Case history

Case history

A 37-year-old primigravida with a dichorionic, diamniotic twin pregnancy presents for a routine antenatal visit at 30 weeks. Her chief complaint is that of itching of the palms of her hands and the soles of her feet for several days' duration. She states that symptoms started at night but have now progressed to generalised pruritus at all times. She cannot sleep at night. She reports no change in fetal movement pattern. She denies new exposures. Her past medical history includes cholecystectomy for cholelithiasis. There is no evidence of jaundice and her liver is non-tender. Serial growth ultrasound scans demonstrate both fetuses to have appropriate growth velocity. Urinalysis is negative for protein or glucose. She has excoriations on her arms, legs, and abdomen from scratching. There is no evidence of ulcers, papules, or urticaria.

Other presentations

ICP can present from the first trimester, although typical onset is in the third trimester.[3][4] The presenting symptom is maternal itch in the absence of a rash, although excoriative lesions are commonly seen.[5] Although the classic distribution of itch is in the palms and soles, it can occur at any site of the body and typically worsens overnight.[6][7][8] Itch alone is not enough for a presumptive diagnosis, but it often precedes biochemical derangement.[6][9]

In addition to raised serum bile acid concentrations, around 80% of women with ICP have evidence of liver dysfunction, and dark-coloured urine frequently occurs.[10][11] A minority experience symptoms of steatorrhoea, hyperbilirubinaemia, or yellowing of conjunctivae.[5][10][12] Women with steatorrhoea may have malabsorption of fat-soluble vitamins, including vitamin K, and are at risk of postnatal or fetal haemorrhage.[13][14][15]

Women with ICP have high rates of cholelithiasis (around 12%) and often report symptoms of right upper quadrant pain and fatigue.[16][17] They also have higher rates of gestational diabetes mellitus and pre-eclampsia, with their attendant presenting symptoms.[18][19][20]

Due to the increased risk of preterm birth, women may present with spontaneous preterm labour; reduced (or altered) fetal movements may herald the diagnosis of stillbirth in women with severe disease.[2][21]

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