USMLE Forum - Largest USMLE Community

A 25-year-old primipara presents at 27 weeks of gestation with new onset of mild intermittent pruritus. Physical examination is negative for jaundice or features of underlying chronic liver disease; uterine size is 30 weeks’ gestation.

Results of laboratory studies are as follows: international normalized ratio (INR), 0.9; albumin, 3.3 g/dL; bilirubin, 1.0 mg/dL; alkaline phosphatase, 267 U/L; aspartate aminotransferase (AST), 26 U/L; alanine aminotransferase (ALT), 27 U/L; and gamma-glutamyltransferase (GGT), 47 U/L. Ultrasonography of the liver and biliary tree is normal.

Appropriate initial management of this patient’s pruritus would be:

(A) Reassurance with frequent outpatient monitoring of symptoms, liver tests, and fetal activity

(B) Cholestyramine

© Diphenhydramine hydrochloride (Benadryl)

(D) Phenobarbital

(E) Induction of labor

Ans is A....Reassurance...as she presents with mild symptoms without liver abnormalities...

a..

A) Reassurance with frequent outpatient monitoring of symptoms, liver tests, and fetal activity

a..

aa

answer is A



This patient presents in the early third trimester of pregnancy with mild and intermittent pruritus but without any other features of liver disease. The mild nature of her symptoms suggests that only outpatient monitoring is warranted; other specific intervention is not currently indicated. In the absence of liver disease, this condition has been commonly referred to as pruritus gravidarum. It is benign, usually self-limited, and rarely associated with progression to more serious disease or hepatobiliary conditions. However, pruritus may also be the presenting symptom and clinical feature of intrahepatic cholestasis of pregnancy or underlying biliary tract disease, such as primary biliary cirrhosis. It is also rarely associated with viral hepatitis and acute fatty liver of pregnancy. Nonetheless, in all of the latter conditions, liver tests are abnormal and worsen with progression of the pregnancy. Therefore, it is critical to closely monitor the pregnant woman complaining of pruritus for the emergence of any features of the aforementioned conditions.

Pruritus gravidarum is due to a functional disorder of biliary excretion, that is, intrahepatic cholestasis, and resolves after delivery of the infant. Occasionally, the pruritus may be so severe that other interventions are indicated, including cholestyramine or ursodeoxycholate. Phenobarbital may be useful but will transfer across the placental membrane and could depress fetal respiration in the early postpartum period. Diphenhydramine hydrochloride (Benadryl) is ineffective for pruritus of cholestasis and is contraindicated in pregnancy.

The elevation in alkaline phosphatase may simply reflect a placental source because all other liver enzyme levels are normal, and the slight reduction in albumin is due to the volume expansion characteristic of pregnancy.