QuestionSBA
QuestionChoice
This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. There is a raised bilirubin in only a quarter of cases and raised bilirubin lacks specificity for this pathology.
53016
e
Serum bilirubin
QuestionChoice
Uraemia can cause skin itching; however, this patient has no known risk factors for renal failure and no other signs consistent with it on history or examination, such as asterixis, confusion or pericarditis.
53013
b
Serum urea
QuestionChoice
This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
53014
c
Serum ALT
QuestionChoice
This patient likely has intrahepatic cholestasis of pregnancy, which presents typically with persistent itching (especially on the hands/feet and nocturnally) in the third trimester and can run in families. Alanine transaminase (ALT)/aspartate transaminase (AST) may be mildly elevated, as well as bilirubin, but total serum bile acid is the most specific test and will be markedly raised in around 80% of cases. There is an increased risk of foetal compromise and stillbirth with this condition; therefore, early delivery may be indicated.
53012
a
Bile acids
QuestionChoice
This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
53015
d
Serum AST
QuestionComment
this is so dumb you're never going to order just one liver investigation.. and you need to see the other results to exclude other causes anyway
27620
QuestionComment
preach my brother!

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Serpiginous Retrograde
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Kawasaki Dermis
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# Summary


Obstetric cholestasis is a pregnancy-related condition typically occurring after 24 weeks of gestation, characterised by the accumulation of bile acids. Key signs and symptoms include pruritus, fatigue, nausea, loss of appetite, occasional mild maternal jaundice, and right upper quadrant abdominal pain. Key investigations encompass liver function tests, bile acids measurement, and fetal monitoring. Management strategies include administration of chlorphenamine and vitamin K, early delivery planning, and off-license use of Ursodeoxycholic Acid (UDCA).


# Definition


Obstetric cholestasis, also known as intra-hepatic cholestasis of pregnancy, is a pregnancy-related hepatobiliary disorder that typically manifests after the 24th week of gestation. The condition is characterised by impaired bile flow leading to the accumulation of bile acids.

# Aetiology


The exact cause of obstetric cholestasis is not fully understood. However, it is believed to be influenced by hormonal and genetic factors, as well as environmental triggers.


# Signs and Symptoms

Clinical manifestations of obstetric cholestasis include:

- Pruritus: This is often severe and typically more intense on the hands and feet. It is not associated with a rash, although excoriation marks from scratching may be present.
- General discomfort: Patients may experience fatigue or malaise.
- Gastrointestinal symptoms: Nausea and loss of appetite are common.
- Jaundice: Mild maternal jaundice characterised by dark urine and pale stools may occasionally occur.
- Abdominal pain: Pain is typically localised in the right upper quadrant.


# Differential Diagnosis


The differential diagnoses for obstetric cholestasis include:

- Pruritic urticarial papules and plaques of pregnancy (PUPPP): Characterised by itchy, red bumps and large patches of hives.
- Prurigo of pregnancy: Characterised by small, itchy bumps on the skin.
- Pruritus gravidarum: Generalised itching during pregnancy with no apparent cause.
- Other hepatobiliary disorders: These include viral hepatitis and gallstones, which can present with similar symptoms.

# Investigations

Investigations for obstetric cholestasis focus on liver function tests and bile acids measurement. Fetal monitoring may be required due to the risk of spontaneous intrauterine death associated with the condition.

# Management

Obstetric cholestasis is managed with the administration of chlorphenamine and emollients to alleviate itching, vitamin K to minimize the risk of bleeding, and early delivery planning to reduce the prolonged risk of spontaneous intrauterine death. Ursodeoxycholic Acid (UDCA) can be used on an off-license basis to reduce serum bile acids and relieve pruritus, but its routine use is no longer recommended by RCOG.

# References

[RCOG - Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43)](https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.17206)
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Obstetric cholestasis
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Obstetrics
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Obstetric cholestasis
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HELLP Syndrome
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Obstetric cholestasis
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Rash in pregnancy
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Obstetric cholestasis
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Quesmed Tutorial: Obstetrics 2
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Intrahepatic cholestasis of pregnancy presents with intense itching, particularly on palms and soles, and is diagnosed by elevated serum bile acids.
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Pruritus
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Dermatology
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Pruritus
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Gastrointestinal including liver
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Pruritus
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Obstetrics and gynaecology
A 34-year-old primigravida woman who is 35 weeks pregnant presents with itchy skin for 5 d to A&E. There has been no response to antihistamines or creams. The itching is particularly intense on her palms and soles and at night. Her pregnancy has been unremarkable so far and she has no prior health conditions. She reports that her mother had a similar problem during her pregnancies. On examination, she has extensive scratch marks to her arms and abdomen. The remainder of the examination is normal.

Which investigation is most specific for her underlying diagnosis?
a