Anyone who remembers the last case the histology confirmed the suspected left dermoid but the left ovary contained only a serous cystadenoma.

New case -

  1. First pregnancy.
  2. 36+ weeks.
  3. Presents to her FP at 36 weeks with generalised pruritis.
  4. She's read an article in lay ( parenting ) press about obstetric cholestasis. She tells her FP that's what she thinks she's got.
  5. FP says no - you've got a rash - it must be a viral infection !
  6. Rash is maculo-papular, worst in groins, then legs, then upper arms, scarcely anything on forearms, nothing on trunk.
  7. Liver function tests show raised bilirubin ( 20 ) and raised transaminases. All other routine labs normal.
  8. Decide she does have obstetric cholestasis as she thought - therefore given increased fetal risk ( supposedly ) and recently reported observation that fetla demise is not always predicted by CTG, etc ( AJOG article ), to induce her.
  9. Three doses of PGE2 later - no real change in cervix, she's pyrexial, and increasingly unwell.

What to do next ?

Bear in mind it's now Saturday evening and its the NHS in UK ( ~3rd World ).

Send your answers by email to puzzler@obgyn.net

Malcolm

Replies

I personally wouldn't deliver her right now unless I have documented maturity. I WOULD give hydroxyzine, cholestyramine, and hydration... and watch the baby like a hawk (as opposed to a dove?).

Joe P.
DoctorJoe@aol.com

Malcom:

In patients with intrahepatic cholestasis of pregnancy, it would be very unusual to see such high elevations in the serum bilirubin concentration. How elevated are the transaminases and have other liver injury and liver function tests been performed (GGTP, Prothrombin time). I would be concerned about obstructive jaundice or acute viral hepatitis (and the possibility of fulminant hepatitis and hepatic failure and evaluate/manage the patient accordingly.

Best Wishes

Steven Laifer MFM Bridgeport, CT
bpthosp.chime.org

Does the patient have Acute Fatty Liiver of pregnancy with necrosis?

Deliver

Myer

Myer S. Bornstein, M.D.,F.A.C.O.G. Chairman Department Obsterics and Gynecology
Morton Hospital and Medical Center Taunton, MA 02780
Myer.S.Bornstein@massmed.org

This type of rash is not uncommon at onset of hepatitis B, or even hepatitis due to mono. If bili is predominantly indirect (unconjugated) which I would expect without other GI symptoms to suggest obstruction, fulminant hepatitis is a major concern. Integrity of clotting cascade is suspect as well.

Arthur Freeland
Warrensburg Missouri
Arthurfree@aol.com

Some points:

9) Three doses of PGE2 later - no real change in cervix, she's pyrexial, and increasingly unwell.

  1. Sounds like you may have to deliver her if she's at this stage - but what does 'increasingly unwell' mean?
  2. What were the results of the following: -USS liver [I presume that if it's Saturday now, it was Friday when she came in - and your SHO has used all his persuasive powers with the ultrasonographers:) ] -B19 serology -Bilirubin in the urine? -IM screen (Glandular fever) The point being, if you can find an alternative cause (other than IHCP/AFLP then you might want to wait until Monday, when the NHS gets back to work)
  3. Try Dilapan (hygroscopic cervical dilator).
  4. How old is she? If she is low risk for DVT, and only having one pregnancy, no documented benefit in vaginal delivery vs. 'elective' CS? (Controversial?)

Similar patient recently, but 35 weeks - itching like crazy, we were lucky & successful induction, but thickest meconium I've seen. Fetal assessments and CTG's all normal.

Eagerly waiting the Roald-Dahl twist to the plot!

Sam Saidi, University Hospital, Nottingham, UK
sam@saidi.prestel.co.uk

Unless any one gets it soon I'll come clean.

Malcom:

With the [limited] clinical and laboratory info you've provided, I would suspect acute viral hepatitis (A; she is HepBSAg negative). Other helpful info might be exposures, ingestion of shell fish, ?drug or toxin exposure, occupation, blood pressure, Hgb, platelets. If she has acute viral hepatitis, I would be reluctant to deliver her in the acute setting unless there is evidence of fetal compromise.

Happy Fourth to Listmembers; with respectful consideration to our colleagues in the UK.

S. Laifer MFM Bridgeport, CT
pslaif@bpthosp.chime.org

We're entering the rarer realms of the hepatitides I think.

Cytomegalovirus? HSV? Leptospirosis? Ascending cholangitis?

Any marks for wild guessing, then? I'm sure you're hiding something from us.....

