Cases/Maternity and Reproductive Health

Woman On Sertraline Planning Her First Pregnancy — Free SCA Practice Case

Woman on sertraline planning her first pregnancy

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

Rachel Cole

Age

31 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My partner and I have decided to start trying for a baby. I take sertraline for my anxiety and low mood, and I'm not sure whether I should stop it, or what I should be taking before I get pregnant."

Medical Records

●PMH: Depression and generalised anxiety (well controlled for the past 18 months).
●Medications: Sertraline 100 mg OD.
●Allergies: NKDA.
●Recent notes: Stable mood on sertraline; previous relapse when medication stopped 2 years ago. Cervical screening up to date.

Patient Script

For the friend playing the patient role

Character Overview: You are Rachel, a 31-year-old solicitor, planning your first pregnancy. You have taken sertraline for a couple of years and feel well and stable on it. You are conscientious and have read conflicting things online — some say you must stop antidepressants in pregnancy, which frightens you because you were very unwell when you last stopped. You want clear, balanced advice. You are not set on stopping; you just want to do the right thing for the baby and yourself.

Opening Sentence: "Hi Doctor. My partner and I are ready to start trying for a baby, which is really exciting. But I take sertraline, and I've read all sorts online about antidepressants in pregnancy. I'm worried — should I stop it? And is there anything I should be doing or taking beforehand?"

History if Asked (Data Gathering Phase)

●Her mental health: "I've been really well for about 18 months on the sertraline — stable, coping well at work and at home. I'd say I'm the best I've been in years."
●Previous relapse: "The last time I tried to come off it, about two years ago, I relapsed badly — really low, couldn't function, ended up back on it. That's what scares me about stopping."
●The medication question: "I've read you should stop antidepressants in pregnancy. But I'm frightened of getting ill again, especially with a baby on the way."
●Pregnancy planning: "We've just started thinking about it — not pregnant yet. I want to get everything right before we start."
●General health: "I'm generally well, no other conditions, no other medications."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Rachel has absorbed the message that antidepressants must be stopped in pregnancy and assumes she will probably have to come off sertraline. "I've come in half-assuming you'll tell me I have to stop the sertraline."
●Concerns: Her dominant concern is relapsing if she stops — she remembers how unwell she became last time — set against a fear of the medication harming the baby. She is torn between the two. "I'm frightened both ways — scared the tablets could harm the baby, but terrified of getting as ill as I was last time, especially when pregnant."
●Expectations: She wants clear, balanced advice on what to do about the sertraline, and to know what else she should be doing to prepare. "I want honest advice weighing it all up, and to know what I should be taking or doing before we try."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Current stability: "Stable and well for about 18 months. No current symptoms of depression or anxiety."
●Medications: "Just sertraline 100mg. Nothing else."
●Alcohol/smoking: "I drink occasionally, don't smoke."
●Folic acid: "I'm not taking any vitamins yet — should I be?"
●Other risk factors: "No diabetes, no epilepsy, healthy weight, no family history of neural tube defects."
●Rubella/screening: "I think I had my childhood vaccinations. Smears are up to date."

Social History and Lifestyle Impact

Rachel is a solicitor. She lives with her partner.

●Work/home: "Demanding job, but I manage well now. Supportive partner, stable relationship."
●Lifestyle: "Healthy weight, occasional alcohol, non-smoker, reasonably active."
●Support: "Good support from my partner and friends."
●Mood: "Genuinely well at the moment — that's what I want to protect."

Responses to Management (The Negotiation Phase)

●If the Doctor advises against abruptly stopping sertraline: "So I shouldn't just stop it? I thought that's what you had to do in pregnancy." (The tested point is explaining that antidepressants should not be stopped abruptly, and that untreated illness carries its own risks.)
●If the Doctor explains the balance of relapse risk versus drug risk: "So it's about weighing up the risk of getting ill against the risk of the medication? How do I decide?" (The tested point is a genuine shared-decision discussion of relapse risk versus the small drug risks, tailored to her history of relapse.)
●If the Doctor discusses staying on sertraline: "Is sertraline one of the safer ones to stay on if we decide to continue it?"
●If the Doctor advises folic acid and pre-conception measures: "What dose of folic acid, and what else should I be doing before we start trying?"
●If the Doctor mentions specialist input: "Would I need to see a specialist about this?"

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 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Do Not Reflexively Stop Antidepressants for Pregnancy

●Antidepressants should not be stopped abruptly for pregnancy or pregnancy planning. Untreated depression/anxiety in pregnancy carries real risks — relapse, impaired self-care, adverse pregnancy outcomes, and postnatal depression — and abrupt discontinuation risks both relapse and discontinuation symptoms.

Balancing Relapse Risk Against Drug Risk

●The decision is a balance: the small risks of the medication versus the risk of relapse (heavily influenced by illness severity and relapse history).
●A woman who is well but has a history of severe relapse on stopping is often safer continuing treatment; the decision should be shared and individualised, not a blanket rule.

SSRIs in Pregnancy — Proportionate Risk

●Sertraline is among the SSRIs with more reassuring pregnancy data and is commonly continued where indicated.
●Potential risks are small: a debated small association with certain outcomes; neonatal adaptation syndrome (transient, self-limiting) if used near term; and a much-debated small cardiac association. These are weighed against relapse risk.

Managing Any Change Safely

●If a decision is made to reduce or stop, do so by a slow, supported taper with close monitoring, never abruptly. Continued psychological therapy and support should be in place.

Pre-Conception Optimisation

●Folic acid 400 micrograms daily from before conception to 12 weeks (5 mg if higher risk — e.g. BMI ≥30, diabetes, epilepsy on relevant medication, previous neural-tube defect, family history).
●Vitamin D 10 micrograms daily; optimise alcohol, smoking, and weight; check rubella immunity and cervical screening; optimise chronic conditions and review all medications.

Specialist Input and Monitoring

●Consider perinatal mental health team input for medication and planning decisions, with close monitoring of mental state through pregnancy and the postnatal period (a high-risk time for relapse).

Shared Decision-Making

●These are preference-sensitive decisions. Provide balanced information, respect the woman's autonomy, arrive at a shared, documented decision, and ensure support whatever she chooses.

Common Candidate Mistakes in This Case

●Reflexively stopping the antidepressant: advising cessation because of pregnancy, ignoring the relapse risk — the key error.
●Advising abrupt discontinuation: rather than a slow, supported, monitored change if any.
●One-sided risk communication: either frightening her about the drug or dismissing the risks.
●Omitting pre-conception optimisation: forgetting folic acid (and its dosing), vitamin D, and lifestyle/immunity checks.
●No specialist input or monitoring plan: making a complex decision without support or relapse safety-netting.

Free MRCGP SCA practice case for GP registrars covering Woman On Sertraline Planning Her First Pregnancy — Maternity and Reproductive Health. 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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