Severe ICP — structured oral station (12 minutes)

Opening prompt — "Tell me your reading of these results and your plan."

Model response — say it in this order: ^[1][11]

• "This is severe intrahepatic cholestasis of pregnancy. Bile acids of 125 micromol/L place her in the highest risk tier — the Ovadia 2019 IPD meta-analysis showed a sharp rise in stillbirth at concentrations of 100 or more."
• "I will admit her for inpatient surveillance, start ursodeoxycholic acid 500 mg twice daily titrated up to 2 g per day for symptomatic relief, give vitamin K 10 mg daily given her INR is mildly prolonged, and plan expedited delivery at 35-36 weeks — which means now — once steroids are given."
• "I will counsel her that the pruritus is severe and distressing, that the bile acids put her baby at increased risk of stillbirth, and that delivery is the prevention."

Examiner is listening for: tier recognition, Ovadia evidence, immediate bundle, delivery-timing defence. ^[1]

Probe 1 — "She asks whether the CTG this morning is reassuring and whether she can go home."

• "A reactive CTG this morning is reassuring for the next few minutes, but it does not predict stillbirth in ICP — the Ovadia data show stillbirths in ICP are often sudden and intrapartum. CTG surveillance is reassurance, not prevention."
• "Delivery is prevention. She should not go home; she should be admitted for surveillance and planned delivery."^[1]

Probe 2 — "Her partner asks whether ursodeoxycholic acid will protect the baby."

• "UDCA helps with her itch. The PITCHES trial showed it does not reduce adverse perinatal outcomes, including stillbirth. I will be honest about that."
• "The decision to deliver at 35-36 weeks is what protects the baby — not the medicine."^[2]

Probe 3 — "She is terrified of preterm delivery and asks whether there is any alternative."

This is a scored communication domain. Demonstrate it out loud: ^[1]

• Sit at her eye level, use her name, acknowledge the fear: "I can see this is frightening — let me explain the numbers."
• "At 35-36 weeks your baby's lungs are nearly mature, and we will give you steroids to help. The risk of staying pregnant with bile acids over 100 is greater than the risk of delivering now."
• "I will be with you through this. We will plan the delivery together, and the neonatal team will be ready."

Probe 4 — "She has a sister with two children and asks if she is at risk of the same problem."

• "ICP has a strong familial and genetic component — heterozygous mutations in ABCB4 and related transporters run in families. Her sister should be aware of the symptoms and ask for bile acid testing early in any future pregnancy."
• "Recurrence in the same woman is high — typically 45-90%."^[11]

Probe 5 — "What is your postpartum plan?"

• "Confirm resolution of pruritus within 2 weeks and bile acids and LFTs by 6 weeks. If persistent, re-investigate for chronic liver disease — primary biliary cholangitis, autoimmune hepatitis, chronic viral hepatitis."
• "Counsel on the high recurrence in her next pregnancy and on contraception — progesterone-only methods safe; combined oral contraceptive generally avoided while LFTs abnormal."^[11]