Cases/Maternity and Reproductive Health

Woman At 30 Weeks Whose Bile Acids Came Back Raised — Free SCA Practice Case

Woman at 30 weeks whose bile acids came back raised

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•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

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Materials for Candidate

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Patient Profile

Full Name

Harpreet Sandhu

Age

34 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked to discuss blood results.

Reason for Encounter

"Blood test results from last week. Itchy hands and feet in pregnancy."

Medical Records

●PMH: Gravida 2, para 1, first pregnancy uncomplicated. Now 30 weeks, singleton, anomaly scan normal.
●Medications: Pregnancy multivitamin. Allergies: NKDA.
●Social: Veterinary nurse. Non smoker.

Recent Notes

●Glucose tolerance test, 26 weeks: Normal.
●Locum visit, 8 days ago: Itchy palms and soles for 10 days, no rash. BP 108/64, urine protein negative.
●Results: Total bile acids 52 micromol/L (random, no earlier result). ALT 88, AST 64, bilirubin 11. Hb and renal function normal.

Patient Script

For the friend playing the patient role

Character Overview: You are Harpreet Sandhu, a 34 year old veterinary nurse at a small animal practice, where you work four days a week. You are 30 weeks pregnant with your second baby. You live with your husband Navdeep, a site engineer who works away during the week and is home at weekends, and your daughter Tara, who is eight. Your mum lives fifteen minutes away and collects Tara from school on your work days. Tara was born in the midwife led birth centre and you remember it fondly, and you are booked to go back there. About two and a half weeks ago your palms started to itch, then your soles, and it has crept up your shins and forearms. A locum took bloods last week, and this morning the receptionist rang to say the result was raised and a doctor wanted to speak to you today. You are practical and brisk, play things down and hate making a fuss. You sound tired, speak a little fast, and your voice wobbles when you talk about the baby.

Opening Sentence: "Hello, Doctor. The receptionist rang to say my blood test from last week was raised and that I needed to talk to someone today, and I've not been able to think about anything else. It's only my itchy hands and feet, isn't it? I was hoping you could give me a cream or something. Is it going to be a problem?"

History if Asked (Data Gathering Phase)

●The itch: "It started about two and a half weeks ago in my palms, then my soles. Now it's up my shins and forearms as well. It's a deep, burning itch, not like a bite."
●Night time and sleep: "It's so much worse at night. I'm lucky if I get four hours, in bits. Cold water over my hands helps for about ten minutes."
●Rash or skin changes: "No rash. My skin looks normal apart from scratch marks on my shins and wrists."
●What she has tried: "Calamine, a thick moisturiser, and one percent hydrocortisone cream on my wrists. None of it has helped. I haven't taken any tablets while I'm pregnant."
●The baby's movements: "Baby's moving like normal, lots of kicking this morning. Nothing has changed."
●Pregnancy so far: "Scans have all been fine and there's just the one baby. The midwife checks my blood pressure and wee every time and they've been fine."
●Jaundice, stools, pain and preeclampsia symptoms (if asked): "No yellow eyes, my wee and poo look normal, no pain under my right ribs, no sickness, no headaches, no flashing lights. My rings still fit. My ankles go a bit puffy in the evening, same as last time."
●Bleeding, waters and tightenings: "No bleeding, nothing leaking, a few tightenings but nothing regular or painful."
●Anyone else itching: "No. Navdeep and Tara are fine, and nobody at work has been itching."
●Animals (if asked about work or infections): "We had a dog in with mange about three weeks ago and I held him for his treatment, so I did wonder if I'd caught something off him."
●Medicines, supplements and recent illness: "Just my pregnancy vitamin. No herbal things, no antibiotics, nothing new. No bugs, no temperature, no sore throat."
●Other symptoms (if asked): "No fever, diarrhoea, stomach pain, joint pains or urinary symptoms. My appetite's fine."

