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Presentation of cholestasis in woman pregnant with twins (03HDC06196)

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(03HDC06196, 03 September 2004)

Midwife ~ General practitioner ~ Practice nurse ~ Medical centre ~ Cholestasis ~ Standard of care ~ Professional standards ~ Rights 4(1), 4(2)

A woman 32½ weeks pregnant with twins attended her GP complaining of itching and vomiting. The GP was her lead maternity carer and shared her care with a midwife. The GP had seen the woman regularly over the preceding weeks and, although the woman had previously suffered from vomiting, this was the first complaint of itching. There is some disagreement about the exact symptoms reported. The GP recorded vomiting and a slight itch; he considered that these symptoms were not atypical of a woman carrying twins, and therefore did not conduct further investigations. As he was to be absent for the next two weeks, he made arrangements for a second GP at the practice to cover the first week, and a third GP at another practice to cover the second week; an obstetrician also agreed to provide specialist care if required. The GP informed the woman of his absence and the arrangements for cover.

The frequency of the woman's vomiting increased, and during a routine ultrasound at a public hospital the ultrasonographer became concerned about her condition and advised her to seek a review. The woman replied that she would see her GP at the next routine appointment, but was advised not to wait until then as she might have liver trouble. The woman agreed to speak to her midwife, as she was seeing her in three days' time for a tour of the delivery suite. There is disagreement about whether a maternity assessment was also scheduled at this meeting; one did not take place and, although the woman said she was feeling generally unwell, she did not mention her itching or the discussion with the ultrasonographer.

The next maternity assessment followed a week later, and the woman and midwife have different recollections of what occurred. The midwife stated that the assessment included measurement of girth and clinical gestation; she recorded blood pressure, absence of protein in the urine, and satisfactory fetal heart rate and movements; she also noted swelling in the ankles and feet, and vomiting, and that diet and oral Maxolon (previously prescribed by the GP) were discussed. The woman said that she complained of severe itching, especially in her feet, which was keeping her awake at night, and of vomiting bile five to six times at 12-hourly intervals. The midwife examined the woman and found no rash or abrasions caused by scratching, and did not observe the woman scratching during the hour-long assessment. She offered sleeping pills, which were declined, discussed fluid management and Maxolon, and told the woman to seek further assistance from her or the GP if her vomiting worsened.

The woman continued to experience nausea and itching. She had read in a book on twin pregnancy that chronic itching could be a symptom of cholestasis. (Cholestasis is a poorly understood condition, and may be difficult to diagnose. The symptoms often present in the third trimester and the itching is typically over the palms of the hands and the soles of the feet. There are risks to the fetus, including hypoxia, fetal distress, stillbirth and preterm delivery.)

The woman decided to contact her GP's locum. She spoke to the practice nurse, who informed her that neither of the GPs was available, and advised her to consult her midwife. The woman insisted that she see a GP and, as the other GPs at the practice did not specialise in obstetrics, the practice nurse offered to arrange an appointment with the third GP. There is disagreement about whether the appointment was requested urgently. The practice nurse telephoned the other medical centre soon afterwards, but the third GP was unavailable and fully booked that afternoon. However, she was told that on his arrival at the centre he would be informed of the woman's situation and an appointment made.

The practice nurse at the second medical centre made a brief note of the call, and no sense of urgency was evident (the GP attempted to contact the woman at 7 o'clock that night). The first practice nurse telephoned the woman to inform her of the arrangements.

In the meantime, the woman attempted to contact the covering obstetrician and his locum; both were unavailable, but a nurse who worked with the locum arranged for immediate review at the public hospital. The woman was admitted with suspected cholestasis, and safely delivered her twins by emergency Caesarean.

The woman complained that the midwife and first GP did not adequately investigate her symptoms as reported to them; that the midwife failed to refer her for investigation; and that the practice nurse did not respond appropriately to her request to see a doctor urgently.

It was held that there was no breach of the Code. While the extent of the information conveyed to the midwife is unclear, it was considered that her investigation of the woman's symptoms was adequate and her decision not to refer reasonable. The first GP's assessment of the symptoms as they presented at the time was also held to be reasonable; his cover arrangements were thorough and, although not as robust as expected, met the standard of care expected of a responsible GP practising obstetrics. The practice nurse's request for an appointment with the third GP was prompt and the referral was held to be appropriate; her advice to contact the midwife was also appropriate.

However, it would have been advisable for the practice nurse to have documented the clinical situation covered in the telephone call and enquired of the woman whether she was content with the assessment.

Fortunately, the woman's perseverance in seeking medical attention in trying circumstances for a rare yet very serious condition averted a potential tragedy.