Which medication would warrant an immediate referral to the patient’s GP for a review given her desire to conceive and complex medical history?

• A. Metformin
• B. Sodium valproate
• C. Folate
• D. Levothyroxine

Answer: (B)

The main idea here is that some medicines are highly dangerous to a developing fetus and require urgent preconception review to plan a safe course of action. Sodium valproate is well known for its strong teratogenic risk, including neural tube defects and long-term neurodevelopmental effects. Because these risks are substantial and most pronounced early in pregnancy, women of childbearing potential who wish to conceive must have valproate reviewed urgently by a GP (often with a neurology or epilepsy specialist) to consider stopping or switching to a safer alternative and to establish a pregnancy planning plan.

Metformin can be continued or adjusted for pregnancy planning in conditions like diabetes or PCOS and is not associated with the same immediate, high-stakes fetal risks as valproate. Folate supplementation is routinely recommended before conception to reduce neural tube defects and is part of standard preconception care, not a trigger for urgent referral. Levothyroxine is essential for hypothyroidism and can be managed with dose adjustments during pregnancy, but it does not carry the same urgent risk profile as valproate.

So, the need for an immediate GP referral stems from the high teratogenic risk of valproate in someone planning pregnancy, making it the best choice.