Intrahepatic_Cholestasis_of_Pregnancy_Flashcards
What is intrahepatic cholestasis of pregnancy?
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a liver disorder that affects around 1% of pregnancies in the UK.
How common is intrahepatic cholestasis of pregnancy in the UK?
Intrahepatic cholestasis of pregnancy affects around 1% of pregnancies in the UK.
What is the risk associated with intrahepatic cholestasis of pregnancy?
It is associated with an increased risk of premature birth.
What are the features of intrahepatic cholestasis of pregnancy?
Features of intrahepatic cholestasis of pregnancy include intense pruritus, especially worse on the palms, soles, and abdomen, clinically detectable jaundice in around 20% of patients, and raised bilirubin in over 90% of cases.
How common is clinically detectable jaundice in intrahepatic cholestasis of pregnancy?
Clinically detectable jaundice occurs in around 20% of patients with intrahepatic cholestasis of pregnancy.
What percentage of cases of intrahepatic cholestasis of pregnancy show raised bilirubin?
Raised bilirubin is seen in over 90% of cases of intrahepatic cholestasis of pregnancy.
What is the common practice for managing intrahepatic cholestasis of pregnancy at 37-38 weeks?
Induction of labour at 37-38 weeks is common practice for managing intrahepatic cholestasis of pregnancy, although it may not be evidence-based.
What medication is widely used for intrahepatic cholestasis of pregnancy, despite unclear evidence?
Ursodeoxycholic acid is widely used for intrahepatic cholestasis of pregnancy, despite an unclear evidence base.
What supplementation is recommended for intrahepatic cholestasis of pregnancy?
Vitamin K supplementation is recommended for intrahepatic cholestasis of pregnancy.
What is the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
The recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is 45-90%.
summarise intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth.
Features
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
Management
induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies
A 34-year-old woman who is 32 weeks pregnant presents to her local antenatal unit for a midwife check-up. Her pregnancy has also been complicated by intrahepatic cholestasis of pregnancy, which has been treated with ursodeoxycholic acid. This is her first pregnancy, and she has had no previous miscarriages. She is epileptic, and is being treated with lamotrigine.
She tells her midwife that her step-sister has just had another term stillbirth, after already having 2 prior. This has made her worried about her own pregnancy.
Which part of her medical history puts her most at risk for this outcome?
Her age
Her step-sister having recurrent stillbirths
Intrahepatic cholestasis of pregnancy
Lamotrigine treatment
Nulliparity
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
Intrahepatic cholestasis of pregnancy is commonly cited to put women at increased risk of stillbirth, due to elevated levels of circulating bile acids. Some literature has possibly shown that this is no longer the case, but the general consensus is a relatively high risk of causing stillbirth. It is still recommended that the risk is high enough, that early induction of labour should be offered.
Whilst increasing maternal age is a risk factor for stillbirth, an age of 34-year-old would not be considered as older maternal age, as this is considered to be 35-years-old or older.
Whilst there may be a genetic link to stillbirths, and a family history may have an influence on the likelihood of stillbirths, it is important to recognise that what has been described is not a family history. Her step-sister is not biologically related to her, as they are family by marriage her parent, to her step-sister’s parent. Therefore, medical conditions cannot be passed between them due to a genetic link.
Lamotrigine is considered the safest anti-epileptic to use in pregnancy. There is no evidence that it increases the risk of stillbirth.
Nulliparity is not known to be a risk factor for stillbirths, and therefore this cannot be the correct answer.
A 25-year-old G1P0 woman who is 30 weeks pregnant presents to her GP complaining of intense itching of her palms. She also complains of fatigue but has been struggling with this throughout her pregnancy. On examination, you cannot see any rash on her hands.
Given the likely diagnosis, which of the following is she at an increased risk of?
Eclampsia
Miscarriage
Oligohydramnios
Primary post-partum haemorrhage (PPH)
Stillbirth
Stillbirth
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
The correct answer is ‘stillbirth’.
This patient is likely to be suffering from intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis). Patient’s typically present in the third trimester with intense itching that is generally worst on the palms of the hands and soles of the feet. It is not associated with a rash. Intrahepatic cholestasis of pregnancy increases the risk of stillbirth.
Eclampsia is the occurrence of at least one convulsion in a pre-eclamptic woman. It is an obstetric emergency. Intrahepatic cholestasis of pregnancy is not known to increase the risk of this. Risk factors for pre-eclampsia (and therefore eclampsia) include nulliparity, hypertension and chronic kidney disease.
A miscarriage is the loss of a pregnancy at less than 24 weeks gestation. As this patient is past this point in her pregnancy she can no longer have a miscarriage and a loss of her pregnancy would instead be classed as a stillbirth.
Oligohydramnios refers to a low level of amniotic fluid during pregnancy. Intrahepatic cholestasis of pregnancy is not known to increase the risk of this. Causes of oligohydramnios include placental insufficiency, renal agenesis and viral infections.
Primary PPH is the loss of at least 500ml blood per-vagina within 24 hours of delivery. Intrahepatic cholestasis of pregnancy is not known to increase the risk of this. Risk factors for PPH include multiple pregnancy, placental problems and instrumental delivery.
