Counsel a young woman with a Fontan circulation on contraception, pregnancy, and staying in care — OSCE

Candidate brief (5 minutes to read)

You are the registrar in the adult congenital heart disease clinic. A 19-year-old woman with a single ventricle palliated to a Fontan circulation has returned after a two-year gap in care. She has a new partner, wants advice about contraception, and says she might want children one day. She feels reasonably well but is breathless on stairs. In eight minutes, re-engage her in care without judgement, advise on safe contraception, counsel realistically about a future pregnancy, address endocarditis prophylaxis, and agree a lifelong follow-up plan. [1] [4]

Marking criteria

Communication and relationship (6 marks)

• Re-engages her warmly and without blame for the gap in care; explores why she disengaged and what would help her stay in care. [4]
• Explores her own priorities — the relationship, contraception, and her wish for children — before delivering information, and checks understanding throughout. [1]
• Delivers realistic, potentially unwelcome pregnancy information honestly while holding her hopes and distress; avoids both false reassurance and blunt prohibition. [8]

Content — contraception and pregnancy (8 marks)

• Advises avoiding combined oestrogen-containing contraception because the Fontan circulation carries a high thrombotic risk. [7]
• Recommends progestogen-only methods or long-acting reversible contraception (implant or intrauterine device) as safe and effective, and explains why an effective method matters most in a high-risk lesion. [7]
• Explains that a Fontan circulation is modified WHO class III (high risk) for pregnancy, needing expert shared maternal-cardiac care, and names the real risks of arrhythmia, heart failure, thromboembolism, and adverse fetal outcomes. [8]
• Uses registry-based risk data (for example ROPAC and the CARPREG II score) to give individualised figures rather than vague reassurance, and counsels before conception. [9]

Endocarditis prophylaxis and follow-up (4 marks)

• States that with no prosthetic material or prior endocarditis she does not routinely need antibiotic prophylaxis, and gives the current high-risk indications; emphasises oral hygiene. [11]
• Agrees a lifelong follow-up plan: re-stage the lesion, resume six-to-twelve-monthly ACHD centre review, give a portable summary, and arrange active recall so she is not lost again. [1]

Shared decision and closure (2 marks)

• Summarises the plan, confirms understanding, agrees a contraception choice and a follow-up appointment, and offers a named contact and psychosocial support. [4]

Examiner notes

The discriminating candidate re-engages the patient without a hint of blame, recognising that loss to follow-up is a system failure as much as a patient one, and that this returning patient is a success to protect. On content, the candidate must separate contraception (safe, effective, avoid oestrogen) from pregnancy (high risk, class III, counsel before conception) and must resist two failure modes: falsely reassuring her that pregnancy is fine, or bluntly forbidding it without exploring her values and the shared-care options. Raising endocarditis prophylaxis correctly — that she does not need it — and securing active recall so she is not lost a third time demonstrate the systems thinking the station tests. [8] [4]