ICPC Flashcards
What is the definition of obstetric cholestasis and how many pregnancies does it effect?
Also known as intrahepatic cholestasis of pregnancy (ICP), this is a disorder of the liver where the normal flow of bile out of the liver is reduced.
It affects around 1:140 pregnancies in the UK.
What is bile?
Is yellow-green produced by the liver which contains-
Chemicals to aid digestion (Including bile acids)
Waste products for excretion via the bowel (including bilirubin)
How is bile transferred around the body?
Bile passes from the liver cells via small hepatic ducts which join to become the common hepatic duct.
The gallbladder stores bile and is attached via the cystic duct.
The common bile duct carries bile from the common hepatic and the cystic duct to the duodenum (part of the small intestine)
What is the role of bile in the intestines?
It acts as a detergent, breaking the fat into very small droplets so that it can be absorbed from food. It also makes it possible for the body to take up the fat-soluble vitamins A, D, E and K from the food passing through the gut.
What are some factors that are suggested could cause obs choli
Hormonal factors i.e. later in pregnancy Inc in hormones, multiple pregnancy, hormone therapy
Genetic factors
Environmental factors i.e. lower vit D.
What are symptoms of obs choli?
Pruritus without rash (itching)
-particularly worse on palms and soles
-often worse at night (due to producing more bile acids during the day when eating.
Loss of appetite
Malaise
Jaundice
Pale stools
What are predisposing factors of obs choli?
-History of obs choli (recurrent rate of 40-70%)
- Family history (1st degree family relative)
Ethnicity (Indian, Pakistani, south America, indigenous people of Chile)
- Women with Heap C or liver conditions
-Seasonal variations (more common in winter due to deck vit D)
Assisted reproduction pregnancies
Progesterone supplements
Multiple pregnancies (Due to Inc of hormones)
What are some maternal implications of obs choli?
Coping with itching
Difficulty sleeping
Anxiety and impact on MH
Risk of gestational diabetes and pre-eclampsia
Increased risk of hepatobiliary disease i.e. gallstones
Vit K deficiency
What are the implications of obs choli on the fetus?
-Risk of prem birth
-Risk of meconium liquor (bile acids are toxic to fetus do can get distressed)
-Risk of infant requiring neonatal care
-Risk of stillbirth- linked to bile acids (In 90% of women with cholestasis bile acids will not go above 100mmol/L, but in the remaining 10% there is a 10 x increase in risk of stillbirth throughout pregnancy, but especially after 35 weeks. Further increase by other comorbidities.
How do we diagnose obs Chole?
-Same day referral to maternity unit for assessment and obs review
- Careful history noting (no new medications, allergies etc.)
Exclude other causes
Urine dipstick for proteinuria
Blood pressure
CTG?
Blood tests
-Liver function test
-Bile acids
Viral screening for Heap A, B, C, Epstein Barr and cytomegalovirus
Liver autoimmune screening for chronic active hepatitis and primary billary cirrhosis
Liver ultrasound (if we suspect something else is going on.
Why do we do urine dipstick for proteinuria and blood pressure when diagnosing?
Due to Inc risk of PET
What does RCOG say about stillbirth prevention with CTG and what should we be talking to women about instead?
CTG’s are poor at predicting stillbirth, but most local guidance say to use them.
We need to be talking t women about FM’s
What are the clinical features of gestational puritus (just itching in pregnancy) and what should we do if shes still itching?
Itching and peak bile acids <19mmol/L
If shes still itching we bring ehr back in 1-2weeks for repeat ICP testing.
What are the clinical features of mild ICP?
Itching and peak bile acids 19-39mmol/L
What are the clinical features of Moderate ICP
Itching and peak bile acids 40-99mmol/L
What are the clinical features of severe ICP?
Itching and raised peak bile acids >100mmol/L
What else could itching be?
Stretch marks
Drug/allergic reaction
Pruritic urticaria of pregnancy (PUP) (over abdomen, not involving umbilical area, no risk to fetus and more likely in multiples)
Chilblains
Dry skin (not uncommon due to hormone changes)
Eczema
Diabetes
Athlete foot
ETC…
What is the management of obs Chole?
-There is no cure whilst pregnant
-Topical ointments and antihistamines
-Blood tests to test for LFTS’s and bile acids should be repeated frequently
-Ursodeocyvholic acid may be given to reduce prurits and improve liver function, it was previously through to reduce adverse outcomes but this was discounted after the PITCHES (Chappell et al 2019)
-Vit K in women with evidence of reduced absorption or abnormal clotting
-Give advice on monitoring FM due to risk of stillbirth.
Where will women with ICP be advised to give birth?
Obstetric unit
What is the birth plan for women with severe obs Chole who have an increased risk of stillbirth?
Consider birth at 35-36 weeks. CTG throughout labour.
What is the birth plan for women with