Sam Saidi, University Hospital, Nottingham, UK sam@saidi.prestel.co.uk

PS: Passing by Luton tomorrow - maybe I should nip in to labour ward and cheat! :)

Malcolm's Response:

With the [limited] clinical and laboratory info you've provided, I would suspect acute viral hepatitis (A; she is HepBSAg negative).

She is negative for:

Other helpful info might be exposures,

She works as a care asssistant with disturbed adolescents. Her husband is afro-caribean and is a psychiatric nurse. She was due to be vaccianted against Hep-B, but delayed it when she discovered she was pregnant.

ingestion of shell fish,

Luton is about as far away from the coast as it's possible to be in the UK. Shellfish ingestion is very upper middle class ( which she ain't ! )

?drug or toxin exposure,

No !

occupation,

See above under exposures !

blood pressure,

Normotensive

Hgb, platelets.

Within normal range

If she has acute viral hepatitis, I would be reluctant to deliver her in the acute setting unless there is evidence of fetal compromise.

Interested to know why you say that ? Presumably at this gestation there are risks of fetus of pyrexia, viraemia, etc. There are obvious maternal risks, but only if labaoratory tests are sinister. Delivery by CS may be preferable to vaginal for some viruses in terms of vertical transmission. At this gestation ( and having given her already three doses of PG-E2 - possibly inappropriately ) delaying delivery for a few weeks to allow her to recover completely doesn't seem like a tenable option !

You were quite close - any other suggestions ???

Happy Fourth to Listmembers;

Is this referring to something by Bruce Springsteen ?

with respectful consideration to our colleagues in the UK.

Any consideration from NEW ENGLAND gratefully received !

Best wishes to those in the ( former ) colonies !

Malcolm Griffiths, MD,MRCOG,MFFP,Cert.Mgmnt
Obstetrician & Gynaecologist
Luton & Dunstable Hosp., LU6 2DT, UK.
Malcolm@mgriff22.demon.co.uk
http://www.obgyn.net/board/griffith.htm

With a maculo-papular rash and altered liver functions that suggest a hepatitis, I would vote for something weird: HEPATITIS CAUSED BY MEASLES. Never seen one, just heard of it.

On the other hand, how high is her "pyrexia"? It could be one of the side effects of PGE. Just a thought.

Greetings from San Jose, Costa Rica.

Sing-Hung Chang
Resident
changl@cariari.ucr.ac.cr

Malcolm's Verdict!

We're entering the rarer realms of the hepatitides I think.

Gosh this guy is persistent !

Cytomegalovirus?
HSV?
Leptospirosis?
Ascending cholangitis?

I asked for a diagnosis - this is wider than a differential ! I think though you may have something here !

Any marks for wild guessing, then? I'm sure you're hiding something from us.....

I am offended by the mere suggestion ;-) No I haven't hidden anything. Largely I'm trying to reproduce the conditions as I experienced them.

Saturday evening last week, I contact my microbiology consultant colleague. Said I thought I had a woman with acute viral hepatitis. The hepatis has been quite mild. Only in a good light has she ever looked jaundiced.

My differential was HepA or B ( microbiologist was worried about C,E, ... Z ! I wondered about Epstein-Barr, my wife ( remember she's am FP ) said E-B was likeliest. Other choice was CMV.

The other possibility we considered was cholestasis + other bacterial infection. MSU was clear. Blood cultures grew a fairly benign skin staph - contaminant ?

My major issue was that if the cause was acute hepB, that the baby would need fairly prompt active AND passive hepB immunisation. We actually delayed the CS until we were certain we'd have hepB status of mother within 2 hours of delivery. We confirmed all staff involved were hepB immune and did CS. Shortly afterwards serology was negative for hep A, hepB, monospot was negative, but positive for CMV.

Transaminases peaked on Sunday/Monday and have steadily declined since then mother was slightly confused and verging on hallucinations on Monday. She went home today ( 1 week in hospital ). Gastroenterology advice is no precautions except weatch LFTs go back to normal. Microbiologists have restested serum - results awaited - and sent samples to national reference lab.

PS: Passing by Luton tomorrow - maybe I should nip in to labour ward and cheat! :)

Why just pass Luton ?

I'm sure all the staff would maintain confidentiality. As staff largely alternate weekends, there'd be no-one around who saw her !

VERDICT:

Samir wins, but only because he gave a very wide differential !

Malcolm Griffiths, MD,MRCOG,MFFP,Cert.Mgmnt
Obstetrician & Gynaecologist
Luton & Dunstable Hosp., LU6 2DT, UK.
Malcolm@mgriff22.demon.co.uk
http://www.obgyn.net/board/griffith.htm