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Essay 294 - Itching in pregnancy

Essay 294 - Itching in pregnancy Posted by PAUL A.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]
Posted by Leen K.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

(a) I would obtain as more detailed history of her symptoms such as any precipitating or relieving factors for the itch, whether she has had itching before(pre-pregnancy and during this pregnancy), any associated rash or lesions, as well as their location, whether she feels generally unwell (eg, nausea and vomiting). I would also find out if she has had any problems antenatally, and ask about her previous pregnancies (such as history of obstetric cholestsis- as there\'s an increased risk of obstetric cholestasis with past history of it). Past medical history should include any potential causes of itching or deranged liver function, such as hepatitis infection. I would ask about her taking drugs that may impair liver function, including alcohol and illicit drugs.

On examination, I would assess her general wellbeing, in particular looking for signs of jaundice and rash or lesions, as well as the location and nature of the rash/lesion (eg. macular/papular/disseminated/localised). I would also ascertain fetal wellbeing by performing a cardiotocograph(CTG).

Initial blood tests should include liver function tests(LFT), and infection screens (eg hepatitis B & C screen) as well as autoimmune screens. I would also arrange an ultrasound of her liver to check for cirrhosis and signs of a blocked bile duct.

(b) The most likely diagnosis is obstetric cholestasis (OC). The itching, which is intense and worse at night, is usually not associated with any rash, and is accompanied by deranged liver function, characterised by an increase in bile acid level. No other causes for abnormal liver function is usually found.

(c) I would explain to her what OC is, as well as its associated risk of increased stillbirth rate and give her written information to back up my counselling. I would prescribe her piriton (antihistamine) for symptomatic relief of her itch. It is safe for use in pregnancy and may help her sleep better at night, however does not help in a proportion of women. Calamine lotion is topical, but found to be unhelpful in most women. Ursodeoxycholic acid has not shown much benefit in terms of improved fetal outcome, and does not improve itching. Vitamin K may help reduce the risk of maternal and fetal bleeding ( which is raised in patients with obstetric cholestasis), and should be offered to the patient.
I would arrange for weekly LFT to monitor for the decline in her liver function as well as weekly CTG to monitor the wellbeing of her fetus. Although early delivery has not been proven to significantly reduce the rate of stillbirth, most units would attempt to delivery these women before her due date. I would check the protocol in her unit, and follow it. The anaesthetist should be informed of her admission with labour.
Intrapartum, I would monitor the fetus with continuous CTG monitoring. Her LFT, clotting studies and platelets should be checked and measures taken to try reduce her risk of post partum haemorrhage (which is increased in OC) - such as active management of 3rd stage of labour. Epidural and spinal might not be suitable if her clotting is abnormal, as there is an increased risk of haematoma.
Posted by Aarthi M.
A/ Describe your initial assessment of the patient [7 marks].

I would first ask her whether the itching is associated with a rash. Also whether anyone else is complaining of itching in her family and whether she has come into contact with anyone with an infection for example, chickenpox or measles. I would find out whether she has had chickenpox or measles in the past as well. I would ask her about any previous pregnancies and whether she had similar symptoms in these pregnancies and whether she was diagnosed with obstetric cholestasis (OC) as this has a high recurrence rate in future pregnancies. I would ask if any members of her family suffered from OC in their pregnancies as OC has a higher incidence in relatives of OC patients. I would also ask whether her baby has been moving adequately as per normal. I would ask whether she has any history of liver problems and how much alcohol she drinks or has drunk in the past. I would ask whether her urine is dark and whether her stools are pale. Finally, I would ask about any allergies and whether she has come into contact with any substances she is known to be allergic to.
I would examine her abdomen and check that the symphysio-fundal height is adequate for her gestation. I would look for any signs of jaundice or a rash on her body. I would check her hepatitis B and C status. I would also check her blood pressure, pulse, temperature and dip her urine as well as performing a cardiotocograph.

B/ State the most likely diagnosis and how you would confirm the diagnosis [3 marks].

The most likely diagnosis is obstetric cholestasis (OC) and I would confirm this by performing blood tests. I would check her bile acids and liver function tests, specifically looking for elevation of aspartate transaminase and hyperbilirubinaemia. Sometimes, a high alkaline phosphatase can also be present. I would not, however, rule out a diagnosis of OC if the bile acids and liver function tests are normal as sometimes, symptoms can precede abnormalites in biochemistry, so I would repeat the blood tests in a week.

C/ Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

I would explain the condition of obstetric cholestasis to the patient and the need for close maternal and fetal monitoring. I would arrange for the patient to be seen every two weeks in the antenatal clinic with two-weekly liver function tests carried out. Also, I would explain that we would need to review the patient in the fetal assessment unit where a cardiotocograph, as well as blood pressure monitoring will be carried out two to three times a week. I would also ask her to attend the hospital as soon as possible if she complains of reduced fetal movements at any time. I would also organize a scan of the baby every four weeks to check for fetal wellbeing with doppler assessment if there was any suspicion of growth retardation. I would explain to the patient that there is a risk of stillbirth with OC and that the severity of the disease does not correlate with the biochemistry or severity of the symptoms. I would also start her on ursodeoxycholic acid from 32 weeks and also give her emollients for symptom control and anti-histamines, for example, chlorpheniramine, but I would explain this may make her drowsy. I would also explain the need for Vitamin K from 36 weeks gestation as her liver may not be producing enough clotting factors. I would also explain she has a higher risk of haemorrhage including post-partum haemorrhage. I would give her written information of all of this. I would plan to induce her between 37 and 38 weeks gestation as long as there were no other contraindications to a vaginal delivery. I would explain that this would be a high-risk induction and this should be perfomed on the delivery suite during daylight hours. I would make sure that there was continuous fetal monitoring during labour. I would also explain the risk of a post-partum haemorrhage and recommend an active third stage of labour with a low threshold for a syntocinon infusion post-partum. I would inform the paediatricians when this patient was in labour as they would be needed to check the baby post delivery.

Posted by Shalini  M.
Shalini
a)A detailed history of the itching should be taken to include the frequency(increased at night),exclusion of palms n soles,and sleep disturbance due to itchingwhich would be suggestive of obstetric cholestasis.Any indigestion or pain abdomen should be asked for to rule out gall stones as a cause.Also history of previous pregnancis should be noted as obstetric cholestasis recurrs in subsequent pregnancies as also with the use of OCPs which should be asked also.Any history of fever ,loss of appetite, jaundice or deeply yellow urine should be asked to rule out hepatitis.On examination any pruritc papules or rashes should be looked for to rule out prurigo of pregnancy and any vesicular lesions that itch could be pemphigoid gestationis.Systematic examination should look for hepatomegaly which would be suggestive of hepatitis.
b)Most likely diagnosis is obstetric cholestasis.Since it is a diagnosis of exclusion it is important to rule out hepatitis due to Hepatitis A,B,C,HIV,Ebstein barr virus,CMV,by serological investigations.Ultrasound abdomen should be done to rule out gall stones and acute faty liver of pregnancy.Blood investigations include liver enzymes,urea,electrolytes,bile acids,y-glutamyl transferase,coagulogram.Also normal liver enzymes and raised bile acids alongwith raised gamma glutamyl tranferase are suggestive of obstetric cholestasis.Elevated liver enzymes would point towards hepatitis.Coagulation studies are important as coagulopathy complicates obstetric cholestasis and needs urgent correction.
c)It is important to explain the diagnosis to the patient and her partner and the risk of meconium stained liquor,prematurity,still-birth and postpartum hemorrhage that might require blood transfusion.also the risk of it recurring with subsequent pregnancy and with the use of OCPs.She should be booked for delivery in a consultant led unit.Herfull blood count liver enzymes.bile acids and coagulation studies should be monitered every 2 weeks to look for any deterioration.There is no consensus on the most appropriate method of fetal monitoring to predict fetal jeopardy and thus CTG after 36 weeks should be done weekly.Vitamin K orally should be started to prevent hemorrhagic complications in both mother and fetus.Group and save should be kept with blood in hand when the lady goes in labour and continous CTG should be done in active labour.Although there is no consensus whether labour should be induced at 37 weeks to prevent still birth many prefer it.Obsttri cholestasis is not an indication for cesarean section.Difficult vaginal deliveries should be avoided and neonatologist should attend delivery.Any evidence of fetal distress or meconium stained liquor in early labour necessitate cesarean section Active management of third stage should be done to decrase blood loss.Liver function studies should be repeated after 10 days of delivery when they normalise as they rise physiologically after delivery.other causes should be loked for if the liver fubction studies are not normal by 10 days.
Posted by H H.
A) I would ask of nature,severity and effect on quality of life of the itch ,making her not able to sleep.Will ask of sites of itch eg more on soles and palms.Will ask if there is an associated rash and its distribution.Did she notice any change in colour of urine and stools.Will ask if she has any allergies and if she took any medications in the past 3 days.
On examination will measure temp(fever may be hepatitis)
,pulse blood pressure, look for rash distinguishing it from exoriations and will see distribution of rash(umbilical sparing in polymorphic eruption of pregnancy).Look for jaundice and see if there is tenderness in right hypochondrium.


B)Most likely diagnosis inn absence of rash is obstetric cholestasis(OC), but it is a diagnosis of execlusion ,need to exclude chronic forms of virus hepatitis .In presense of rash dermatological conditions of pregnancy eg herpes gestations,prurigo of pregn or polymorphic eruption of pregnancy.
To confirm I do liver function tests(LFT) and serum bile acids, if normal will repeate weekly.Liver scan in OC is normal. If LFT high do antimitochondrial antibody and anti DNA tests to exclude chronic forms of viral hepatitis.

B) Management should be by a multidisciplinary team composed of consultant obstetrician, internal medicine physician, if needed dermatologist, midwife and neonatologist in addition to primary care team.Management should follow local guidelines and protocols.I would explain the situation to her and give her information sheet according to her final diagnosis. If diagnosed as OC I would explain that the management will be supportive alleviating symptoms but there are risks to her fetus including being born early,liability to develop distress ,the liquor might stain with meconium and risk of hemorrhage in fetal brain and death.Close monitoring will be done, but this would not easily detect the problem.Itching is managed by antihistaminics and ursodeoxycholic acid but these has no effect on outcome.Water soluble vit K is given orally to overcome the decrease in its absorption and so reduced clotting factors.Early delivery at 37WK is usually the role but the RCOG say that there is no evidence to support this. Blood for FBC,group and save , Continuous electronic fetal monitoring ,proper analgesia and securing an IV line for fear of post partum hemorrhage (this is theoretical) should be done intrapartum for this high risk patient. Neonatologist should be available. Active management of third stage. Baby given intramuscular vit K.
If the diagnosis is a dermatological condition ,she is to be seen by the dermatologist, given symptomatic treatment and close monitoring of fetus antenatally and intrapartum in case of herpes gestations.

If diagnose virus hepatitis this should be treated in conjunction with infectious disease physician and care during labour to attendants from needle stick injuries and avoid invasive procedures during labour to avoid vertical trannsmisiob to the baby. Consider active and passive immunization to fetus

Posted by DARE A.
a. A brief history looking at the onset of itching, whether her symptom is getting worse and what makes it better or worse. I will ask about involvement of other parts of her body and if there are any skin rashes. Patient will be asked about other symptoms such as fatigue, increased nausea, decrease in appetite, upper right quadrant pain, jaundice, darkening of her urine, pale stools and pain in her joints. A history of blood transfusion, liver disease and any drug use is important. I will ask about previous pregnancies, previous history of pruritus in these pregnancies and their outcome. Is there any family history of similar complaints? And lastly, I will ask about adequacy of fetal movements. During examination, I will look for patient’s general wellbeing, jaundice and any rash of scratch marks. I will assess symphysio-fundal height and confirm fetal viability.
b. The most likely diagnosis is obstetric cholestasis. The diagnosis is by exclusion of other possible causes and resolution of symptoms within 8 weeks postpartum. These include preeclampsia, the HELLP syndrome, and acute fatty liver of pregnancy. Furthermore, other causes of hepatitis, like hepatitis viruses and certain medications, should also be considered. Hence, I will take blood for liver function tests, serum bile acid, clotting screen and hepatitis panel. Normal liver function tests, negative hepatitis panel and a raised serum bile acids in the presence of itching without rash localised to the abdomen, legs, palms, and soles, but can be generalized, will almost be diagnostic of obstetric cholestasis.
c. I will have a full discussion with patient concerning the diagnosis and the implication such as risks of preterm delivery, fetal distress and small risks of intrauterine fetal death. I will start her on antihistamine such as chlorpheniramine 4mg thrice daily to combat itching and ursodeoxycholic acid to reduce serum bile acids. I will request twice weekly cardiotocography to monitor fetal wellbeing. Patient will be referred to consultant-led antenatal clinic for the entirety of the pregnancy fortnightly. I will repeat serum bile acids, liver function tests and clotting screen every two weeks. Patient will be delivered at 37 weeks either by induction of labour or by caesarean section if indicated. Patient will be monitored by continuous fetal cardiotocography throughout her labour and delivery. Patient will be given a leaflet detailing the diagnosis, risks and implication for future pregnancies.
Posted by Sophia Y.
(a) We need to ask history about the symptoms of itchiness, location. We should also ask her about any precipitating factors that might cause allergic reaction - eg recent change of soap or washing detergent , consumption of new drugs or food eg shellfish, presence of mites or mosquito bites. She should also be asked if there is anyone in family with similar symptoms. She should also be asked about symptoms of vomiting, lethargy pale stools, dark urine & signs of jaundice and upper abdominal pain. She should also be asked if foetal movement has been active.

On examination she should be checked for signs of jaundice, area of itchiness, any signs of rashes around that region of itchiness & record the type of rashes and location. CTG should be commenced to assess fetal well being.

She should have bloods taken for FBC (to assess platelet level), LFT, bile acids. Pregnancy serum level should be used. If LFT is deranged (eg raised bilirubin or ALT), other causes of liver diseases need to be excluded. Therefore hepatitis screen (Hep B & C, CMV & Ebstein Barr virus) & autoantibodies (anti-smooth muscle Ab & anti-mitochondrial Ab for chronic active hepatitis & primary biliary cirrhosis) need to be excluded.

(b) Obstetric cholestasis is the likely diagnosis. It is a diagnosis of exclusion where there is symptoms of itchiness during pregnancy, absence of rashes, LFT is deranged +/- raised bile acids using pregnancy reference level.

(c) She should be counselled that in the past women with obstetric cholestasis were offered induction of labour at 37/38 to prevent still birth. However there is no strong evidence about association of OC & stillbirth. In addition there is no method of fetal monitoring - eg USS or CTG that can predict the outcome of fetus in order to prevent still birth. In addition there is no correlation between level of deranged LFT or bile acids & fetal outcome. She should be counselled that there is a risk of spontaneous & iatrogenic preterm birth.
Antenatally she should have FBC, liver function & bile acids monitored weekly. She can be offered topical emollients (eg calamine lotion or aqeous cream with methol) or ursodeoxchoic acid to relieve symptoms of itchiness although efficancy is uncertain. She can also be offered anti-histamine. From 36/40 onwards, she should be advised to take oral vitamin K 10mg od as she is at risk of vitamin K malabsorption.

