Itchy

A 27 year old primiparous lady presents at 29 weeks of gestation with generalized pruritus for one week. The pruritus is most prominent on the palms and soles and is worse at night.

Her pregnancy has been otherwise uncomplicated. Her medical history is unremarkable for dermatological diseases and allergic conditions.

Her full blood count, renal functions and clotting profile are normal. Her urine tests negative for proteins.

Select Relevant Investigations
Liver function tests

Performed

ALT 48 IU/L (normal 0-35)
AST 56 IU/L (normal 0-30)
ALP 354 IU/L (normal 35-135)
GGT: 24 IU/L (normal 0-38)
Total bilirubin: 1.8 mg/dL (normal 0.1-1.2)
Conjugated bilirubin: 1.2 mg/dL
Bile acids: 14 micromol/L (normal <11)
Autoimmune screen

Performed

ANA: negative
Anti-smooth muscle antibodies: absent
Anti-mitochondrial antibodies: absent
Hepatitis Serology

Performed

HBsAg: negative
IgM anti HBc: negative
IgM anti-HCV: negative
Hep E antibody: negative
Liver biopsy

Performed

There is no evidence of inflammation. Bile plugs in the hepatocytes and canaliculi are noted. The bile ducts are not dilated, and there are no signs of injury.

Select Relevant Management
Ursodeoxycholic acid
Vitamin K
Emergency delivery
N-acetyl-cysteine