Cases/Dermatology

Hair Loss Three Months After Giving Birth, Still Taking Lisinopril — Free SCA Practice Case

Woman with hair loss three months after giving birth, still taking lisinopril

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Aisha Rahman

Age

33 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My hair is falling out in handfuls since I had my baby and I'm really upset about it. And I've been meaning to ask about the blood pressure tablet I'm still on — I'm breastfeeding and I'm worried about it."

Medical Records

●PMH: Pre-eclampsia in recent pregnancy (delivered 3 months ago). Otherwise well.
●Medications: Lisinopril 10 mg OD (started post-delivery for persistently raised blood pressure).
●Allergies: NKDA.
●Recent results: Postnatal bloods at delivery normal. No ferritin or thyroid function on file since delivery. Blood pressure at 6-week postnatal check: 132/84.

Patient Script

For the friend playing the patient role

Character Overview: You are Aisha, a 33-year-old first-time mother, three months postpartum. You are tired and emotional — adjusting to a new baby, breastfeeding, and now frightened by how much hair you are losing. You are not tearful throughout but the hair loss has genuinely upset you and dented your confidence. You are also anxious about being on a blood pressure tablet while breastfeeding, having read something online about a small risk. You want reassurance but also to be taken seriously.

Opening Sentence: "Hi Doctor. Since having the baby, my hair is coming out in clumps — it's all over the pillow, blocking the plughole, I can see my scalp in places. It's really upsetting me. And while I've got you, I'm still on that blood pressure tablet and I'm breastfeeding — I read there's a small risk and I'm worried I shouldn't be taking it."

History if Asked (Data Gathering Phase)

●The hair loss: "It started maybe a month ago, so about two months after the birth. It's coming out all over — when I brush, when I wash it. Not in patches, just generally thinner everywhere."
●The scalp: "No bald patches as such, no itching, no redness, no scaling. The scalp looks normal, just less hair on it."
●The blood pressure story: "I had pre-eclampsia at the end of the pregnancy. After the birth my blood pressure stayed up, so they started me on lisinopril before I left hospital. I've just kept taking it."
●Breastfeeding: "I'm breastfeeding and planning to carry on. That's why the tablet worries me — is it getting into my milk? I saw something about a one-in-a-thousand risk and it's been playing on my mind."
●General: "I'm shattered, obviously, new baby. But no other symptoms really."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Aisha fears the hair loss might be permanent, or a sign that something is wrong with her (she wonders about her thyroid, or her iron, having read about both). She does not know that hair loss after birth is common and usually temporary. "Part of me is scared it won't grow back, or that it means something's wrong — my thyroid, or my iron levels, maybe?"
●Concerns: Two concerns run together: distress about the hair loss and its effect on her already-fragile postnatal confidence, and anxiety about harming her baby through the medication in her breast milk. "It's knocked my confidence at a time when I'm already all over the place. And the tablet — I just couldn't bear the thought of it affecting the baby."
●Expectations: She wants to know why her hair is falling out and whether it will stop, and she wants clarity on whether her blood pressure tablet is safe while breastfeeding — ideally to be switched to something she can feel comfortable with. "I want to understand what's happening with my hair, and I really want the tablet sorted so I'm not worrying every feed."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Pregnancy and pre-eclampsia: "First baby. Got pre-eclampsia near the end — high blood pressure and protein in my urine. Induced at 38 weeks."
●Postnatal blood pressure: "Stayed high after the birth, so they started the lisinopril. At my six-week check it was 132 over 84, which they said was okay."
●Lisinopril: "Ten milligrams, once a day. Been on it since just after the birth, so about three months."
●Iron/thyroid history: "I was a bit anaemic in pregnancy, took iron tablets for a while. Nobody's checked my thyroid that I know of."
●Allergies: "None."

Social History and Lifestyle Impact

Aisha is on maternity leave from her job as a teacher. She lives with her husband. First baby.

●Home and support: "It's my husband and me and the baby. He's supportive but back at work now, so days are long."
●Feeding and sleep: "Breastfeeding, up several times a night. Exhausted, like any new mum."
●Diet: "Eating a bit haphazardly with the baby — grabbing what I can. Probably not enough iron-rich stuff."
●Mood: "I'm coping, but I'm tired and emotional. The hair thing has really got to me on top of everything."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about the pattern of loss (diffuse vs patchy): "Diffuse — all over, thinner everywhere. Definitely not patches."
●If asked about scalp symptoms (itch, redness, scaling, scarring): "No, none of that. Scalp looks and feels normal, just less hair."
●If asked about hair loss elsewhere (eyebrows, body): "No, just my head."
●If asked about thyroid symptoms (cold/heat intolerance, weight change, palpitations, mood): "I'm tired but that's the baby. No obvious temperature or weight changes. Mood's up and down but I put that down to the situation."
●If asked about iron symptoms / heavy bleeding / diet: "I was anaemic in pregnancy. My diet's a bit all over the place at the moment. Bleeding after birth has settled."
●If asked about postnatal mood / how she's really coping (sensitive): "I'm tired and a bit weepy, but I feel bonded with the baby and I'm managing. I don't feel hopeless or anything."
●If asked about blood-pressure symptoms (headache, visual disturbance): "No headaches, no visual problems. I feel well in that respect."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the hair loss is likely telogen effluvium and will recover: "So it's a normal thing after having a baby? It'll actually grow back? How long will that take?" (The tested point is confident, accurate reassurance about postpartum telogen effluvium and its self-limiting course, while still excluding treatable causes.)
●If the Doctor suggests checking ferritin and thyroid function: "Do you think it could be my iron or my thyroid then? Is that why you're testing?"
●If the Doctor addresses the lisinopril and breastfeeding: "So is the lisinopril safe while I'm breastfeeding, or should I be on something else?" (The tested point is knowing that NICE NG133 names enalapril as the postnatal ACE inhibitor for breastfeeding women, so a switch from lisinopril should be considered, and reviewing whether antihypertensive treatment is still needed at all postnatally.)
●If the Doctor suggests the blood pressure may no longer need treating: "You mean I might not need the tablet at all soon? How would we know?"
●If the Doctor explores her mood: "Why are you asking about my mood? Is that connected?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Postpartum Telogen Effluvium

