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MRCOG PART 2 SBAs and EMQs

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Essay 265 - obstetric cholestasis

Posted by J P.
a;I would look for any obvious eruptions associated with itching to suggest psoriasis or eczema ,dermatographia artefacta [in obstetric cholestasis],site of onset [umbilus in pemphogoid gestationalis],extent of lesion [peri umb sparing in prurigo of pregnancy].O.C usually causes generalisd itching
.b.To do LFTs for bilirubin and transaminases,srum bile acids .If abnormal hepatitis viral screen-hep A,B,C,EBV,CMV,anti mitochondrial and anti smooth muscle anti bodies,liver USG.
c.Once diagnosis is made LFTs to be done weekly.Explain maternal and featal risks like prematurityrisk of neonatal bleeding.Evidence for the increase inc/s rate ,meconium stained liquor,PPH is insufficient.Still bith rate not increased.Initial management like topical emollients can be given,There is insufficient evidence for use of S-AM,UDCA,Steroids.USG,BPP,CTG not useful in predicting fetal compromise.Delivery decision will not be influenced by LFTS.Frequent antenatal visits to be done .Elective indution at 37 completed weeks may be done.To give vit K oral 10 mg daily to improve maternal and neonatal bleeding.Aim for vaginal delivery.Information leaflets to be given,access to obstetric cholestasis support group.
d.Risk of PPH ,vigilant care to be done .LFT to repeated after 10 days .Neonate given im vit K and adequate neonatal care to look for HDN.Follow up apointment and adequate counselling given,Contaception -to avoid estrogen containing combinations.Risk of high recurrence in subsequent prenanacy explained.Information leaflet,support groups access to be given.
Posted by Farina A.
Initial clinical assesment will include history, duration of symptoms and the extent it is effecting the routine life and sleep as this will give an idea about severtity of the disease. Any remedy the pt has tried before is also useful for further prescription. history of any dermatological disease or contact is useful to exclude dermatological disease or consultation with a dermatologist. History of jaundice or similar problem outside pegnancy can give an idea about pre-existing liver disease. Her previous obstetric out come, and similar condition in previuos pregnancy can direct towards the diagnosis.after checking routine vital signs, a top to toe examination for any signs of jaundice, erruptions and there distribution will give an idea about liver disease and skin disease respectively. Presence of sratch marks or scabs will give an idea about the severity of the symptoms.
b) I wouil like to check for her liver function tests, bile acids, hepatitis B& C profile, Prothrombine time and a detailed US scan for fetal well bieng including biophysical profile.
c) Pt should be informed about the diagnosis and the risk of fetal loss with the condition. If her symptoms are not so severe and investigations are not so deranged she can be managed as an out pt with symptomatic relief by antihistamins and regular followup weekly to check for her bile acids and biophysical profile and later on elective induction at 39 wks. other options for symptom relief are urseodexicolic acid which acts as chelating agent, s adenosyl methionine and local emolients. Severe and intractable cases can be managed as in pts with corticosteriod therapy and betamethasone for possible preterm delivery. Multidisciplinary approach including physician, hepatologist, senior obstetricians and paeditrician all should be involved in decision making process.Pts wishes, her previous obtetrical outcome, availability of beds in NICU can influence the management.Conservative managemnt to prolong the pregnancy till 34 wks is one of the options in case pt improves on treatment. Otherwise labour can be induced by prostaglandins. Labour should be monitored by continues CTG and a senior obstetrician should check the progress .CS for obstetrical indications in the presence of senior obstetrician, paediiatrician and aneasthetist.
d)Post partum she is at risk of PPh so active management of third stage with confimed avaailability of blood and FFPs is wise. pt can be trasferred to level 2 intensive care unit if her clinical condition allows.Her liver functions are likely to become normal after delivery and should be checked before discharged. Followup appointment should be given after 3wks with a repeat LFTS and bile acids. This pt can have any contraception however IUCD may be the best. Pt should be informed about the risk of recurrence in future pregnancies. Written information should be provided.
Posted by H H.
A Clinical Assessment should include onset ,course and severity of itching.was there history of hepatitis B or C exposure.Any treatment taken.was it associated with rash and distribution (started in umbilicus, Herpes gestationes or with umblical sparing as in polymorphic eruption of pregnancy).was there allergy to certain drugs taken .was there change in colour of urine and stools ,jaundice and fever which point to hepatitis B or c.multidisciplinary input should include dermatologist and infectious disease physician.

B-Will include hepatitis screen , liver functions including liver enzymes which are slightly elevated in obsteric cholestasis(oc) and markedly elevated in hep b c. serum bile acids elevated in oc,serum bilirubin and clotting profile affected in liver affection.monitoring of fetus with biophysical profile.


C-patient told the implictions of oc on pregnancy incuding
Posted by H P.
a) Initial clinical assessment would involve detailed history regarding the onset, duration and severity of the symptoms. I would like to inquire about any associated skin rash, eruptions, bleeding or pus discharge, the extent and the distribution of itching and skin lesions. I would inquire about any chronic skin disorder with pruritus like psoriasis or eczema. Flaky micaceous lesions and past history would favour psoriasis while a history of allergy favours eczema. Distribution of papular lesion over palms and in the interdigital spaces with poor hygiene may suggest an infective condition like scabies. Chronic skin disorders should be treated in consultation with dermatologist. A history of dark urine and fatty pale stools would be suggestive of hepatic condition; further inquiry should be made about history of anorexia, nausea, epigastric discomfort. There could be a family history of obstetric cholestasis.
High blood pressure and proteinuria may be suggestive of pre ecclampsia and associated HELLP syndrome or acute fatty liver of pregnancy should be ruled out.
Apart form her general condition, I would look for pedal oedema, weight gain during pregnancy, and presence of jaundice or other signs of altered coagulation profile like petechiae and bruises.

(b) I would send blood for complete blood count, liver function tests (LFTs), and screening for viral hepatitis like hepatitis A, B, C, E, CMV, EBV and coagulation profile ( PT and APTT). If the liver function tests are abnormal according to the pregnancy specific range and no infective cause is determined, further investigations would include serum gamma glutamyl transpeptidase and serum bile acids. If proteinuria is detected, 24-hour urinary protein excretion, renal function test and serum uric acid should also be sent to rule out preeclampsia and HELLP syndrome. An ultrasound of the liver should be arranged to rule out other causes like biliary tract obstruction, cirrhosis or fatty liver. . An autoimmune screen of antimitochondrial and anti smooth muscle antibody may point to conditions like chronic active hepatitis or primary biliary cirrhosis. Prurigo of pregnancy which will not be associated with any biochemical abnormalities should be ruled out.
Her LFT may be normal as many women may have symptoms weeks before biochemical abnormality, so in case pruritus persists, LFTs should be repeated weekly.


