Objective -To highlight the importance of interpreting abnormal liver function tests (LFTs) in pregnant women with suspected “intrahepatic cholestasis of pregnancy” (ICP) with atypical features.

Case Report - A 30-year-old Asian woman, primigravida, presented with severe pruritus at 30+4 weeks gestation. She had no known co-morbidities and screening for obstetric cholestasis revealed deranged LFTs and raised bile acids. Ursodeoxycholic acid was commenced, hepatitis serology and antibody screening were normal. Despite the treatment, the symptoms and LFTs continued to worsen. Woman reported significant weight loss and poor compliance with medication due to poor appetite. A liver ultrasound scan at 33+5 weeks revealed vascular lesions within the liver and spleen highly suspicious of malignancy. Following a case discussion at the gastroenterology multidisciplinary team (MDT) meeting, MRI scan was arranged in the immediate postnatal period. Induction of labour was arranged at 37+4 weeks and she had an uncomplicated vaginal delivery with good foetal outcome.

A postnatal MRI reported a large lesion displacing brachiocephalic and pulmonary arteries. Multiple enlarged mediastinal, coeliac, gastric lymph nodes and multiple large lesions in liver and spleen were also reported. The radiological Impression was of lymphoma and histology revealed Classical Hodgkin lymphoma of a nodular sclerosing type.

Discussion – Hodgkin lymphoma (HL) is the most common hematologic malignancy complicating pregnancy, with the peak incidence coinciding with reproductive years, and as many as 3% of all HL patients present with concurrent pregnancy. The management of a pregnant patient with HL requires a MDT approach combining expertise in medical oncology, high-risk obstetrics, and neonatology.

There are no current guidance on the management of HL in pregnancy. The RCOG guidance on “intrahepatic cholestasis of pregnancy” (August 2022) recommend considering additional antenatal testing only if there are atypical clinical symptoms, presence of relevant comorbidities, or where early onset severe ICP is noted. This woman had atypical clinical features (loss of weight, poor appetite) with no improvement with conventional treatment.

Conclusion- Itching of normal skin, liver dysfunction and elevated bile acid concentrations are non-specific and have a wide range of causes. An Obstetrician should consider other potential diagnoses: these may be pregnancy specific or coincidental to the pregnancy. Management of HL in pregnancy can be extremely difficult. Management should focus on achieving the best outcome for the mother with minimal risk to the foetus. Management depends on presenting features, gestational age at diagnosis, foetal risks and the patient’s wishes regarding the continuation of pregnancy.