A 37-year-old woman, gravida 2 para 1, comes to the emergency department due to decreased fetal movement for the last 2 days. She has had no contractions, vaginal bleeding, or leakage of fluid. The patient had no issues with this pregnancy until a few weeks ago, when she began to develop generalized itching that is worse on her hands and feet. She has also had nausea for the past 3 days but no vomiting or diarrhea. The patient recently immigrated to the United States and has had no prenatal care. Temperature is 37 C (98.6 F) and blood pressure is 134/76 mm Hg. Fundal height is 38 cm. There is no scleral icterus. Cardiac and pulmonary examinations are normal. The right upper quadrant is tender to palpation, but there is no rebound or guarding. Bilateral lower extremities have 1+ pitting edema. Diffuse excoriations are noted on the skin. Laboratory results are as follows: A transabdominal ultrasound reveals a 38-week intrauterine gestation with no fetal cardiac activity. Which of the following is the most likely cause of this patient's presentation?

Question

A 37-year-old woman, gravida 2 para 1, comes to the emergency department due to decreased fetal movement for the last 2 days.  She has had no contractions, vaginal bleeding, or leakage of fluid.  The patient had no issues with this pregnancy until a few weeks ago, when she began to develop generalized itching that is worse on her hands and feet.  She has also had nausea for the past 3 days but no vomiting or diarrhea.  The patient recently immigrated to the United States and has had no prenatal care.  Temperature is 37 C (98.6 F) and blood pressure is 134/76 mm Hg.  Fundal height is 38 cm.  There is no scleral icterus.  Cardiac and pulmonary examinations are normal.  The right upper quadrant is tender to palpation, but there is no rebound or guarding.  Bilateral lower extremities have 1+ pitting edema.  Diffuse excoriations are noted on the skin.  Laboratory results are as follows:  A transabdominal ultrasound reveals a 38-week intrauterine gestation with no fetal cardiac activity.  Which of the following is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d9ff_ced6_bc81_038c88fa6ff9_MD0003_00 This patient's elevated total bile acids and intrauterine fetal demise are consistent with intrahepatic cholestasis of pregnancy (ICP). ICP typically occurs in the third trimester because increased estrogen and progesterone levels cause hepatobiliary tract stasis and decreased bile excretion. This results in elevated total bile acids (≥10 µmol/L), which accumulate in the liver (resulting in elevated aminotransferases and bilirubin levels) and skin (resulting in pruritus that is worse on the hands and feet). Risk factors include prior ICP, maternal age ≥35, and multiple gestation. Although ICP does not cause maternal complications, bile acids can cross the placenta and cause fetal complications, as seen in this patient. The maternal serum bile acid level is directly proportional to the risk of complications because bile acids accumulate in the fetal circulation and become increasingly toxic. The risk of intrauterine fetal demise (IUFD) is particularly high when serum bile acids are ≥100 µmol/L. Additional complications of ICP include preterm delivery, meconium-stained amniotic fluid, and neonatal respiratory distress. Because of the risk of IUFD, management of ICP includes ursodeoxycholic acid (which can decrease bile acid levels), frequent antepartum monitoring (eg, nonstress test), and delivery by 37 weeks gestation. (Choice A) Acute fatty liver of pregnancy can present with right upper quadrant pain, elevated transaminases, and IUFD. However, patients typically have symptoms of fulminant hepatic failure (eg, scleral icterus, encephalopathy), leukocytosis, and platelet count ≤100,000/mm³. (Choice B) This patient is immune to hepatitis A and B without evidence of acute disease. Acute viral hepatitis is often accompanied by jaundice with malaise and decreased appetite; in addition, it does not typically cause IUFD. (Choice C) HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome can present with elevated liver transaminases and IUFD. Patients with HELLP syndrome have platelet counts of ≤100,000/mm³ and typically have associated hypertension, making this diagnosis less likely. (Choice E) Preeclampsia with severe features can present with elevated transaminases and cause IUFD due to uteroplacental insufficiency; this patient is normotensive, making this diagnosis unlikely. Educational objective: Intrahepatic cholestasis of pregnancy presents with pruritus that is worse on the hands and feet. Patients are at increased risk of fetal complications, including intrauterine fetal demise, particularly with markedly elevated total bile acids. 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 37-Year-Old Woman, Gravida 2 Para 1, Comes to the Emergency