(c) Once the diagnosis of obstetric cholestasis is made, I would counsel her that it is the most common pregnancy induced liver disorder and may worsen as pregnancy progresses. However, complete resolution is usually expected within 48 hours of delivery. She should be explained that postnatal resolution of symptoms and biochemical abnormalities is needed for confirming the diagnosis. There are no evidence based interventions to improve the maternal or fetal outcome but she can be offered symptomatic treatment.
The condition may pose a risk to the fetus as it is associated with preterm labour which could be spontaneous or iatrogenic due to severe maternal symptoms. She should be given antenatal corticosteroids for fetal lung maturity.
There is a risk of obstetric haemorrhage due to malabosorption of vitamin K and she should be started on oral water-soluble vitamin K- menadione 10mg daily. Her LFTs should be monitored weekly.
Topical emollients like calamine lotion may be beneficial for itching and in case of secondary infection of skin lesions; topical antibacterials should be prescribed. If the symptoms are severe, she may benefit from oral antihistaminics but she should be informed about the side effects like drowsiness. She may be given mild sedatives in case of sleep disturbance due to itching.
Current data do not suggest increase in incidence of stillbirth or meconium stained liquor. She should be explained that there is no specific fetal monitoring modality for the prediction of fetal death, however, serial fetal growth scans and fetal surveillance by Doppler and CTG should be offered.
If the woman has severe unrelenting symptoms, decision of an elective delivery at 37-38weeks should be made after discussing with her the potential risks of respiratory morbidity to the baby. A neonatologist and hepatologist should be involved during decision making.
During labour, venous access should be maintained and blood sent for group and save. Continuous intrapartum fetal monitoring is recommended. Information regarding the obstetric cholestasis support group and leaflets should be provided.

(d) She is at high risk for post partum haemorrhage, so active management of third stage should be done. The neonate should be given intramuscular vitamin K and intracranial haemorrhage ruled out. I would follow her to ensure that LFTs return to normal by 10-14 days postnatally, pruritus resolves and all investigations carried out during the pregnancy have been reviewed. I would reassure her about the lack of long-term sequelae for mother and baby. She should be given contraceptive counseling and advice to avoid using oestrogen-containing methods. She should be aware of the high recurrence rate and the increased incidence of obstetric cholestasis in family members.

Posted by Priti T.
a]Detailed history should be taken as obstetric cholestasis is a pregnancy specific disorder,the pruritis being worse at night and may involve palm and soles of feet.Other causes of pruritis must be excluded like eczema,psoriasis,and pruritic eruption of pregnancy;dermatographia artifacta [skin trauma due to intense itching].Other evidence ofcholestasislike pale stool,dark urine and family history of obstetric cholestasis should be sought.
b]In clinical practice,abnormalities in LFT [Liver function Test] transaminases,gamma glutaryl transferase[GGT],bilirubin and bile salts are considered sufficient to support the diagnosis of obstetric cholestasis.Only pregnancy specific ranges should be applied as the upper limit of normal is 20% lower than the non pregnancy range.Other causes of abnormal LFT must be excluded.A viral scan for hepatitis A,B,C,Ebstein Barr ,CMV,Liver autoimmune screen for anti muscle and anti mitochondrial antibody[chronic active hepatitis and primary biliary cirrosis] and liver USG should be carried out.
c]For the ante natal care LFTs are carried out weekly.The women should be explained about the diagnosis and the risk to the fetus specially about the prematurity-spontaneous/iatrogenic.The British liver Trust has the patient information Leaflet and also there is Obstetric Cholestsis support group to which the patient can enroll.
The patient should have the regular monitoring of the fetus by CTG,fetal kick count,USG;even though the evidence is lacking that the fetal monitoring can predict fetal death or compromise,the stillbirth rate is not increased.But ,in Obstetric Cholestasis the evidence for the increased risk of meconium stained liqor ,caesarian section or PPH is inconclusive.The only definitive treatment is Delivery as the signs/symptoms revert to normal in 48 hours.This delivery should be planned at 37 weeks with the patient\'s informed consent.Preferrably vaginal and caesarian only for other Obstetric indication.
Patient symptoms of pruritis can be treated by the mild emollients and anti histaminics like chlorphenaramine.Severe pruritis can be treated with SAM[S adenosyl methionine].UDCA[Ursodeoxycholic acid]is the most widely prescribed anti pruritic in UK ,but it is not licensed for the treatment still in UK.Resistant cases can be treated by Dexamethasone 10 mg/day for 7 days in consulation with the patient.Vitamin K 10 mg/day should be supplemented from 36 weeks of pregnancy as it reduces the risk of PPH and neonatal bleeding.
d]Neonate should be supplemented by vitamen K and monitored for HDN.Post Natally LFTs shold be deferred till 10 days.The patient should be counselled about avoiding the oestrogen containing oral contraceptives.Also ressured about the lack of long term sequeale for the mother and the baby.But there is high incidence of recurrence in next pregnancy and the family members.
Posted by N S.
A) I will know that is there any rash, yellowness of skin associated with itching. I will ask the patient what time is the itching at its worse. How is this itching affecting her quality of life and daily activities? I would also ask about the aggravating and the relieving factor of itching. Is there any relationship with change in diet or clothing material or washing detergents? I would also like to ask of any previous history skin disease for example eczema. Has she used any treatment for this itching?

B) I would like to perform the Liver function test and bile acid due to the high suspicion f obstetrics cholestasis. I would like to do the viral screen for hepatitis B, C to exclude viral infection. There is no role for performing u/scan of liver to exclude any pathology. Obstetrics scan for the fetal well being and growth. By performing the Anti smooth muscle and anti mitochondrial antibodies we can exclude chronic liver disease. There is no benefit of performing liver biopsy.

C) Following the confirmation I would arrange regular reviews at the obstetrics day unit for the patient at least twice weekly. While her visit at the obstetrics day unit LFT’Sand bile acid will be done .if there is high levels ob bile acid the Urodeoxycholic acid should be considered though there is not enough evidence available regarding the safety. Chelateing agents can be used as well however no information about the safety is available. Usacn and CTG should be performed; however there is no definite measure to assess the fetal well in patient suffering from obstetrics cholestasis. Patient should be given vitamin k to reduce the risk of haemorrhagic disease in the newborn. The induction of labour is usually planned around 38 weeks of gestation to reduce the risk of perinatal mortality and morbidity. During labour no contraindication to epidural analgesia. Caesarean section should only be performed for obstetrics indication.

