A MRCOG station on MedMock, start to finish

Hello, I'm Dr Mensah, one of the registrars in the obstetric team. Could I just check your name and date of birth, please? I understand you've come in to talk about your recent blood test results. Before I explain anything, could you tell me how you've been feeling and what you've been told so far?

Beth Carter. Thirtieth of May, nineteen ninety-eight. I've been absolutely itching like mad for about two weeks now. It's mainly my hands and feet but it's relentless, especially at night. I'm barely sleeping. The midwife said the blood tests came back and there's something about my liver, but nobody's really explained what that means yet or what I'm supposed to do about it. I'm worried sick it's going to affect the babies. I probably should have called in sooner but a colleague said itching was normal with twins, so I thought I was just being soft about it.

Thank you, Beth. I'm sorry you've been so uncomfortable and not sleeping, that sounds exhausting. And you weren't being soft at all: itching of the hands and feet in pregnancy is exactly the sort of thing we want to know about, so you did the right thing getting it checked. Before I explain, can I ask two quick things? Do you know whether your twins share a placenta or have one each, and is there anything in particular about the babies that you're most worried about?

They're separate placentas. Two of each, two sacs, the whole lot. I've got that written down at home actually. They checked all that at the earlier scans. As for what I'm worried about... mainly just that this liver thing won't hurt them, you know? I keep thinking if I'd rung in sooner maybe I could've stopped it getting worse. And I suppose I'm worried about what happens now. Will they need to come out early? Will they be alright? I don't want them in special care if I can help it. And I need to know if this medicine you might give me is safe for them. That's the big one really.

Those are really important questions and I'll go through each of them. The condition is called obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy. In some women, the pregnancy hormones slow down the way the liver moves bile, so substances called bile acids build up in the blood, and that's what causes the itching, typically on the hands and feet and worse at night. It's more common in twin pregnancies, and I want to be clear that it isn't caused by anything you did, and ringing sooner wouldn't have stopped it developing. The good news is it goes away after the babies are born. Does that make sense so far?

Yeah, that makes sense. So it's the pregnancy hormones doing it, not something I did wrong. That's... that's a relief actually. And it'll go away after they're born, that's good to know. But what I'm still not clear on is what it means for the babies right now. You said it causes the itching, but is there something it does to them? Like, is there a risk to them while they're still inside? And you mentioned the bile acids building up — is that dangerous? That's what I'm most scared of really, that something could happen to them because of this.

I'll be honest with you, because it's a fair question. Most babies of mothers with cholestasis are born healthy. It does carry some extra risks: the babies are more likely to be born early, more likely to pass their first poo into the waters before birth, and there's a small increase in the risk of stillbirth. The important thing is that the risk is closely linked to how high the bile acid level is. When the highest level stays below 40, the risk of stillbirth appears to be about the same as in a pregnancy without cholestasis, and it's at higher levels that the risk goes up, which is why we'll keep checking it. Did the midwife mention what your bile acid number was?

I think she said thirty-six? Let me just check my notebook to be sure. Yeah, thirty-six. So that's... that's below the forty you mentioned, isn't it? That's good then. But you said you'd keep checking it — does that mean it could go up? And if it did go up past that forty, what would happen then? Would you have to deliver them early? I'm trying to understand what the plan actually is. Like, when are they supposed to come out, and what happens between now and then?

Yes, thirty-six is below forty, which is reassuring. It can change, so we'd repeat your liver tests and bile acids regularly, usually weekly, and see you in the twins clinic alongside your usual scans. For twins like yours, with a placenta each, we'd already recommend the babies are born from 37 weeks, and with your current level cholestasis doesn't change that. If the level went above forty, 37 weeks would still be about right, but if it went very high, 100 or more, the guidance is to consider birth earlier, around 35 to 36 weeks, and the consultant would talk that through with you. Babies born at 37 weeks usually do well and most don't need special care. How does that sound as a plan?

That does sound like a plan, yeah. So weekly checks, and they'd be born around 37 weeks anyway because they're twins. I can work with that. I suppose my worry is if things change suddenly. Like, what if my bile acids jump up between appointments? And you mentioned medication earlier — is there something you can give me to help with the itching and maybe keep the levels down? Because honestly I'm not sleeping at all and I'm scratching until I bleed. I need some relief from that. Is ursodeoxycholic acid safe for twins? I looked it up a bit and I'm worried about putting anything through to them.