Ideas, Concerns, Expectations

Gating note: Harpreet does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks the itching is either something she caught from the dog at work or pregnancy hormones, unpleasant but harmless. "I didn't think it could be anything to do with the baby until the receptionist said the result was raised."
●Concerns: Her main worry is that the baby will have to be taken out early, like her cousin's, born at 30 weeks. "When she said raised, my mind went straight to the baby having to come out early. My cousin's little boy was born at thirty weeks and was in the baby unit for two months." If the doctor asks gently what else she has been thinking or has read, a quieter fear comes out, said with a wobble: "I looked it up on my phone last night. One page said babies can die. I closed it straight away. I haven't told Navdeep."
●Expectations: She came expecting a cream or a tablet to stop the itch and to be told it was nothing. "I was hoping you'd give me something for the itching and tell me it's nothing. I didn't think I'd have to go anywhere."

If Asked: Medical History and Medications

Gating note: Harpreet answers each of these plainly when the doctor asks about it.

●Health, liver or gallbladder problems: "Nothing. I'm normally really healthy. No liver, gallbladder or stomach problems, ever."
●Previous pregnancy: "Tara, eight years ago. Completely straightforward, born in the birth centre at 40 weeks. No blood pressure problems, no diabetes, no itching."
●Contraception before this pregnancy: "The mini pill, on and off, with no problems."
●Family history (in pregnancy, or of itching or liver problems): "My mum had terrible itching in her last pregnancy, with my brother. He was born a few weeks early. Nobody ever told her why. My sister had nothing, and there's no liver trouble in the family that I know of."
●Allergies, alcohol and smoking: "No allergies. I don't drink and I've never smoked."
●Plans for the birth: "I'm booked into the birth centre again. I loved the pool and how calm it was."

Social History and Lifestyle Impact

●Work: Four days a week, on her feet all day holding animals and assisting in theatre, exhausted by the afternoon. She plans to finish work in about six weeks.
●Home: She says "I don't want to be a nuisance" but agrees once she understands why. Navdeep is away until the weekend. Tara finishes school at ten past three. Harpreet's mum collects Tara on her work days and could be asked today, but Harpreet does not like asking for extra.
●Lifestyle impact: "I'm shattered. I snapped at Tara twice this week and I cried in the car after work a couple of days ago, which isn't like me. I think it's just the tiredness." If asked about mood: "Tearful, but not low in myself." If asked about harming herself: "No, never."

Responses to Management (The Negotiation Phase)

●
If the doctor explains the result and gives it a name:
- ●Reaction: Taken aback. "Oh. So it's a proper condition? Did I do something to cause it?" If told it is not her fault and not from the dog: "That's a relief about the dog, at least." If asked to show her skin on camera or take her own blood pressure, she declines politely: "I haven't got a machine. Don't they need to see me in person anyway?"
●
If the doctor says she needs to be seen by the maternity team:
- ●Reaction: Anxious and a little resistant. "Does it have to be today? Navdeep's away and Tara needs collecting at ten past three. It's only itching and I don't want to be a nuisance." If the doctor explains why and offers to phone the unit and ring her back: "Okay. I can ask my mum to get Tara. Will you ring me back? What number do I call if I can't get through? Will they keep me in?" If given vague reassurance, or told to ring her midwife herself: "But the receptionist made it sound urgent. If it's nothing, why today?"
●
If the doctor talks about the risk to the baby and when it might be born:
- ●Reaction: If told only that the baby might come early: frightened. "How early? Like my cousin's baby?" She is relieved once given actual timings: "So they wouldn't take the baby out now? Not for weeks yet? What if the bloods go up?" If the doctor gives the stillbirth risk for her level, she goes quiet, then steadier: "So for now it's about the same as anyone else's? That's what I needed to know. I'd read something awful." If told that scans and heartbeat monitoring do not prevent stillbirth here: "Won't they scan me every week, then? How will I know the baby is alright?"
●
If the doctor says she should plan to give birth in hospital rather than the birth centre:
- ●Reaction: Disappointed. "But I wanted the birth centre again. Is there really no way?" She accepts once the reasons are explained and she hears she is still involved in the decisions.
●
If the doctor suggests treatment for the itch:
- ●Reaction: About a cream: "I've done moisturiser and calamine. Is this actually different?" About an antihistamine: "Is it safe for the baby? Will it knock me out? I still have to get Tara to school." She accepts once risks and benefits are explained. About ursodeoxycholic acid: "Is that safe? Will it protect the baby?"
●
If the doctor gives safety netting, or asks about her sleep and how she is coping:
- ●Reaction: To vague netting such as "come back if it gets worse": "Worse how? What exactly should I be looking out for, and who do I ring?" To instructions about movements: "Baby's quieter at night. What counts as less? And what if it's the middle of the night?" Asked how she is coping, a brief silence, then: "I cried in the car the other day and felt so silly. I'm just so tired." She is grateful if told it is not silly. If told what happens after the birth: "So it goes away after the baby? Will I get it again?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Harpreet is 30 weeks pregnant with itchy palms and soles and a random total bile acid of 52 micromol/L. The skill is recognising intrahepatic cholestasis of pregnancy (ICP, also called obstetric cholestasis), grading it, talking honestly about the baby, and getting her into consultant led care the same day without defaulting to the emergency department.
●Model answer: take a focused history, name the condition, grade it as moderate, ring the maternity unit today with the result, agree when she will be seen, and sort out the school run. Explain the baby's risk at her grade, likely timing and place of birth, monitoring, the movements safeguard, relief for the itch, specific safety netting and the outlook after birth.
●Also acceptable: same day attendance or a day assessment slot if movements are normal; any plain emollient; chlorphenamine, promethazine or no antihistamine; either postnatal timing; extra tests ordered in parallel.

