2. BIO DATA
My patient Erum Waqas age 26 years married to Waqas Munir age 27 years for 9 months
is a resident of Barahkohu, Islamabad.
Her marriage is nonconsanguineous.
She is Primigravida with no history of miscarriages or stillbirth.
Her LMP is 25th November 2021 and EDD is 2nd September 2022 and the gestational age as
per today is 30+6 weeks
Her Blood Group is O+ and that of her husband is B-
She pursued formal education till bachelor’s and is currently an HR manager at a private
firm. Her husband is an Army officer.
She was booked at 19 weeks on 7th April 2022
She is fully vaccinated against COVID but was not vaccinated against TB at birth.
3. PRESENTING COMPLAINT
She presented in the OPD for her routine antenatal checkup on 16th June
2022 with the complaint of itching all over the body for the last one week
i.e. since 9th June 2022 at the gestational age of 28 weeks.
Her LFTS came out to be deranged
4. HOPC
My patient was in her usual state of health when she started experiencing itching on 9th June
2022 i.e. at 28 weeks of gestation. The itching started gradually on the soles of her feet and then
advanced to full body in one week. It was especially prominent on her palms & soles and was
consistent in nature.
It got worse at night disturbing her sleep.
It was aggravated on eating spicy and hot food and got alleviated with anti-histamine softin
which she used once daily for 4 days before visiting the OPD.
The itching is not associated with pain, rash, fever, yellowing of skin or eyes, yellowing of urine
or stools, vomiting, diarrhea, or burning micturition. There’s no history of any recent new drug
intake, change of environment, or change in food choices. No history of injectibles either. The
nearby relatives don’t have any complaints of itching.
She followed up in the OPD on 16th June 2022 at 29 weeks of gestation with increased liver
enzymes on LFTs
The systemic inquiry is unremarkable with no history of polydipsia, polyuria, cold or heat
intolerance, loss of consciousness, or constipation.
5. OBSTETRICS HISTORY
1ST TRIMESTER
She has no history of contraception use in and the pregnancy is planned according to her.
It was confirmed by UPT at a local clinic on 1st January at 5+2 weeks.
She had no complaints of nausea, excessive vomiting, fever, rash, fatigue, SOB,
palpitations, vaginal discharge, bleeding, pelvic or abdominal pain, burning micturition, or
urgency.
Her Ultrasound was done on 5th February 2022 at 6 weeks of gestation and confirmed IUP
Her blood Test was conducted on the same day and showed HB levels of 12.8
Urine R/E was normal with no pus cells
She was regularly taking folic acid supplements in 2nd and 3rd month of pregnancy.
There was no drug history
6. 2nd TRIMESTER
Quickening was felt at 20 weeks of GA
Her diet was non-veg with no history of barefoot walking, pica and raw rice eating.
She had no complaints of nausea, excessive vomiting, fever, rash, fatigue, SOB,
palpitations, vaginal discharge, bleeding, pelvic or abdominal pain, burning
micturition, or urgency.
Her anomaly scan was done at 21 week of GA and showed a single normal fetus with
no gross anomalies and adequate liqor.
Her blood test and urine R/E were unremarkable with normal Hb
She was taking Calcium supplements
There was no drug history
7. 3rd TRIMESTER
Fetal movements are normal with the perception of 8-10 movements per day
Fetal heart tracing was normal
There were no complaints of sore throat, fever, nausea, vomiting or burning
micturition.
Generalized itching at 28 weeks with no jaundice or rash
Her LFTs were deranged
She has received her 1st dose of TT
She is taking calcium and iron supplements
9. GYNAECOLOGICAL Hx
Her age of menarche was 15 yrs
Her cycle is regular of 4/28 days
The flow is normal and she soaks 1 pad for every day she bleeds
There is no history of dysmenorrhea, IMB, PCB
Her pap smear test hasn’t been done
10. PAST MEDICAL & SURGICAL Hx
She has no history of any liver disease or gallstones or injectibles.
No history of eczema or allergies
She has a positive history of TB at 11 years of age for which she received home
treatment for 9 months.
There is no history of HTN, DM, IHD, asthma or drug allergies.
Past surgical history is unremarkable.
11. FAMILY Hx
The family history for liver disease, gallstones and eczema is negative.
Her grandmother died of TB at 71 years of age when she was 9 years old.
No family history of HTN, DM, IHD, asthma, liver cirrhosis, malignancies, or
mental illnesses.
12. PERSONAL Hx
Her sleep has been disturbed ever since she developed pruritis
She has no Hx of substance abuse or IV drug addictions
No history of blood transfusions
Her appetite is adequate
Bowel habits are normal
Her office timings are 10-6 Mon-Sat and she spends her time cooking and
cleaning at home
She walks 30 mins every day
13. SOCIO-ECONOMIC Hx
She lives in a joint family of 8 people. The total earners are 4 and the total
household income is around 120k. Her house is well ventilated with 6 rooms
Her family income is 60k
They consume water for drinking from a nearby filter plant
She has 2 rabbits, 4 hens and a pair of parrots as pets
14. GPE
On examination my patient was conscious well oriented and cooperative. She was afebrile. Her pulse
was 80 beats/min. Her RR was 19 breaths/min and her B.P was 110/70.