D) Postnatally there is no contraindication to breast feeding. Newborn should be given Vitamin K oral/ IM at the time of delivery to reduce the risk of haemorrhagic disease. LFT’s should be repeated at 10th postnatal day and they start to become normal then it confirms obstetrics cholestasis. Patient should avoid the oestrogen based contraception and consider alternative options. Pt should also be informed of very high risk of recurrence of obstetrics cholestasis in future pregnancies.

Posted by Srivas  P.
(a) Since history is recent, I will enquire about any change in cosmetics, recent drug ingestions, insect bites which can cause allergy and pruriris. I will also take H/O high colored urine, change in color of stools, presence of any skin rashes and Family history of Obstetric cholestasis. Any history of past skin manifestations like Psoriasis, eczema etc, any recent exposure to Chicken pox will be taken. I will find out if her sleep is getting affected due to itching.

I will examine her to look for icterus, any skin rashes or marks from intense itching, the presence, site and nature of skin lesions if present to differentiate from polymorphic eruptions of pregnancy and will look for liver/spleen enlargements.

(b) I will do LFT-serum bilirubin, bile acids, bile salts, transaminases, Gamma glutamyl tranferase and if itching persist this should be repeated 1-2 weekly. If LFT is abnormal, viral screening for Hepatitis A, B, C, Ebstein Barr and CMV would be done along with Liver autoimmune screen which includes anti smooth muscle and anti mitochondrial antibodies to diagnose Chronic active hepatitis and primary biliary cirrhosis and this can be confirmed by Liver Ultrasound. Fetal surveillance using CTG fortnightly, though no particular method is reliable to prevent IUD.

(C) I would tell her about the diagnosis and its implications for her pregnancy.
She is at risk for spontaneous and iatrogenic preterm labor. The risks of still birth, meconium staining of liquor, increased risk of C.S and PPH though reported in some studies, the data are inconclusive. The degree of abnormality of biochemical results do not correlate with risk of IUD. Also no specific fetal monitoring modality can predict fetal death. Fetus can be monitored using fetal kick counts, Doppler studies and CTGs though none can guarantee prevention of IUD.

She is at risk of deficiency of Vit K due to malabsorption and subsequent deficiency of fat soluble vitamins and can contribute to PPH and fetal and neonatal intracranial hemorrhage. Hence Vit K supplements should be given orally in antenatal period.

Further management of this woman should be individualized depending on her distress due to itching. No treatment modality improves maternal and neonatal outcomes though symptoms may be reduced with combination of treatments. Topical emollients like calamine lotion may decrease pruritis.Chlorphenaramine does not affect pruritis but may help her sleep. Other treatments like S -adenosyl methionine and ursodeoxycholic acid have been tried and there is no evidence of its improving maternal or neonatal outcome. Cholestyramine may improve pruritis but can exacerbate vit K deficiency.

Plan for early delivery has no scientific basis and decision is individualized depending on her tolerance of her symptoms and after discussing with her about possible risks of IUD versus risks of early delivery like admission to special care baby units which are more if delivered early at 37 wks compared to at 39 wks. She should be given details of Obstetric cholestasis support groups and leaflets to help her understand and informed decision should be taken from the woman.

(d) Postnatally she should be followed up to see LFT’s have come back to normal and this is checked after 10 days of delivery as normally LFT is increased soon after delivery. It is important to ensure her symptoms have subsided. She should be told about Obstetric cholestasis running in families but having no long term sequelae. There is possibility of recurrence of symptoms in her next pregnancy and when introduced on estrogen containing oral contraceptives. She is best put on progesterone only contraception or IUCD.
Posted by Asma kamal K.
Initial clinical assesment of this patient needs a detail histry to confirm the diagnosis,exclude the differential diagnosis and to evaluate the extent of the disease.

a detail history about the site and extent of pruritus and any associated rash, malaise, stetorrhoea or dark urine.any histroy of drug intake.Past medical and surgical history with special emphysis on gall stone and viral hepatitis should be ellucidated.

Family history of such problem should be asked as in 1/3 of cases it is seen in close family memebres.

Investigation of symptoms:

Obstetric cholestasis(OC) of pregnancy is diagnosis of exclusion hence different test to rule out other differiential should be done.ultrasound hepatic and biliry tract to exclude gall stones, virology to rule out hepetitis A, B,C,cytomegalovirs infection and ebstenbarr virus infection.anti mitochondrial and anti smooth muscle anti bodies to rule out primary biliary cirrhosis and chronic active hepatitis repectively.
Liver function test(specially to be interpreted according to the pregnanacy values) and bile salts to see the extent of the problem.

Susequent Antenatal care:

OC of pregnancy posis certain risk to the mother and the fetus and these risks should be explained the couple and subsequent antenatal care planed in view of these risk factors.
risk to the mother is symptoms of the disease, increase liklihood of operative delivery in view of fetal distress (commonly seen with OC) and postpartum hemorrhage(because of mal.absortion of fat soluble Vit-K).
Risk to fetus are prematurity(spontaneous/Iatrogenic),meconium stained liqour,fetal distress,and intra uterine fetal demise.Neonatal risk is intra cranial hemorrhage.
in view these risk she should be seen in aday case centre where a CTG(daily),USS for liqour volume(weekly) and fetal growth perametrs and doppler velocemtery(two weekly) hsuld be done. though none of these test con predict fetal compromise effectively in this particular case but is reassuring for the coulple and the carers.
weekly maternal clotting profile and LFTs should be done
Maternal symptoms if mild to moderate can be traeted with cold baths ,emolients and anti histamines at night(associated with sedation).These all may give her some relief . in severe cases Ursodeoxycholic acid (UDCA) can be given though not recomended in pregnanacy,but usually given and not associated with adverse out come so far,effective in reducing symptoms and improving LFTs but no effect on fetal outcome.
oral watersoluble Vit K 10mg daily from 34 weeks.
offer elective induction of labour at 37-38 weeks in view of IUD near term,if any fetal or maternal problem indicate delivery before 37 weeks give antenatal corticosetroids for lung maturity.
aim will be vaginal delivery with cesarean section only for obstetric reasons.

