Station 59

Jasmine Walker

Age: 30 years old female

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name: Jasmine Walker

Age: 30-year-old female 

Past medical history

  • Nil
  • Currently Pregnant 

Drug and Allergy History 

  • Nil
  • No known drug allergy

Recent Notes/Consultation

  • Nil

 

Patient booked urgent telephone consultation to discuss some concerns

Patient's Story (Role player’s brief)

Patient’s Story 

You are Jasmine Walker, a 30-year-old woman currently 33 weeks pregnant with your first child. You are calling for an urgent telephone consultation because you have developed widespread itching over the past two days, and it seems to be getting worse.

Opening statement: Doctor, I want some tablets for my itching. I’ve been itching all over and it’s getting really uncomfortable.

If asked to elaborate: 

The itching is particularly bothersome at night and has begun to disturb your sleep. You have tried using regular moisturisers, but they have not helped. You have no rash, have not been in contact with anyone else experiencing similar symptoms, and your pregnancy has been uneventful so far. 

You are up to date with all midwife appointments, and you continue to feel normal baby movements.

Social History: This is your first pregnancy; you are a non-smoker; you do not drink alcohol; you work as a beautician (nail technician); you live with your supportive husband;you are due to travel to Albania for a holiday tomorrow.

Idea: You’ve heard that itching can be common in pregnancy

Concern: You are worried the itching might affect your sleep and holiday in Albania 

Expectation: You would like the GP to prescribe a safe medication to stop the itching

Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.   

Marking Scheme

Data Gathering and Diagnosis 

  • Ask how many weeks pregnant she is (gestational age), as conditions like obstetric cholestasis and polymorphic eruption typically begin after 28 weeks
  • Ask when the itching started and how it has changed. 
  • Ask if the itch is localised or generalised 
  • Ask if there is a rash 
  • Ask about associated symptoms suggesting obstetric cholestasis: jaundice, dark urine, pale stools, right upper quadrant abdominal pain, and malaise.  
  • Ask if itch is worse at night (Obstetric cholestasis causes night-time itch)  
  • Ask about recent contact with anyone else who is also itching, to rule out scabies
  • Ask about any triggers (e.g., heat, hot showers, sweating). 
  • Ask about any prescribed or over-the-counter medications, especially opioids, as they can cause itching. 
  • Ask if she feels her baby move normally (foetal movements are usually noticed between 16 and 24 weeks.) 
  • Ask about red flag symptoms such as night sweats, unexplained weight loss, or lumps, which could suggest more serious pathology such as lymphoma
  • Ask about lifestyle factors: smoking, alcohol, illicit drug use. 
  • Ask if she is attending antenatal care and whether the pregnancy has been progressing normally 
  • Ask how the itching is affecting her daily life and sleepquality. 
  • Ask about her home situation and whether she has adequate support at home
  • Give a diagnosis of itching in pregnancy, and explain the need to rule out obstetric cholestasis. 

Example of explanation to patient​

Jasmine, thank you for sharing what’s been going on. Like you mentioned, itching in pregnancy can be common.

However, because you’re 33 weeks pregnant and it’s getting worse, we do need to make sure there’s nothing more serious going on. One condition we want to rule out is something called obstetric cholestasis. It’s a liver condition that can happen during pregnancy, where your body doesn’t clear a substance called bile acids properly. This usually causes itching, often worse at night, without a rash and it is very similar to what you’re describing.

So, I will be arranging for you to be seen today at the maternity assessment unit if that’s okay with you. When you get there, they’ll do some blood tests, including checking your liver functions, and they’ll also check on the baby’s wellbeing. If everything is fine, that’s great, we’ll look at ways to manage the itch and help you sleep better.

But if obstetric cholestasis is confirmed, the team will put together a personalised plan for you. This may involve regular blood tests, and sometimes early delivery is discussed depending on how things progress. They may also offer medications to reduce the itch and bile acid levels. 

I know you’re planning to travel to Albania tomorrow, but I would strongly advise against it for now. It’s really important to get these tests done and make sure you and the baby are safe. If you have travel insurance, you may be able to make a claim given the medical advice.

If the tests come back normal, we can help manage the itching with things like menthol cream, and if needed, a mild antihistamine at night to help you sleep

Management

Management

  • Arrange same-day assessment/admission to the maternity assessment unit for urgent blood tests, including liver function tests and bile acids, to rule out obstetric cholestasis
  • Explain that at the hospital, they will carry out blood tests and also monitor the baby’s wellbeing through appropriate foetal assessments
  • If obstetric cholestasis is diagnosed, inform the patient that an individualised care plan will be developed based on her results and clinical situation; this may include regular blood tests to monitor liver function and bile acid levels, possible early delivery depending on severity and gestational age, or treatment with ursodeoxycholic acid (UDCA) to relieve itching and reduce bile acid levels.
  • Advise against travelling to Albania at this time, as it is important to complete investigations and ensure the safety of both mother and baby
  • Inform her that if she has travel insurance, she may be able to make a claim based on medical advice not to travel
  • Advise that if investigations return as normal, she should book a follow-up appointment to consider treatment options such as menthol 0.5% or 1% in aqueous cream to relieve the itch, and a sedating antihistamine at night (e.g., chlorphenamine or promethazine) to improve sleep—noting that this is an off-label use in pregnancy
  • Provide safety netting advice: if symptoms worsen, new symptoms develop, or if there are any concerns about baby movements or general wellbeing before or after attending hospital today, seek urgent medical attention without delay

Learning point from this station: ​

Itching in pregnancy can result from a pre-existing skin condition or may be due to pregnancy-specific causes. It is important to take a careful history and examine for the presence or absence of a rash to guide diagnosis.

Common pregnancy-related causes include:

Obstetric cholestasis – typically causes generalised itching without a rash, often worse at night. This condition requires urgent blood tests to assess liver function and bile acid levels, due to associated risks to the baby.

Polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis – these usually present with itching accompanied by a rash, often starting from the abdomen.

It is important to remember that itching in pregnancy can also be unrelated to pregnancy, such as due to eczema, allergies, or scabies. A focused history and clinical assessment are key to identifying the correct cause and ensuring appropriate management.

Further reading