She should have continuous CTG monitoring during delivery. FBC & clotting & G&S should be checked. Evidence about risk of PPH or meconium is uncertain. Baby should receive vitamin K injection to reduce risk of haemorrhagic disease of newborn.
Posted by Johnson  O.
History of the presenting symptoms, when the itching is worse, day or night.Associated skin rash. I would ask about medication which may cause allergic reaction. Colour of her urine, pale stool to exclude jaundice. Any history of fever as in infection like hepatitis. Associated headache, visual disturbance or epigastirc pain in pre-eclampsia.If she is multiparous, I would ask about previous history of obstetric cholestasis, mode of deliveries. Previous history of itching with oral contraception.
Examination would include blood pressure measurement to exclude pre-eclampsia, temperature to exclude infection. I would inspect her body for skin rash. Abdominal examination for palpable liver. Fundal height and fetal heart rate.
B/
Obstetric Cholestasis is the most likely diagnosis. I would perform the following investigations to confirm the diagnosis and rule out differentials.
Liver function test, most especially transaminases, if they abnormally raised, the diagnosis is likely Obstetric Cholestasis with normal blood pressure.. At the initial stage Liver function test may be normal, therefore, I would repeat the test in a week.
Blie acid would also be requested, normal result does not exclude the diagnosis, but high level confirm the diagnosis. Antimitochondria antibody and anti smooth muscle antibody to exclude Chronic active hepatitis and primary liver cirrhosis
Ful Blood count, white blood cell count and CRP to exclude infection. I would request screening for hepatitis A, B and C. Liver ultrasound scan to exclude liver pathology.
C/
I would counsel the woman, inform her the diagnosis and the management plan. I would inform her that no medication can completely cure her but they may relief her of the symptoms. Definitive cure is delivery at the appropriate time agreed with the woman involvement. Oral antihistamine like piriton can improve her sleep in the night . Topical cream to reduce itching. Ursodeoxycholic acid is not license for use in pregnancy but it is a chelating agent to mop up the bile acid..
Oral Vitamin K 10-20mg daily would be prescribed to reduce the risk of maternal and neonatal bleeding. Steroid would be giving if there is possibility of premature delivery.
Fetal assessment in Day care weekly, by doing CTG, ultrasound scan for liqour volume and Doppler. I would inform her that the assessment can not reliably predict fetal outcome. Weekly Liver function test.
To reduce the risk of intrauterine death, meconium stain liqour and birth aspyxia, I would aim for delivery around 37-38weeks gesation. Vaginal delivery except for obstetric indication for caesarean section. The woman would be involved in decision making.
Written information leaflet would be provided to enable her make well informed decision. Clear management plan in her notes. I would follow unit protocol in her management. Im vitamin K to baby after delivery. Discussion about future occurence and she should avoid oestrogen containing contraception.
Posted by dr neelangini G.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]




a) My initial assessment would include history in detail about intensity of itching , association with rash or pruritic lesions, itching at other sites. I would also like to know if she has known allergies to certain substances & exposure to allergens. If associated vomiting, fever, malaise to rule out acute hepatitis. Her gravidity , parity, pregnancy outcome is important as far as obstetric history is concerned. If she had similar history of itching during previous pregnancies or h/o jaundice . If pruritus, jaundice & / or unexplained stillbirth goes in favour of cholestatic jaundice or cholestasis of pregnancy. I would also like to know associated medical illnesses like hypertension, diabetes, skin disorder, liver disease. Examination include BMI, general conditions of patient like pulse rate, B.P, yellowish discoloration of sclera to rule out or confirm jaundice. Uterine height to see fetal growth, lie , presentation . auscultation of FHS. At 30 weeks of gestation palpation for hepatomegaly will be difficult. General examination of hands & legs to see any lesions apart from scratch marks. Bullous lesions around umbilicus extending down to legs is suggestive of pemphigoid of pregnancy.
b) The most likely diagnosis in this case would be cholestasis of pregnancy as it is common in third trimester. The condition is associated with itching starting on hands & legs. Ethnicity is also important as women from Asia & Scandinavians have more predisposition to gety cholestasis of pregnancy. For diagnosis- previous h/o cholestasis in pregnancy, h/o cholestasis associated with combined oral contraceptive pills is also important. Liver Function tests may give clue but are not diagnostic. In this condition bile acids are increased. Liver enzymes can also be raised, usually serum bilirubin is within normal limit.
c) Subsequent antenatal management include regular antenatal visits to see the progress & severity of the condition. Regular liver function tests , FBC, U& E, Coagulation screen. Asking the patient to keep record of daily fetal movements . Doing serial growth scans, CTG, assessment of amniotic fluid as this condition is associated with more risk of developing stillbirth. Reassuring the patient & telling her that most of the time the course is selflimiting apart from itching it will not cause other untoward complications. But risk of preterm Labour , prematurity, stillbirth is increased. There is also more risk of developing postpartum haemorrhage. For itching , local application of emollients is helpful. Oral antihistaminic also help to relieve intense pruritus . There are few studies mentioning use of Ursodeoxycholic acid to correct biochemical abnormality associated with cholestasis . but outcome is not improved with ursodeoxycholic acid & more studies are needed. Corticosteroids are also used , but risk of worsening of diabetes if associated – should be taken into account . Longterm use of steroids may have effect on growing fetus & development of growth restriction should be considered. If condition is not severe , delivery at term is indicated. Id deranged liver functions , early induction of labour at 37- 38 weeks is mandatory. Patient should be provided with written information about the condition. During labour continuous CTG , as fetal distress is a possibility. Routine investigations like FBC, U& E, & coagulation screen as possibility of bleeding Group & save as risk of postpartum haemorrhage. Presence of neonatologist during labour for management of neonatal complications.
Posted by robina K.
(A) History should be obtained about the characteristic of itching as generalised itching may indicate dermatological conditions or skin manifestation.History of rash could be due to allergy.Information should be obtained about severity of itching affecting her quality of life such as sleeplesness.Previous pregnancies with similar symptoms should be asked as recurrent risk of obstetrics cholestasis is very high about 90 percent.History of jaundice, fever, pain abdomen specifically in right hypochondrium, dark urine and pale stools should be asked about.Fetal movements should also be inquired.A general physical examination should be carried out scratch marks which indicates severity of itching.Skin examination is carried out for any bleeding, rash and jaundice.An abdominal examination is performed to determine fundal height,hepatomegaly and tenderness..Fetal heart should be checked with CTG. (B)The most likely diagnosis is obstetric cholestasis, however other dermatological conditions ,skin manifestations and allergy should be ruled out.A liver function test should be performed including bilesalts,,serum bilirubin.transaminases(AST,ALTand alkaline phosphatase).Bile acids may be normal which should be repeated after a week as a normal bile acid does not exlude obstetric choestasis. An ultra sound scan for gallblader stones and fetal wellbeing should be offered.Final confirmation of diagnosis is done by postnatal normalisation of LFT at tenth day. (C) Diagnosis should be explained to the women in a supporting way.Risks should be explained like preterm delivery,fetal distress,meconiumm stained liquor,PPH,fetal intra ventricular hemorrhage and still birth may occur.But in the majority out come is normal.Tests of fetal wellbeing should be offered according to the unit protocol but these cannot predict or prevent adverse outcome.Vitamin 10 mg orally should be offered to the women to prevent hemorrhagic conditions in mother and fetus.Symptomatic treatment should be offered to the mother like antihistamines and skin lotions like balneum plus.Ursodeoxycholic acid may be effective but not licensed for use in obstetric cholestasis.LFTs,Full blood count and clotting profile is monitored weekly.Induction of labour is offered at 37 weeks according to unit protocol.Information leaflets should be provided and support groups should be offered like British Liver society and obstetric cholestasis support group. For induction of labour membrane sweeping,prostaglandins or oxytocin may be offered according to unit protocol and maternal wishes.Cesarean section is performed for obstetric indication,during labour continous electronic fetal monitoring is offered.Neonatologist should be informed to be present at delivery.Third stage of labour should be managed actively with IM sntometrine.
Posted by Mohamed A.
I will start by accurate confirmation of the expected date of delivery by asking about timing and result of dating scan if performed, is this pregnancy singleton or multiple pregnancy (obstetric cholestasis more common in multiple). History of obstetric cholestasis in previous pregnancies (almost 90% risk of recurrence) and a positive family history (in 35% of cases of obstetric colestasis).History of preterm deliveries or IUFD or still birth.
History of dermatoses, or recent drug intake or exposure to chemicals may denote allergic reaction. Itching of trunk, palms and soles often worst at night, insomnia and fatigue. Anorexia, malaise, epigastric discomfort, steatorrhoea and dark urine usually indicate obstetric cholestasis. Also I will enquire about the adequacy of fetal movements.

General examination should include blood pressure, pulse, temperature and presence of jaundice. The abdomen should be examined to look for scratch marks and excoriation to exclude pruritic urticarial papules and plaques of pregnancy, palpate for hepatomegaly, and tender upper quadrant to exclude hepatitis. Also the symphysio-fundal height should be noted, and fetal heart should be checked.


My initial investigations will include ultrasound to assess gestational age, fetal size and fetal well being.
Liver ultrasound to exclude cholelithiasis, serology for Hepatitis A,B,C, Epstein Bar virus and cytomegalovirus. Liver autoantibodies to exclude primary biliary cirrhosis. Anti-smooth muscle antibodies to exclude chronic active hepatitis.

The most likely diagnosis is obstetric cholestasis. Confirming the diagnosis is based on abnormal liver function tests, abnormalities in transamniasis, gmma glutamyl transferase bilirubin and bile salts are considered sufficient to support diagnosis of obstetric cholestasis but pregnancy-specific ranges should be used. Serum bile acids concentrations are markedly raised (10-100 folds) and may be the only abnormality detected.
Also to confirm the diagnosis I should exclude other causes of itching and liver dysfunction and postnatal resolution of pruritis and liver function tests should be confirmed.

I will counsel the woman for the risks of obstetric cholestasis which includes postpartum hemorrhage (10-20%), preterm labour (both iatrogenic and spontaneous), meconium stained liquor, fetal distress and intrauterine fetal death. And that risk increase toward and beyond term but don’t correlate with symptoms or liver function tests.

Liver functions should be assessed weekly together with clotting time. Vitamin K 10 mg orally daily should be given from time of diagnosis to decrease the risk of postpartum hemorrhage. Fetal surveillance with regular ultrasound scan and CTG although can’t reliably predict outcome, normal findings are reassuring.

Control of symptoms may be achieved by antihistaminics and topical emollients, diprobase, Balneum plus and calamine lotion. Ursodeoxycolic acid (UDCA) helps to relieve pruritis and liver function tests however women should be aware that there are insufficient data to support its use.

Delivery should be induced at 37-38 weeks, however there are insufficient data to support or refute that practice. and woman should be counseled about the consequences of iatrogenic delivery including repiratory morbidity versus term delivery with the risk of stillbirth.

Intrapartum continuous fetal monitoring is mandatory, as well as checking her clotting times as there is increased risk of postpartum hemorrhage, I will ask for group and save.

Women should be offered follow up after delivery to ensure resolution of pruritis and that LFTs have returned to normal (test to be done at least 10 days after delivery). Reassure about the lack of long term sequelae for mother and baby. Advise to avoid estrogen containing contraceptives and the increased incidence of recurrence.
Posted by Nur Sakina K.
NSK

From A
I’d enquire re severity, site of her itch and whether it’s progressively worsening. I’d also assess whether it’s worst during the day or nite time. Obstetrics cholestasis(OC) mainly affects the palms and soles of foot. It is worse at nite and can lead to severe sleep deprivation. Other associated symptoms such as presence of jaundice, anorexia, malaise and dark urine are elicited and is associated with OC. Presence of rash is queried. This may be associated with other viral illnesses such as varicella and rubella. Her obstetrics history for previous OC or a family history of this is important. There is an upto 90% risk of recurrence in subsequent preganancies and upto 35% woman have a family of OC. I’d also query recent exposure to other unwell individuals for possibility of CMV, EBV or hepatitis infection. Recent new medication usage is asked to exclude possibility of an allergic reaction.
Examination aims at assessing temperature for pyrexia to exclude a viral illness, blood pressure and urine for proteinuria to exclude PET. The skin is examined for the site of itch and presence of rashes or scratch marks. OC is not associated with rashes, but scratch marks is found. Abdomen is examined for scratch marks, striae which can also cause pruritis in pregnancy. The abdomen should be palpated for fundal height to exclude small for dates and assess liquor volume and fetal lie/presentation. A CTG is done to assess fetal well-being.

Fr B:

Most likely diagnosis is OC. A serum liver function test(LFT) for serum transaminase, GGT (elevated), ALP (higher than normal pregnancy range) and bile salts(10-100 times higher) taken. The upper normal limit in pregnancy is 20% lower than the upper normal for non-pregnant woman.A clotting screen for PT may be prolonged which is due to vitamin K malabsorption. However a normal LFT and bile salt does not exclude the diagnosis as symptoms may occur for days or weeks before abnormal LFT’s occur. If symptoms persist, weekly LFT’s done.

Fr C:
She should be managed in a multi-disciplinary team approach involving the haematologist, gastroenterologist, obstetrician, anaesthetist, gp, midwives and paediatrician. Regular and frequent follow to assess worsening of symptoms and monitor fetus for IUGR or distress is crucial.
The mother and her partner is educated re OC, the complications that can occur such as preterm delivery, stillbirth and obstetrics haemorrhage(20%). She should be advised to contact us if fetal movements are felt to be reduced as this can be a sign of fetal compromise. An information leaflet with the contact details in hospital is given.
I would monitor fetal growth and wellbeing by performing 2 weekly growth scans, dopplers and a CTG to detect fetal distress. However, there are no specific test that will predict this. The patients LFT’s, coagulation screen should also be monitored regularly to assess deterioration. The severities of blood indices do not predict severity of OC, maternal or fetal outcome.
I would start her on ursodeoxycholic acid 600mg Bd(unlicensed for use in pregnancy). It may help reverse LFT abnormalities but is not proven to improve maternal or fetal outcome. Symptomatic treatment of itch with use of antihistamine, aqueous cream and calamine lotion can be offered. However, it’s efficacy is not proven. Vitamin K 10 mg PO is started from 32/40. This aims at providing vit K supplements and reducing the risk of bleeding. A water-soluble based vit K is chosen to avoid the risk of fat malabsorption.
Intrapartum care includes offering IOL at 38/40 to reduce the risk of stillbirth. A c/s is only for obstetrical reasons. Continous CTG should be done in labour for early detection of fetal distress. Active management of 3rd stage helps reduce the risk of postpartum bleeding. The baby should be given IM vitamin k at birth to reduce the risk of bleeding.
Postnatally, I would repeat the LFT’s and bile salts at least 10 days postpartum to ensure resolution and confirm the diagnosis of OC. I’d also counsel her re the risk of recurrence in future pregnancy (upto 90%) and risks to other family members of getting OC. I’d also advise her to avoid COCPs as it can worsen cholestasis. I’d also advise for her to present early for prepregnancy counselling in subsequent pregnancies.

thanks paul.
Posted by Manoj M.
M
(a) A history of severity of itching without rash and worse at night may suggest Obstetric cholestasis(OC).
A history of pale stool and dark urine may support likelihood for OC.
A history associated with rash may suggest other causes like pruritic eruptions of pregnancy.
A past history of skin diseases like eczema may suggest a flare up of same.
An allergen history of food, drug or clothing may suggest like cause of itching.
Examination of the skin may show dermatographia artefacta suggestive of artefacts from skin scratching and exclude skin rashes as causes of itching.
A history of fetal movement will suggest viability of pregnancy.

(b) Most likely diagnosis is Obstetric cholestasis from a history with itching involving palm and hand and without rash.
Biochemical abnormalities of liver function test like transaminase, gamma glutary transferase, bilirubin and bile salts will aid diagnosis of OC.
OC is a diagnosis of exclusion after excluding other causes of abnormal LFT like viral causes like hepatitisB, C, CMV,EBV, autoimmune causes like primary biliary cirrhosis and chronic active hepatitis by blood investigations and ultrasound scan of liver to exclude gall stones.

(c) A full explanation of the condition to the patient with increased likelihood of iatrogenic/spontaneous premature delivery.
Explanation regarding inconclusive evidence regarding increased risk of meconium liquor, caesarean section and post partum haemorrhage.
Risk of unexplained fetal death and no specific monitoring modality to predict the same. Ultrasound is not helful for same.
A tailored approach of care with patients individual circumstances and degree of symptoms to optimise outcome of care with weekly LFT and CTG monitoring followup with consultant led care.
Steroid therapy with betamethosone 12mg 2 doses 24 hours apart to reduce risk with prematurity like RDS.
Vitamin K oral therapy from diagnosis and more emphasis if abnormal prothrombin time.
Symptom relief with emollients, chropheniramne maleate may help symptom control but no benefit with fetal outcome.
S-adenosyl methionine and Ursodeoxycholic acid has no robust data to suggest will improve fetal outcome and symptom relief and use discussing this with the patient.
Dexamethasone is not recommended for symptom control and may cause adverse effect.
Recommend induction of labour by 37-38weeks and explanation this is popular practise and not based on robust evidence.
Intrapartum care with continous CTG monitoring as increased risk of fetal distress with OC.
IV access with group and save as increased risk of PPH.
Options for epidural as pain relief as increased risk of caesarean section.
An agreed protocol for management of complications like PPH.

