cholestasis in pregnancy

Question 1

what is obstetric cholestasis

Answer 1

pruritis in the absence of skin rash with abnormal LFTs, neither of which has an alternative cause and both of which resolve after birth

Question 2

clinical features of cholestasis

Answer 2

pruritis without a rash - itching is classically on the palms and soles of the feet although it may be more widespread
pruritis is worst at night, and women may exhibit dermatographia artefacts (skin trauma from intense scratching
malaise
steatorrhea with fat malabsorption
jaundice: uncommon, but can occur in 10-15% of cases

Question 3

other potential causes you should exlcude

Answer 3

autoimmune hepatitis
hepatitis A, B, C, or E
epstein Barr
cytomegalovirus
gall bladder disease
liver disease eg. cirrhosis, acute fatty liver
early HELLP syndrome or preeclampsia
skin conditions eg. eczema, pruritic eruption of pregnancy, scabies

Question 4

laboritory tests

Answer 4

bile acids: levels >10 are a common diagnostic marker
LFTS:
- ALT and AST can be raised by up to 20 tmes the normal level
- GGT activity is unusual but indicative of MDR3 gene mutation leading to increased bile acids, or of underlying liver disease
- uncommon to have raised serum bilirubin

Question 5

investigations

Answer 5

fasting serum bile acids to make the diagnsosis
weekly LFTs after diagnosis
FBC
coagulation studies may be ordered if abnormal LFTs, prolonged prothrombin time may reflect vit K deficiency
viral screen for hepatitis A, B, C, EBV and cytomegalovirus
liver autoimmune screen
liver US

Question 6

timing of birth in cholestasis

Answer 6

aim to deliver between 37 and 38 weeks gestation or earlier if there is sufficient risk for maternal morbidity or fetal compromise
consider administration of corticosteroids if IOL is anticipated before 36+6

Question 7

treatment of maternal pruritis

Answer 7

the use of topical emollients eg. calamine lotion may provide temporary relief of itching. they are safe but their efficacy is unknown
offer advice to decrease skin irritation
encourage a low fat diet and advise to increase water intake
sedative anti histamines at night
ursodeoxycholic acid

Question 8

ursodeoxycholic acid

Answer 8

improves pruritis and liver function in women with obstetric cholestasis

Question 9

vitamin K supplimentation

Answer 9

obstetric cholestasis can lead to a reduction in circulating enterohepatic bile acids causing reduced absorption of fat-soluble vitamins
vit K is a fat-soluble vitamin required for coagulation
consider vit K supplementation to reduce the risk of PPH

Question 10

nutritional supplimentation

Answer 10

steatorrhea and fat malabsorption may lead to nutritional deficiency
consider multivitamin supplimentation
consider referral to dietician for low fat diet

Question 11

counselling prior to discharge

Answer 11

risk of recurrence in subsequent pregnancy is 40-60%
reassurance about the lack of long term sequelae for mother and baby
pruritis normally resolves within 48 hours but may last up to 4-8 weeks
women who have severe familial form of obstetric cholestasis are at risk of chronic liver disease and should have long term follow up
female family membranes may be at increased risk of obstetric cholestasis
avoid COCP for life
HRT is safe
arrange GP follow up