Antenatal Care: Cholestasis of Pregnancy & Acute Fatty Liver of Pregnancy Flashcards
What is obstetric cholestasis?
Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver during pregnancy. The condition resolves after delivery of the baby.
Relatively common complication of pregnancy (1%).
When does obstetric cholestasis typically occur?
It usually develops later in pregnancy (i.e. after 28 weeks)
What is obstetric cholestasis thought to be the result of?
Increased oestrogen & progesterone
What ethnicity is obstetric cholestasis more common in?
South Asian
Describe journey of bile from liver to intestines
1) Bile acids are produced in the liver from the breakdown of cholesterol.
2) Bile acids flow from liver to the hepatic ducts, past the gallbladder
3) Bile acids flow out of the bile duct to the intestines
What are bile acids made from?
Breakdown of cholesterol
What happens in obstetric cholestasis?
In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis).
What complication is obstetric cholestasis associated with?
an increased risk of stillbirth.
What is the key symptom of obstetric cholestasis?
Itching (pruritus) - particularly affecting the palms of the hands and soles of the feet.
Symptoms of obstetric cholestasis?
1) Pruritus
2) Fatigue
3) Dark urine
4) Pale, greasy stools
5) Jaundice
Is there a rash associated with obstetric cholestasis?
No - if a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.
Classic LFT feature in most obstetric cholestasis cases?
raised bilirubin is seen in > 90% of cases
Where is itching tyically worse in obstetric cholestasis?
palms, soles and abdomen
Differentials of obstetric cholestasis (i.e. other causes of pruritus and deranged LFTs)?
1) Gallstones
2) Acute fatty liver
3) Autoimmune hepatitis
4) Viral hepatitis
What 2 investigation should be done in women presenting with pruritus?
1) LFTs: abnormal liver function tests (LFTs), mainly ALT, AST and GGT
2) Bile acids: raised
What is a normal LFT change in pregnancy?
It is normal for alkaline phosphatase (ALP) to increase in pregnancy.
A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.
Why does ALP rise in pregnancy?
Placenta produces ALP
1st line treatment of obstetric cholestasis?
Ursodeoxycholic acid: it improves LFTs, bile acids and symptoms.
How can symptoms of itching be managed in obstetric cholestasis?
1) Emollients (i.e. calamine lotion) to soothe the skin
2) Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
What can be given in clotting (prothrombin) time is deranged in obstetric cholestasis?
Water-soluble vitamin K
How can a lack of bile salts in obstetric cholestasis lead to vitamin K deficiency?
What can this lead to?
1) Bile acids are important in the absorption of fat-soluble vitamins in the intestines.
2) A lack of bile acids can lead to vitamin K deficiency.
3) Vitamin K is an important part of the clotting system, and deficiency can lead to impaired clotting of blood.
Monitoring of obstetric cholestasis?
Monitor of LFTs is required during pregnancy (weekly) and after delivery (after at least ten days).
When does sobstetric cholestasis typically resolve?
After birth
Potential management of obstetric cholestasis when LFTs and bile acids are severely deranged.?
Planned delivery after 37 weeks may be considered