Obstetric cholestasis

Question 1

Explain a diagnosis of obstetric cholestasis and risks to the woman and fetus

Answer 1

• Pregnancy-related conditions where bile acids are not taken up well by the liver and accumulate.
• Causes:
  
  • Genetic
  • Underlying liver disease
  • Hormones: more common in multiple pregnancy.
• Maternal:
  
  • Causes symptoms such as itching and sleep disturbance.
  • Vitamin K deficiency and increased bleeding tendency including PPH.
  • Increased chance of CS
• Fetal:
  
  • Increased risk stillbirth esp. if bile acids >100.
  • Preterm birth
  • Meconium passage and aspiration.
  • Fetal distress.
  • Intracranial haemorrhage

Question 2

List a differential diagnosis list for obstetric cholestasis and investigations to exclude other causes

Answer 2

• HELLP syndrome/PET
• Viral hepatitis
• Biliary: AFLP, pancreatitis, primary biliary cirrhosis
• Autoimmune hepatitis
• Dermatoses: eczema, PEP, atopic eruption of pregnancy, pemphigoid gestationis

Investigations:

• Bile salts
• FBC, LFTs, Cr, coagulation study
• Blood gas: glucose, lactate, ammonia
• Viral hepatitis panel: Hep A/B/C, CMW, EBV
• Liver autoantibodies: anti-Sm, anti-mitochondrial, ANA
• Liver/upper GI USS
• Urine PCR

Question 3

Outline a management plan for obstetric cholestasis

Answer 3

Antenatal:

• Secondary obstetric care
• Weekly bile salts and LFTs
• Serial growth scans
• Consider coagulation studies prior to delivery +/- Vitamin K menadiol sodium phosphate 10 mg po daily.
• Monitor for development of PET.
• Ursodeoxycholic acid 1000-1500 mg daily in two to three divided doses
• Sedating antihistamine at night e.g. promethazine 25 mg nocte.

Intrapartum:

• IOL 36/40 if bile acids ≥100
• IOL 36-37/40 if bile acids 40-99
• IOL 37-38+6/40 if bile acids <40
• IOL <36/40: severe pruritis, worsening hepatic function, hx stillbirth due to obstetric cholestasis.
• Deliver in hospital with CEFM.
• IVL, FBC and G&H
• Active third stage management

Postpartum:

• Neonatal IM Vit K
• Check LFTs resolved 6/52 postnatal.
• Contraception: avoid oestrogen-containing.
• Antenatal: recurrence rate 45-90%