Postnatal care:

closely monitor for PPH.
intramuscular injection of Vit K to the neonate.
repeat LFTs after 10-14 day post delivery for the resolution of the disease.
Counselling:as the problem is associated with an abnormal response of the body to the estrogen level recurrence can occur in menstrual cycles,with oral contraceptive pills which should be avoided,newer low dose pills may be tolerated well but should not taken without supervision,recurrence in future pregnanacy is very high that is 75-90%.
Posted by Sabahat S.
a) Initial clinical assessment is based on a detailed history and careful clinical examination. I would like to ask about intake of any drug or exposure to chemical or food allergies, which might have caused generalized itching. An enquiry will be made about appearance of skin rash or eruption along with itching as it may be due to dermatoses or viral infections. Presence of systemic symptoms like fever, malaise, anorexia, vomiting, upper abdominal pain and yellowish discolouration of skin will be suggestive of viral hepatitides. History of dark coloured urine and pale stools will denote obstructive eitologye.g cholestasis or biliary obstruction. Past H/O liver disease, gallbladder disease, autoimmune liver disease (primary biliary cirrhosis), renal disease (uremia) will be taken to exclude preexisting pathology. On examination a cahectic, ill looking, dehydrated, jaundiced lady is likely to have systemic viral infection. Presence of raised skin wheels will be suggestive of urticarial reactions, where as papular/vesicular eruptions are associated with dermatological disorders or viral infections. In cholestasis of pregnancy, only skin excoriation and scratch marks without rash will be seen due to intense itching.
b) Regarding investigations, liver function tests along with total serum bile acids should be done promptly. If the results are abnormal showing raised transaminases (ALT, AST), bile acids, and alkaline posphatase (above pregnancy level) and Gama glutamyl transpeptidase, then exclusion of hepatobiliary pathologies is essential. Therefore other investigations like USS liver, gallbladder and biliary tree will be requested, Serology for hepatitis A, B, C, EBV and CMV, will be done. Immunological tests like anti-smooth muscle&anti-mitochondrial antibodies are requested in cases where LFT&USS results are not very conclusive.
c) Once the diagnosis of obstetric cholestasis of pregnancy is made, the mother should be counselled about the possible risk to the fetus ( preterm delivery, fetal distress and intrauterine death) and need for fetal surveillance. Close surveillance of the fetus can be done (at day assessment clinic) by a combination of daily CTG, USS for fetal growth every fortnight and for liquor volume and Doppler blood flow analysis twice a week. It is not clear which parameter predict accurately the risk of fetal death. Maternal LFTs, including bile acids and prothrombin time should be monitored weekly, to decide optimum timing for delivery.Vit.K 10mg daily orally given to mother reduces the risk of maternal and fetal bleeding. Antihistamines such as terfenadine or chlorphenaramine may help to relieve pruritis.Topical emollients are safe in pregnancy.Ursodeoxycholic acid is a choleretic agent and reduces serum bile acids, although it is not licensed for use in pregnancy, but has been used without adverse outcome. A course of steroids can be given for fetal lung maturation, if delivery before 36 weeks is anticipated. Planned induction of labour at 37-38 weeks is advised in view of risk of perinatal mortality.Ceasarean section is reserved for obstetric indications and fetal compromise. A written information leaflet will be provided to her to know about the condition more precisely along with addresses of obstetrics cholestasis patient support groups.
d) I will reassure her that complete recovery is usual.Vit.K supplement will be given to baby to reduce risk of intracranial bleeding. Maternal LFTs are deferred for 10th day as the results are normalized by this time. I will discuss with her the high risk of recurrence (75-90%) in future pregnancy. She will be advised to avoid oral contraceptive containing estrogen as it may disturb liver functions. Follow up is done to ensure that LFTS are reverted to normal.

Posted by Arjuna L.
a)The severity of itchiness and whether it is associated with specific skin lesion (rashes or vesicles) should be established. Presence of dark urine or pale stool should be asked. History of resent drug ingestion should be rule out. Similar family history or family history of obstetric cholestais should be established. Prior history of fever may suggestive of underlying viral infection and history of autoimmune diseases should be asked. Physical examination should stress on the presence of skin lesion or excoriation scar due to excessive scratching mark. Presence of jaundice should be illicit as it may suggestive of abnormal liver function. Abdominal examination to look for palpable liver or presence of tenderness on the right hypocondric region should be carried out.
b). Liver function test should be sent, these include in the form of transaminases, bilirubin, bile acid, gama GT and ALP. Viral screening include Hep A, B, C , Cytomegalovirus, Epstein Barr viruses should be carried out. Possibility of liver auto-immune should be rule out by sending anti smooth muscle antibody or anti mithocondrail antibody. Ultra-sound of liver should be arranged to see if there is any gall bladder stone.
c. The patient should be explained carefully that Obstetric Cholestasis (OC) is a specific liver disease in pregnancy. Multi-displinary approach with the gastroenterology should be arranged. The patient should be counseled that OC is associated with increased risk of preterm labour and haemorrhagic diseases. The explanation about this disease should be supported with written information. The patient should be made aware that the association of OC to fetal distress, meconium aspiration and stillbirth is unclear. The severity of her itchiness should be assessed and symptomatic treatment in the form of emmolient and antihistamin should be initiated. In a severe condition, bile acid chelating agent like ursydeoxycholic acid (USDC) can be prescribed. But this medicine is not licensed to be used in pregnancy. Another alternative is corticosteroid administration may be considered. Close fetal surveillance in the form of CTG, Doppler and fetal growth should be arranged. But the patient should be made aware that none of these tools could predict fetal outcome or prevent stillbirth. Weekly LFT should be done. Oral vitamin K should be given from 34 weeks to reduce the risk of hemorrhagic diseases. Labout can be induced at 37 to 38 weeks but the risk of respiratory morbidity to her unborn child should be explained.
d. Her symptoms of itchiness should be monitored post delivery. Risk of post partum hemorrhage should be bare in mind. Her baby should be given vitamin K injection to prevent neonatal hemorrhagic diseases. LFT can be sent 10 days post delivery. If her symptoms and her abnormal LFT resolve post delivery then conformation of OC can be ascertained. She should be counseled regarding risk of recurrent (75-90%) in the future pregnancy and risk of similar episode in her female family members. Oestrogen contained contraceptive pill should be avoided. Further follow-up should be arranged and written information should be given.
Posted by Iffat ara M.
Answer:
a): in my antenatal Clinic I will take proper history regarding itching & will examine her clinically for any skin lesions .As obstetric cholestasis is most common pregnancy induced liver disease due to intrahepatic cholestasis which presents after 30 week and with out rash there may be associated Anorexia ,malaise ,steatorrhoea , Epigastric discomfort, dark colour urine .

b):Regarding investigations I will request following investigations to rule out other causes of purities and elevated liver enzymes. E.g viral Hepatitis, Biliary tract cirrhosis, PET, acute fatly liver.
So FBC, LFTS, Serum bile acids
(which are up to 10 - 100 times)
especially serum transaminase.
Alkaline transferase , increase gamma glutamyl, transpeptidase.
(as normal levels in pregnancy is 20% lower than non pregnant woman.)

c): Regarding managmentI will counsel her the nature of disease and risk of fetus And mother as maternal morbidly is due to increase Pruiritis and lack of sleep.
In fetus there is increse chances of PTL, IUFD, Stillbirth ,MSL.so I will explain the important of fetal surveillance in pregnancy and delivery.