Diagnosis and Grading by Peak Bile Acids

●The Royal College of Obstetricians and Gynaecologists (RCOG) Green top Guideline 43 (2022) says to consider ICP in a pregnant woman with itch of normal looking skin and a raised random total bile acid of 19 micromol/L or more. The sample need not be fasting. It affects about 0.7% of UK pregnancies and up to 1.5% in women of Indian Asian or Pakistani Asian origin. Primary care advice is in NICE Clinical Knowledge Summaries (CKS) Itch in pregnancy.
●The itch is typically on the palms and soles, worse at night, with no primary rash. Alanine transaminase (ALT) and aspartate transaminase (AST) are often raised and supportive, but isolated raised transaminases with normal bile acids should not be labelled ICP.
●Grading follows the highest level in the pregnancy: mild 19 to 39, moderate 40 to 99, severe 100 or more micromol/L. Harpreet's 52 is moderate, and the grade can move up as well as down. Bile acids and liver function tests (LFTs) are repeated after about a week, because levels fluctuate.
●If itch persists with normal bloods, repeat the tests, because ICP can declare itself up to 15 weeks later. Take a structured history so skin disease, infestation, medicines, gallstones and preeclampsia are not missed.

What the Grade Means for the Baby

●The RCOG, drawing on the Ovadia meta analysis, reports stillbirth prevalence of 0.13% in mild, 0.28% in moderate and 3.44% in severe ICP, against a UK background of 0.29%. The risk rises above background only at 100 micromol/L or more, and in moderate ICP stays near background until 38 to 39 weeks.
●Gestational diabetes, preeclampsia and twin pregnancy appear to raise the risk and can change the plan, so blood pressure, urine and glucose checks continue (NICE NG3).
●Moderate and severe ICP carry more spontaneous and planned preterm birth, meconium stained liquor and neonatal unit admission. This is the honest answer to a fear of early birth: it is more likely than usual, but it is not planned now.

Same Day Liaison with Maternity and Place of Birth

●NICE CKS advises same day referral to the local maternity unit for features suggesting obstetric cholestasis, and the RCOG advises review in a consultant led unit. The GP makes it happen: contact the day assessment unit, triage or on call obstetric team with the result, agree when she will be seen, and make sure she knows where to go and whom to ring.
●Neither source sets a time limit. A health board guideline (Cwm Taf Morgannwg, 2024) accepts a day assessment appointment when there are no other symptoms such as altered movements. Aim for same day contact and review at the time the unit chooses; same day attendance is equally guideline supported.
●Reduced fetal movements, bleeding, regular contractions, features of preeclampsia or jaundice need immediate or same day assessment instead.
●Birth is usually advised in a consultant led obstetric unit with neonatal facilities. NICE NG235 lists liver disease with abnormal LFTs among the reasons for planned obstetric unit birth, and induction and continuous monitoring need one. She hears the risks and chooses.
●School pick up and a husband working away can stop a woman attending, so ask and help solve them. Blood pressure and the fetal heart cannot be assessed by video, so she must be seen in person.

