Jaundice in Pregnancy

Question 1

What is obstetric cholestasis?

Answer 1

A multifactorial pregnancy condition

Features include: pruritus but no rash, abnormal LFTs

Question 2

Describe the pruritus in OC

Answer 2

Intense itching, usually starts on palms and soles
Intense at night
No associated rash

Question 3

What investigations should be done for suspected OC?

Answer 3

LFTs, bile acids, viral screen - hep A,B,C, EBV, CMV
Liver autoimmune screening - anti smooth muscle and anti mitochondrial antibodies
USS abdomen - liver and gallstones

Question 4

Is OC a diagnosis of exclusion?

Answer 4

Yes

Question 5

What do the tests usually show in OC?

Answer 5

Liver transaminases mildly raised
Alkaline phosphatase generally raised in pregnancy, but especially so in OC
Raised gamma GT
Raised bilirubin seen in 90% 
Raised bile acids

Question 6

What risks are associated with OC?

Answer 6

Maternal: vitamin K deficiency, increased risk of PPH
Fetal: stillbirth risk increases, fetal distress, meconium, preterm labour, ICH

Question 7

How is OC managed?

Answer 7

Maternal vitamin K from 36w
Neonatal vitamin K
Fetal surveillance
Delivery at fetal maturity 
Give ursodeoxycholic acid for pruritus, also antihistamine and calamine helpful

Question 8

When do symptoms of OC resolve?

Answer 8

Within days of delivery

Question 9

In those with OC p, what percentage have clincallydetectable jaundice?

Answer 9

20%

Question 10

What is the incidence of obstructive cholestasis?

Answer 10

Affects around 1% of pregnancies

Question 11

Other than OC, what other causes of jaundice in pregnancy are there?

Answer 11

Acute fatty liver of pregnancy
Viral hepatitis 
Jaundice of severe pre-eclampsia
Hepatitis associated with halothane for anaesthesia
HELLP syndrome 
Hepatitis B

Question 12

What is acute fatty liver of pregnancy?

Answer 12

Rare but very serious

Mother develops abdominal pain, jaundice, headache, vomiting, hypoglycaemia +/- thrombocytopenia and pancreatitis

Question 13

What condition is associated with acute fatty liver of pregnancy?

Answer 13

Pre eclampsia in 30-60%

Question 14

What does USS of the liver show in acute fatty liver of pregnancy?

Answer 14

Steatosis

Microdroplets of fat in liver cells

Question 15

How should acute fatty liver of pregnancy be managed?

Answer 15

Supportive care
Treat hypoglycaemia
Once stabilised delivery is definitive management

Beware of PPH and neonatal hypoglycaemia