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Case Discussion: Generalised Itch

Case Discussion: Generalised Itch. May 2014. Consider Julie…. Julie is a an OSC patient of yours She is 35 yo primary school teacher, G1 P0 She is 31/40 and her pregnancy to date has been uneventful. All routine investigations have been normal

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Case Discussion: Generalised Itch

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  1. Case Discussion: Generalised Itch May 2014

  2. Consider Julie… • Julie is a an OSC patient of yours • She is 35 yo primary school teacher, G1 P0 • She is 31/40 and her pregnancy to date has been uneventful. All routine investigations have been normal • She presents a week earlier than her scheduled review as she is finding it difficult to tolerate a generalised itch • What are the possible diagnoses? • What further information would you like from the history and examination?

  3. History & Examination: • Symptoms started 2 weeks prior whilst on a 10 day holiday in Bali • She thought it was the humidity and resort toiletries and sheets • However it has persisted on her return, she thinks it is due to the hot weather • No other symptoms apart from some general malaise and fatigue as the itch disturbs her sleep • Itch of the hands and feet are the worst, nil change in skin colour nor in colour of her urine nor faeces • No recent illness and no recent new medications • Nil past history of dermatitis • Nil past history of gallstones • Examination reveals excoriations from itching only • U/A NAD • What investigations do you order?

  4. Investigation Findings… • ALT & fasting serum Bile Acids elevated • AST, GGT, Bilirubin- normal • EBV- IgG positive only • CMV- Negative • Hepatitis serology- NAD • U/S- normal Liver & gall bladder with nil cholelithiasis visualised • What is the diagnosis? • How do you manage Julie now?

  5. Take Home Messages… • Consider the wide differential diagnosis of pruritis in pregnancy • Cholestasis of pregnancy is an uncommon (0.02-2.4% of pregnancies) but important diagnosis not to miss, pruritis can precede jaundice by 2-4 weeks • In cholestasis of pregnancy LFTs can initially be normal but eventually rises in bilirubin, ALP & GGT will occur, elevated total serum bile acid is diagnostic • The diagnosis of cholestasis requires specialist involvement in management as it can be complicated by premature birth, severe IUGR, intrapartum foetal distress and stillbirth • Cholestasis of pregnancy tends to recur in subsequent pregnancies and can be precipitated by OCP as it is genetically linked, hormonally induced • Cetirizine and promethazines are the antihistamines of choice for treatment of pruritis when cholestasis has been excluded

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