your epilepsy and the pregnancy.
Concerns: You’re particularly worried about the impact of your antiepileptic medications on your baby’s health and development.
Expectations: You’re wondering whether you should stop your medications immediately.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask when and how the patient confirmed the pregnancy (e.g. urine pregnancy test, home test, or scan).
- Ask about the last menstrual period (LMP) and whether the patient has an idea of how far along the pregnancy might be, especially given amenorrhoea from depot use.
- Ask if the pregnancy was planned or unplanned.
- Ask about her epilepsy history – frequency of seizures, when the last seizure occurred, and any recent changes.
- Ask if the patient drives
- Ask if she is currently taking any over-the-counter medications or supplements.
- Ask about smoking, alcohol, or recreational drug use.
- Ask if she has been pregnant before – and if so, inquire about any complications or relevant issues in that pregnancy.
- Ask about her home environment – who she lives with, whether she has adequate support, and her general living situation. Screen for safeguarding concerns – Ask if the patient feels safe in her relationship and whether anyone is pressuring her to make decisions against her will.
- Ask if there have been any symptoms in this pregnancy so far (e.g. abdominal pain, vaginal bleeding, cramping).
- Explore her Ideas, Concerns and Expectations
Example of explanation to patient
Sarah, thanks for getting in touch and for sharing what’s been going on. First of all, congratulations on your pregnancy. I can understand this must feel a bit overwhelming, especially with your history of epilepsy and your current medications. You’re absolutely right to be asking questions at this stage, it’s important that you’re fully informed, and I’m glad you reached out.
I want to reassure you that you’ve done the right thing by continuing your medication. It’s really important that you don’t stop taking your anti-seizure medicines suddenly. Stopping them without specialist advice can increase your risk of having a seizure, and that can actually be more harmful to your baby than continuing the medication. So, for now, please continue taking your lamotrigine and levetiracetam as prescribed
I’ll refer you urgently to be seen by a neurologist. They will review your medication in more detail, check your levels if needed, and ensure the safest plan for both you and your baby moving forward. These team have lots of experience managing epilepsy in pregnancy, and they’ll guide us on what adjustments, if any, are needed.
In the meantime, you should register for antenatal care as soon as possible. You can do this directly using the Badger Notes app — it’s part of the NHS system for pregnancy care. I’ll send you the link by text straight after this call so you can get started.
Because you’ve just found out about the pregnancy and we don’t yet know how far along you are, I’m going to prescribe folic acid 5mg daily, which is a higher dose than standard, and it’s recommended for women on epilepsy medications. You should continue this until 12 weeks of pregnancy, or until your dating scan confirms how many weeks pregnant you are.
Also, it’s recommended to take vitamin D (10 micrograms daily) throughout pregnancy to support both your health and the baby’s development, so please start that as well if you haven’t already.”
You’re doing the right thing by asking these questions early. We’ll make sure you’re fully supported throughout your pregnancy, and you won’t be managing this alone. Does all of that make sense so far?
Management
Management
- Reassure and advise the patient not to stop her antiepileptic medications, as poorly controlled seizures during pregnancy can pose a greater risk to both mother and baby than the medications themselves.
- Discuss the potential risks to the fetus from antiseizure medications, including an increased risk of congenital malformations, neurodevelopmental disorders, and fetal growth restriction. However, explain that abruptly stopping epilepsy medication carries a greater risk, as uncontrolled seizures can lead to trauma, miscarriage, or even harm to both mother and baby.
- Arrange an urgent referral to neurologist for her antiepileptic regimen can be reviewed, and an individualised management plan developed.
- Encourage her to register for antenatal care as soon as possible. This can be done via the NHS Badger Notes app. Offer to text her the link for easy access. Explain that she will likely be under the care of a specialist team throughout her pregnancy.
- Explain that the midwife will carry out initial assessments, including blood tests, urine checks, blood pressure monitoring, weight/height measurements, and will arrange an ultrasound scan to help accurately date the pregnancy (especially since she is unsure of her last menstrual period).
- Prescribe folic acid 5mg daily, which is the recommended high-dose supplement for women on antiepileptic drugs. Advise her to continue this until her dating scan confirms how far along she is, and then continue until 12 weeks gestation is reached.
- Recommend a daily vitamin D supplement (10 micrograms per day) throughout her pregnancy to support bone and immune health.
- Encourage her to notify her pregnancy to the UK Epilepsy and Pregnancy Register, which helps monitor outcomes and contributes to national guidance on epilepsy in pregnancy.
- Offer appropriate vaccinations, including influenza and COVID-19 vaccines at any stage of pregnancy, pertussis (whooping cough) vaccine from 16 weeks gestation, and RSV (Respiratory Syncytial Virus) vaccine from 28 weeks gestation.
- Arrange a follow-up call in 2 weeks to check if she has registered with antenatal services and whether she has been seen by a specialist.
- Safety net: Advise her to contact the practice or seek urgent medical help if she has any concerns, seizure activity, or new pregnancy-related problems.
Learning point from this station:
Ideally, women on antiepileptic medication should receive pre-conception counselling, including advice about effective contraception to avoid unplanned pregnancies. However, if a woman presents with an unplanned pregnancy while taking antiseizure medication:
- Emphasise the importance of continuing her current antiseizure medication, as stopping it abruptly can increase the risk of seizures, which may be more harmful to both mother and fetus.
- Advise not to stop medication without specialist input.
- Arrange an urgent referral to an epilepsy specialist to review her treatment and adjust medication if necessary.
- Prescribe folic acid 5 mg daily (if not already taking it), ideally continued until 12 weeks of gestation to reduce the risk of neural tube defects.
- Encourage registration with the UK Epilepsy and Pregnancy Register to support national safety monitoring and improve outcomes.