●During pregnancy, high oestrogen keeps more hairs in the growing (anagen) phase; after delivery, the hormonal fall pushes many hairs synchronously into the shedding (telogen) phase.
●The result is diffuse hair shedding, typically 2–4 months postpartum, which is self-limiting and usually recovers fully over 6–12 months.
●It is a clinical diagnosis: diffuse thinning with a normal scalp (no scaling, redness, scarring, or discrete bald patches). Reassurance is the mainstay.

When Hair Loss Needs More Than Reassurance

●Patchy loss (alopecia areata), scarring alopecia (redness, scaling, loss of follicular openings), or loss with scalp symptoms point away from telogen effluvium and warrant closer assessment or referral.
●Progressive or prolonged shedding beyond the expected course also merits review.

Excluding Treatable Contributors

●Even when telogen effluvium is likely, check ferritin and thyroid function: iron deficiency and thyroid disease (including postpartum thyroiditis) can cause or worsen diffuse hair loss and are readily treatable.
●This patient's pregnancy anaemia and haphazard postnatal diet make iron deficiency particularly worth excluding.

Postnatal Management of Hypertension After Pre-eclampsia (NICE NG133)

●Blood pressure often remains elevated for days to weeks (sometimes months) after pre-eclampsia and then settles.
●NICE NG133 recommends postnatal review of antihypertensive treatment, reducing and stopping medication as blood pressure allows, with monitoring — rather than assuming indefinite treatment.
●Women with a history of pre-eclampsia should also be counselled about their increased long-term cardiovascular risk and the importance of ongoing blood-pressure surveillance.

Postnatal Antihypertensive Choice (NICE NG133)

●ACE inhibitors are contraindicated in pregnancy (teratogenic), but are used postnatally, and treatment must be compatible with breastfeeding.
●For postnatal hypertension, NICE NG133 recommends enalapril as the ACE inhibitor of choice (with monitoring of maternal renal function and serum potassium) — it is the ACE inhibitor named because it is suitable during breastfeeding.
●NG133 postnatal alternatives include nifedipine or amlodipine (nifedipine or amlodipine are favoured for women of black African or African–Caribbean family origin) and labetalol; combinations are used if a single agent does not control blood pressure.
●Lisinopril is not the NG133-named postnatal choice. Recognising this and switching to enalapril (or another NG133 option) is the learning point here.

Reassuring About Medication and Breast Milk

●Address specific parental anxieties with accurate, proportionate information: most antihypertensives pass into milk in only small amounts, and treatment can usually be managed safely without stopping breastfeeding.
●Use authoritative resources (e.g. Specialist Pharmacy Service / UKDILAS) to guide drug choice and counselling.

Maternal Mental Health

●The postnatal period carries a significant risk of postnatal depression and anxiety. A distressing physical symptom (hair loss) on top of exhaustion can compound low mood.
●Screen sensitively for mood and coping, distinguish normal postnatal tiredness from depression, and signpost or refer for support as needed.

Hair-Care Advice and Expectation Setting

●Advise gentle hair care and give realistic timescales for regrowth (months, not weeks). Avoid recommending unproven or costly treatments for a self-limiting condition.

Follow-Up and Safety-Netting

●Arrange follow-up to review ferritin and thyroid results, blood-pressure control and step-down, and mood.
●Safety-net for features that would change the picture: patchy or scarring loss, progressive shedding, or new symptoms.

Common Candidate Mistakes in This Case

●Reassuring about the hair without checking ferritin/thyroid: missing a treatable contributor in a woman with prior anaemia.
●Leaving the lisinopril unquestioned: not reviewing whether the antihypertensive is still needed, and not recognising that NG133 names enalapril (not lisinopril) as the postnatal choice.
●Telling her to stop breastfeeding: an unnecessary and harmful response to a manageable medication question.
●Ignoring maternal mood: overlooking postnatal mental health in a distressed, exhausted new mother.
●Treating the two problems in isolation: failing to bring together the hair loss and the medication review into one coherent, reassuring plan.

Free MRCGP SCA practice case for GP registrars covering Hair Loss Three Months After Giving Birth, Still Taking Lisinopril — Dermatology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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