That's a good question to ask. Ursodeoxycholic acid has been used in pregnancy for many years, including large trials, and no harm to babies has been shown. But I want to be honest about what it does: a big UK trial found it doesn't reduce the risks to the babies, so we don't give it for that, and its effect on the itch is modest, though some women do find it helps, so you're welcome to try it if you'd like. Alongside that, a cooling moisturiser such as one with menthol, cool showers, loose cotton clothing and keeping your nails short can help, and a sedating antihistamine at night may help you sleep. Would you like to try the ursodeoxycholic acid, or would you rather start with the other measures?

I'd like to try the ursodeoxycholic acid. At least give it a go, you know? If it might help even a bit with the itching I should try it. And I'll do the other stuff too — the cooling cream, shorter nails, all of that. I can manage that. But I need to know what to watch for. You said there's risks if things change. What should I actually look out for? Like, if something goes wrong or gets worse, when do I ring you straightaway instead of waiting for my next appointment? And I need that plan written down — dates of appointments, what tablets to take, all of it. That helps me feel like I've got a grip on things.

Absolutely, I'll write it all down for you, and I'll give you the RCOG leaflet on cholestasis and details of the charity ICP Support. I'll prescribe the tablets today and book your weekly blood tests and next clinic visit before you leave. Please ring the maternity assessment unit straight away, day or night, if the babies are moving less or their pattern changes, and don't wait until the next day or use a home heartbeat monitor. Also ring if the itching suddenly gets much worse, you notice yellowing of your skin or eyes, dark urine or pale poo, or you get tummy pain, bleeding, your waters break or regular tightenings, or a bad headache, blurred vision or sudden swelling. Just so I know I've explained it clearly, could you tell me in your own words what the plan is?

Right, so I've got the tablets to take — the ursodeoxycholic acid, is it? And I'll do the creams and keep my nails short. I'm having blood tests every week and coming back to clinic. The babies should come out around 37 weeks unless things change. And I need to ring straight away if the babies move less, or if the itching gets suddenly worse, or if I notice my skin or eyes going yellow, or dark wee, or if I get tummy pain or bleeding or my waters break or regular tightenings. And headaches or blurred vision or sudden swelling. I've written most of that down. Is that about right?

That's exactly right, Beth, you've got it. Just a couple of last things. Cholestasis on its own doesn't mean you need a caesarean; how the twins are born depends mainly on their positions, and the consultant will go through your birth plan with you in the coming weeks, with both babies' heartbeats monitored continuously in labour. After the birth the itching usually settles quickly, and we'll check your liver blood tests a few weeks later to make sure they're back to normal. It's also worth knowing it often comes back in a future pregnancy, so do tell your team early next time. What questions do you have for me?

I think I've got what I need, really. Just one thing — you said it often comes back next time. Does that mean I should think about not having more children after this? Or is it just something to watch out for? And I suppose... I'm still a bit worried about those risks you mentioned, even though my level's okay now. Like, I know it can go up. Is there anything else I should be doing to try to keep it stable, or is it just the tablets and the monitoring?

No, it's not a reason to stop having children, it just means we'd know to look out for it and test your bloods early if the itching came back. As for keeping it stable, I'm afraid there's nothing you could have done to cause it and nothing proven, like a special diet, that keeps the level down, so please don't put that pressure on yourself. The most useful things are keeping to the weekly blood tests and ringing us straight away if the babies' movements change. It's completely understandable to still feel worried, and if more questions come up before your next visit, the maternity unit is always there to talk to. Is it all right if I go and arrange your prescription and appointments now?

Yeah, that's fine. That's good actually, knowing it's not something I've done wrong and there's nothing special I need to be doing diet-wise or anything. Takes the pressure off a bit. So just the tablets, the creams, the weekly blood tests, and ring if anything changes with the babies or I get those warning signs. I can do that. And you've given me the leaflet and the charity details, which is helpful. Right then, yeah, go ahead and sort out the prescription and book me in. I feel like I've actually got my head around it now, which is better than I did when I came in. Thanks for explaining it properly.

You're very welcome, Beth, and you've asked all the right questions. I'll sort the prescription and bookings now and bring you the written plan before you go. Take care, and remember, ring us any time if you're worried.

Yeah, okay. Thank you. I'll make sure I've got all that written down properly when you give me the plan. And I'll ring if anything worries me. It's been good to talk through it all properly. I feel a lot better knowing what's happening and that the babies should be alright. I was really scared coming in here, to be honest, but you've made it make sense.