TEALE FENNING

Nick Raine-Fenning

Obstetrics 4: March 2008

Woman presents at 33 weeks with itching on hands and feet, what are the differential diagnoses? (4 marks)

What investigations are the most appropriate? (6 marks)

It turns out to be OC so how would you manage it? (10 marks)

premgunny · Joined: 09 Apr 2008 Posts: 16

detailed history about symptom including worsening of itching during night causing sleep deprivation, associated rash, general wellbeing, nausea/vomiting, fetal movement, recent change in toiletries.
Obstetric history regarding previous pregnancy in association with obstetric cholestasis or family h/o OC as high recurrence rate.

intense pruritus worsens at night involving palm and sole in the absence of rash, abnormal liver function test, pale stool, dark urine and complete resolution after delivery favours OC
itching with maculo papular rash more commonly starts in abdomen over striae gravidorum and common in Asian women goes for polymorphic pruritic eruption of pregnancy.
Previous eczema history, more suspicion of eczema exacerbation.
skin trauma due to intense scratching due to allergy, stress or psychosomatic reason- dermatograhia artifacta.

can't think of anything else.

premgunny · Joined: 09 Apr 2008 Posts: 16

I would like to arrange liver function test especially increased ALT with pregnancy specific reference range, bile acids eventhough normal value not exclude OC, virology screen including hepatitis A,B,C, epstein Barr and cytomegalo virus, Liver auto immune screen to rule out other causes of abnormal liver funtion.

premgunny · Joined: 09 Apr 2008 Posts: 16

Explain to the woman about OC being a condition specifically pregnancy associated which resolves completely postdelivery. Risk of stillbirth, meconium stained liquor, caesarean section, postpartum heamorrhage are in conclusive. Relevant patient information leaflet needs to be given.

Weekly liver function tests and bile acids to be arranged with day obstetric unit.No specific fetal monitoring modality (CTG, USS,doppler, FM kick chart, amniocentesis, meconium, mature lecithin:sphingomyelin) predicts fetal death as it occurs by sudden onset of acute hypoxia.

Insufficient data to support early (37we) induction of labour to reduce stillbirth. No specific treatment for improving maternal/fetal outcome. Symptomatic treatment for pruritus with topical emollients like calamine lotion, aqueous cream with menthol, systemic treatment like cholestyramine (bile acid chelating agent), anti histamines, activated charcoal, uresodeoxy cholic acid, S-adenosyl methionine (needs intravenous administration), dexamethasone (not as first line).

Vitamin K as oral 10mg to mother from 36weeks and as intramuscular injection to newborn at birth to decrease PPH, fetal/neonatal bleeding.

Postnatal - Repeat LFT 2-3weeks postdelivery and ensure normality and pruritus subsides. Reassure regarding lack of longterm sequelae in mother/baby. High recurrence rate in future pregnancy and increased risk for family members to be mentioned. Advice to avoid estrogen containing contraceptives because of liver metabolism.

manoj · Joined: 22 Jun 2008 Posts: 7

Woman presents at 33 weeks with itching on hands and feet, what are the differential diagnoses? (4 marks)

What investigations are the most appropriate? (6 marks)

It turns out to be OC so how would you manage it? (10 marks)

1. Differential diagnosis for a woman presenting with itching on hands and feet could be a) preexisting skin conditions worsening or flare ups like eczema or psoriasis or new occurance of these conditions in pregnancy, but usually are associated with skin lesions.
b) Allergic reaction of skin to new food/clothing/detergents etc is a possibility and mostly will have skin erythema or allergic signs
c) Dermatoses of pregnancy like polymorphic eruption of pregnancy, pemphigoid gestationalis, prurigo of pregnancy, pruritic folliculitis of pregnancy, again these condition are mostly associated with skin lesions and lesions may involve on abdomen.
d) Most important of all to Obstetritian is Obstetric Cholestasis which is not associated with rash and presents with itching to start with most commonly on palms and feet, it can cause skin lesion associated with scratching described as dermatographia artifacta.

2. Investigation include Blood tests for liver function tests to look for any abnormalities in transaminases, bilirubin/ or bile salts. These are sufficient to support a diagnosis of Obstetric cholestasis at this gestation. When LFT's are derranged other causes of abnormal LFT's should be excluded, this includes viral screen for hepatitis A,B and C, Epstein Barr Virus and Cytomegalo virus, a liver auto immune screen for primary biliary cirrhosis and chronic active hepatitis and an ultrasound scan of liver to exclude other conditions of extra biliary cholestasis.
At this gestation if LFT's are deranged investigations necessary for preeclampsia and acute fatty liver of pregnancy should also be considered
Once diagnosis of Obstetric cholestais is made then measure LFT's weekly till delivery and post natally after 10 days because normally in pregnancy LFT's increase in the first 10 days.
Blood clotting studies should also be done when abnormal LFT's are seen because can cause increase anaesthetic risks for epidurals etc in labour and also increases risk for post partum haemorrhage and neonatal haemorrhagic complications.
Investigations like CTG should be done as required with clinical situation like reduced fetal movements.
If other conditions of skin are considered to be the cause of itching relevant investigation in liason with dermatologist like skin biopsy, immunofluroscence study etc should be considered.

3. Management of Obstetric cholestasis involves medications to control itching starting with topical emollients like calamine lotions, anti histamine like chlorpheniramine helps mostly to contol symptoms at night which may help improve quality of sleep.
Other medications like Ursodeoxycholic acid and S-adenosy methionine could be tried with intention of reducing itching symptoms but should be explained to the patient regarding lack of robust evidence with these medications and use with informed patient choice.
Steroids like dexamethosone could be tried for symptom relief but not recommended.
Explain to patient there is no medications to completely revert the condition other than delivery but at the same time 33 weeks is too early for delivery. She should also be explained about the association of unexplained still birth with obstetric cholestasis is unclear, but the popular practise is to deliver around 37-38weeks gestation and this is aimed at reducing late still births. Also explain there is no tests to predict stillbirths.
She should be also well informed regarding risks of prematurity and to consider steroids if <32 weeks with preterm labour to reduce the risks associated with prematurity like neonatal respiratory distress symptoms and involve neonatal team.
It is advisable to give oral vitamin K from 36 weeks gestation or Vitamin K (injection or orally) to baby immediate after delivery.
Give written information and contact details to attend labour ward if any concerns.
Expain the inceased risk of recurrance in subsequent pregnancies.