For mother local application of calamine
Lotion + antihistamine+32 wk onward.For fetal surveillance I will recommend growth scan , Doppler study ctg(but all these test are unreliable to detect sudden iufd.
Timing of delivery would be 37 to 38wks.i will discuss the risk & benefits of early delivery
d):postnatal care
1)neonatal vit k im to avoid risk of icH.
2)LFTs should return to normal after 10 days.
3)symptoms should resolve.
4)Avoid COCp.
5)Explain there is increase chanse of recurrence in the subsequence pregnancy& in family members
6)ensure there is no long term impact on fetus & mother
Posted by H H.
History taking include onset duration ,course and effect on quality of life of the itching.Family history of obstetric homeostasis (oc).History of exposure to blood born infections like hepatitis B ORC.History of skin rash and distribution.Umblical sparing on clinical examination in polymorphic eruption of pregnancy.In herpes gestationes umbilicus is involved.History of allergy to drugs, foods or cosmotics.


Weekly liver function tests(LFT) including enzymes.Serum bile acids and salts increased in oc.Antismooth muscle antibodies and ant mitochondrial antibodies in auto immune liver affection. Clotting studies due to vit k deficiency.

Patient told of implications of oc including liability to preterm delivery.Inconclusive evidence of increased fetal distress, me conium staining of liquor intrauterine fetal death or increased cesarean section. The neonate liable to hemorrhagic disease of newborn due to vit k def. The mother is liable to post partum hemorrhage due to decreased coagulation factors due to vit k def.Monitoring of blood coagulation during antenatal care is a must and vit k is supplied starting at 32 wk (this patient 32wk).LFT are done weekly.The fetus is monitored by CTG Doppler , biophysical profile but mother is told that these can not guarantee fetal wellbeing.
Symptomatic management with emolients has a reliefing effect.Corticosteroids may be of value(inconclusive).Ursodeoxycholic acid will cheate bile acids.It is not licensed for use in oc and used only in trials.All these told to patient.
Early induction of labour at 37-38 wk can be undertaken but according to royal college value inconclusive on perinatal outcome.

Follow up until LFT return to normal(usually within 10 days) and pruritus disappears.Mother told that there is high risk of recurrence in future pregnancy.The neonate is given intramuscular vit k and followed by neonatologist for fear of me conium aspiration.Breast feeding allowed. Hormonal contraception containing estrogen is
Posted by Sam M.
to diagnose obstetric cholestasis a detailed history about on set of itching, its,intensity and association with any drug or food is needed to sort out .i will ask about any rash she had .if yes then type of rah,generalized eruptios after exposure to allergens or site specific ,as contact dermatitis , eczyma or psoriais eruptions,starting from umbilicus as in pemphigoid gestationalis or umbilcus sparing for example in prurigo pf pregnancy, any specific dermatomal involvement as in herpes zoster,history of exposure to blood born viral infections as hepatitis b or c ,history of viral infections in currnt pregnancy,sypmtoms of fever abdominal pain,generalised malaise ,as seen in acute viral infections.history of dark coloured urine or clay coloured stools to rule out obstructive billiary disease. specifically i will ask for on set of itching from hands and sole then spreading to arms and rest of body in absence of eruptions,family history of obstetric cholestasis. on examination depending upon presence or absence of associated other conditions ,in healthy pregnant patient who only complains of intense itching with out other symptoms ,scratch marks of itching would be a sign only.she needs investigations as liver enzymes transaminases,bilirubin level and bile acids, if history suggest viral screen for hepatitis b and c ,to rule out autoimmune cause ,antimitochondrial and anti smootnmuscle antibodies,,coggulation profile and ultrasonograpyu for fetal wellbeing and liqor volume ,. i will advise her that she can take antihistamines for exapmle chlorpheneramine for itching and emoliantsto sooth her skin,and council her that there is no clear ev idence for use of ursodeoxycholic acid to remove bile salts for improving fetal outcome,no rol e of s adenosine methionine,and role of steroids is not clear, what she needs is to start vit k 10 mg per day and weekly liver functiontest
.there is no evidence that ultrasonography ,biophysical profile and CTG can predict fetal death and risk of premature delivery is there.elective inductions doesnot improve fetal outcome.best is to have vaginal delivery ,as ceasarean sectionsare suitable for obstetric reason only.after delivery baby should be seen by neonatologist and be given vitamin k to prevent intracranial haemorrhages.mother should be looked for postpartum haemorrahges because of lack of vit k dependent clotting factors.and had liverfunctiontest 10 days postpartum.should have regular follow up and she should be provided with information leaflets and information about support groups.she will be told that there is risk of recurrence in next pregnancy 50 to 75 %.shold avoid ora contraceptives as liver functions are not normal.
Posted by SK K.
2) It is necessary to identify the cause of itching as it would guide the further management.
On history taking, I would ask for the onset of itching, associated rash, previous history of liver disorders, jaundice and similar itching as taking COCS, family associated symptoms. History of itching during pregnancy or while on COCS.
At 32 weeks in the absence of rash the most likely diagnosis would be obstetric cholestasis this suspicion would be further confirmed if there is a family history of the same or previous history with intake of COCS.
I would enquire into the symptoms of sleep deprivation indicating the severity of itch, jaundice, steatorrhea ,pale stools.
Also as obstetric cholestasis is a diagnosis of exclusion I would try to seek any history that would suggest hepatitis b, c, a , EBV, CMV , chronic hepatitis, biliary cirrhosis, gall stones.

On clinical examination
Absence of rash with scratch marks would favour obstetrics cholestasis, jaundice would be mild.
I would look for rt. Hypochondrial mass, tenderness, hepatosplenomegaly, any e/o portal hypertension , signs of dermatosis, degree of jaundice, so as to rule out other conditions.

