8A) Antenatal Care: Obstetric cholestasis

Question 1

Incidence of OC

Answer 1

0.7% of pregnancies (1.2-1.5% of Indian/Pakistani population)

Question 2

Incidence of pruritus in pregnancy

Answer 2

23%

Question 3

How often to repeat LFTs if symptoms persist but bloods normal?

Answer 3

Every 1-2 weeks

Question 4

When to check LFTs postnatal?

Answer 4

Defer at least 10 days (can usually be done at 6w PN check)

Question 5

How often to repeat LFTs once OC diagnosis confirmed?

Answer 5

Weekly

Question 6

Monitoring in labour

Answer 6

Continuous CTG

Question 7

Risks of OC

Answer 7

• ?Stillbirth
• Preterm birth (mostly iatrogenic)
• Increased passage of meconium

Question 8

How can outcome in OC be predicted?

Answer 8

Can’t be predicted by biochemical results, USS or CTG.

Question 9

When to deliver with OC?

Answer 9

Discussion re: IOL from 37 weeks.

Question 10

Recurrence rate of OC

Answer 10

45-90%

Question 11

Treatment for OC

Answer 11

Topical emollients - safe but may not be effective.
Chlorphenamine - sedation but doesn’t affect pruritus.
URSO - improves pruritus and LFTs.
Vitamin K (5-10mg daily) if PT prolonged.

Not in use:
Colestyramine
SAME
Dexamethasone

Question 12

Risk factors of obstetric cholestasis

Answer 12

Multiple pregnancy
IVF
Older women
Hx of gallstones or hep C
Sisters of affected women
Oral progesterone for PTB prevention
Low selenium and vitamin D intake

Question 13

What percentage of cases of OC can be explained by known genetic variation?

Answer 13

10-15% (mutations in bile acid receptor FXR or transport proteins)

Question 14

What percentage of women present after 30 weeks?

Answer 14

80%

Question 15

What percentage of women get jaundice?

Answer 15

<10%

Question 16

FHx present in what percentage

Answer 16

14%

Question 17

Gallstones found in what percentage

Answer 17

13%

Question 18

Suggested “cut off” as high risk OC and recommend delivery from 37 weeks

Answer 18

Bile acids > 40

Question 19

When to start URSO?

Answer 19

Only if bile acids are raised (not just if abnormal LFTs)

Question 20

What produces AST?

Answer 20

Also skeletal/cardiac muscle (as well as liver)

Question 21

Risk of stillbirth in OC

Answer 21

1.5%

Question 22

Percentage of women with stillbirths associated with OC who have other comorbidities

Answer 22

70%

Question 23

Second line treatment for OC

Answer 23

Rifampicin

Question 24

Future risks after OC

Answer 24

HPB disease and cancer.
Immune mediated disease.
Cardiovascular disease.
Metabolic disease in child.

Question 25

Conditions associated with anti-nuclear antibodies

Answer 25

PBC
PSC
Autoimmune hepatitis

Question 26

Condition associated with anti-mitochondrial antibodies

Answer 26

PBC

Question 27

Condition associated with pANCA

Answer 27

PSC

Question 28

Conditions associated with aSMA

Answer 28

PSC

Autoimmune hepatitis

Question 29

Other antibodies seen in autoimmune hepatitis

Answer 29

LKM1
Anti-soluble liver antigen
Anti-liver pancreas antibodies.