Obs - 2nd and 3rd trimester complications

Question 1

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. She is unable to sleep at night due to the symptoms.

On examination, there is no rash other than dermatitis artefacta due to scratching. Obstetric examination is normal.

What are your main differentials?

Answer 1

1. normal pruritis of pregnancy
2. obstetric cholestasis
3. gallbladder or liver pathology
4. polymorphic eruption of pregnancy (would have a rash)
5. pemphigoig gestationis (would have a rash)
6. coinciding skin disease e.g. eczema (would have a rash)

Question 2

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. She is unable to sleep at night due to the symptoms.

On examination, there is no rash other than dermatitis artefacta due to scratching. Obstetric examination is normal.

Which investigations would you perform and why?

Answer 2

1. LFTs inc. AST, ALT, gamma-GT and bilirubin: increased AST, ALT and gamma-GT with normal bilirubin in OC
2. total bile acids: increased in AC
3. viral screen for HepA/B/C, EBV and CMV: exclude viral hepatitis
4. liver autoimmune screen - anti-smooth muscle and anti-mitochondrial Abs: exclude chronic active hepatitis and biliary cirrhosis
5. clotting profile: if OC lasts several weeks, liver dysfunction can cause decreased vitK reabsorption and decreased prothrombin production, prolonged PTT
6. liver USS: exclude gallstones

Question 3

What are the risk factors for obstetric cholestasis?

Answer 3

• previous OC (90% risk)
• FHx of OC (35% risk)
• multiple pregnancy
• Asian ethnicity
• pruritis on the COCP

Question 4

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. Other conditions are excluded and she is diagnosed with obstetric cholestasis.

How would you manage her?

Answer 4

• regular LFT measurements
• regular foetal monitoring and continuous foetal monitoring during delivery
• daily maternal oral vitamin K (to reduce risk of PPH)
• symptom relief:
  
  • URSODEOXYCOLIC ACID (may displace bile salts and protect hepatocytes)
  • antihistamine (may help to sleep)
  • topical emollients
• delivery at foetal maturity
• neonatal vitamin K
• f/u LFTs 10 days PN

Question 5

A 25-year-old lady presents to you at 26 weeks gestation complaining of sudden onset SOB, pleuritic chest pain and cough. How would you assess and manage her initially?

Answer 5

1. clinical assessment
2. bloods: FBC, UandE, LFTs
3. CXR + ECG
4. start Tx dose LMWH (dalteparin or enoxaparin)
5. leg doppler USS - if shows DVT: further management as PE
6. if CXR normal do V/Q scan, if CXR abnormal do CTPA

Question 6

A 25-year-old lady presents to you at 26 weeks gestation complaining of sudden onset SOB, pleuritic chest pain and cough. CTPA confirms a PE. How would you manage her in the long term?

Answer 6

Tx dose LMWH until 6-12 wks post-partum (omit dose 24hrs before planned IOL or CS or if woman thinks she is going into labour).

LMWH should be taken throughout antenatal period in any subsequent pregnancies.