Obstetric Cholestasis; Polymorphic eruption of pregnancy

Question 1

What causes obstetric cholestasis? [2]

Answer 1

result of increased oestrogen and progesterone levels
- In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis).

Question 2

Obstetric cholestasis is associated with an increased risk of [].

Answer 2

Obstetric cholestasis is associated with an increased risk of stillbirth.

Question 3

What are the clinical features of intrahepatic cholestasis of pregnancy? [3]

Answer 3

• pruritus - may be intense - typical worse palms, soles and abdomen
• clinically detectable jaundice occurs in around 20% of patients
• raised bilirubin is seen in > 90% of cases
• pale greasy stools

NB: no rash present

Question 4

How do you investigate for obstetric cholestasis? [1]

Answer 4

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
Raised bile acids

TOM TIP: It is normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.

Question 5

How do you manage obstetric cholestatis? [4]

Answer 5

• induction of labour at 37 weeks is common practice but may not be evidence based
• Emollients (i.e. calamine lotion) to soothe the skin
• ursodeoxycholic acid - again widely used but evidence base not clear
• vitamin K supplementation if clotting deranged (A lack of bile acids can lead to vitamin K deficiency, which lead to impaited clotting)

Question 6

What are the symptoms of polymorphic eruption of pregnancy? [4]

Answer 6

Lesions are pruritic but spare the periumbilical region, face, and mucosal surfaces:
* Urticarial papules (raised itchy lumps)
* Wheals (raised itchy areas of skin)
* Plaques (larger inflamed areas of skin)

Systemic symptoms are absent.

Question 7

How do you manage PMEP? [1]

Answer 7

Topical emollients
Topical steroids
Oral antihistamines
Oral steroids may be used in severe cases

Question 8

During which trimesters of pregnancy does atopic eruption of pregnancy occur? [1]
What are the two types? [2]

Answer 8

first and second trimester of pregnancy:

E-type, or eczema-type:
- with eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest.

P-type, or prurigo-type:
- with intensely itchy papules (spots) typically affecting the abdomen, back and limbs.

Question 9

Describe what is meant by melasma [1]

Answer 9

Increased pigmentation to patches of the skin or face

No active treatment is required if the appearance is acceptable to the woman. Management is with:

Avoiding sun exposure and using suncream
Makeup (camouflage)
Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care
Procedures such as chemical peels or laser treatment (not usually on the NHS)