Gastro- hepatology - Maternal medicine Module part2

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1) Postnatally, LFTs should be repeated in obs cholestasis at;

2) Regarding rupture of arterial aneurysm in pregnancy, all are true except;

3) All are the complications associated with obs cholestasis except;

A 24-year-old primigravida woman at 20 weeks of gestation presents to ANC in her booking
She is known to have Crohn's disease (CD). She has multiple perianal ulcers and an ano-cutaneous
fistula which is currently well healed. She is being managed with oral prednisolone and Infliximab by
IV infusion by her gastroenterologist.

4) How would you plan her intrapartum care?

5) Most common dermatosis of pregnancy is;

6) Fetal loss in perforated appendix is;

A primiparous woman is seen in the antenatal clinic at 9 weeks of gestation. She has ulcerative
colitis, which has been medically managed with sulfasalazine and corticosteroid enemas. She has not
required surgery. She stopped all her medication during pregnancy due to anxiety about the effects
on the baby. She has her bowels open 6–8 times per day, which she says is normal for her.
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on the baby. She has her bowels open 6–8 times per day, which she says is normal for her.

7) What advice would you give her regarding optimising her pregnancy outcome?

8) Prevalance of obstetric cholestasis is highest in;


A 34 yr old , nulliparous at 33 weeks of pregnancy with DCDA twins, presents with rash ocer
abdomen but periumbilical sparing, the rash is pruritic erythematous papules twhich spread to trunk
but face is not involved.
Biopsies reveal epidermal changes such as spongiosis, and hyper‐ and parakeratosis
The most probable diagnosis is;

A 22 years old woman, presented to the emergency department in her first pregnancy at
37 + 6 weeks of gestation. She gave a 4‐day history of right sided abdominal pain and feeling
generally unwell. She had some nausea but no vomiting, bowel or urinary symptoms. On
examination she was normotensive at 100/50 mmHg, with a pulse of 80 beats per minute and a
temperature of 38.1°C. Her abdomen was soft, with a gravid uterus appropriate for dates and right

iliac fossa tenderness with localised guarding but no rebound. Urinalysis was negative. Blood analysis
showed a C‐reactive protein of 20 mg/L, white cell count of 12x109/L with a neutrophilia, normal
liver function tests.

10) What is the most appropriate diagnosis?


A 26 yr old woman at 26 weeks presents with rash which appears around the umbilicus as
urticarial papules and plaques, which join to form bullae, extending to involve the trunk, extremities,
palms and soles with mucosal sparing.
Direct immunofluorescence studies reveal C3 deposition along the basement membrane


What is the median time from onset of symptoms to first presentation in woman whose
caesarean section has been complicated by acute colonic pseudo-obstruction?

13) All are true regarding obs cholestasis except;

A 28-year-old primigravida woman presents at 33 weeks of gestation to ANC with
generalised itching, especially in the hands and feet.
Initial investigations showed an ALT of 84 iu/l and fasting bile acids of 32 umol/l.

14) The viral and autoimmune hepatitis screen is negative and a liver scan is unremarkable.

What is the next most appropriate step in her management plan?

15) Recurrance rate of obs cholestasis is;

An obese 38-year-old woman known to have gallstones presents with severe epigastric pain
radiating to her back accompanied by nausea and vomiting. She is 31 weeks pregnant. Initial
investigations show a significantly elevated serum amylase.

16) What are the most appropriate first steps in the management of her condition?


A 29-year-old woman at 32 weeks of gestation in her second pregnancy presents to labour
suite feeling unwell and dizzy for last 12 hours. She also complains of upper abdominal pain and
vomiting for the same duration. She denies any headache or visual disturbances. She reports normal
fetal movements.
On examination, she looks unwell with a pulse of 100/min, a BP of 158/96 mmHg, a respiratory rate
of 20/minute, and a SpO2 96% on air. She is apyrexial. The capillary blood sugar was low at 2.4. Her
abdomen felt soft with mild tenderness over epigastrium and right upper quadrant. There are
normal knee reflexes. There is a clinically well grown baby. Urinanalysis showed + proteinuria.
The investigation results are:
• haemoglobin = 101 g/l
• white blood count = 14 x 109/l
• platelet count = 145 x 109/l
• ALT = 350 IU/l
• alkaline phosphatase = 650 IU/l
• albumin = 26 g/l
• urea = 4.6 mmol/l
• creatinine = 86 mmol/l
• moderately prolonged prothrombin time
• arterial blood gas pH = 7.4, pCO2 4.9 = HCO3- = 22, lactate = 2
• cardiotocography (CTG) pathological.
The working diagnosis is acute fatty liver of pregnancy.
What is the most appropriate next stage of her management?


A primigravida who had an elective caesarean 3 days ago developed acute colonic pseudoobstruction and was being managed with supportive care (inclusive of nil by mouth, nasogastric tube
on free drainage and rehydration). Her C‐reactive protein is continuing to rise and she now has
significant leucocytosis with a low-grade pyrexia. What should the next step in her management be?

19) Which conrtraceptive should be avoided in obs cholestasis patients?

20) Regarding management of appendicitis in pregnancy, all are true except;

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