Intrahepatic cholestasis of pregnancy — structured SAQ (15 marks)

(a) Diagnosis and definition (2 marks)

One mark per element. ^[5][11]

• Intrahepatic cholestasis of pregnancy (ICP) — a reversible cholestatic disorder of late pregnancy defined by maternal pruritus (palms and soles, worse at night, no primary rash) and elevated serum bile acids.
• Diagnostic threshold: bile acids above 10 micromol/L using the standard threshold, or above 19 micromol/L using the higher-threshold definition (Mitchell 2021). The normal GGT excludes biliary obstruction as a contributor.

(b) Immediate management (5 marks)

One mark per intervention with drug, dose and rationale. ^[2][3]

• Start ursodeoxycholic acid (UDCA) 500 mg twice daily, titrate to a maximum of 2 g per day for symptomatic relief of pruritus. Acknowledge PITCHES showed no perinatal benefit.
• Topical emollients for skin comfort and chlorpheniramine 4 mg nocte for sleep (it does not affect bile acids).
• Stratify by bile acid tier — 78 micromol/L places her in the moderate range (40-99); plan delivery 37-38 weeks.
• Counsel the woman about the bile-acid-stillbirth relationship, the rationale for surveillance and the high recurrence in a future pregnancy.
• Check coagulation — INR may prolong in moderate-severe disease; supplement vitamin K 10 mg daily if abnormal.

(c) Surveillance (3 marks)

One mark per element. ^[1][11]

• Serial bile acids every 1-2 weeks — track the trajectory; if she reaches 100, escalate the plan.
• Fetal surveillance — CTG and serial growth scans in moderate-severe disease (the evidence for CTG preventing stillbirth is weak, but surveillance is standard).
• Exclusion of differential diagnoses — abdominal ultrasound to exclude biliary obstruction; consider viral and autoimmune screens if atypical.

(d) Delivery and postpartum (5 marks)

One mark per element. ^[1][3][11]

• Planned delivery at 37-38 weeks for moderate ICP (40-99 micromol/L).
• Escalate delivery to 35-36 weeks once steroids given if bile acids reach 100 or more.
• Vaginal induction preferred unless obstetric indication for caesarean.
• Postpartum follow-up at 6-12 weeks — confirm resolution of pruritus and normalisation of bile acids and LFTs; if persistent, investigate for chronic liver disease.
• Counsel on contraception — progesterone-only methods safe; oestrogen-containing combined pills generally avoided while LFTs abnormal.