Posted by Shaimaa M.
A.
Initial assessment of the patient should include more detailed history on her itching, timing, severity, precipitating factors, being more at day or night time. Previous itching earlier in pregnancy and family history of cholestasis. History of viral hepatitis, chronic skin condition like eczema, psoriasis. Drug history or allergy or atopy. Asking about urine and stool colour (dark urine, pale stools may point to liver condition). Examination should include general examination looking for signs of jaundice (yellow sclera). Skin inspection of any pruritic lesions identifying papules, macules or vesicles that willa id in differential diagnosis. Abdominal examination may rule out hepatomegaly, right hypochondrial tenderness.
Investigations should be directed to rule out cause of itching and exclude other reasons for abnormal liver enzymes. Investigations should include, Liver functions tests, ALT, Gamma GT, alkaline phosphatase is normally elevated in pregnancy, Bilirubin Direct and total as well as bile salts however pregnancy specific range should be applied as normal pregnancy values is 20% less than non pregnant level
Hepatitis viral markers including Hepatitis A, B, C, Epstein Bar virus, Cytomegalovirus.
Antimitochondrial antibodies and anti smooth muscle antibodies for Liver autoimmune disease and primary billiary cirrhosis
Radiological investigation including liver and gallbladder ultrasound.

B
Most likely diagnosis is cholestasis of pregnancy. Symptoms would be suggestive of cholestasis of pregnancy which is worse at night and during cold weather also associated with dark urine and pale stools and jaundice might be noticed. however other skin causes of itching should be excluded, cholestasis is associated with elevated liver enzymes, bile salts however other causes of elevated LFT should be excluded. Cholestasis is primarily a diagnosis of exclusion and careful inspection of the skin and any identifiable skin lesion to rule out other conditions like polymorphic eruptions of pregnancy where the itching is associated with rash, papules and plaques distributed in the abdomen, with umbilical sparing, thighs, buttocks , breasts and upper arms.
Other skin conditions like pemphigoid gestationis which is associated with vesicles. Prurigo of pregnancy which shows mainly red/brown excoriation. Pruritic folliculitis of pregnancy can also present with itching.

C.
The condition and its effect on pregnancy and the fetus should be explained to the patient. She should be aware of the increased risk ore preterm delivery both spontaneous and iatrogenic. She should be informed also that the stillbirth rate due to cholestais is equal to that of general population and that there is no conlusive evidence on the increased risk of meconium stained liquor and increased postpartum haemorrhage.
LFT + Bile salts should be monitored weekly with no evidence that abnormal levels will determine the timing of delivery. There is also no robust evidence on the modality of fetal monitoring to prevent fetal death, CTG and ultrasound could be offered however there is no evidence that they can predict fetal death, however abnormal CTG or Umbilical artery Doppler can point out fetal compromise and necessitate delivery which again might not be related to cholestasis.
Mother should be offered symptomatic treatment to relive her itching like topical emollient (calmien lotion), systemic antihistminics might be of help,
S Adenosyl methionine,Ursodeoxycholic acid which acts as a chelating agent for bile acid have been used however there are no evidence of improved itching or safety margin for the fetus but it is still widely used.
Dexamethsone as 10mg daily for 7 days has been tried however should not be used as first line of treatment and women should be informed about adverse effects on fetus.
Vitamin K can be used based on its decreased absoption of steatorrhoea and its role in coagulation factors.
There is no data also to support the trend of early induction of labour at 37 weeks.
Mode of delivery should be planned on obstetric indications, postnatal followup with LFTs measured after 10 days of delivery as spontaneous resolution will confirm the diagnosis of cholestasis. Advice on contraception as oestrogen containing agents should be avoided.
Posted by G. K.
A) Initial assessment entails a thorough history regarding the severity of symptoms,any aggravating or relieving factors.Inquiries should be made about presence of an associated rash.A recent change in the use of toiletries should be inquired about.Also inquire about the symptoms being worse at any particular time of the day or night.Inquire about personal and family history of atopy, any drug allergies and any recent use of any medication.
If the woman is multipapara, she should be asked about occurence of same problem in her last pregnany/pregnancies.Also inquire about family history of similar problems in other female members of the family.
A quick review of her chart will help exclude the possibility of rubella infection. She should also be inquired about any previous history of chickenpox infection.

Examination should be done to rule out any associated skin rash. Palpatio n of fundal height, and a CTG should be carried out for fetal well being.
B) The most likely diagnonsis in this scenario is obstetric cholestasis. It is a diagnosis of exclusion and can be confirmed by ascertaining raised transaminases , raised bilirubin and bile acids after ruling out other causes which can cause similar biochemical abnormalities. For this purpose , a hepatitis serology is carried out to rule out an infectious cause. An autoimmune screen should be done to rule out the possibility of chronic active hepatitis and primary biliary cirrhosis.A liver U/S is done to rule out acute fatty liver of pregnancy. A full blood count and a coagulation screen alongwith urinalysis and B.P measurement is done to rule out PET.

C) Subsequent management aims to relieve symptoms and ensure fetal wellbeing and timely delivery to avoid the potential risk of intrauterine fetal death.
For relief of symptoms topical application ofbland emmollients such as calamine lotion, eqeuous cream in menthol can be used. Antihistamines such as chlorpheniramine can be used to relive itching to some extent.
Other modalities of treatment include cholestyramine which is a bile chelating agent, S adenosylmethionine, rifmpicin and ursodeoxycholic acid have been used with varying degrees of success.
Vit K should be prescribed daily to reduce the risk of haemorrhegic disease of newborn.
Fetal monitoring is done by regular checking of LFTS, regular CTGs according to the unit protocol.Steroids should be prescribed for fetal lung maturity in case of preterm delivery.Other modalities of investigations such as dopplers and regular ultrasounds are not predictive of fetal well being in this situation.Induction of labour can be carried out at around 37 to 38 weeks to avoid the risk of sudden intrauterine fetal death.
During labour continuous electronic fetal monitoring is carried out and liquor checked for the presence of meconium.Caesarian section is for obstetric indications such as the presence of meconium and a pathological CTG. A neonatologist should be present at delivery in case if meconium staining of liquor is present. Cordbloods should be taken after delivery to assess fetal blood PH to rule out fetal acidosis.
Posted by A A.
Part A
There is a need to assess whether it is pregnancy specific cause and if there is associated rash.I will ask about severity of itching, any other body parts involved like abdomen, arms or legs and presence of rash. I will ask about its effect on her quality of life.History of itching in pregnancy in absence of rash might suggest obstetric cholestasis or pruritis gravidarum and will exclude other pregnancy specific causes like polymorphic eruptions of pregnancy,prurigo or pemphigoid gestations.Any previous. History of eczema, contact with allergens like soaps, detergents will indicate cause. skin infestation like scabies and involvement of other family members will indicate cause. History of pale colored stool and dark urine is also suggestive of cholestasis. History of itching in previous pregnancies, antenatal complication and pregnancy outcome because there is a high risk of recurrence of obstetric cholestasis. History of Fever, Jaundice, Malaise, or GIT symptoms for viral Hepatitis. Any drug history and family history of obstetric cholestasis. In examination presence skin trauma due to intense scratching (excoriation) and absence of rash will be suggestive of obstetric cholestasisnot. I will check sclera for Jaundice. In abdominal examination I will check for hepatomegely, hepatic tenderness, SHF, lie / presentation and for fetal heart sound. In investigation I will do FBC for HB level, liver function test (alanine aminotransferase,aspartate aminotransferase,gama glutamyl transferase ,alkaline phosphatise,bilirubin) and serum total bile acids.If these tests are normal but symptoms persist then I will repeat the test weekly. If transaminases levels ara high(use pregnancy specific ranges),to exclude other causes of liver dysfunction I will screen for viral hepatits, A, B, C, E, CMV, Epstein bar. For auto immune hepatitsI will send anti smooth muscle cell Ab and antimitochondrial Ab. CTG for fetal well being. Ultrasonograhy for liver and biliary tract.USG for fetal biometry, amniotic fluid volume and Bio Physical Profile.
Part B
Most likely diagnosis obstetrics cholestasis. It is a diagnosis of exclusion made by excluding other causes of abnormal LFTs like cholithiasis, extra hepatic obstruction by ultrasonography, serum hepetatis screen and auto immune disease of liver. So presence of intense itching in the absence of rash associated with abnormal LFTs with no other obvious cause of abnormal Liver Function will confirm obstetric cholestasis. A previous history of obstetric cholestiasis will strongly suggestive of it.

Part 3
I will explain the diagnosis to the woman that it is pregnancy specific liver disorder which presents with pruritis. I will counsel her concerning metarnal and fetal risk e.g. increased risk of spontaneous and iatrogenic prematurity and still birth. Increased risk of meconium stained liquor,fetal distress, caesarean section and PPH. I will inform her that there are no tests (like CTG, BPP, USG and Doppler Studies) that predicts or prevents adverse outcome. But I will reassure of her that in majority of cases outcome is good. So I will offer her fetal monitoring according to my unit protocol.
For maternal symptoms topical treatment like emollients, antihistamins (Cholorpheniramine) /ursodeoxycholic acid can be given that will provide temporary relief but it will not improve the pregnancy outcome. There is no role of S-adenosylmethonine for the relief of symptoms or improved pregnancy outcome. I will monitor her LFTs weekly. I will start oral water soluble vitamin K according to my unit protocol to minimize hemorrhagic riskof mother and new born. If there is a risk of Iatrogenic or spontaneous premature delivery, I will give two doses of betamethasone 12mg 24 hours apart.Dexamethasone is not used for symptom control.Regarding timing and mode of delivery I will discuss the risk and benefit of early delivery. Elective early delivery results in increased respiratory morbidity compared with later delivery but with an increased risk of still birth after 37 weeks of gestation. Aim is for vaginal delivery and c-section will be for obstetric indication. So I will offer her elective delivery by induction of labour between 37 and 38 weeks of gestation and explanation that it is not evidence based. I will provide written information and provide contact details of hospital. Regarding intra partum management provide 1 to 1 care to the woman,continuous electronic fetal heart rate monitoring to detect fetal distress and timely delivery . Then early anesthetic review if emergency section is required. Regional analgesia can be offered in consultation with anesthetist if clotting profile is normal. I will send blood for FBC, group and save and clotting profile.Save IV line as there is risk of PPH.. Neonetologist should be present at the time of delivery to assess the baby. Then active management of third stage of labour should be done. Baby should be given IM vitamine K.


Posted by SUNDAY A.
a) This would incude taking a full history about the onset, severity, duration of the itching, any associated rash in any part of the body, excoriation, previous history of itching, any relieving or aggravating factors, yelowness of the eyes(sclera) etc, drug use, history of any medication used to relieve symptoms, relevant past medical history. I would also ask about any reduction in fetal movement.
I would then proceed to a general examination, checking for jaundice, pallor, pulse rate. A quick cardiovascular and respiratory examination should be done and thereafter i would palpate the
abdomen -check the fundal height, presentation, listen to fetal heart and abnormality would necesitate request for growth scan, liquor volume and umbilical artery velocimetry. I would also check for any rash and skin lesion particularly on the abdomen and back as well as the hands & feet.

b) the most likely diagosis is Obstetric cholestasis and since the diagnosis is infact that of exclusion i would confirm the diagnosis with elevated bile acids, +/- deranged liver function test - AST or ALT in the absence of any other liver patholgy.

c)The unit protocol should be followed and this would include relieve of symptoms with antipruritic agent like piriton, emolients can also be used. The use of ursodeoxycholic acid ( UDCA) would be discussed with the patient if symptoms are severe and bile acids markedly elevated but would inform the patient that its not licenced for use in pregnancy.
Regular monitoring of fetal movement is required with particular attention to fetal movement and i would ensure patient is followed up regularly in the anrtenatal clinic and offered induction of labour at 38 weeks due to the high risk of still birth beyond this gestation
I would recommend the use of Vitamin K 10mg daily as from 34 weeks to prevent post partum heamorrhage and also Vit k administration for the neonate post delivery.
Intra-partum care would follow as a high risk patient with continous fetal monitoring, and low threshold for intervention for obstetrics reasons as per the protocol.The third stage of labour should be managed actively with syntocinon infusion. The peadiatric team should be alerted after delivery as well.


Posted by SUNDAY A.
a) This would incude taking a full history about the onset, severity, duration of the itching, any associated rash in any part of the body, excoriation, previous history of itching, any relieving or aggravating factors, yelowness of the eyes(sclera) etc, drug use, history of any medication used to relieve symptoms, relevant past medical history. I would also ask about any reduction in fetal movement.
I would then proceed to a general examination, checking for jaundice, pallor, pulse rate. A quick cardiovascular and respiratory examination should be done and thereafter i would palpate the
abdomen -check the fundal height, presentation, listen to fetal heart and abnormality would necesitate request for growth scan, liquor volume and umbilical artery velocimetry. I would also check for any rash and skin lesion particularly on the abdomen and back as well as the hands & feet.

b) the most likely diagosis is Obstetric cholestasis and since the diagnosis is infact that of exclusion i would confirm the diagnosis with elevated bile acids, +/- deranged liver function test - AST or ALT in the absence of any other liver patholgy.

c)The unit protocol should be followed and this would include relieve of symptoms with antipruritic agent like piriton, emolients can also be used. The use of ursodeoxycholic acid ( UDCA) would be discussed with the patient if symptoms are severe and bile acids markedly elevated but would inform the patient that its not licenced for use in pregnancy.
Regular monitoring of fetal movement is required with particular attention to fetal movement and i would ensure patient is followed up regularly in the anrtenatal clinic and offered induction of labour at 38 weeks due to the high risk of still birth beyond this gestation
I would recommend the use of Vitamin K 10mg daily as from 34 weeks to prevent post partum heamorrhage and also Vit k administration for the neonate post delivery.
Intra-partum care would follow as a high risk patient with continous fetal monitoring, and low threshold for intervention for obstetrics reasons as per the protocol.The third stage of labour should be managed actively with syntocinon infusion. The peadiatric team should be alerted after delivery as well.


Posted by A R.
a) I’ll take a complete history about previous similar episodes of itching and if had been present and if occurred when pregnant, or with intake of oral contraceptive pills containing oestrogens, since this will indicate the diagnosis of obstetric cholestasis to me. It is typical to have itchng of the palms and soles in Cholestasis of pregnancy. Also I would rule out other causes of itching which can be due to allergies, by asking her about any food or drug she is using now, hepatitis by finding out a history of exposure to infected persons, other viral infections like ebstein barr virus and toxoplasmosis by asking her she if she had exposure to a cat or a person infected with EBV. Also rule out autoimmune disorders like primary biliary cirrhosis and chronic active hepatitis by a asking if anyone in the family is also similarly affected. I will also ask about dark coloured urine and pale stools to exclude hepatitis.
In the examination, I would look for jaundice, pallor, scratch marks, Hepato-splenomegaly, dilated veins on the abdomen…

I would order the basic investigations like full blood count, MSSU, liver function tests to look for elevated levels of AST, ALT, GGT and Bilirubin. Increased bile acid levels have to be looked for as they are also seen in Obstetric Cholestasis. I will check for coagulation profile as cholestasis has shown to cause vitamin K deficient coagulation disorders. An ultrasound examination to look for bile stones eventhough the presence of tem donot necessarily indicate obstruction.




b. Obstetric Cholestasis is a diagnosis of exclusion. In the post partum period the recovery would be very fast, therefore the repeat investigations have to be done 10 days post partum and not before as normal post partum LFT’s tend to go up.
Symptoms like itching mainly over the palm and soles…pregnancy or during a oestrogenized state like on oestrogen replacement therapy or on combned oral contraceptive pills. Signs and symptoms go away once the oestrogens are removed from the body.

