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

Hypertensive disorders of pregnancy for UKMLA AKT: High-Yield Women’s Health Lessons

Quick Overview

Hypertensive disorders complicate 10-15% of pregnancies and remain a leading cause of maternal/fetal morbidity. NICE NG133 stratifies management by severity: gestational hypertension, pre-eclampsia, and severe pre-eclampsia, each with distinct diagnostic thresholds and treatment escalation. Timely recognition, appropriate antihypertensive therapy, and judicious use of magnesium sulfate for seizure prophylaxis are critical to prevent maternal stroke, eclampsia, and perinatal compromise.

Core Facts & Concepts

📊 Diagnostic Thresholds

Gestational hypertension: BP ≥140/90 mmHg after 20 weeks without proteinuria/organ dysfunction
Pre-eclampsia: BP ≥140/90 mmHg PLUS proteinuria (≥300 mg/24h or PCR ≥30 mg/mmol) OR organ dysfunction
Severe pre-eclampsia: BP ≥160/110 mmHg OR severe organ/uteroplacental dysfunction

Figure 1: Fundoscopy showing bilateral retinal haemorrhages and cotton-wool spots in severe pre-eclampsia

🚩 Organ Dysfunction Markers

Acute kidney injury (creatinine ≥90 μmol/L)
Liver involvement (transaminases >70 IU/L ± RUQ pain)
Haematological: platelets <150×10⁹/L, DIC, haemolysis
Neurological: eclampsia, stroke, persistent headache/visual disturbance
Uteroplacental: fetal growth restriction, abnormal Doppler, stillbirth

💊 First-Line Antihypertensives (NICE NG133)

Drug	Starting Dose	Maximum Dose	Notes
Labetalol	100 mg BD PO	800 mg TDS	Avoid in asthma
Nifedipine MR	10 mg BD PO	40 mg BD	Use modified-release
Methyldopa	250 mg BD-TDS PO	1 g TDS	Avoid postpartum (depression risk)

Target BP: 135/85 mmHg (avoid over-treatment; maintain uteroplacental perfusion)

Problem-Solving Approach

Step-by-Step Management

Confirm diagnosis: Repeat BP measurement after 30 min rest; quantify proteinuria (PCR or 24h urine)
Assess severity: Bloods (FBC, U&E, LFT, urate), fetal monitoring (CTG, USS growth/Doppler)
Initiate treatment if BP ≥140/90: Start labetalol/nifedipine/methyldopa (see table above)
Severe features (BP ≥160/110): Admit; IV labetalol 20 mg bolus OR oral nifedipine 10 mg (repeat every 30 min PRN)
Magnesium sulfate criteria: Severe pre-eclampsia with imminent/actual eclampsia OR during delivery if BP ≥160/110
- Regimen: 4 g IV loading over 5-15 min, then 1 g/h infusion for 24h
- Monitor: Respiratory rate ≥16/min, patellar reflexes, urine output ≥25 mL/h
Delivery timing:
- Severe pre-eclampsia: Consider delivery from 34 weeks (balance maternal/fetal risk)
- Uncontrolled BP/organ dysfunction: Deliver urgently regardless of gestation
- Gestational hypertension alone: Aim for 37-40 weeks

⚠️ Warning: Rapid BP reduction (target 135/85, NOT normotension) risks placental hypoperfusion and fetal compromise

Analysis Framework

Differential Diagnosis: Hypertension in Pregnancy

Feature	Chronic HTN	Gestational HTN	Pre-eclampsia	Severe Pre-eclampsia
Onset	<20 weeks	≥20 weeks	≥20 weeks	≥20 weeks
Proteinuria	Absent	Absent	Present	Present
Organ dysfunction	Absent	Absent	May be present	Always present
BP threshold	≥140/90	≥140/90	≥140/90	≥160/110
Risk of eclampsia	Low	Low	Moderate	High

🎯 Key Discriminators

Proteinuria distinguishes gestational HTN from pre-eclampsia
Severe BP/organ dysfunction mandates magnesium sulfate consideration
HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets): variant of severe pre-eclampsia requiring urgent delivery

Visual Aid

Key Points Summary

✓ Diagnostic thresholds: Gestational HTN ≥140/90 (no proteinuria); pre-eclampsia ≥140/90 + proteinuria/organ dysfunction; severe ≥160/110 or organ involvement
✓ First-line drugs: Labetalol 100 mg BD → 800 mg TDS, nifedipine MR 10 mg BD → 40 mg BD, methyldopa 250 mg BD-TDS → 1 g TDS
✓ Target BP 135/85 mmHg (avoid over-treatment)
✓ Magnesium sulfate: 4 g IV load + 1 g/h infusion for severe pre-eclampsia with imminent eclampsia or during delivery if BP ≥160/110
✓ Delivery timing: Severe pre-eclampsia from 34 weeks; urgent delivery if uncontrolled BP/organ dysfunction
✓ Monitor MgSO4: Respiratory rate ≥16/min, reflexes present, urine output ≥25 mL/h (toxicity antidote: calcium gluconate 10 mL 10% IV)
✓ HELLP syndrome is severe pre-eclampsia variant requiring urgent delivery

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