Monitoring Mother and Baby

●Consider repeat LFTs and bile acids after 1 week, then individually, often every 1 to 2 weeks while itch persists, because a rise to 100 or more would bring birth forward. State the first repeat and say the team decides the rest.
●Ultrasound and cardiotocography do not predict or prevent stillbirth in ICP, and extra scans are not needed for ICP alone. The safeguard open to every woman is knowing her baby's usual movements and being assessed immediately if they reduce or change.

Timing and Mode of Birth

●The RCOG suggests considering planned birth by 40 weeks or continued care for mild ICP with no other risk factors, at 38 to 39 weeks for moderate, and at 35 to 36 weeks for severe. These are options to discuss, not instructions.
●Comorbidities such as gestational diabetes, preeclampsia and twin pregnancy can bring timing forward. ICP does not by itself decide the mode of birth: induction, planned caesarean or waiting for labour are chosen on usual obstetric grounds and her preferences. Continuous fetal monitoring in labour is advised at bile acids of 100 or more.

Treating the Itch and What Not to Promise

●No treatment improves pregnancy outcome or lowers bile acids, and itch treatments have limited benefit. Say so, so a cream or tablet is not mistaken for protection of the baby.
●NICE CKS advises a plain emollient used liberally, menthol 0.5% or 1% in aqueous cream if that fails, a fan, cool baths and loose cotton clothing. Leave on aqueous cream can sting (Medicines and Healthcare products Regulatory Agency), so any tolerated plain emollient is reasonable.
●An antihistamine at night, such as a single dose of chlorphenamine 4 mg or promethazine 25 mg (off label), may help through sedation rather than any effect on itch. The British National Formulary (BNF) notes no evidence of teratogenicity but warns that late third trimester use may cause irritability and tremor in the newborn. Drowsiness can last up to 12 hours.
●The RCOG says not to routinely offer ursodeoxycholic acid to improve outcomes, because the PITCHES trial showed no significant benefit, and its effect on itch is small. It is for the obstetric team to discuss, not something to present as protecting the baby.
●Vitamin K (menadiol sodium phosphate 10 mg daily) is only for pale greasy stools or a prolonged prothrombin time.

Investigations and Safety Netting

●The RCOG no longer recommends routine liver imaging, viral serology, autoimmune screens or clotting studies in uncomplicated ICP. They are for atypical features, early onset severe disease or results that stay abnormal after birth. Severe or atypical presentations are discussed with a hepatologist. Never delay the maternity call to arrange them.
●Reduced or changed fetal movements: ring the maternity unit immediately, day or night, without waiting for morning.
●Jaundice, dark urine, pale stools, severe right sided pain, severe headache, visual disturbance, sudden swelling, bleeding, leaking fluid or regular contractions: contact the unit the same day, as they point to preeclampsia, rising severity or preterm labour.
●Worsening itch, sleep loss or low mood: contact the midwife or GP. Give a number she can call at any hour and check she has it.

After the Birth and Future Pregnancies

●Itch usually settles within days of birth. The RCOG advises LFTs and bile acids at least 4 weeks after birth, often at the 6 week check; NICE CKS advises from about 2 weeks, avoiding the first 10 days. Either is reasonable, and persistent abnormality needs further assessment.
●Recurrence is more likely, so LFTs and bile acids are checked at booking next time.
●Under the UK Medical Eligibility Criteria, past pregnancy related cholestasis is category 1 for progestogen only and intrauterine methods and category 2 for combined methods, which wait until itch, LFTs and bile acids are normal.

Common Candidate Mistakes in This Station

●Treating the result as ordinary pregnancy itch and offering a cream and a routine midwife appointment.
●Not contacting maternity the same day, or sending her to the emergency department by default when movements are normal and there are no other symptoms.
●Grading 52 as severe and quoting 35 to 36 weeks, promising an early birth, or saying the baby is at no risk.
●Quoting the severe stillbirth figure, or avoiding her question about the baby dying because it feels frightening.
●Offering extra scans, heartbeat monitoring or ursodeoxycholic acid as protection, or ordering a battery of tests before telephoning maternity.
●Saying "come back if it gets worse" instead of specific instructions on movements and a number to ring.
●Ignoring the school run, her husband working away and the loss of her birth centre plan, so she leaves not intending to go.
●Missing the sleeplessness and low mood, or leaving out postnatal bloods and recurrence.

Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.

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