Elevated LFT’s which are elevated from the normal for the pregnant population. Also there can be increased bile acids in the blood. Screen for hepatitis and Toxoplasmosis and Epstein Barr Viruses. Exclude autoimmune disorders like chronic active hepatitis by checking for anti smooth muscle antibodies and primary biliary cirrhosis by excluding anti mitochondrial antibodies in the blood.

c. Ideally follow up should start intensely from 32 weeks of pregnancy onwards to achieve a healthy and viable baby and a healthy mother.
Delivery should be planned for 37-38 weeks with twice weekly CTG’s weekly umbilical artery Doppler assessment and twice monthly assessment for foetal growth and liquor quantity.
Even with all these assessments it cannot be guaranteed that the baby will not have any issues at birth as the assessment systems are not reliable in obstetric cholestasis.

There is also suggestion that amniocentesis is done for meconium assessment as there is a high chance of having meconium stained liquor at birth. There is also a higher risk of perinatal morbidity and mortality in obstetric cholestasis.

Simultaneously the mother is monitored for coagulation defects and disorders in the LFT’s and supplemented with vitamin K 10 mg daily to prevent bleeding during delivery.

If she is itching uncontrollably I wuld offer her antihistamine to give her relief. She can also be offered ursodeoxycholicacid, which has shown to reduce the bile acid levels and in turn the itching. Some have tried using cholestiramne too.

If the mother and baby continue to be well, then labour is planned to be induced at 37-38 weeks of pregnancy with blood grouped and saved.
Once the baby is born it should be given vitamin K to prevent bleeding problems.

The woman should be advised against any oestrogen supplementation in the future as this can bring about the signs and symptoms again. She should be offered a progesterone only contraceptive is she needs one.

She would also be told that in future pregnancies she could expect to be affected again.



Posted by SA M.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

(a) I will take the detailed history of her itching, its severity, site ,association with any rash and interfering with sleep. Any previous history of eczema, atopy,allergy, any skin problem. Iwill enquire about the colour of urine, stetorrhoea and pale stools as it indicates cholestasis.
Any history of recent travelling,fever ,nausea or vomiting,anorexia,pain in epigastrium and yellowish discolouration of eyes and skin may indicate viral hepatitis.Any previous liver disease, drug abuse or alcohol abuse may point towards chronic liver problem. Personal and family history of cholestasis and itching while taking OCP is strongly suggestive of cholestasis of pregnancy.I will ask her LMP and confirm the dates with previous scans as it is important in case of premature delivery.
In general examination I will check her pulse,bloodpressure, temperature, jaundice, any rash, striae. I will look for any scratch marks,features of polymorphic eruption of pregnancy, pemphigoid gestationis and scabies. On abdominal palpation any tenderness in right hypochondrium and any liver enlargement should be noticed. Height of fundus and fetal heart should be checked.

(b) The most likely diagnosis is Obstetric Cholestasis. This is a diagnosis of exclusion and it usually presents in third trimester of pregnancy. Liver functions should be done and it should be kept in mind that upper limit of LFT\'s during normal pregnancy is 20% lower than non-pregnant women and pregnancy specific values should be used to interpret the results. There is 2-4 fold increase in serum transaminase level, Gamma Glutamyl Transferase are also elevated, serum bilirubin is mildly increased, alkaline phosphatase can also be above normal pregnancy values. Total bile acids increased upto 10-100 folds. Sometimes the LFT\'s may take time to rise though the pruritis is present so the LFT\'s should be checked weekly. Hepatitis serology for hepatitis A,B, C, CMV and EBV should be checked. Autoimmune liver disease is to be excluded by doing Anti-smooth muscle antibodies for chronic hepatitis and anti-mitochondrial antibodies for Primary Biliary Cirrhosis.
Ultrasound to exclude gallstones should be done although the presence of gallstones does not mean that cholestasis is due to this reason. In atypical or early cases it should be differentiated from Pre-ecclampsic toxemia and fatty liver.

(c) There is maternal risk of PPH due to deficiency of Vit. K dependant clotting factors as there is disruption of Vit. K absorption. Fetal risks include iatrogenic and spontaneous prematurity, IUD, increased risk of intracranial hemorrhage, ante and intrapartum fetal distress and meconium stained liquor. Counselling is very important and should be individualised regarding these risks and that there is no method which can prevent or predict the stillbirth which is due to acute anoxia.There is no treatment to improve fetal outcome. Problems of prematurity should also be discussed.
In mother, weekly and clotting screen should be done to see the progress of disease. Treatment is needed to reduce the maternal morbidity due to severe itching. Antihistamines like promethazine, chlorphrenamine is commonly used but its efficacy is not proven and causes drowsiness. Emolients and water based cream with menthol are also widely used but efficacy is unknown. Ursodeoxycholic acid (UDCA) though not licensed for use in pregnancy but it is used widely during pregnacy as there is no evidence of any adverse effect. It improves LFTs and clinical condition of patient but its efficacy for preventing stillbirth and safety for neonate and fetus is unproven. Oral Vit. K (water soluble form) should be given to the mother from 32 weeks of pregnancy to prevent PPH and fetal/neonatal bleeding. Cholestyramine is a bile acid chelating agent, may improve pruritis but it is poorly tolerated and also exacerbates vit. K deficiency so it is not used.
S-adenosyl methionine is not effective for the control of maternal symptoms and for improving fetal outcome and needs IV infusion so not acceptable to the women.
Dexamethasone should not be the first line treatment for cholestasis of pregnancy but can be given for fetal lung maturity if premature delivery is anticipated.
Though there is no method to predict the IUD but regular fetal growth scans, dopplers, CTGs should be done. The woman should be counselled that the risk of fetal death is equivalent to the general population.
There is insufficient data to support that early induction of labour at 37 weeks is of benefit in reducing the IUD so the timing of the early delivery and risk to the baby due to increased respiratory morbidity should be discussed with the mother.
During labour, there should be a continous fetal monitoring as increased risk of fetal distress and may lead to emergency ceasarean section. After delivery, Vit. K should be given to the neonate to prevent haemorrhage.
Posted by PAUL A.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

(a) I would obtain as more detailed history of her symptoms such as any precipitating or relieving factors for the itch, whether she has had itching before(pre-pregnancy and during this pregnancy), any associated rash or lesions, as well as their location, whether she feels generally unwell (eg, nausea and vomiting) (1) . I would also find out if she has had any problems antenatally like what? In practice, open questions are valuable but in the exam, there are no marks for such a non-specific history , and ask about her previous pregnancies (such as history of obstetric cholestsis- as there\'s an increased risk of obstetric cholestasis with past history of it (1) ). Past medical history should include any potential causes of itching like what? or deranged liver function, such as hepatitis infection. I would ask about her taking drugs that may impair liver function, including alcohol and illicit drugs.

On examination, I would assess her general wellbeing, in particular looking for signs of jaundice and rash or lesions (1) , as well as the location and nature of the rash/lesion (eg. macular/papular/disseminated/localised). I would also ascertain fetal wellbeing by performing a cardiotocograph(CTG). would you check BP and dipstix urine?

Initial blood tests should include liver function tests(LFT), and infection screens (eg hepatitis B & C screen) as well as autoimmune screens do you do these as ‘initial’ tests in a woman presenting with itching? . I would also arrange an ultrasound of her liver to check for cirrhosis and signs of a blocked bile duct as initial investigation?? .

(b) The most likely diagnosis is obstetric cholestasis (OC). The itching, which is intense and worse at night, is usually not associated with any rash, and is accompanied by deranged liver function (1) , characterised by an increase in bile acid level. No other causes for abnormal liver function is usually found (1) .

(c) I would explain to her what OC is, as well as its associated risk of increased stillbirth rate is this increased in treated cases? and give her written information to back up my counselling is stillbirth the only risk? . I would prescribe her piriton (antihistamine) for symptomatic relief of her itch. It is safe for use in pregnancy and may help her sleep better at night, however does not help in a proportion of women. Calamine lotion is topical, but found to be unhelpful in most women. Ursodeoxycholic acid has not shown much benefit in terms of improved fetal outcome, and does not improve itching if it does not improve itching and does not alter outcome, why is it the most widely used drug? Have any of the drugs that you will prescribe been shown to be effective? . Vitamin K may help reduce the risk of maternal and fetal bleeding ( which is raised in patients with obstetric cholestasis), and should be offered to the patient how / when? .
I would arrange for weekly LFT (1) to monitor for the decline in her liver function as well as weekly CTG to monitor the wellbeing of her fetus ? value . Although early delivery has not been proven to significantly reduce the rate of stillbirth, most units would attempt to delivery these women before her due date. I would check the protocol in her unit, and follow it (1) . The anaesthetist should be informed of her admission with labour.
Intrapartum, I would monitor the fetus with continuous CTG monitoring (1) . Her LFT, clotting studies and platelets should be checked and measures taken to try reduce her risk of post partum haemorrhage (which is increased in OC) - such as active management of 3rd stage of labour (1) . Epidural and spinal might not be suitable if her clotting is abnormal, as there is an increased risk of haematoma.
Posted by PAUL A.
A/ Describe your initial assessment of the patient [7 marks].

I would first ask her whether the itching is associated with a rash. Also whether anyone else is complaining of itching in her family and whether she has come into contact with anyone with an infection for example, chickenpox or measles. I would find out whether she has had chickenpox or measles in the past as well do these conditions present with itching? . I would ask her about any previous pregnancies and whether she had similar symptoms in these pregnancies and whether she was diagnosed with obstetric cholestasis (OC) (1) as this has a high recurrence rate in future pregnancies. I would ask if any members of her family suffered from OC in their pregnancies as OC has a higher incidence in relatives of OC patients. I would also ask whether her baby has been moving adequately as per normal. I would ask whether she has any history of liver problems and how much alcohol she drinks or has drunk in the past. I would ask whether her urine is dark and whether her stools are pale (1) . Finally, I would ask about any allergies and whether she has come into contact with any substances she is known to be allergic to (1) .
I would examine her abdomen and check that the symphysio-fundal height is adequate for her gestation. I would look for any signs of jaundice or a rash (1) on her body. I would check her hepatitis B and C status is this doing a blood test or looking in her notes? . I would also check her blood pressure, pulse, temperature and dip her urine it is not clear that you recognise the specific need to exclude pre-eclampsia as a potential cause of abnormal LFTs as well as performing a cardiotocograph. would you do any investigations?

B/ State the most likely diagnosis and how you would confirm the diagnosis [3 marks].

The most likely diagnosis is obstetric cholestasis (OC) and I would confirm this by performing blood tests. I would check her bile acids and liver function tests, specifically looking for elevation of aspartate transaminase and hyperbilirubinaemia NO – raised bile acids Sometimes, a high alkaline phosphatase can also be present. I would not, however, rule out a diagnosis of OC if the bile acids and liver function tests are normal as sometimes, symptoms can precede abnormalites in biochemistry, so I would repeat the blood tests in a week (1) .

C/ Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

I would explain the condition of obstetric cholestasis to the patient and the need for close maternal and fetal monitoring. I would arrange for the patient to be seen every two weeks in the antenatal clinic better seen in the day assessment unit with two-weekly weekly liver function tests carried out. Also, I would explain that we would need to review the patient in the fetal assessment unit where a cardiotocograph, as well as blood pressure monitoring will be carried out two to three times a week If you are that worried, she should be an in-patient! . I would also ask her to attend the hospital as soon as possible if she complains of reduced fetal movements at any time. I would also organize a scan of the baby every four weeks to check for fetal wellbeing with doppler assessment if there was any suspicion of growth retardation if you think a fetus is growth RESTRICTED, will you do scans and Dopplers every 4 weeks? . I would explain to the patient that there is a risk of stillbirth ? is risk increased in treated cases? with OC and that the severity of the disease does not correlate with the biochemistry or severity of the symptoms. I would also start her on ursodeoxycholic acid from 32 weeks she presents at 30 weeks – what is the reason for waiting 2 weeks before treatment? and also give her emollients for symptom control and anti-histamines, for example, chlorpheniramine, but I would explain this may make her drowsy. I would also explain the need for Vitamin K from 36 weeks gestation as her liver may not be producing enough clotting factors how would you administer vitamin K? . I would also explain she has a higher risk of haemorrhage including post-partum haemorrhage. I would give her written information of all of this. I would plan to induce her between 37 and 38 weeks gestation (1) as long as there were no other contraindications to a vaginal delivery. I would explain that this would be a high-risk induction and this should be perfomed on the delivery suite during daylight hours do you / should you be starting any inductions at night? . I would make sure that there was continuous fetal monitoring during labour (1) . I would also explain the risk of a post-partum haemorrhage and recommend an active third stage of labour (1) with a low threshold for a syntocinon infusion post-partum. I would inform the paediatricians when this patient was in labour as they would be needed to check the baby check for what? post delivery.

Please refer to RCOG guidelines on OC
Posted by PAUL A.
Shalini
a)A detailed history of the itching should be taken to include the frequency(increased at night), exclusion of palms n soles ,and sleep disturbance due to itchingwhich would be suggestive of obstetric cholestasis are you suggesting itching from obstetric cholestasis excludes palms & soles? .Any indigestion or pain abdomen should be asked for to rule out gall stones as a cause.Also history of previous pregnancis should be noted as obstetric cholestasis recurs (1) in subsequent pregnancies as also with the use of OCPs which should be asked also.Any history of fever ,loss of appetite, jaundice or deeply yellow urine pale stools should be asked to rule out hepatitis.On examination any pruritc papules or rashes (1) should be looked for to rule out prurigo of pregnancy and any vesicular lesions that itch could be pemphigoid gestationis.Systematic examination should look for hepatomegaly which would be suggestive of hepatitis will you check BP and dipstix urine? Will you do any investigations? .
b)Most likely diagnosis is obstetric cholestasis.Since it is a diagnosis of exclusion it is important to rule out hepatitis due to Hepatitis A,B,C,HIV,Ebstein barr virus,CMV,by serological investigations when women attend your hospital with itching, do you do all these tests before diagnosing OC? .Ultrasound abdomen should be done to rule out gall stones and acute faty liver of pregnancy do you do this in your hospital? .Blood investigations include liver enzymes,urea,electrolytes,bile acids,y-glutamyl transferase,coagulogram. Also normal liver enzymes and raised bile acids alongwith raised gamma glutamyl tranferase is this not a liver enzyme? are suggestive of obstetric cholestasis.Elevated liver enzymes would point towards hepatitis This is incorrect .Coagulation studies are important as coagulopathy complicates obstetric cholestasis and needs urgent correction.
c)It is important to explain the diagnosis to the patient and her partner and the risk of meconium stained liquor,prematurity,still-birth and postpartum hemorrhage preterm delivery is the only risk that is definitely increased that might require blood transfusion.also the risk of it recurring with subsequent pregnancy and with the use of OCPs.She should be booked for delivery in a consultant led unit.Herfull blood count liver enzymes.bile acids and coagulation studies should be monitered every 2 weeks weekly to look for any deterioration.There is no consensus on the most appropriate method of fetal monitoring to predict fetal jeopardy and thus CTG after 36 weeks should be done weekly (1) follow unit guidelines.Vitamin K orally should be started from when? to prevent hemorrhagic complications in both mother and fetus.Group and save should be kept with blood in hand what does this mean? Group & save OR cross match? when the lady goes in labour and continous CTG (1) should be done in active labour.Although there is no consensus whether labour should be induced at 37 weeks to prevent still birth many prefer it WHAT WILL YOU DO?? .Obsttri cholestasis is not an indication for cesarean section. Difficult vaginal deliveries should be avoided are there any circumstances where difficult vaginal deliveries should be done? and neonatologist should attend delivery.Any evidence of fetal distress or meconium stained liquor in early labour necessitate cesarean section why should your threshold for intervention be any different? Are you going to classify CTGs differently? If so, which guidelines will you use? Active management of third stage (1) should be done to decrase blood loss.Liver function studies should be repeated after 10 days of delivery not asked about post-natal care when they normalise as they rise physiologically after delivery.other causes should be loked for if the liver fubction studies are not normal by 10 days.
Posted by PAUL A.
A) I would ask of nature,severity and effect on quality of life (1) of the itch ,making her not able to sleep.Will ask of sites of itch eg more on soles and palms.Will ask if there is an associated rash (1) and its distribution.Did she notice any change in colour of urine and stools (1) pale stools.Will ask if she has any allergies and if she took any medications in the past 3 days why 3 days? .
On examination will measure temp(fever may be hepatitis)
,pulse blood pressure, look for rash distinguishing it from exoriations (1) and will see distribution of rash(umbilical sparing in polymorphic eruption of pregnancy).Look for jaundice and see if there is tenderness in right hypochondrium. will you dipstix urine? Will you do any blood tests?


