(A) History should be obtained about the characteristic of itching as generalised itching may indicate dermatological conditions or skin manifestations.History of associated rash may 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 obstetric 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 for scratch marks which indicates severity of itching.Skin should be examined for any bleeding, rash, jaundice.An Abdominal examination should be carried out for 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 manifestaions and allergy should be ruled out.A Liver function test should be performed including bile salts ,Serum bilirubin,Transaminases(ALT,AST and Alkaline phosphatase) .Bile acids may be normal which should be repeated after a week as a normal bile acid does not exclude obstetric cholestasis.An ultrasound abdomen for gall bladder stones should be offered fetal wellbeing should be performed. Final confirmation of diagnosis is done by postnatal normalisation of the LFT at tenth postnatal day (C) Diagnosis should be explained to the woman in a supporting way.Risks should be explained like Pre term delivery,Fetal distress,Meconium stained liqour.PPH,intraventricular hemorrhage and fetal death may occur.But in majority the outcome is normal.Tests of Fetal monitoring should be offered according to the unit protocols but these cannot predict or prevent adverse outcome.Vitamin K 10 mg should be offered according to unit protocol to prevent hemorrhagic conditions in mother and fetus.Symptomatic treatment should be offered to mother like antihistamines and skin lotions like balneum plus Ursodeoxycholic acid may be effective but not liscenced for use in obstetrics cholestasis.LFT ,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 help of support groups should be offered like british liver society and obstetric cholestatisis support groups.For induction of labour membrane sweeping, pfostaglandins.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 infomed to be present at delivery.Third stage of labour should be managed actively by I.M syntometrine.