According to the patient her weight is 79 kg and her height is 5’4. Her BMI is 29.9 which lies in the
category of overweight.
On examination Mild excoriations on extensor surfaces of arms and legs were observed. On
examination of her hands, there was no pallor or erythema. Her capillary perfusion was normal. There
was no clubbing or koilonychia.
Her hair weren’t sparse or brittle. She didn’t have acne or rashes or vesicular eruption.
There were no signs of jaundice or anemia.
Her Oral hygiene was satisfactory with no mouth ulcers.
There was no neck enlargement either in the thyroid region.
Her submental, submandibular, preauricular, postauricular, subclavicular, axillary lymph nodes were not
palpable.
There were no visible scar marks on her chest or abdomen and her breasts were symmetrical with signs
of discharge or nipple retraction.
There was no pitting edema on her legs or feet. No varicose veins were observed either.
16. SYSTEMIC EXAM
Heart sounds were normal on cardiac examination
Bilateral chest sounds were heard with biventricular vesicular breathing
CNS exam was unremarkable
17. DIFFERNTIAL DIAGNOSIS
Obstetric Cholestasis –Provisional Diagnosis
Allergy (contact, food or drug)
Cholelithiasis
Active Liver disease (Viral Hep)
Scabies or other Skin infection
Pre-eclampsia and acute fatty liver of pregnancy
18. INVESTIGATIONS
Baseline: CBC, Urine R/E (color of urine + bile salts), BSR, Blood grouping
LFTs check for rise in ALT, AST and gamma GT. Pregnancy specific reference range
which is 20% lower than non-pregnant range should be used. Conjugated bilirubin could
be raised in cholestasis
Serum Bile acid levels
Clotting screen only if already suspected low platelets/ bleeding tendencies or already
highly deranged LFTs
Virology Screen (Hepatitis A, B, C, D, E) Epstein Barr and Cytomegalovirus)
USG to rule out gallstones + liver pathology
Liver autoimmune screen for chronic active hepatitis and primary biliary cirrhosis (anti-
smooth muscle and anti-mitochondrial antibodies)
19.
20. MANAGEMENT
No need to admit only at term risk of sudden IUD
MATERNAL:
GENERAL advice:
Have frequent tepid baths
Try not to get too hot
Wear loose cotton clothing
Lower fat intake
SPECIFIC:
Biophysical profile twice a week
FETAL:
Mother to maintain Kick chart at home everyday same time every day for 1 hour count how many
times baby moves
CTG
Every week till 37 weeks visit + fetal wellbeing: height of fundus & amount of liqor & fetal Heart
21. TREATMENT
Only partial relief, condition goes away after pregnancy
Calmine lotion or oil local application for symptomatic relief
Anti-histamine with sedation
URSO Ursodeoxycholic Acid 250 mg 2+2 (remove more hydrophobic bile salts
from bile acids) this protects hepatocyte membrane, enhance bile acid
clearance and protect cardiomyocytes,
If PT prolonged, Vitamin K 5-10 mg OD also due to malabsorption of fat soluble
vitamins due to failure of excretion of bile salts. Reduces risk of PPH.
Sedation
22. COUNSELLING
Explain Diagnosis and symptomatic treatment outcome. Condition will resolve on its own after
pregnancy only symptomatically lotion or oil on skin, taking bath.
1.5% of pakistani Asian women affected
33% genetic related sisters mothers have a high possibility
Maternal morbidity: Insomnia might be bothersome
No harm to baby after deliver
FETAL Complications: meconium passage esp in severe (bile acids 40 mm/l a.c.t. mild i.e:
<20mm/l)
Iatrogenic prematurity,
Increased risk of C section 10-36%, fetal distress 33%
Preterm birth or Spontaneous IUD 2%
Monitoring every week
Kick chart maintence
Delivery at 37 completed weeks
23. PLAN FOR DELIVERY
If comes into labors before 37 monitor closely
37 weeks electively no beyond,
Discuss mode of delivery and place with patient.
Confirm no contradiction for vaginal delivery i.e. Cephalic presentation CPD
Induction: bishop score method to find out response of patient to method of induction of
labour how will she respond check for cervical length dilation consistency, position and
station of head total score: 10 6 is good less than 6 less favorable
Tablet gel syntocinon drip
24. POST NATAL
Administer Vit K to baby
LFTs at 6 weeks return to normal, pruritis resolves. Serum bile acids should
return to normal too. Postnatal resolution of symptoms and normalization of
LFTs is crucial in confirming the diagnosis of OC.
High recurrence rate 45-90% in the subsequent pregnancies
Contraception: avoid estrogens. 10% risk of developing pruritus or hepatic
impairment or both with estrogen-containing contraception
There are no known developmental problems for the baby and no increased
risk of developing neonatal jaundice