B)Most likely diagnosis inn absence of rash is obstetric cholestasis(OC), but it is a diagnosis of execlusion ,need to exclude chronic forms of virus hepatitis (1) .In presense of rash dermatological conditions of pregnancy eg herpes gestations,prurigo of pregn or polymorphic eruption of pregnancy.
To confirm I do liver function tests(LFT) and serum bile acids, if normal will repeate weekly (1) .Liver scan in OC is normal. If LFT high do you expect LFTs to be normal in OC? do antimitochondrial antibody and anti DNA tests to exclude chronic forms of viral hepatitis.

B) Management should be by a multidisciplinary team composed of consultant obstetrician, internal medicine physician, if needed dermatologist why are they needed? , midwife and neonatologist in addition to primary care team.Management should follow local guidelines and protocols.I would explain the situation to her and give her information sheet according to her final diagnosis. If diagnosed as OC I would explain that the management will be supportive alleviating symptoms but there are risks to her fetus including being born early,liability to develop distress ,the liquor might stain with meconium and risk of hemorrhage in fetal brain and death prematurity is the only risk that is definitely increased .Close monitoring will be done, but this would not easily detect the problem.Itching is managed by antihistaminics and ursodeoxycholic acid but these has no effect on outcome (1) .Water soluble vit K is given orally from what gestation age? to overcome the decrease in its absorption and so reduced clotting factors.Early delivery at 37WK is usually the role but the RCOG say that there is no evidence to support this so what will you do? That is what the examiner wants to know . Blood for FBC,group and save , Continuous electronic fetal (1) monitoring ,proper analgesia and securing an IV line for fear of post partum hemorrhage (this is theoretical) should be done intrapartum for this high risk patient. Neonatologist should be available. Active management of third stage (1) . Baby given intramuscular vit K.
If the diagnosis is a dermatological condition ,she is to be seen by the dermatologist, given symptomatic treatment and close monitoring of fetus antenatally and intrapartum in case of herpes gestations when you find yourself beginning with: If the diagnosis is ….you should know that you are unlikely to get any marks. There are a number of other conditions that the woman could have and you are not expected to go through all of them. The question makes what is required very clear .

If diagnose virus hepatitis this should be treated in conjunction with infectious disease physician and care during labour to attendants from needle stick injuries and avoid invasive procedures during labour to avoid vertical trannsmisiob to the baby. Consider active and passive immunization to fetus
Posted by PAUL A.
a. A brief history Why the rush? Why can you not take a detailed rather than a brief history? looking at the onset of itching, whether her symptom is getting worse and what makes it better or worse. I will ask about involvement of other parts of her body and if there are any skin rashes (1) . Patient will be asked about other symptoms such as fatigue, increased nausea, decrease in appetite, upper right quadrant pain, jaundice, darkening of her urine, pale stools (1) and pain in her joints. A history of blood transfusion, liver disease and any drug use is important. I will ask about previous pregnancies, previous history of pruritus (1) specifically obstetric cholestasis in these pregnancies and their outcome. Is there any family history of similar complaints? And lastly, I will ask about adequacy of fetal movements. During examination, I will look for patient’s general wellbeing, jaundice and any rash of scratch marks (1) . I will assess symphysio-fundal height and confirm fetal viability ? BP / proteinuria – if LFTs are abnormal, how do you know she has not got pre-eclampsia? Will you do any investigations? .
b. The most likely diagnosis is obstetric cholestasis. The diagnosis is by exclusion of other possible causes (1) and resolution of symptoms within 8 weeks postpartum. These include preeclampsia you did not check BP , the HELLP syndrome, and acute fatty liver of pregnancy how do you exclude these? . Furthermore, other causes of hepatitis, like hepatitis viruses and certain medications, should also be considered. Hence, I will take blood for liver function tests, serum bile acid, clotting screen and hepatitis panel do you do hepatitis screen in all your patients before confirming a diagnosis of OC? . Normal liver function tests , negative hepatitis panel and a raised serum bile acids in the presence of itching without rash localised to the abdomen, legs, palms, and soles, but can be generalized, will almost be diagnostic of obstetric cholestasis NO, liver enzymes are usually mildly elevated .
c. I will have a full discussion with patient concerning the diagnosis and the implication such as risks of preterm delivery, fetal distress and small risks of intrauterine fetal death preterm del is the only risk that is definitely increased . I will start her on antihistamine such as chlorpheniramine 4mg thrice daily to combat itching and ursodeoxycholic acid to reduce serum bile acids (1) . I will request twice weekly cardiotocography to monitor fetal wellbeing. Patient will be referred to consultant-led antenatal clinic for the entirety of the pregnancy fortnightly. I will repeat serum bile acids, liver function tests and clotting screen every two weeks weekly . Patient will be delivered at 37 weeks (1) either by induction of labour or by caesarean section if indicated. Patient will be monitored by continuous fetal cardiotocography (1) throughout her labour and delivery. Patient will be given a leaflet detailing the diagnosis, risks and implication for future pregnancies.
Posted by H H.
Please Paul, In the initial assessment do we include in addition to history and examination, investigations. When should we include it and when not, much obliged
Posted by PAUL A.
(a) We need to ask history about the symptoms of itchiness, location. We should also ask her about any precipitating factors that might cause allergic reaction (1) - eg recent change of soap or washing detergent , consumption of new drugs or food eg shellfish, presence of mites or mosquito bites. She should also be asked if there is anyone in family with similar symptoms. She should also be asked about symptoms of vomiting, lethargy pale stools, dark urine (1) & signs of jaundice and upper abdominal pain is this a symptom or a sign? . She should also be asked if foetal movement has been active.

On examination she should be checked for signs of jaundice, area of itchiness, any signs of rashes (1) around that region of itchiness & record the type of rashes and location. CTG should be commenced to assess fetal well being ? BP & abdominal examination .

She should have bloods taken for FBC (to assess platelet level), LFT, bile acids. Pregnancy serum level should be used (1) ? urine dipstix . If LFT is deranged (eg raised bilirubin or ALT), other causes of liver diseases need to be excluded. Therefore hepatitis screen (Hep B & C, CMV & Ebstein Barr virus) & autoantibodies (anti-smooth muscle Ab & anti-mitochondrial Ab for chronic active hepatitis & primary biliary cirrhosis) need to be excluded (1) do you do these tests in all women before diagnosing OC?.

(b) Obstetric cholestasis is the likely diagnosis. It is a diagnosis of exclusion (1) where there is symptoms of itchiness during pregnancy, absence of rashes, LFT is deranged +/- raised bile acids using pregnancy reference level.

(c) She should be counselled that in the past women with obstetric cholestasis were offered induction of labour at 37/38 to prevent still birth what is the point in telling her what happened in the past? . However there is no strong evidence about association of OC & stillbirth so what is your current approach? Allow her to go to term / post-dates?? . In addition there is no method of fetal monitoring - eg USS or CTG that can predict the outcome of fetus in order to prevent still birth (1) . In addition there is no correlation between level of deranged LFT or bile acids & fetal outcome. She should be counselled that there is a risk of spontaneous & iatrogenic preterm birth are there any other possible risks? .
Antenatally she should have FBC, liver function & bile acids monitored weekly (1) . She can be offered topical emollients (eg calamine lotion or aqeous cream with methol) or ursodeoxchoic acid to relieve symptoms of itchiness although efficancy is uncertain (1) . She can also be offered anti-histamine. From 36/40 onwards, she should be advised to take oral vitamin K 10mg od as she is at risk of vitamin K malabsorption (1) water soluble .

She should have continuous CTG monitoring (1) during delivery. FBC & clotting & G&S should be checked. Evidence about risk of PPH or meconium is uncertain. Baby should receive vitamin K injection to reduce risk of haemorrhagic disease of newborn.
Posted by PAUL A.
History of the presenting symptoms, when the itching is worse, day or night.Associated skin rash (1) . I would ask about medication which may cause allergic reaction (1) . Colour of her urine, pale stool (1) to exclude jaundice. Any history of fever as in infection like hepatitis. Associated headache, visual disturbance or epigastirc pain in pre-eclampsia.If she is multiparous, I would ask about previous history of obstetric cholestasis (1) , mode of deliveries. Previous history of itching with oral contraception.
Examination would include blood pressure measurement to exclude pre-eclampsia (1) ? urine dipstix , temperature to exclude infection. I would inspect her body for skin rash (1) . Abdominal examination for palpable liver. Fundal height and fetal heart rate. will you do any investigations?
B/
Obstetric Cholestasis is the most likely diagnosis. I would perform the following investigations to confirm the diagnosis and rule out differentials.
Liver function test, most especially transaminases (1) , if they abnormally raised can they be normally raised?? , the diagnosis is likely Obstetric Cholestasis with normal blood pressure.. At the initial stage Liver function test may be normal, therefore, I would repeat the test in a week (1) .
Blie acid would also be requested, normal result does not exclude the diagnosis, but high level confirm the diagnosis. Antimitochondria antibody and anti smooth muscle antibody to exclude Chronic active hepatitis and primary liver cirrhosis
Ful Blood count, white blood cell count and CRP to exclude infection. I would request screening for hepatitis A, B and C. Liver ultrasound scan to exclude liver pathology
do you do these tests in all women before making a diagnosis of OC? .
C/
I would counsel the woman, inform her the diagnosis and the management plan. I would inform her that no medication can completely cure her but they may relief her of the symptoms. Definitive cure is delivery at the appropriate time agreed with the woman involvement. Oral antihistamine like piriton can improve her sleep in the night . Topical cream to reduce itching. Ursodeoxycholic acid is not license for use in pregnancy but it is a chelating agent to mop up the bile acid (1) What will this achieve?..
Oral Vitamin K 10-20mg daily would be prescribed to reduce the risk of maternal and neonatal bleeding water soluble. From what gestation age? . Steroid would be giving if there is possibility of premature delivery.
Fetal assessment in Day care weekly, by doing CTG, ultrasound scan for liqour volume and Doppler. I would inform her that the assessment can not reliably predict fetal outcome (1) . Weekly Liver function test (1) .
To reduce the risk of intrauterine death, meconium stain liqour and birth aspyxia, I would aim for delivery around 37-38weeks gestation (1) . Vaginal delivery except for obstetric indication for caesarean section. The woman would be involved in decision making.
Written information leaflet would be provided to enable her make well informed decision. Clear management plan in her notes. WHAT ABOUT INTRA-PARTUM CARE??? I would follow unit protocol in her management. Im vitamin K to baby after delivery. Discussion about future occurence and she should avoid oestrogen containing contraception THIS IS POST-NATAL CARE .
Posted by PAUL A.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]




a) My initial assessment would include history in detail about intensity of itching , association with rash (1) or pruritic lesions, itching at other sites. I would also like to know if she has known allergies to certain substances & exposure to allergens (1) . If associated vomiting, fever, malaise to rule out acute hepatitis. Her gravidity , parity, pregnancy outcome is important as far as obstetric history is concerned. If she had similar history of itching during previous pregnancies (1) because of risk of recurrence of OC or h/o jaundice . If pruritus, jaundice & / or unexplained stillbirth goes in favour of cholestatic jaundice or cholestasis of pregnancy. I would also like to know associated medical illnesses like hypertension, diabetes, skin disorder, liver disease. Examination include BMI, general conditions of patient like pulse rate, B.P, yellowish discoloration of sclera to rule out or confirm jaundice (1) . Uterine height to see fetal growth, lie , presentation . auscultation of FHS. At 30 weeks of gestation palpation for hepatomegaly will be difficult. General examination of hands & legs to see any lesions apart from scratch marks (1) . Bullous lesions around umbilicus extending down to legs is suggestive of pemphigoid of pregnancy.
b) The most likely diagnosis in this case would be cholestasis of pregnancy as it is common in third trimester. The condition is associated with itching starting on hands & legs (1) . Ethnicity is also important so why did you not mention it in your Hx or examination? as women from Asia & Scandinavians have more predisposition to gety cholestasis of pregnancy. For diagnosis- previous h/o cholestasis in pregnancy, h/o cholestasis associated with combined oral contraceptive pills is also important you are repeating your Hx . Liver Function tests may give clue but are not diagnostic. In this condition bile acids are increased. Liver enzymes can also be raised, usually serum bilirubin is within normal limit you have not recognised that this is a diagnosis of exclusion .
c) Subsequent antenatal management include regular antenatal visits is this every week or every 8 weeks? to see the progress & severity of the condition. Regular liver function tests see above – if you write this in the notes, how will anyone know how often you want the tests done? , FBC, U& E, Coagulation screen. Asking the patient to keep record of daily fetal movements kick charts are not of value and simply cause anxiety . Doing serial growth scans how often is serial?? , CTG, assessment of amniotic fluid as this condition is associated with more risk of developing stillbirth. Reassuring the patient & telling her that most of the time the course is selflimiting apart from itching it will not cause other untoward complications. But risk of preterm Labour , prematurity, stillbirth is increased not increased in treated cases . There is also more risk of developing postpartum haemorrhage. For itching , local application of emollients is helpful . Oral antihistaminic also help to relieve intense pruritus . There are few studies mentioning use of Ursodeoxycholic acid to correct biochemical abnormality associated with cholestasis . but outcome is not improved with ursodeoxycholic acid & more studies are needed so will you use it? Are you suggesting there is better evidence in support of the use of antihistamines / emollients? . Corticosteroids are also used , but risk of worsening of diabetes if associated – should be taken into account . Longterm use of steroids may have effect on growing fetus & development of growth restriction should be considered. If condition is not severe , delivery at term is indicated how do you measure severity and what is the relationship between such measures of severity and outcome that justify this statement? . Id deranged liver functions , early induction of labour at 37- 38 weeks is mandatory what is the evidence that makes this mandatory? . Patient should be provided with written information about the condition. During labour continuous CTG (1) , as fetal distress is a possibility. Routine investigations like FBC, U& E, & coagulation screen as possibility of bleeding Group & save as risk of postpartum haemorrhage. Presence of neonatologist during labour for management of neonatal complications.

SEE RCOG GUIDELINES ON OC
Posted by PAUL A.
(A) History should be obtained about the characteristic of itching as generalised itching may indicate dermatological conditions or skin manifestation.History of rash (1) could be due to allergy.Information should be obtained about severity of itching affecting her quality of life such as sleeplessness (1) .Previous pregnancies with similar symptoms should be asked as recurrent risk (1) of obstetrics cholestasis is very high about 90 percent.History of jaundice, fever, pain abdomen specifically in right hypochondrium, dark urine and pale stools (1) should be asked about.Fetal movements should also be inquired.A general physical examination should be carried out scratch marks which indicates severity of itching.Skin examination is carried out for any bleeding, rash (1) and jaundice.An abdominal examination is performed to determine fundal height,hepatomegaly and tenderness..Fetal heart should be checked with CTG (1) will you check BP?? . (B)The most likely diagnosis is obstetric cholestasis, however other dermatological conditions ,skin manifestations and allergy should be ruled out (1) .A liver function test should be performed including bilesalts,,serum bilirubin.transaminases(AST,ALTand alkaline phosphatase).Bile acids may be normal which should be repeated after a week (1) as a normal bile acid does not exlude obstetric choestasis. An ultra sound scan for gallblader stones and fetal wellbeing should be offered.Final confirmation of diagnosis is done by postnatal normalisation of LFT at tenth day. (C) Diagnosis should be explained to the women in a supporting way.Risks should be explained like preterm delivery, fetal distress,meconiumm stained liquor,PPH,fetal intra ventricular hemorrhage and still birth may occur evidence that these risks are increased is weak .But in the majority out come is normal (1) .Tests of fetal wellbeing should be offered according to the unit protocol but these cannot predict or prevent adverse outcome (1) .Vitamin 10 mg orally should be offered to the women to prevent hemorrhagic conditions in mother and fetus water soluble. From what gestation age? .Symptomatic treatment should be offered to the mother like antihistamines and skin lotions like balneum plus.Ursodeoxycholic acid may be effective but not licensed for use in obstetric cholestasis (1) .LFTs,Full blood count and clotting profile is monitored weekly (1) .Induction of labour is offered at 37 weeks according to unit protocol (1) .Information leaflets should be provided and support groups should be offered like British Liver society and obstetric cholestasis support group. For induction of labour membrane sweeping,prostaglandins or oxytocin may be offered according to unit protocol and maternal wishes.Cesarean section is performed for obstetric indication,during labour continous electronic fetal monitoring (1) is offered.Neonatologist should be informed to be present at delivery.Third stage of labour should be managed actively (1) with IM sntometrine.

