8.17 Obstetric Cholestasis

Question 1

What the classic symptom of obstetric cholestasis?

Answer 1

Itching
particularly the palms of the hands and soles of feet.
worse at night
(no rash)

Question 2

Other than itching what other symptoms are related to cholestasis?

Answer 2

• Fatigue
• Dark urine
• Pale, greasy stools
• Jaundice

Question 3

Other than obstetric cholestasis, what other causes of pruritis and deranged LFTs are there?

Answer 3

• Gallstones
• Acute fatty liver
• Autoimmune hepatitis
• Viral hepatitis

Question 4

What abnormal bloods would you expect in obstetric cholestasis?

Answer 4

• abnormal LFTs, mainly ALT, AST and GGT
• raised bile acids

TOM TIP: normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.

Question 5

How common is obstetric cholestasis and when does it present?

Answer 5

About 1% (0.7%) of pregnancies.
Present later ie after 28 weeks.
More common in South Asian ethnicity

Question 6

What are bile acids made from?

Answer 6

breakdown of cholesterol in the liver

Question 7

Why is there more cholesterol to breakdown in pregnancy?

Answer 7

increased progesterone and oestrogen levels

Question 8

What is happening in obstetric cholestasis?

Answer 8

outflow of bile acids is reduced, causing build up in the blood and itching.

Question 9

What risk is obstetric cholestasis associated with?

Answer 9

stillbirth

also:
fetal distress
preterm labour
meconium

Question 10

What is the primary treatment for obstetric cholestasis?

Answer 10

Ursodeoxycholic acid (UDCA)
improves LFTs, bile acids and symptoms.

Question 11

What else can be used for itch symptoms in obstetric cholestasis?

Answer 11

• emollients (i.e. calamine lotion) to soothe the skin

- antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)

Question 12

What can people with a lack of bile acids in their intestines become deficient in?

Answer 12

Vitamin K

and other fat soluble vitamins

Question 13

What do you give if clotting / prothrombin time is deranged in obstetric cholestasis?

Answer 13

10mg PO/24hr vitamin K to mum

1mg IM to baby at birth

Question 14

When should obstetric cholestasis mums deliver?

Answer 14

offer IOL from 37 weeks

Question 15

When can obstetric cholestasis recur?

Answer 15

oestrogen containing COCP
or
future pregnancy (40-60%)