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MALCOLM'S PUZZELERFrom: Barbara Nesbitt (roberta.speyer@obgyn.net@barbara.nesbitt@OBGYN.net)Wed Jul 2 19:18:38 1997
Malcolm's Puzzeler is up at OBGYN.net at: http://www.obgyn.net/english/pubs/features/whatwould03.htm CC YOUR ANSWERS TO puzzeler@obgyn.net Answers so far are listed below. Anyone know who won Bernards Last week? Anyone Game to do one next Wednesday or beyond? Drop me a line and We'll put it up. Malcolm Wrote: 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
-- Barbara Nesbitt Co-Moderator, Womens Health Forum OBGYN.net
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