Good answer
Posted by PAUL A.
I will start by accurate confirmation of the expected date of delivery by asking about timing and result of dating scan if performed, is this pregnancy singleton or multiple pregnancy You should accept the gestation age given in the question and assume that it is a singleton pregnancy unless indicated otherwise in the question. Otherwise you will have to write this in every obstetric essay (obstetric cholestasis more common in multiple). History of obstetric cholestasis in previous pregnancies (1) (almost 90% risk of recurrence) and a positive family history (in 35% of cases of obstetric colestasis).History of preterm deliveries or IUFD or still birth.
History of dermatoses, or recent drug intake or exposure to chemicals may denote allergic reaction (1) . Itching of trunk, palms and soles often worst at night, insomnia and fatigue. Anorexia, malaise, epigastric discomfort, steatorrhoea and dark urine (1) usually indicate obstetric cholestasis. Also I will enquire about the adequacy of fetal movements.

General examination should include blood pressure, pulse, temperature and presence of jaundice (1) . The abdomen should be examined to look for scratch marks and excoriation to exclude pruritic urticarial papules and plaques of pregnancy (1) , palpate for hepatomegaly, and tender upper quadrant to exclude hepatitis. Also the symphysio-fundal height should be noted, and fetal heart should be checked.


My initial investigations will include ultrasound to assess gestational age at 30 weeks????(-1) , fetal size and fetal well being.
Liver ultrasound to exclude cholelithiasis is this the first test you will do? If not, why write it first? , serology for Hepatitis A,B,C, Epstein Bar virus and cytomegalovirus. Liver autoantibodies to exclude primary biliary cirrhosis. Anti-smooth muscle antibodies to exclude chronic active hepatitis do you do these tests in every woman with suspected OC? YOU HAVE NOT EVEN DONE LFTs!!! .

The most likely diagnosis is obstetric cholestasis. Confirming the diagnosis is based on abnormal liver function tests (1) , abnormalities in transamniasis, gmma glutamyl transferase bilirubin and bile salts are considered sufficient to support diagnosis of obstetric cholestasis but pregnancy-specific ranges should be used. Serum bile acids concentrations are markedly raised (10-100 folds) and may be the only abnormality detected.
Also to confirm the diagnosis I should exclude other causes of itching and liver dysfunction (1) and postnatal resolution of pruritis and liver function tests should be confirmed.

I will counsel the woman for the risks of obstetric cholestasis which includes postpartum hemorrhage (10-20%), preterm labour (both iatrogenic and spontaneous), meconium stained liquor, fetal distress and intrauterine fetal death preterm delivery is the only risk that is definitely increased . And that risk increase toward and beyond term but don’t correlate with symptoms or liver function tests.

Liver functions should be assessed weekly (1) together with clotting time. Vitamin K water soluble 10 mg orally daily should be given from time of diagnosis to decrease the risk of postpartum hemorrhage. Fetal surveillance with regular ultrasound scan and CTG how often is regular? Every other day / every 4 weeks? although can’t reliably predict outcome (1) , normal findings are reassuring.

Control of symptoms may be achieved by antihistaminics and topical emollients, diprobase, Balneum plus and calamine lotion. Ursodeoxycolic acid (UDCA) helps to relieve pruritis and liver function tests however women should be aware that there are insufficient data to support its use (1) .

Delivery should be induced at 37-38 weeks (1) , however there are insufficient data to support or refute that practice. and woman should be counseled about the consequences of iatrogenic delivery including repiratory morbidity versus term delivery with the risk of stillbirth.

Intrapartum continuous fetal monitoring (1) is mandatory should be offered / recommended , as well as checking her clotting times as there is increased risk of postpartum hemorrhage, I will ask for group and save.

NOT ASKED ABOUT POST-NATAL CARE Women should be offered follow up after delivery to ensure resolution of pruritis and that LFTs have returned to normal (test to be done at least 10 days after delivery). Reassure about the lack of long term sequelae for mother and baby. Advise to avoid estrogen containing contraceptives and the increased incidence of recurrence.
Posted by Ron C.
RnRn

A.
On history taking I’ll explore exact onset and nature of complaints, any provoking factors or accompanying rash and contacts with other people having a rash or known to have hepatitis. I’ll ask for changes in colour of stools (light) and urine (dark). Family history or personal history of itch in pregnancy. I’ll enquire regarding problems in previous or current pregnancy, in particular pregnancy induced hypertension and will look at notes for (booking) blood pressure and proteinuria, as well as serology of booking blood. I’ll enquire on headache, visual complaints and fetal movements. On examination I take blood pressure and pulse and dipstick urine for proteinuria. I’ll look for jaundice, oedema and test reflexes. Abdominal assessment includes symphisis-fundal height, assessment of clinical liquor and – though difficult at 30 weeks, palpation and percussion of liver (and epigastric region).

B.
Obstetric cholestasis (OC) is the most likely diagnosis Raised liver enzymes and bile-acids support this, but OC can only be assumed after ruling out other possible causes, especially since symptoms can precede blood changes up to several weeks. To rule out hepatitis serology for hepatitis A-B-C and EBV & CMV is sent, as well as bloods to rule out auto-immune liver disease. Pregnancy induced hypertensive disease (pre-eclampsia, HELLP) is another important disease entity that needs to be ruled out and for which FBC, liver & renal function tests (including urate) and coagulation screen is sent, with urine test for proteinuria.

C.
I’ll explain her that after ruling out other causes, OC will be assumed as a cause. In the past this was thought to lead to higher incidence of IUD and fetal distress, but later research suggests it may not be markedly altered. She will be given neutral cream for skin (diprobase or calamine lotion) and oral piriton 4 mg tds for the itchiness. Ursodeoxycholic acid will improve bile-acids and liver enzymes and can markedly improve itch, but there is currently no good evidence for its use. Liver functions are repeated twice weekly and blood pressure and proteinuria will be checked every visit. Patient will be instructed to report if she develops headache, visual complaints or experiences reduced fetal movements. When there is doubt regarding fetal condition or growth, ultrasound for growth, liquor and Doppler flow is arranged. Unless fetal compromise is suspected, standard early induction is not done anymore, also because majority of reported IUD’s were before 37 weeks anyway. Water-soluble Vitamin K 10 mg od form 36 weeks onwards may reduce potential risk of fetal hemorrhage or post-partum hemorrhage caused by reduced vit K. once in labour it is reasonable to commence continuous fetal monitoring.
Posted by PAUL A.
NSK

From A
I’d enquire re severity, site of her itch and whether it’s progressively worsening. I’d also assess whether it’s worst during the day or nite time. Obstetrics cholestasis(OC) mainly affects the palms and soles of foot. It is worse at nite and can lead to severe sleep deprivation. Other associated symptoms such as presence of jaundice, anorexia, malaise and dark urine (1) are elicited and is associated with OC. Presence of rash (1) is queried. This may be associated with other viral illnesses such as varicella and rubella. Her obstetrics history for previous OC (1) or a family history of this is important. There is an upto 90% risk of recurrence in subsequent preganancies and upto 35% woman have a family of OC. I’d also query recent exposure to other unwell individuals for possibility of CMV, EBV or hepatitis infection. Recent new medication usage is asked to exclude possibility of an allergic reaction (1) .
Examination aims at assessing temperature for pyrexia to exclude a viral illness, blood pressure and urine for proteinuria to exclude PET (1) . The skin is examined for the site of itch and presence of rashes or scratch marks (1) . OC is not associated with rashes, but scratch marks is found. Abdomen is examined for scratch marks, striae which can also cause pruritis in pregnancy. The abdomen should be palpated for fundal height to exclude small for dates and assess liquor volume and fetal lie/presentation. A CTG is done to assess fetal well-being. any investigations?

Fr B:

Most likely diagnosis is OC. A serum liver function test(LFT) for serum transaminase, GGT (elevated), ALP (higher than normal pregnancy range) and bile salts(10-100 times higher) taken. The upper normal limit in pregnancy is 20% lower than the upper normal for non-pregnant woman you have not indicated that this is a diagnosis of exclusion .A clotting screen for PT may be prolonged which is due to vitamin K malabsorption. However a normal LFT and bile salt does not exclude the diagnosis as symptoms may occur for days or weeks before abnormal LFT’s occur. If symptoms persist, weekly LFT’s done (1) .

Fr C:
She should be managed in a multi-disciplinary team approach involving the haematologist, gastroenterologist why? Do you get these specialists involved in the management of women with OC in your hospital? , obstetrician, anaesthetist, gp, midwives and paediatrician. Regular and frequent what is regular & frequent? Every day or every 4 weeks? follow to assess worsening of symptoms and monitor fetus for IUGR or distress is crucial.
The mother and her partner is educated re OC, the complications that can occur such as preterm delivery, stillbirth and obstetrics haemorrhage(20%) evidence that these risks are increased is weak . She should be advised to contact us if fetal movements are felt to be reduced as this can be a sign of fetal compromise. An information leaflet with the contact details in hospital is given.
I would monitor fetal growth and wellbeing by performing 2 weekly growth scans, dopplers and a CTG to detect fetal distress. However, there are no specific test that will predict this (1) . The patients LFT’s, coagulation screen should also be monitored regularly if you wrote this in the notes, will your SHO know how often to do the tests? to assess deterioration. The severities of blood indices do not predict severity of OC, maternal or fetal outcome.
I would start her on ursodeoxycholic acid 600mg Bd is this your normal starting dose? (unlicensed for use in pregnancy). It may help reverse LFT abnormalities but is not proven to improve maternal or fetal outcome (1) . Symptomatic treatment of itch with use of antihistamine, aqueous cream and calamine lotion can be offered. However, it’s efficacy is not proven. Vitamin K 10 mg PO is started from 32/40 water soluble . This aims at providing vit K supplements and reducing the risk of bleeding. A water-soluble based vit K (1) is chosen to avoid the risk of fat malabsorption.
Intrapartum care includes offering IOL at 38/40 (1) to reduce the risk of stillbirth. A c/s is only for obstetrical reasons. Continous CTG (1) should be done in labour for early detection of fetal distress. Active management of 3rd stage (1) helps reduce the risk of postpartum bleeding. The baby should be given IM vitamin k at birth to reduce the risk of bleeding.
Postnatally, I would repeat the LFT’s and bile salts at least 10 days postpartum to ensure resolution and confirm the diagnosis of OC. I’d also counsel her re the risk of recurrence in future pregnancy (upto 90%) and risks to other family members of getting OC. I’d also advise her to avoid COCPs as it can worsen cholestasis. I’d also advise for her to present early for prepregnancy counselling in subsequent pregnancies.
NOT ASKED ABOUT POST-NATAL CARE

thanks paul.
Posted by PAUL A.
M
(a) A history of severity of itching without rash and worse at night may suggest Obstetric cholestasis(OC).
A history of pale stool and dark urine (1) may support likelihood for OC.
A history associated with rash (1) may suggest other causes like pruritic eruptions of pregnancy.
A past history of skin diseases like eczema may suggest a flare up of same.
An allergen history (1) of food, drug or clothing may suggest like cause of itching.
Examination of the skin may show dermatographia artefacta suggestive of artefacts from skin scratching and exclude skin rashes (1) as causes of itching.
A history of fetal movement will suggest viability of pregnancy past Hx of OC, BP & URINE DIPSTIX FOR PROTEINURIA, INVESTIGATIONS .

(b) Most likely diagnosis is Obstetric cholestasis from a history with itching involving palm and hand and without rash.
Biochemical abnormalities of liver function test like transaminase, gamma glutary transferase, bilirubin and bile salts will aid diagnosis of OC.
OC is a diagnosis of exclusion (1) after excluding other causes of abnormal LFT like viral causes like hepatitisB, C, CMV,EBV, autoimmune causes like primary biliary cirrhosis and chronic active hepatitis by blood investigations and ultrasound scan of liver to exclude gall stones (do you do these tests in your hospital before making a diagnosis of OC? .

(c) A full explanation of the condition to the patient with increased likelihood of iatrogenic/spontaneous premature delivery.
Explanation regarding inconclusive evidence regarding increased risk of meconium liquor, caesarean section and post partum haemorrhage (1) .
Risk of unexplained fetal death and no specific monitoring modality to predict (1) the same. Ultrasound is not helful for same this phrase is not in common use in the UK .
A tailored approach of care with patients individual circumstances and degree of symptoms to optimise outcome of care with weekly LFT (1) and CTG monitoring followup with consultant led care
Steroid therapy with betamethosone 12mg 2 doses 24 hours apart to reduce risk with prematurity like RDS are you likely to deliver before 34 weeks because of OC?? ..
water soluble Vitamin K oral therapy from diagnosis and more emphasis if abnormal prothrombin time.
Symptom relief with emollients, chropheniramne maleate may help symptom control but no benefit with fetal outcome.
S-adenosyl methionine and Ursodeoxycholic acid has no robust data to suggest will improve fetal outcome and symptom relief and use discussing this with the patient (1) .
Dexamethasone is not recommended for symptom control and may cause adverse effect.
Recommend induction of labour by 37-38weeks (1) and explanation this is popular practise and not based on robust evidence.
Intrapartum care with continous CTG monitoring (1) as increased risk of fetal distress with OC.
IV access with group and save as increased risk of PPH.
Options for epidural as pain relief as increased risk of caesarean section.
An agreed protocol for management of complications like PPH.
Posted by Maayka ..
maayka


(a) A proper history will be taken to find out if the itching is associated with a rash or not since without a rash it is likely to be obstetric cholestasis (OC) and so other conditions will have to be ruled out. The pruritus may be worse at night . She may have other pre- existing pruritic skin condition which may have flared up e.g eczema , or an allergic type reaction to a new product used – perfumes, lotions . the presence of pale stools and dark urine would strongly suggest OC. A family history of OC or previous OC in an earlier pregnancy would be relevant.
Examination should be aimed at ruling out the other possible causes such as viral hepatitis or pre- eclampsia ( PET). I would look for icterus, ensure the abdomen fundal height is appropriate for gestation age and check fetal heart rate. The vital signs like BP, pulse and a urinalysis for protenuira should rule out pre- eclampsia. Initial blood investigations should include a CBC and LFTs.

(b) OC is the likely cause and it is confirmed by excluding other causes of pruritus and deranged LFTs like PET – by looking at BP, pulse and urinalysis, or other viral infections – especially hepatitis B,C. The latter is checked for looking back at the booking maternal serum for antibodies or checking her serum at that time for antigen levels. LFT performed should reveal elevated transaminases and bile acids.

(c) Antenatal management includes care of the mother foremost who is symptomatic of the pruritus, and the fetus. The women should be told of the nature of the condition and the risks to her and the baby – of the increased incidence of preterm labour and the following being possible - meconium stained liquour, postpartum haemorrhage and unexplained stillbirth.

Maternal symptomatic relief can be provided with topical emollients like calamine lotion and oral chlorpheniramine 4 mg three times daily but be told of the sedative effect. The use of Ursodeoxycholic acid is a bile acid chelating agent and can be started immediately, she would be told that it has not been approved in pregnancy but there is no known teratogenic effect. Vitamin K in the water soluble form, like menadiol 10mg once daily can be started simultaneously to reduce the risk of low production of fat soluble clotting factors – it will reduce the chance of PPH occurring

The fetus should be monitored with weekly CTG and the mother have weekly LFTs. Early delivery would be recommended to prevent the chance of an unexplained stillbirth , and is usually planned between 37- 38 weeks. The hospital policy will need to be checked though on the induction of labour for OC before this planning.
Intrapartum care involves CTG monitoring and active management of 3rd stage to prevent PPH.


