A 29-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a routine prenatal visit. For the past week, the patient has had increasing pruritus that has been most severe on her palms. She has tried using oatmeal baths and lotion, but the pruritus has continued. The patient also has nausea and difficulty sleeping due to pruritus and increasing back pain. She now takes diphenhydramine and acetaminophen nightly to help her sleep. The patient has chronic hypertension that has been well controlled during this pregnancy. Blood pressure is 138/86 mm Hg and pulse is 76/min. Fundal height is 30 cm. Fetal heart rate is 150/min. There are multiple excoriations on the abdomen and thighs. The remainder of the examination is normal. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a routine prenatal visit.  For the past week, the patient has had increasing pruritus that has been most severe on her palms.  She has tried using oatmeal baths and lotion, but the pruritus has continued.  The patient also has nausea and difficulty sleeping due to pruritus and increasing back pain.  She now takes diphenhydramine and acetaminophen nightly to help her sleep.  The patient has chronic hypertension that has been well controlled during this pregnancy.  Blood pressure is 138/86 mm Hg and pulse is 76/min.  Fundal height is 30 cm.  Fetal heart rate is 150/min.  There are multiple excoriations on the abdomen and thighs.  The remainder of the examination is normal.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da25_cda2_bc81_0ba8be348d09_MD0003_00 This patient's pruritus that is most severe on the palms with no associated rash is consistent with intrahepatic cholestasis of pregnancy (ICP), which typically occurs during the third trimester. ICP is likely due to increased estrogen and progesterone levels that cause hepatobiliary tract stasis and decreased bile excretion. This results in elevated total bile acids (≥10 µmol/L), which are diagnostic for ICP and can cause a generalized, intractable pruritus that is worse on the palms and soles. Some patients may have right upper quadrant pain and elevated aminotransferases; alkaline phosphatase is often elevated but is not specific for ICP because it is also produced by the placenta. ICP does not increase the risk of maternal complications; however, due to transplacental passage of bile acids, it does increase the risk of fetal complications (eg, intrauterine fetal demise, meconium-stained amniotic fluid). Therefore, management includes both treatment of maternal pruritus and prevention of fetal complications. First-line treatment is with ursodeoxycholic acid, which improves pruritus and may decrease obstetric complications. In addition, patients require regular fetal assessment (eg, nonstress test) and delivery at 37 weeks gestation. (Choices A and B) Emergency delivery and magnesium sulfate may be indicated in patients who have chronic hypertension with superimposed preeclampsia. These patients may have elevated aminotransferases; however, this diagnosis is unlikely because this patient is normotensive. (Choice C) N-acetylcysteine is used in the treatment of acetaminophen poisoning, which can present with elevated aminotransferases. However, patients typically have acute nausea and vomiting that develop into right upper quadrant pain and hepatomegaly; aspartate and alanine aminotransferase levels are usually >1,000 U/L. (Choice D) Topical corticosteroids are used for polymorphic eruption of pregnancy (or pruritic urticarial papules and plaques of pregnancy), which causes pruritus and rash within the abdominal striae; the pruritis spreads centrifugally but spares the palms and soles. Topical corticosteroids do not improve pruritis associated with ICP. Educational objective: Intrahepatic cholestasis of pregnancy presents in the third trimester with pruritus that is worse on the hands and feet with no associated rash. Diagnosis is confirmed by elevated total bile acids (≥10 µmol/L). Management includes ursodeoxycholic acid and delivery at 37 weeks gestation. References: Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. (http://www.ncbi.nlm.nih.gov/pubmed/30773280) Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26071912)

A 29-Year-Old Woman, Gravida 1 Para 0, at 30 Weeks