*Cholestasis

Question 1

When does ICP usually present?

Answer 1

3rd trimester. Around 30 weeks

Question 2

*Pathophysiology?

Answer 2

Reduction in bile secretion and flow through the liver
–> bile acids accummulate in maternal blood
–> which are thought to be fetotoxic

Liver produces bile
Gallbladder stores bile
Gall bladder is affected by pregnancy hormones
Role of bile salts - emulsify fats

Know liver is invovled and bile acids build up.

Question 3

Diagnosis ICP

Answer 3

• Otherwise unexplained pruritis (typically hands/feet)
• Raised bile acids
• Abnormal LFTs

Diagnosis confirmed by:
 Clinical features
 Exclusion of other forms of liver disease or cholestasis
 Laboratory findings

Question 4

Clinical features of ICP

Answer 4

• Pruritis without a rash (worse at night)
• Fatigue / Malaise
• Dark urine
• Steatorrhea / pale stool
• Jaundice (less common)

Question 5

ICP Risks

Answer 5

• Preterm birth (iatrogenic or spontaneous)
• Fetal distress
• Mec-stained liquor
• Stillbirth
• Distress to woman

Question 6

Diagnosis / Investigations for ICP

Answer 6

• (Non)-fasting SBA
• LFTs
• FBP
• Coagulation studies
• USS and CTG at discretion of obstetric team and woman (not shown to be predictive of fetal death)

No longer recommend Viral screen, Auto-immune screen or Liver ultrasound

Question 7

Management of ICP

Answer 7

Medication
* UDCA (Ursodeoxycholic acid)
* Vit K supps (due to decreased Vit K absorption)
* Phenergan (antihistamine)

Cool baths
Topical emollients
Cotton clothing
Low fat diet
Planned birth depending on bile acid levels

Question 8

Postnatal considerations for ICP

Answer 8

• Resolves spontaneously after birth (48hr postpartum)
• May reoccur in subsequent pregnancies
• Re-check LFTs 2-4 weeks after birth
• Severe, familial ICP needs long-term hepatic follow up (increased risk of chronic liver disease)
• Avoid use of combined oral contraceptive pill
• Vit K IM injection for neonate

Question 9

Implications and recommendations for midwives - ICP

Answer 9

• 2 weekly antenatal visits

In labour and birth
* Increased likelidhood of PPH due to Vit K deficiency (presence of bile acids in blood stream decreases absoprtion of fat solube vits)
* G+H on admission
* Continous CTG
* Paed at birth

Implications if left untreated - FDIU
Possibility of iatrogenic or sponatneous prematurity

Question 10

Assessment in MFAU for Suspected cholestasis

Answer 10

1. Document a maternal history. Note where pruritis is felt. When did the pruritis
   commence? Is it worst at night? Is a rash present? Note other symptoms e.g.
   steatorrhea, jaundice, malaise.
2. Record baseline maternal observations – temperature, pulse, blood pressure
   and urinalysis.
3. Perform an abdominal palpation, noting:
    Fundal height
    Lie and presentation (as appropriate for gestation)
    Uterine tenderness/irritability/fetal activity
4. Assess fetal wellbeing
    Auscultate the fetal heart rate
    Perform a CTG if more than 30 weeks gestation
    Arrange an ultrasound for biophysical profile and fetal wellbeing
5. Investigations
    Serum Bile Acid levels, preferably fasting levels
    Full blood picture
    Liver function tests
    Coagulation screen (if abnormal liver function)
    Viral screen for hepatitis A,B and C, Epstein Barr and cytomegalovirus
    Liver autoimmune screen for chronic hepatitis and primary biliary cirrhosis
    Liver ultrasound

Question 11

X produces bile
Y stores biles
Z is affected by pregnancy hormones
Role of bile salts - ZZ

Answer 11

Liver produces bile
Gallbladder stores bile
Gall bladder is affected by pregnancy hormones
Role of bile salts - emulsify fats