Posted by PAUL A.
A.
Initial assessment of the patient should include more detailed history on her itching, timing, severity, precipitating factors, being more at day or night time. Previous itching earlier in pregnancy and family history of cholestasis. History of viral hepatitis, chronic skin condition like eczema, psoriasis (1) ? cholestasis in previous pregnancy . Drug history or allergy or atopy (1) . Asking about urine and stool colour (1) (dark urine, pale stools may point to liver condition). Examination should include general examination looking for signs of jaundice (yellow sclera). Skin inspection of any pruritic lesions identifying papules, macules or vesicles (1) that willa id in differential diagnosis. Abdominal examination may rule out hepatomegaly, right hypochondrial tenderness.
Investigations should be directed to rule out cause of itching and exclude other reasons for abnormal liver enzymes. Investigations should include, Liver functions tests (1) , ALT, Gamma GT, alkaline phosphatase is normally elevated in pregnancy, Bilirubin Direct and total as well as bile salts however pregnancy specific range should be applied as normal pregnancy values is 20% less than non pregnant level
Hepatitis viral markers including Hepatitis A, B, C, Epstein Bar virus, Cytomegalovirus.
Antimitochondrial antibodies and anti smooth muscle antibodies for Liver autoimmune disease and primary billiary cirrhosis
Radiological investigation including liver and gallbladder ultrasound
do you do these in all women presenting with itching? BP & urine dipstix for protein .

B
Most likely diagnosis is cholestasis of pregnancy. Symptoms would be suggestive of cholestasis of pregnancy which is worse at night and during cold weather also associated with dark urine and pale stools and jaundice might be noticed (1) . however other skin causes of itching should be excluded, cholestasis is associated with elevated liver enzymes, bile salts however other causes of elevated LFT should be excluded (1) . Cholestasis is primarily a diagnosis of exclusion and careful inspection of the skin and any identifiable skin lesion to rule out other conditions like polymorphic eruptions of pregnancy where the itching is associated with rash, papules and plaques distributed in the abdomen, with umbilical sparing, thighs, buttocks , breasts and upper arms.
Other skin conditions like pemphigoid gestationis which is associated with vesicles. Prurigo of pregnancy which shows mainly red/brown excoriation. Pruritic folliculitis of pregnancy can also present with itching.

C.
The condition and its effect on pregnancy and the fetus should be explained to the patient. She should be aware of the increased risk ore preterm delivery both spontaneous and iatrogenic. She should be informed also that the stillbirth rate due to cholestais is equal to that of general population and that there is no conlusive evidence on the increased risk of meconium stained liquor and increased postpartum haemorrhage (1) .
LFT + Bile salts should be monitored weekly (1) with no evidence that abnormal levels will determine the timing of delivery. There is also no robust evidence on the modality of fetal monitoring to prevent fetal death, CTG and ultrasound could be offered however there is no evidence that they can predict fetal death (1) , however abnormal CTG or Umbilical artery Doppler can point out fetal compromise and necessitate delivery which again might not be related to cholestasis.
Mother should be offered symptomatic treatment to relive her itching like topical emollient (calmien lotion), systemic antihistminics might be of help,
S Adenosyl methionine,Ursodeoxycholic acid which acts as a chelating agent for bile acid have been used however there are no evidence of improved itching or safety margin for the fetus but it is still widely used (1) will you use them? .
Dexamethsone as 10mg daily for 7 days has been tried however should not be used as first line of treatment and women should be informed about adverse effects on fetus.
Vitamin K can be used will you use it? If so, when will you start treatment? based on its decreased absoption of steatorrhoea and its role in coagulation factors.
There is no data also to support the trend of early induction of labour at 37 weeks SO WHAT WILL YOU DO? The exam is not about quoting what the guidelines say. The examiner wants to know how you use this information to treat patients. .
Mode of delivery should be planned on obstetric indications, postnatal you were not asked about postnatal care. Where is the bit on intra-partum care? followup with LFTs measured after 10 days of delivery as spontaneous resolution will confirm the diagnosis of cholestasis. Advice on contraception as oestrogen containing agents should be avoided.
Posted by PAUL A.
A) Initial assessment entails a thorough history regarding the severity of symptoms,any aggravating or relieving factors.Inquiries should be made about presence of an associated rash (1) .A recent change in the use of toiletries should be inquired about.Also inquire about the symptoms being worse at any particular time of the day or night.Inquire about personal and family history of atopy, any drug allergies and any recent use of any medication (1) .
If the woman is multipapara, she should be asked about occurence of same problem in her last pregnany/pregnancie (1) .Also inquire about family history of similar problems in other female members of the family.
A quick review of her chart will help exclude the possibility of rubella infection. She should also be inquired about any previous history of chickenpox infection.

Examination should be done to rule out any associated skin rash (1) BP and urine for proteinuria . Palpatio n of fundal height, and a CTG should be carried out for fetal well being.
B) The most likely diagnonsis in this scenario is obstetric cholestasis. It is a diagnosis of exclusion (1) and can be confirmed by ascertaining raised transaminases , raised bilirubin and bile acids after ruling out other causes which can cause similar biochemical abnormalities (1) . For this purpose , a hepatitis serology is carried out to rule out an infectious cause. An autoimmune screen should be done to rule out the possibility of chronic active hepatitis and primary biliary cirrhosis.A liver U/S is done to rule out acute fatty liver of pregnancy do you do all these tests in all women with itching? . A full blood count and a coagulation screen alongwith urinalysis and B.P measurement is done to rule out PET why did you not mention in your examination? .

C) Subsequent management aims to relieve symptoms and ensure fetal wellbeing and timely delivery to avoid the potential risk of intrauterine fetal death.
For relief of symptoms topical application ofbland emmollients such as calamine lotion, eqeuous cream in menthol can be used. Antihistamines such as chlorpheniramine can be used to relive itching to some extent.
Other modalities of treatment include cholestyramine which is a bile chelating agent, S adenosylmethionine, rifmpicin ?? and ursodeoxycholic acid have been used with varying degrees of success what will you use? That is what the examiner wants to know .
Vit K ? im?? should be prescribed daily to reduce the risk of haemorrhegic disease of newborn.
Fetal monitoring is done by regular checking of LFTS, regular how often is regular?? CTGs according to the unit protocol (1) . Steroids should be prescribed for fetal lung maturity in case of preterm delivery are you likely to deliver her before 34 weeks? .Other modalities of investigations such as dopplers and regular ultrasounds are not predictive of fetal well being in this situation.Induction of labour can be not clear enough – is this what you will do? carried out at around 37 to 38 weeks to avoid the risk of sudden intrauterine fetal death.
During labour continuous electronic fetal monitoring (1) is carried out and liquor checked for the presence of meconium.Caesarian section is for obstetric indications such as the presence of meconium and a pathological CTG. A neonatologist should be present at delivery in case if meconium staining of liquor is present. Cordbloods should be taken after delivery to assess fetal blood PH to rule out fetal acidosis.
Posted by PAUL A.
Part A
There is a need to assess whether it is pregnancy specific cause and if there is associated rash.I will ask about severity of itching, any other body parts involved like abdomen, arms or legs and presence of rash (1) . I will ask about its effect on her quality of life.History of itching in pregnancy in absence of rash might suggest obstetric cholestasis or pruritis gravidarum and will exclude other pregnancy specific causes like polymorphic eruptions of pregnancy,prurigo or pemphigoid gestations.Any previous. History of eczema, contact with allergens (1) like soaps, detergents will indicate cause. skin infestation like scabies and involvement of other family members will indicate cause. History of pale colored stool and dark urine (1) is also suggestive of cholestasis. History of itching in previous pregnancies (1) , antenatal complication and pregnancy outcome because there is a high risk of recurrence of obstetric cholestasis. History of Fever, Jaundice, Malaise, or GIT symptoms for viral Hepatitis. Any drug history and family history of obstetric cholestasis. In examination presence skin trauma due to intense scratching (excoriation) and absence of rash (1) will be suggestive of obstetric cholestasisnot. I will check sclera for Jaundice. In abdominal examination I will check for hepatomegely, hepatic tenderness, SHF, lie / presentation and for fetal heart sound. In investigation I will do FBC for HB level, liver function test (alanine aminotransferase,aspartate aminotransferase,gama glutamyl transferase ,alkaline phosphatise,bilirubin) and serum total bile acids (1) .If these tests are normal but symptoms persist then I will repeat the test weekly (1) . If transaminases levels ara high(use pregnancy specific ranges),to exclude other causes of liver dysfunction I will screen for viral hepatits, A, B, C, E, CMV, Epstein bar. For auto immune hepatitsI will send anti smooth muscle cell Ab and antimitochondrial Ab. CTG for fetal well being. Ultrasonograhy for liver and biliary tract do you routinely do these tests before diagnosing OC? .USG for fetal biometry, amniotic fluid volume and Bio Physical Profile. BP / Urine for proteinuria
Part B
Most likely diagnosis obstetrics cholestasis. It is a diagnosis of exclusion (1) made by excluding other causes of abnormal LFTs like cholithiasis, extra hepatic obstruction by ultrasonography, serum hepetatis screen and auto immune disease of liver. So presence of intense itching in the absence of rash associated with abnormal LFTs with no other obvious cause of abnormal Liver Function will confirm obstetric cholestasis (1) . A previous history of obstetric cholestiasis will strongly suggestive of it.

Part 3
I will explain the diagnosis to the woman that it is pregnancy specific liver disorder which presents with pruritis. I will counsel her concerning metarnal and fetal risk e.g. increased risk of spontaneous and iatrogenic prematurity and still birth. Increased risk of meconium stained liquor,fetal distress, caesarean section and PPH evidence that these risks are increased is weak . I will inform her that there are no tests (like CTG, BPP, USG and Doppler Studies) that predicts or prevents adverse outcome (1) . But I will reassure of her that in majority of cases outcome is good (1) . So I will offer her fetal monitoring according to my unit protocol (1) what does this involve? .
For maternal symptoms topical treatment like emollients, antihistamins (Cholorpheniramine) /ursodeoxycholic acid can be given that will provide temporary relief but it will not improve the pregnancy outcome (1) . There is no role of S-adenosylmethonine for the relief of symptoms or improved pregnancy outcome. I will monitor her LFTs weekly (1) . I will start oral water soluble vitamin K (1) according to my unit protocol to minimize hemorrhagic riskof mother and new born. If there is a risk of Iatrogenic or spontaneous premature delivery, I will give two doses of betamethasone 12mg 24 hours apart.Dexamethasone is not used for symptom control.Regarding timing and mode of delivery I will discuss the risk and benefit of early delivery. Elective early delivery results in increased respiratory morbidity compared with later delivery but with an increased risk of still birth after 37 weeks of gestation so when will you deliver her baby? . Aim is for vaginal delivery and c-section will be for obstetric indication. So I will offer her elective delivery by induction of labour between 37 and 38 weeks of gestation (1) and explanation that it is not evidence based. I will provide written information and provide contact details of hospital. Regarding intra partum management provide 1 to 1 care to the woman,continuous electronic fetal heart rate monitoring (1) to detect fetal distress and timely delivery . Then early anesthetic review if emergency section is required. Regional analgesia can be offered in consultation with anesthetist if clotting profile is normal. I will send blood for FBC, group and save and clotting profile.Save IV line as there is risk of PPH.. Neonetologist should be present at the time of delivery to assess the baby. Then active management of third stage of labour (1) should be done. Baby should be given IM vitamine K.

Excellent answer
Posted by PAUL A.
a) This would incude taking a full history about the onset, severity, duration of the itching, any associated rash (1) in any part of the body, excoriation, previous history of itching, any relieving or aggravating factors, yelowness of the eyes(sclera) etc, drug use, history of any medication used to relieve symptoms, relevant past medical history this is a single sentence addressing a range of issues. See excellent answer above to see the level of detail required. What does ‘relevant past medical history’ mean? Should the examiner assume that you know what past medical Hx would be relevant? . I would also ask about any reduction in fetal movement.
I would then proceed to a general examination, checking for jaundice, pallor, pulse rate. A quick cardiovascular and respiratory examination if this examination is relevant, why should it be ‘quick’ rather than complete and thorough?? should be done and thereafter i would palpate the
abdomen -check the fundal height, presentation, listen to fetal heart and abnormality would necesitate request for growth scan Would you request a growth scan if you found the FH at say 80bpm?? (-1) , liquor volume and umbilical artery velocimetry. I would also check for any rash and skin lesion (1) particularly on the abdomen and back as well as the hands & feet.

b) the most likely diagosis is Obstetric cholestasis and since the diagnosis is infact that of exclusion (1) i would confirm the diagnosis with elevated bile acids, +/- deranged liver function test - AST or ALT in the absence of any other liver patholgy. which liver pathology and how would you exclude it?

c)The unit protocol should be followed and this would include relieve of symptoms with antipruritic agent like piriton, emolients can also be used. The use of ursodeoxycholic acid ( UDCA) would be discussed with the patient if symptoms are severe and bile acids markedly elevated but would inform the patient that its not licenced for use in pregnancy (1) .
Regular monitoring of fetal movement is required with particular attention to fetal movement ?? and i would ensure patient is followed up regularly if your consultant said to you: ‘bring her to the clinic regularly’, how often would that be? Every week / 4 weeks?? in the anrtenatal clinic and offered induction of labour at 38 weeks (1) due to the high risk of still birth beyond this gestation
I would recommend the use of Vitamin K 10mg daily im?? as from 34 weeks to prevent post partum heamorrhage and also Vit k administration for the neonate post delivery.
Intra-partum care would follow as a high risk patient with continous fetal monitoring (1) , and low threshold for intervention why should your threshold be any lower? Would you deliver with an FBS pH <7.25 instead of the usual 7.20??? for obstetrics reasons as per the protocol.The third stage of labour should be managed actively (1) with syntocinon infusion. The peadiatric team should be alerted after delivery as well.

You need a more detailed answer – you have not made use of the time / space available to you. You seem to have sufficient factual knowledge but need to express it in greater detail
Posted by PAUL A.
a) I’ll take a complete history about previous similar episodes of itching and if had been present and if occurred when pregnant (1) , or with intake of oral contraceptive pills containing oestrogens, since this will indicate the diagnosis of obstetric cholestasis to me. It is typical to have itchng of the palms and soles in Cholestasis of pregnancy. Also I would rule out other causes of itching which can be due to allergies, by asking her about any food or drug she is using now (1) , hepatitis by finding out a history of exposure to infected persons, other viral infections like ebstein barr virus and toxoplasmosis by asking her she if she had exposure to a cat or a person infected with EBV do you expect her to know this? . Also rule out autoimmune disorders like primary biliary cirrhosis and chronic active hepatitis by a asking if anyone in the family is also similarly affected. I will also ask about dark coloured urine and pale stools to exclude hepatitis how does this exclude hepatitis? .
In the examination, I would look for jaundice, pallor, scratch marks ? rash (1) , Hepato-splenomegaly, dilated veins on the abdomen…

I would order the basic investigations like full blood count, MSSU why? , liver function tests to look for elevated levels of AST, ALT, GGT and Bilirubin. Increased bile acid (1) levels have to be looked for as they are also seen in Obstetric Cholestasis. I will check for coagulation profile as cholestasis has shown to cause vitamin K deficient coagulation disorders. An ultrasound examination to look for bile stones eventhough the presence of tem donot necessarily indicate obstruction.




b. Obstetric Cholestasis is a diagnosis of exclusion (1) . In the post partum period the recovery would be very fast, therefore the repeat investigations have to be done 10 days post partum and not before as normal post partum LFT’s tend to go up.
Symptoms like itching mainly over the palm and soles…pregnancy or during a oestrogenized state like on oestrogen replacement therapy or on combned oral contraceptive pills. Signs and symptoms go away once the oestrogens are removed from the body.

Elevated LFT’s which are elevated from the normal for the pregnant population. Also there can be increased bile acids in the blood (1) . Screen for hepatitis and Toxoplasmosis and Epstein Barr Viruses. Exclude autoimmune disorders like chronic active hepatitis by checking for anti smooth muscle antibodies and primary biliary cirrhosis by excluding anti mitochondrial antibodies in the blood do you routinely do these tests before diagnosing OC? .

c. Ideally follow up should start intensely from 32 weeks of pregnancy onwards to achieve a healthy and viable baby and a healthy mother.
Delivery should be planned for 37-38 weeks (1) with twice weekly CTG’s weekly umbilical artery Doppler assessment and twice monthly assessment for foetal growth and liquor quantity.
Even with all these assessments it cannot be guaranteed that the baby will not have any issues at birth as the assessment systems are not reliable in obstetric cholestasis (1) .