Investigation would be ordered so as to exclude other causes & confirm the diagnosis.
In obsetetric cholestatsis, transaminases, bilurubin would be mildly elevated 2-3 fold along with ALKPO4, GGT, urine would test + ve for bile salts, increased serum bile acids 100 fold, though would clinch the diagnosis, test is not easily available in all lab.
Liver USS to exclude gall stones, viral serology for Hep A, B, C, EBV, CMV, antimitochondrial antibodies to r/o autoimmune cause.
Prothrombin time may be affected due to defective absorption of vitamin K requiring bileacids, hence should be maintained.
Liver function test, prothrombin time would be repeated weekly.

Once the diagnosis of obstetric cholestasis is made, it is important to inform the pregnant lady its implication. Which means risk of preterm delivery, meconium staining, intrapartum fetal death, increased risk of IUFD and the risk of fetal intra cranial hemorrhage.
For the lady herself it could cause distress, sleep deprivation, no specific treatment.
The need for frequent fetal monitoring, frequent ANC, repeating lab investigation would be impressed on her.
Fetal surveillance would involve USS for growth, CTG as indicated, BPP twice a week, Doppler velocitometry, though it is not clear which of them predicts IUFD

Tab Vit K 10mg od till delivery from 36 weeks onwards , cold baths, topical emollients, menthol washes to decrease severity of itch, chlophenarimine maleate may also be prescribed.
Though urosdeoxycholic acid is commonly used., it’s use in pregnancy is not liscensed.
Closteremine, activated charcoal could be tried.
Single course of antenatal steroids be administered as risk of PTD is more in this condition.
Plan of delivery to be formulated so as to deliver her by 37-38 weeks. Continuous intraoperative fetal monitoring, high anticipation of PPH, neonate to receive Vit K at birth.
The lady should be provided with written information & contact numbers of support group.

Postnatally she would be reassured that pruritis could take 1-2week for resolving. LFT would be repeated after 10 days, as they take that long to normalize.
Arrange for uss to r/o gallstones, inform her risk of recurrences is 50-60 %.
Standard COCS to be avoided but low dose COC can be given.



Posted by Farkhanda A.
I will make initial clinical assessment from history and examination. In history, I will ask about duration of symptoms, about any drug for water infection? or for any other drugs to exclude any allergic reaction or dermatitis. I will ask about pain in the epigastric region or upper right quadrant to rule out any liver cause. I will check for any temperature, malaise or any jaundice which may be due to acute viral hepatitis, billiary cirrhosis which is the most common cause of jaundice in pregnancy. Simple scratches of itching without jaundice can give clue of obstetric cholestasis of pregnancy. Previous history of recurrent right upper quadrant may be due to gall bladder stones.
I will send blood for full blood count( total white cell count which increases in infection), liver functions test including bile acids which rise in obstetrics cholestasis of pregnancy(OCP) but normal level does not exclude it and conjugatined bilirubin level will be increased.. Screen her for hepatitis A B C. I will check renal function tests to exclude uraemia. Gall bladder and billiary passages ultrasound scan to rule out stones.
In antenatal care, I will inform her about the diagnosis and its effect on the mother and fetus. On mother it causes morbidity due to terrible itching and admission to hospital more surveillance of baby and so more visits for uss and fetal cardiotocography(CTG) and medications.
Risks to the baby are foetal distress, meconium staining ( controversial) and intrauterine death. Symptomatic treatment is emollient use ( not effective) ,antihistaminic such as terfenadine or chlorpheneramine. There are 2 chelating agents which are mostly used in pregnancy. Ursodeoxycholic acid which is not licensed to use in pregnancy ,but is in use without out any adverse effect on pregnancy outcome.
There is mal absorption of vitamin K and risk of bleeding in mother and baby, so from 34 to 36 weeks on ward daily 10 mg vitamin K tablet.
Fortnightly USS for foetal growth and weekly Doppler for foetal well being, but there is no evidence to improve perinatal outcome.
There is no contraindication for vaginal birth. Continuous electronic monitoring is important. Post natal care ,baby should be given vitamin K injection as there is a risk of intracranial bleeding.
Breast feeding is not contraindicated. Aviod combine contraceptive pills as they can increase itching. Inform mother recurrence incidence is 32-50%.

Posted by hoping ..
a) patient should be enquired about onset of itching and pattern of spread as starting from palms and soles may indicate Intrahepatic cholestasis of pregnancy. If other family members are affected may indicated infestation. If it is associated with rash as primary rash excludes cholestasis and may warrant urgent dermatology review. Enquiry if she has recently started new medication or changed washing soap as may suggest allergy. She should also be asked about colur of stools and urine as liver pathology may cause jaundice. examination should include featurse of icterus, rash. abdomen should be examined for fundal height, hepatomegaly and fetal heart should be auscultated .

b) Blood tests for full blood count should be done. liverfunction including bile acids should also be arranged. if liver function is deranged then liver ultrasound should be requested. she should also have coagulation studies performed and immunology testing for anti smooth muscle and anti nuclear antibodies undertaken. infection screening for hepatitis a, b and c should be done.

c)upon diagnosis of obstetric cholestasis her care should be transferred to consultant led care and pregnancy regarded as high risk. Patient should be informed of diagnosis and surveillance needs. she can be managed as outpatient with weekly Day assesment and antenatal clinic review. She should have FBC and LFT repeated every week to detect biochemical deterioration early and rapid worsening may indicate early delivery and inpatient management. Serial two weekly growth and liquor assesment of fetus should be done until delivery. Routine doppler assesment is no more superior. she should be given 2 doses of corticosteroids 24 hours apart as early delivery may be required. Ursodeoxycholic acid 250mg bd should be started and if pateient sees improvement can be increased further if required. It appears to reduce symptoms though not statistically significant. Prochlorperazine 4mg as required may help in her sleep and symptom improvement. She should be commenced on Vitamin K 10mg daily from 36 weeks onwards to reduce risk of bleeding in baby during delivery. Induction of labour at 37 weekds should be done as there is increased risk of stillbirth beyond this gestation and lack of monitoring tools to predict this complication. Vaginal delivery should be considered provided there are no other complications warranting caesarean. Continuous fetal heart rate monitoring done in labour and she can have epidural if coagulation status is normal. baby should be given vitamin K im after delivery.

d) she should be encouraged to braest feed baby. her liver function should be checked at 6 weeks to confirm return to normal because if it s till abnormal then it is not Obstetric cholestasis and referal to hepatic team made. contraception should be discussed, she can start combined pill if liver function has returned to normal and she is not breast feeding. If patient agrees other methoda like progesterone pills or coil should be preffered . she should also be advised about 50% ecurrence risk with future pregnancies.
Posted by Amanda G.
A.
I would take a history from the patient regarding the length of her symptoms and how it is affecting her including insomnia. The site of her itching may indicate cholestasis as the palms of her hands and soles of her feet is common. I would ask about the presence of a rash which may indicate a dermatological condition e.g. eczema or a change to her cosmetics which may indicate an allergic reaction. I would ask about the presence of pale colour of her stools and dark urine which would suggest obstructive jaundice. I would also ask about vomiting or abdominal pain which may indicate a viral hepatitis. I would also enquire about reduced fetal movements.

