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Opioid use disorder — USMLE Step 3 MCQ

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HardPsychiatry (outpatient management)Opioid use disorderUSMLE Step 3

A 35-year-old at 35 weeks 4 days has intense nocturnal pruritus of the palms and soles. Alanine aminotransferase is mildly elevated, total bile acids are 112 micromol/L, fetal testing is reassuring, and there is no preeclampsia or membrane rupture. Ursodeoxycholic acid improves itching. Which delivery plan is most appropriate?

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Correct answer: B — Plan delivery at 36 weeks because total bile acids exceed 100 micromol/L

The best answer is “Plan delivery at 36 weeks because total bile acids exceed 100 micromol/L”. Severe intrahepatic cholestasis with bile acids at least 100 micromol/L carries a gestation-dependent stillbirth risk, so SMFM recommends delivery at 36 0/7 weeks. Antenatal testing cannot fully predict the sudden fetal events associated with this disease. Route of delivery follows obstetric indications; neither symptomatic improvement nor biochemical normalization justifies extending pregnancy to term.

Reference: SMFM Consult Series 53: Intrahepatic Cholestasis of Pregnancy: https://publications.smfm.org/publications/374-society-for-maternal-fetal-medicine-consult-series-53/