Question of the Week # 206

206)  A 30 year old  pregnant woman with 32 week gestation presents with severe itching that is present through out the day and  interferes with her sleep at night. The itching is more on palms and soles. She had a similar problem during her previous pregnancy. She denies any history of eczema or liver disease in the past. Physical examination reveals excoriations on the skin. There are no papules, wheals or plaques. There is no scleral icterus. Laboratory investigations reveal an elevated Asparate aminotransferase ( AST) 140u/l , Alanine Aminotransferase (ALT) 150u/l, alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) and Total bilirubin 2.2mg%. Complete blood count is with in normal limits. Hepatitis profile is negative. The most appropriate next step in managing this patient?

A) Serum Bile Acid level

B) Liver Biopsy

C) Ursodeoxycholic acid

D) Immediate delivery

E) Long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) mutation testing

8 Responses

  1. A: serum bile acids, Since the itching is more on palms and feet and there is no antecedent symptoms like fever nausea , jaundice( she is anecteric), the clinical daignosis is most likely Intrahepatic Cholestasis of Pregnancy.
    He is asking the “next step” so I will confrim this daignosis with bile acid levels

  2. but doesn’t it take long time for serum bile acids to come back.. so wouldnt you just go straight to treatment with Ursodeoxcyholic acid

  3. Ans C.
    To obtain a diagnosis of ICP, there are two LFT and Serum bile acid test. The liver function tests (LFTs) is a simple blood test, the results of which should be available by the next day. If the ALT level is elevated, this, plus pruritus of palms and soles, should be treated as diagnostic of ICP (however LFT’s are not always elevated in ICP patients). The serum bile acid blood test for ICP is a quantitative measurement of bile salts. The results of this test often take longer to return, but the test is more specific for ICP.

  4. CCC… Diagnosis of ICP can be made by : pruritis witout rash+pregnancy beyond 25th weeks of gestation & elevated serum Bile Acid &/OR elevated transaminases…… since we made the diagnosis now we treat the patient.

  5. C:)

  6. Answer is C

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