A 30-year-old woman presents at 27 weeks gestation with intense itching on her abdomen, hands and feet. The itching is localised to the palms and soles, and you can see no associated rash. On examination, you note scleral icterus but no other abnormalities. Her abdomen is soft and non-tender. Her blood results are as follows:

  • Hb 11.2 g/dL (12-15 g/dL)
  • MCV 81 fl (80-100 fl)
  • Platelets 201 x 109/L (150-400 x 109/L)
  • Bilirubin 30 mmol/L (3-20)
  • ALT 299 IU/L (5-40)
  • Bile acids: 52 mmol/L (3-11)
1. What is the most likely diagnosis?

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This patient has a diagnosis of obstetric cholestasis.

Obstetric cholestasis is a condition where cholestasis and intense pruritis occurs in the second half of pregnancy. The pathogenesis is not fully understood, but it is thought to be related to abnormal biliary transport across the canalicular membrane, and there may be a genetic predisposition.

Presentation is from the 25th week of gestation with intense itching without a discernable rash affecting the palms, soles and abdomen. Jaundice can also occur.

Investigations typically reveal markedly elevated aminotransferases and elevated bile acids.

2. Give two risks to the pregnancy that are associated with this diagnosis.

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Obstetric cholestasis is associated with the following risks to the pregnancy:

  • Stillbirth
  • Premature birth
  • Fetal distress
  • Meconium passage
3. Which drug can be used in the treatment of this condition?

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Treatment is with ursodeoxycholic acid, which lessens itching and improves liver function.

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