I would examine the patient looking for a rash indicating a dermatological disease. If she has cholestasis she may have excoriations from scratching due to intense itching. I would palpate the abdomen for hepatomegaly or abdominal pain. I would measure the syphysis-fundal height to assess fetal growth and perform a CTG.

B.
I would investigate her with blood tests including FBC, U+E, LFT and bile acids. If the LFTs are normal it would be important to rule out any other cause for this. I would then check her hepatitis A,B,C,E serology and CM and EBV. I would check for autoimmune liver disease looking for anti smooth muscle antibodies and anti mitochondrial antibodies. I would also arrange a liver ultrasound looking for gallstones (these can occur with cholestasis) or structural liver abnormalities. If her LFTs are normal and she continues to have symptoms she should have weekly LFTs and bile acids as the symptoms can precede the changes in blood tests.

C.
I would explain the diagnosis to the patient and the fact that she will need close monitoring of her pregnancy. I would explain that she needs Consultant led care and hospital delivery. Patients with obstetric cholestasis can usually be managed as outpatients. I would explain that there is a small increased risk of stillbirth although this is difficult to predict. There is also a risk of preterm labour, abruption, fetal distress in labour and meconium stained liquor. There is also a risk of PPH. I would give her an information leaflet about obstetric cholestasis.

She will need an ultrasound for growth, liquor volume and dopplers. This is usually repeated twice weekly. She should also have weekly blood tests for U+E, LFT and bile acids.

She should be commenced on Vitamin K 10mg OD to take until delivery. The baby should be given IM vitamin K after delivery as it is at higher risk of intraventricular haemorrhage. Ursodeoxycholic acid 1000-1500mg OD in divided doses has been shown to reduce bile acid levels and itching but has not been shown to affect outcomes. This drug although commonly used in practice is not licensed in pregnancy. She can take antihistamines at night to help with the itching.

Delivery is usually induced between 37 and 38 weeks to reduce the risk of stillbirth which increases towards term. Delivery may be induced earlier if her bile acids increase steeply as one RCT has shown patients with bile acid over 40 have a higher risk of stillbirth.

D.
As cholestasis is a diagnosis of exclusion it is important to check that all her investigations (Hepatitis screen, autoimmune profile and liver scan) are normal. Her LFTs and bile acids should be checked 10 days after delivery to confirm that they are improving, as they may not decrease immediately after birth. She should be advised to avoid the combined oral contraceptive pill as she may have similar symptoms with this. She should be informed of the high risk of recurrence in further pregnancies (80-90%).
Posted by NARGIS  K.
a) Initial clinical assessment includes patient should be looked for intensity of itching and its effect on quality of life. Presence of characeteristic rash to exclude other skin condition like eczema psoriasis, pemphigoid gestation is to be checked. Presence of scar mark without rash in the sole, pump, trunk, limp is to be looked for suggestive of obstetric cholestasis. Nausea, vomiting, epigastric discomfort, tenderness in the hepatic area is to be inquired. Presence of dark colour urine or pale stool or steatorrhoea may be present.

b) As the clinical examination is normal, it is likely a case of obstetric cholestasis. Investigation is to be done by measuring bile acid concentration which can be the only bio chemical abnormality. A ultrasonography is to be done to exclude gall bladder disease or other billliary pathology. Alkaline phosphatase is to be measured, it is likely to be raised above the upper limit of pregnancy level. Transaminase is to elevated modestly. Gamma glutyle transpeptidase is to be inquired as it is likely to be elevated. Conjugated billirubin level may be raised is to be measured.

c) Antenatal management includes counselling of the patient regarding risk of pre term delivery and its complication, risk of premature rupture of the membrane and meconium stain liquor and its effect on fetus is to be discussed. Risk of antepartem and intrapartem stillbirth is to be informed. No measure is available to predict or prevent the fetal outcome or prevent premature labour need to be discussed. Antihystaminic is to be given to relieve symptom of pruritis. Ursodeoxycholic acid is to be given to reverse the biochemical abnormality although it is not licenced for use in pregnancy. Oral vitamin k is to be given to the patient to prevent haemorrhagic complications. Fetal surveillance is to be done by using ultrasonography for growth scan, Doppler or CTG monitoring. Timing and mode of delivery need to be discussed with the patient. Timing of delivery should be planned at 37 to 38 weeks. Neonatologist must be informed and should be present during the time of delivery.

d) Neonatal vitamin K intra muscular injection is to be given to prevent intracranial haemorrhage. There may be a chance of obstetric haemorrhage so active management of third stage of labour is to be done. Patient should be reassured condition will reverse within 48 hours of delivery. Investigation is to be done to confirm condition is improving. Recurrence rate in subsequent pregnancy is about 75 to 90 percent and this needs to be discussed. Combined Oral Contraceptive pill should be avoided as it may give rise to the same condition.
Posted by Anna L.
A healthy 23 year old primigravida is referred to the day assessment unit at 32 weeks gestation with a 3 day history of generalised itching. (a) Justify your initial clinical assessment [4 marks]. (b) How will you investigate her symptoms, given that clinical examination is normal? [3 marks](c ) A diagnosis of obstetric cholestasis is made. Justify your subsequent antenatal care [10 marks ]. (d) Justify your post-natal care given that she had a normal vaginal delivery [3 marks].

