A 34-year-old woman at 28 weeks gestation presents with severe itching, particularly on palms and soles. Bile acids are elevated. What is the most likely diagnosis?

Intrahepatic cholestasis of pregnancy

Antenatal care for UKMLA AKT: High-Yield Women’s Health Lessons

Quick Overview

Antenatal care (ANC) follows a structured schedule per NICE NG201: 10 appointments for nulliparous women (first pregnancy), 7 for multiparous women (subsequent pregnancies). The booking visit (ideally <10 weeks) establishes risk, initiates screening, and provides education. Subsequent visits monitor maternal/fetal wellbeing, screen for complications, and prepare for delivery. Understanding appointment timing, screening windows, and red flags is essential for safe pregnancy management.

Core Facts & Concepts

Booking Visit (<10 weeks gestation)

History: Obstetric history, medical conditions, medications, family history, mental health, domestic violence screening
Examination: BMI, BP, urinalysis (proteinuria/bacteriuria)
Blood tests: FBC, blood group & antibodies, infectious disease screening (HIV, hepatitis B, syphilis), rubella immunity
Prescribe: Folic acid 400mcg daily (5mg if high-risk: diabetes, BMI >30, anticonvulsants); Vitamin D 10mcg daily
Offer: Combined screening (Down's, Edwards', Patau's syndromes) at 11-13+6 weeks

Figure 1: Ultrasound scan showing fetus with nuchal translucency measurement at 12 weeks gestation

Antenatal Appointment Schedule

Gestation	Nulliparous	Multiparous	Key Actions
<10 weeks	Booking	Booking	History, bloods, screening discussion
11-13+6 weeks	✓	✓	Combined screening (NT + βhCG + PAPP-A)
16 weeks	✓	✓	Review screening results, BP, urinalysis
18-20+6 weeks	✓	✓	Anomaly scan (structural abnormalities)
25 weeks	✓	✗	BP, urinalysis, symphysis-fundal height (SFH)
28 weeks	✓	✓	FBC (anaemia), anti-D (if Rh-negative), BP, SFH
31 weeks	✓	✗	BP, urinalysis, SFH
34 weeks	✓	✓	BP, urinalysis, SFH, anti-D 2nd dose (Rh-neg)
36 weeks	✓	✓	BP, urinalysis, SFH, presentation check, GBS discussion
38 weeks	✓	✓	BP, urinalalysis, SFH, discuss labour/birth plan
40 weeks	✓	✓	BP, urinalysis, SFH, membrane sweep offered
41 weeks	✓	✓	Induction of labour discussion

Screening Test Windows

Combined test: 11-13+6 weeks (nuchal translucency + serum markers)
Quadruple test: 15-20 weeks (if combined missed)
Anomaly USS: 18-20+6 weeks
Gestational diabetes (OGTT): 24-28 weeks (if risk factors)

Problem-Solving Approach

Red Flag Symptoms Requiring Urgent Assessment (🚩)

Vaginal bleeding (any trimester) → ?miscarriage, ?placenta praevia, ?abruption
Severe headache + visual disturbance → ?pre-eclampsia
Epigastric/RUQ pain → ?HELLP syndrome, ?pre-eclampsia
Reduced fetal movements (>24 weeks) → ?fetal compromise
Rupture of membranes (<37 weeks) → ?preterm prelabour rupture
Continuous abdominal pain → ?placental abruption, ?uterine rupture
Fever + abdominal pain → ?chorioamnionitis, ?pyelonephritis

⚠️ Warning: Any BP ≥140/90 mmHg with proteinuria ≥1+ on dipstick requires same-day assessment for pre-eclampsia.

Approach to Abnormal SFH Measurement

SFH <expected (>2cm discrepancy) → USS for fetal growth assessment (?IUGR, ?oligohydramnios)
SFH >expected (>2cm discrepancy) → USS (?macrosomia, ?polyhydramnios, ?multiple pregnancy, ?fibroids)
Measure from pubic symphysis to uterine fundus (cm ≈ weeks gestation after 24 weeks)

Analysis Framework

Risk Stratification at Booking

Risk Factor	Action Required
BMI ≥30	Aspirin 150mg daily from 12 weeks (pre-eclampsia prevention), anaesthetic review if BMI ≥40
Previous pre-eclampsia	Aspirin 150mg daily from 12 weeks
Chronic hypertension/renal disease	Aspirin 150mg daily, increased BP monitoring
Diabetes (pre-existing)	Folic acid 5mg, retinal screening, HbA1c monitoring, growth scans
Previous GDM	OGTT at 24-28 weeks
Previous caesarean	VBAC vs repeat CS discussion, senior review
Mental health conditions	Perinatal mental health referral

Visual Aid

Key Points Summary

✓ Booking <10 weeks: FBC, blood group, infection screen, folic acid 400mcg (5mg if high-risk), vitamin D 10mcg
✓ Appointment schedule: 10 visits (nulliparous), 7 visits (multiparous) per NICE NG201
✓ Key screening windows: Combined 11-13+6 weeks, anomaly scan 18-20+6 weeks, OGTT 24-28 weeks (if risk factors)
✓ Anti-D prophylaxis: 28 weeks + 34 weeks for Rh-negative women
✓ Red flags: Vaginal bleeding, reduced fetal movements, severe headache + visual changes, BP ≥140/90 + proteinuria
✓ SFH discrepancy >2cm: USS for growth assessment (measure from pubic symphysis to fundus after 24 weeks)
✓ Aspirin 150mg from 12 weeks: If BMI ≥30, previous pre-eclampsia, chronic hypertension, or renal disease

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Antenatal care