May 2014

Case Discussion: Generalised Itch

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?

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?

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?

• 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

Take Home Messages…