I will justify my assessment with explaining to the patient that itching in 3rd trimester is very common and usually harmless but Obstetric cholestasis/ other liver diseases should be excluded as they can be harmful for mother (liver dysfunction, Bleeding) or baby (IUD). I will take a detailed history of her complaint: Is the itching on palmes or soles of feet (typical for OC), or rather generalised (common in pregnancy)? Is there a rash/blisters/ulcers? And are there any environmental factor (new soap/washing powder)?. Is she generally well, and is the baby moving well? I will ask for medical history of atopia ( Asthma, Multiple allergies) and family history of OC. I will examine the skin of back, abdomen and extremities, especially checking hands and feet for exanthema, stretch and scratch marks to assess the likelohood of OC, pruritic eruption in pregnancy or other causes. I will palpate the abdomen and measure the symphsis fundal height, as OC is associated with IUGR. I will check her BP, HR, urine dipstick for signs of PET and do a CTG to assess the fetal wellbeing. To check for OC i need to take Blood tests.

b) I will take blood for FBC, LFTs and Bile Acids. OC is associated with elevated liver enzymes and raised bile acids ( cut off levels differ in labs.) However, bile acid test result can take up to 2 weeks and management is often started on clinical suspicion. If the LFTs are elevated, other causes need to be excluded and bloods send for viral and auto immnune hepatitis ( HBV; HCV, EBV, Biliary scerosis). A liver US should be done if the LFTs are high.

c) OC is associated with increased morbidity for the mother (Liver dysfunction, risk of bleeding/ PPH and intervention - IOL/CS) and for the baby (Bleeding, iatrogenic prematurity, IUGR, IUD). The pregnancy should be managed in multi disciplinARY TEAM WITH OBSTETRIC MEDICINE team/ physicians, There is no causative antenatal treatment and focus should be on maternal symptoms. Ursodeoxycholic acid can reduce LFT levels and itching but is not proven to improve outcome. LFTs should be checked weekly. Piriton and cooled calamine soliution can improve the itching and associated insomnia. Vitamin K, 10mg OD, should be given from 34/40 to reduce risk of bleeding and PPH in labour. Fetall surveillance shoud be assessed with growth scans, Amniotic fluid volume and Umbilical artery dopler. However, there is no evidence for the reliability of dopplers in OC. Corticosteroids should be given (Bethamethasone 12mg 2x to reduce risk for fetal RDS with premature delivery). The mother should be counselled to address early with reduced fetal movements or signs of PTL. A plan for delivery should be made and documented in the notes - IOL at 38 weeks, CS on obstetric grouds only. AN checks should be performed weekly (LFTs, BP, CTG) or twice weekly with high LFTs and symptomatic.
c) The patient should be to checked for increased blood loss/PPH in immediate post natal period. The baby should receive Im Vit K to reduce riskk of bleeding and paediatric review. The mother\'s LFTs are exspected to go back to normal within 2 weeks and should be checked after delivery and again after 6 weeks. It should be explained to the wokmen that the recurrence risk in the next pregancy is high( around 50%).
Posted by S G.
(a) Justify your initial clinical assessment [4 marks].
I will ask her whether itiching is more prominent in the night, is it associated with rash, does it involve palms and sole. Has she got any history of blood transfusion, fever or any symptom suggestive of jaundice like pale stool or yellow urine. In the absence of these symptoms the likely diagnosis is of obstetric cholestasis.I will ask her about the frequency of fetal movements. I will do a general examination and per abdominal examination to rule out other differentials like artefacta dermatographia and perform a CTG. OC is associated with the absence of rash.
(b) How will you investigate her symptoms, given that clinical examination is normal? [3 marks]
I will send her blood investigation for full blood count, liver function tests, hepatitis A, B, C screen, CMV test and tests for autoimmune disease like chronic active hepatitis, antimitochondrial and antismooth muscle antibody. I will arrange for her to have a liver scan.LFT like transaminases, transferases, bilirubin, bile salts might be raised but they do not correlate with the severity of condition. For fetal well being, I will arrange a cardiotocography although it does not predict the ling term well being of the fetus.
(c ) A diagnosis of obstetric cholestasis is made. Justify your subsequent antenatal care [10 marks ].
I will repeat her LFT weekly. For symptomatic relief, topical emollients as calamine lotion and antihistamine like chlorphenarimine may help her in itiching. OC is associated with sleep deprivation. Cholestyramine which is a bile salt chelating agent and S adenosyl methionine is not used neither gur gum or activated charcoal is used. Ursodeoxycholic acid is the most widely prescribed medication in UK for OC although enough data regarding its effectiveness is not available. Water soluble vitamin K 10 mgs daily is recommended to prevent neonatal intracranial haemorrhage and post partum haemorrhage in mother. Dexamethasone is not recommended outside clinical trail. Intrauterine death in OC is sudden and there is no evidence of placental insuffiency so umbilical artery Dopplerswill be same as in any other pregnancy. CTG does not predict the future outcome.I will arrange her to have weekly follow up in DAU for LFT and CTG with a view for induction of labour at about 37-38 weeks gestation, provided there is no obstetric indication for LSCS. It will prevent the risk of late IUD but increases the respiratory morbidity slightly in the neonate.

(d)Justify your post-natal care given that she had a normal vaginal delivery [3 marks].
Liver function tests should be repeated after 10 days of delivery to confirm the diagnosis. She should be reassured about the long term sequel in the baby. She should be councelled about the higher risk of recurrence in future pregnany and in the family members. She should be advised to avoid oestrogen containing contraceptive measures.
Posted by San S.
a)A detailed history of distribution and severity of her symptoms is important as in certain condition e.g.obstetric cholestasis, the itching is more pronounce on palms and soles. The severity of symptoms could affect her quality of life. Any associated symptoms e.g. rash, flu-like symptoms or fever may indicate viral cause. Associated right upper quadrant abdominal pain with clinical jaundice, pale stool and dark urine may indicate liver pathology.
b)FBC and CRP is useful markers for inflammatory process. LFTs and bile acids are important in identifying any liver pathology and would be raised. Liver autoimmune and hepatitis screen should be considered if LFTs are deranged. Bile acids would be raised in obstetric cholestasis. An USS of liver may be useful to look for liver pathology if LFTs are abnormal.
c)It is important to explain the nature and consequences of the condition to the patient. The effect of condition on mother are the effect of symptoms, affected liver function which could affect her blood clotting ability. Symptoms can be relieved with antihistamine e.g. piriton, and ursodeoxycholic acid. She should be aware that the treatment may improve symptoms and biochemistry changes but not improve neonatal outcome. She should be started on water soluble vitamin K 10mg once daily from 36 weeks gestation for the synthesis of clotting factors.
Posted by San S.
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c)Maternal wellbeing, LFT and bile acids should be monitored twice weekly at the day assessment unit. Fetus has increased risk of IUGR, preterm delivery and stillbirth. Hence, it is important to monitor fetal well-being by USS and CTG twice weekly and growth by USS once forthnightly. Providing maternal and fetal wellbeing is satisfactory, induction of labour is recommended at 37 weeks gestations onwards and depending on local policies. She should be informed that the condition normally resolve after delivery.
d)Neonatal vitamin K is recommended to decrease risk of IVH. Patient should be reassured that her symptoms and blood results should return to normal after deliveries. LFTs should be repeated more than 10 days postnatal as this may rise immediately postpartum. She should also be warned regarding the high recurrence rate in subsequent pregnancy and to avoid COCP.