There is also suggestion that amniocentesis is done for meconium assessment will you do this? as there is a high chance of having meconium stained liquor at birth. There is also a higher risk of perinatal morbidity and mortality in obstetric cholestasis.

Simultaneously the mother is monitored for coagulation defects and disorders in the LFT’s and supplemented with vitamin K 10 mg daily ? im?? to prevent bleeding during delivery.

If she is itching uncontrollably I wuld offer her antihistamine to give her relief. She can also be offered ursodeoxycholicacid (1) , which has shown to reduce the bile acid levels and in turn the itching. Some have tried using cholestiramne too.

If the mother and baby continue to be well, then labour is planned to be induced at 37-38 weeks of pregnancy with blood grouped and saved. WHERE IS INTRA-PARTUM CARE?
Once the baby is born it should be given vitamin K to prevent bleeding problems.

The woman should be advised against any oestrogen supplementation in the future as this can bring about the signs and symptoms again. She should be offered a progesterone only contraceptive is she needs one.

She would also be told that in future pregnancies she could expect to be affected again.
Posted by PAUL A.
A 30 year old woman presents at 30 weeks gestation with a 3 days history of itching that is worse in her hands and feet. (a) Describe your initial assessment of the patient [7 marks]. (b) State the most likely diagnosis and how you would confirm the diagnosis [3 marks]. (c) Discuss your subsequent antenatal management and your recommendations for intra-partum care. [10 marks]

(a) I will take the detailed history of her itching, its severity, site ,association with any rash (1) and interfering with sleep. Any previous history of eczema, atopy,allergy, any skin problem (1) . Iwill enquire about the colour of urine, stetorrhoea and pale stools (1) as it indicates cholestasis.
Any history of recent travelling,fever ,nausea or vomiting,anorexia,pain in epigastrium and yellowish discolouration of eyes and skin may indicate viral hepatitis.Any previous liver disease, drug abuse or alcohol abuse may point towards chronic liver problem. Personal and family history of cholestasis and itching while taking OCP is strongly suggestive of cholestasis of pregnancy.I will ask her LMP and confirm the dates with previous scans accept the gestation age given in the question as it is important in case of premature delivery.
In general examination I will check her pulse,bloodpressure, temperature, jaundice, any rash (1) , striae. I will look for any scratch marks,features of polymorphic eruption of pregnancy, pemphigoid gestationis and scabies. On abdominal palpation any tenderness in right hypochondrium and any liver enlargement should be noticed. Height of fundus and fetal heart should be checked.

(b) The most likely diagnosis is Obstetric Cholestasis. This is a diagnosis of exclusion (1) and it usually presents in third trimester of pregnancy. Liver functions should be done and it should be kept in mind that upper limit of LFT\'s during normal pregnancy is 20% lower than non-pregnant women and pregnancy specific values should be used to interpret the results. There is 2-4 fold increase in serum transaminase level, Gamma Glutamyl Transferase are also elevated, serum bilirubin is mildly increased, alkaline phosphatase can also be above normal pregnancy values. Total bile acids increased upto 10-100 folds (1) . Sometimes the LFT\'s may take time to rise though the pruritis is present so the LFT\'s should be checked weekly. Hepatitis serology for hepatitis A,B, C, CMV and EBV should be checked. Autoimmune liver disease is to be excluded by doing Anti-smooth muscle antibodies for chronic hepatitis and anti-mitochondrial antibodies for Primary Biliary Cirrhosis do you routinely do this before diagnosing OC? .
Ultrasound to exclude gallstones should be done although the presence of gallstones does not mean that cholestasis is due to this reason. In atypical or early cases it should be differentiated from Pre-ecclampsic toxemia how do you do this if you did not dipstix urine for proteinuria? and fatty liver.

(c) There is maternal risk of PPH due to deficiency of Vit. K dependant clotting factors as there is disruption of Vit. K absorption. Fetal risks include iatrogenic and spontaneous prematurity, IUD, increased risk of intracranial hemorrhage, ante and intrapartum fetal distress and meconium stained liquor preterm delivery is the only risk that is definitely increased . Counselling is very important and should be individualised regarding these risks and that there is no method which can prevent or predict the stillbirth which is due to acute anoxia.There is no treatment to improve fetal outcome. Problems of prematurity should also be discussed.
In mother, weekly and clotting screen should be done ?? to see the progress of disease. Treatment is needed to reduce the maternal morbidity due to severe itching. Antihistamines like promethazine, chlorphrenamine is commonly used but its efficacy is not proven and causes drowsiness. Emolients and water based cream with menthol are also widely used but efficacy is unknown. Ursodeoxycholic acid (UDCA) though not licensed for use in pregnancy but it is used widely during pregnacy as there is no evidence of any adverse effect (1) . It improves LFTs and clinical condition of patient but its efficacy for preventing stillbirth and safety for neonate and fetus is unproven. Oral Vit. K (water soluble form) should be given to the mother from 32 weeks of pregnancy to prevent PPH and fetal/neonatal bleeding (1) . Cholestyramine is a bile acid chelating agent, may improve pruritis but it is poorly tolerated and also exacerbates vit. K deficiency so it is not used.
S-adenosyl methionine is not effective for the control of maternal symptoms and for improving fetal outcome and needs IV infusion so not acceptable to the women.
Dexamethasone should not be the first line treatment for cholestasis of pregnancy but can be given for fetal lung maturity if premature delivery is anticipated.
Though there is no method to predict the IUD but regular how often is regular? Every 4 weeks?? fetal growth scans, dopplers, CTGs should be done. The woman should be counselled that the risk of fetal death is equivalent to the general population but you indicated it was increased earlier .
There is insufficient data to support that early induction of labour at 37 weeks is of benefit in reducing the IUD so the timing of the early delivery and risk to the baby due to increased respiratory morbidity should be discussed with the mother (1) .
During labour, there should be a continous fetal monitoring (1) as increased risk of fetal distress and may lead to emergency ceasarean section. After delivery, Vit. K should be given to the neonate to prevent haemorrhage.
Posted by PAUL A.
Please Paul, In the initial assessment do we include in addition to history and examination, investigations. When should we include it and when not, much obliged

Initial assessment refers to what you will do when you first see the woman (as opposed to what you will do the next day or 3 days later). Clinical assessment = history and examination ONLY but this question asked for ‘assessment’ not ‘clinical assessment’
Posted by PAUL A.
RnRn

A.
On history taking I’ll explore exact onset and nature of complaints, any provoking factors or accompanying rash (1) and contacts with other people having a rash or known to have hepatitis. I’ll ask for changes in colour of stools (light) and urine (dark) (1) . Family history or personal history of itch in pregnancy (1) . I’ll enquire regarding problems in previous or current pregnancy, in particular pregnancy induced hypertension and will look at notes for (booking) blood pressure and proteinuria, as well as serology of booking blood. I’ll enquire on headache, visual complaints and fetal movements. On examination I take blood pressure and pulse and dipstick urine for proteinuria (1) . I’ll look for jaundice, oedema and test reflexes. Abdominal assessment includes symphisis-fundal height, assessment of clinical liquor and – though difficult at 30 weeks, palpation and percussion of liver (and epigastric region).

B.
Obstetric cholestasis (OC) is the most likely diagnosis Raised liver enzymes and bile-acids support this, but OC can only be assumed after ruling out other possible causes (1) , especially since symptoms can precede blood changes up to several weeks so would you repeat tests? . To rule out hepatitis serology for hepatitis A-B-C and EBV & CMV is sent, as well as bloods to rule out auto-immune liver disease do you routinely do these tests? . Pregnancy induced hypertensive disease (pre-eclampsia, HELLP) is another important disease entity that needs to be ruled out and for which FBC, liver & renal function tests (including urate) and coagulation screen is sent, with urine test for proteinuria.

C.
I’ll explain her that after ruling out other causes, OC will be assumed as a cause. In the past this was thought to lead to higher incidence of IUD and fetal distress, but later research suggests it may not be markedly altered so are there any risks that are increased? . She will be given neutral cream for skin (diprobase or calamine lotion) and oral piriton 4 mg tds for the itchiness. Ursodeoxycholic acid will improve bile-acids and liver enzymes and can markedly improve itch, but there is currently no good evidence for its use (1) so will you use it??. Liver functions are repeated twice weekly weekly and blood pressure and proteinuria will be checked every visit. Patient will be instructed to report if she develops headache, visual complaints or experiences reduced fetal movements. When there is doubt regarding fetal condition or growth what would precipitate such doubts? , ultrasound for growth, liquor and Doppler flow is arranged. Unless fetal compromise is suspected, standard early induction is not done anymore so what is done? How are such women managed in your unit? Do you let them go to 40 or 41 weeks? , also because majority of reported IUD’s were before 37 weeks anyway. Water-soluble Vitamin K 10 mg od (1) orally form 36 weeks onwards may reduce potential risk of fetal hemorrhage or post-partum hemorrhage caused by reduced vit K. once in labour it is reasonable to commence continuous fetal monitoring (1) . The examiner wants to know what you will do rather than what used to be done or what is generally done
Posted by PAUL A.
maayka


(a) A proper history will be taken to find out if the itching is associated with a rash (1) or not since without a rash it is likely to be obstetric cholestasis (OC) and so other conditions will have to be ruled out. The pruritus may be worse at night . She may have other pre- existing pruritic skin condition which may have flared up e.g eczema , or an allergic (1) type reaction to a new product used – perfumes, lotions . the presence of pale stools and dark urine (1) would strongly suggest OC. A family history of OC or previous OC in an earlier pregnancy (1) would be relevant.
Examination should be aimed at ruling out the other possible causes such as viral hepatitis or pre- eclampsia ( PET). I would look for icterus, ensure the abdomen fundal height is appropriate for gestation age and check fetal heart rate. The vital signs like BP, pulse and a urinalysis for protenuira (1) should rule out pre- eclampsia. Initial blood investigations should include a CBC and LFTs (1) .

(b) OC is the likely cause and it is confirmed by excluding (1) other causes of pruritus and deranged LFTs like PET – by looking at BP, pulse and urinalysis, or other viral infections – especially hepatitis B,C. The latter is checked for looking back at the booking maternal serum for antibodies or checking her serum at that time for antigen levels. LFT performed should reveal elevated transaminases and bile acids.

(c) Antenatal management includes care of the mother foremost who is symptomatic of the pruritus, and the fetus. The women should be told of the nature of the condition and the risks to her and the baby – of the increased incidence of preterm labour and the following being possible - meconium stained liquour, postpartum haemorrhage and unexplained stillbirth (1) .

Maternal symptomatic relief can be provided with topical emollients like calamine lotion and oral chlorpheniramine 4 mg three times daily but be told of the sedative effect. The use of Ursodeoxycholic acid (1) is a bile acid chelating agent and can be started immediately, she would be told that it has not been approved in pregnancy but there is no known teratogenic effect. Vitamin K in the water soluble (1) form, like menadiol 10mg once daily can be started simultaneously to reduce the risk of low production of fat soluble clotting factors – it will reduce the chance of PPH occurring

The fetus should be monitored with weekly CTG and the mother have weekly LFTs (1) . Early delivery would be recommended to prevent the chance of an unexplained stillbirth , and is usually planned between 37- 38 weeks (1) . The hospital policy will need to be checked though on the induction of labour for OC before this planning.
Intrapartum care involves CTG monitoring (1) and active management of 3rd stage (1) to prevent PPH.

good answer
Posted by PAUL A.
A good answer should include the following

(a)

• Take a detailed history
1) Severity / site of itching and impact on quality of life. Presence of pale stools and dark urine (1 mark)
2) Presence of rash, contact with any allergens (1 mark)
3) History of skin disorders and family history of cholestasis. Cholestasis in previous pregnancies (1 mark)
• Clinical examination for rash (differentiate from excoriations), jaundice, hepatomegaly / hepatic tenderness (1 mark)
• Check BP and urine for proteinuria – important to exclude pre-eclampsia as a cause of abnormal LFTs (1 mark)
• Investigations - LFTs and bile acids (1 mark) .
• If LFTs and bile acids normal but symptoms persist, repeat tests weekly. Know that pregnancy-specific range should be used for LFTs (1 mark)

(b)

• Most likely diagnosis is obstetric cholestasis (1 mark)
• Diagnosis confirmed by a positive history, abnormal LFTs (including bile acids) and after exclusion of other causes of abnormal LFTs like hepatitis, pre-eclampsia and acute fatty liver of pregnancy plus resolution of symptoms and LFT abnormalities after delivery (1 mark)
• In practice, unless there are other indicators like hypertension, proteinuria or hepatic tenderness, further investigation is unnecessary (1 mark)
(c)

Antenatal care

• Explain the diagnosis and its implications to the woman – increased risk of premature delivery and possibly meconium stained liquor, fetal distress and post-partum haemorrhage. Risk of stillbirth not increased in treated cases (1 mark)
• Explain that there are no tests that predict / prevent adverse outcome (1 mark)
• Reassure that outcome is good in the majority of women (1 mark)
• Offer program of fetal monitoring in line with unit protocol (1 mark)
• Know that there is insufficient evidence to recommend any specific treatment for maternal symptoms – ursodeoxycholic acid commonly used but the lack of evidence should be discussed with the woman (1 mark)
• Offer maternal oral water-soluble vitamin K to minimise maternal / neonatal haemorrhagic complications (1 mark)
• Monitor LFTs weekly (1 mark)
• Discuss risks and benefits of early delivery (after 37 weeks) and offer IOL in line with local guidelines (1 mark)

Intra-partum care

• Hospital delivery should be planned (1 mark)
• Continuous fetal monitoring (1 mark)
• Active management of third stage as increased risk of PPH (1 mark)

Ref: Obstetric Cholestasis: RCOG Green top guideline No 43, Jan 2006.
http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdf
Posted by Vinutha G.
Itching of the hands and feet in third trimester of pregnancy is asymptom which warrants further evaluation
I will ask the patient about associated rash ,malaise ,any fever .Iwill also ask her about anorexia ,vomiting ,color of urine and stools .In addition i will check if she has a past history of similiar complaints associated with prevous pregnancies or with the COCP.
Her past obstetric performance is important as cholestasis can cause IUD.I will check if she has any skin problems antecedating the pregnancy .
On exam the distribution of the itch ,any rash (which points at adifferent etiology )excoriation marks will be noted
Besides any icterus ,hepatomegaly must be looked for .
The investigations directed to confirm the diagnosis will be FBC.BILE SALTS AND PIGMENTS ,LFT .Derangements in the hepatic enzymes and the increase in bile salts and pigments would point towards cholestasis of pregnancy as the likely cause .

b)Cholestasis in pregnancy is associated with derangement in the liver function . The risks to the mother include the intense pruritus disrupting sleep besides causing anxiety .
also there is an increased chance of bleeding due to reduction in the VIT K dependent coagulation factors
The need for induction of labour and associated increased risk of operative intervention also exists .
The fetus has an increased chance of IUGR ,IUD ,meconium staining of the amniotic fluid ,intrapartum fetal distress .
Iwill inform the woman about the above factors and the need for additional surveilliance though evidence has not shown a corelation between the severity and fetal outcome .
Thus the increased surveilliance in the form if CTG, bpp, is towards reassurement
I will start the woman on ursodecholic acid (not licensed but helps the biochemical parameters).will give her antihistamines and mollients for relief from pruritus .From 36 weeks onwards ,i will start her on Vitamin K supplements 10 mg . Weekly LFT should be done to check for further deterioration
At 38-39 completed weeks I will offer her induction of labour .
Prostaglandin induction along with continuous CTG monitoring will be instituted .
Epidural analgesia is not contraindicated .
LSCS should be reserved only for obstetric reasons keeping in mind the risk of intrapartum compromise
Postpartum repeat LFT should be done and the woman informed about increased possibbility of recurrence with next pregnanacy as well as with the COCP
Vik k injection should be given to the neonate .


Prostaglandin industion with
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