Obstetric Cholestasis

Question 1

Obstetric cholestasis is also known as intrahepatic (inside liver) cholestasis of pregnancy. Chole- relates to the bile and bile ducts. Stasis refers to inactivity. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby. What is the incidence of Obstetric cholestasis?

1 - 1% of pregnancies
2 - 10% of pregnancie
3 - 15% of pregnancie
4 - 20% of pregnancie

Answer 1

1 - 1% of pregnancies

Question 2

Although the exact cause of Obstetric cholestasis remains unknown there are factors that have been linked with it. Which of the following factors have NOT been associated with Obstetric cholestasis?

1 - Genetic
2 - Hormonal
3 - Environmental
4 - Pancreatitis

Answer 2

4 - Pancreatitis

Question 3

Obstetric cholestasis can present in a number of ways, which of the following is NOT a typical presentation?

1 - pruritus – palms and soles
2 - absence of a skin rash
3 - positive courvoisier’s sign
4 - abnormal LFTs and/or bile acid
5 - darker urine/lighter stool
6 - nausea and reduced appetite
7 - RUQ pain
8 - increased clotting time (vit K deficient)

Answer 3

3 - positive courvoisier’s sign

• 20% of patients present with jaundice
• 90% have raised bilirubin

Question 4

Does obstetric cholestasis remain or resolve following birth?

Answer 4

• resolve spontaneously

Question 5

Which of the following is NOT a typical affect that obstetric cholestasis can have have on delivery?

1 - macrosomia
2 - preterm birth
2 - iatrogenic pre-term induction
4 - fetal death

Answer 5

1 - macrosomia

Question 6

Obstetric cholestasis can raise bile salt levels in the blood. Are these able to cross the placenta?

Answer 6

• yes
• fetal blood brain barrier is not well developed, bile salts can precipitate in the fetal brain and cause kernicterus

Question 7

Kernicterus is a condition where maternal bile salts and bilirubin cross the placenta and then cross the under developed BBB and into the brain, specifically the basal ganglia. Which of the following can this then lead to?

1 - encephalopathy
2 - psycho-motor development
3 - foetal death
4 - cerebal palsy
5 - all of the above

Answer 7

5 - all of the above

Question 8

Obstetric cholestasis can affect the pregnancy. Which of the following is NOT a typical impact Obstetric cholestasis can have on pregnancy?

1 - reduced liver function
2 - increased bile acid leading lead to dermatitis
3 - preterm birth (mainly iatrogenic)
4 - increased risk of neonatal admission and stillbirth
5 - Macrosomnia
6 - Meconium aspiration
7 - Increased risk of caesarean section

Answer 8

5 - Macrosomnia

Question 9

Obstetric cholestasis can be a diagnosis of exclusion by ruling out other causes for the symptoms the patient is presenting with. Which of the following is NOT a typical skin condition that would need to be ruled out when trying to diagnose Obstetric cholestasis?

1 - Polymorphic eruption of pregnancy (PEP)
2 - Pemphigoid gestationis
3 - Toxic epidermal necrolysis
4 - Atopic eruption of pregnancy
5 - Pruritic folliculitis of pregnancy

Answer 9

3 - Toxic epidermal necrolysis

Question 10

Obstetric cholestasis can be a diagnosis of exclusion by ruling out other causes for the symptoms the patient is presenting with. Which of the following is NOT a typical hepatological condition that would need to be ruled out when trying to diagnose Obstetric cholestasis?

1 - hepatitis A, B, and C, EBV, CMV, autoimmune
2 - alcoholic liver cirrhosis
3 - primary biliary cirrhosis
4 - Pre-eclampsia
5 - acute fatty liver of pregnancy

Answer 10

2 - alcoholic liver cirrhosis

Question 11

What 2 measures should be measured in a weekly outpatients clinic in a patient with Obstetric cholestasis?

1 - FBC
2 - LFTs
3 - bile acids
4 - coagulation profile

Answer 11

2 - LFTs
3 - bile acids

Consultant led care particularly for timing and mode of delivery

Question 12

Bile acids above what level are associated with poorer outcomes?

1 - >20 mmol/L
2 - >40 mmol/L
3 - >100 mmol/L
4 - >200 mmol/L

Answer 12

2 - >40 mmol/L

Question 13

Which 2 of the following can patients be prescribed to help alleviate the symptoms, particularly the itching associated with Obstetric cholestasis?

1 - antihistamines (Piriton)
2 - ciclosporin
3 - ursodeoxycholeoic acid (UDCA)
4 - pancreatin

Answer 13

1 - antihistamines (Piriton)
3 - ursodeoxycholeoic acid (UDCA)

Question 14

In patients with Obstetric cholestasis, what timepoint should delivery be aimed for?

1 - <30 weeks
2 - <34 weeks
3 - <37 week
4 - <41 weeks

Answer 14

3 - <37 week
- likely t be c-section
- high risk of meconium

Question 15

Following delivery LFTs and bile salts should return to normal in what time period in mum?

1 - 7 days
2 - 10 days
3 - 2 weeks
4 - 4 weeks

Answer 15

2 - 10 days
- should be advised that this can occur again in future pregnancies

Question 16

What form of contraception are mothers who have had Obstetric cholestasis before be advised to avoid?

1 - progesterone containing
2 - estrogen containing
3 - copper containing
4 - combined estrogen and progesterone contraception

Answer 16

2 - estrogen containing
- estrogen has been linked to causing this

Question 17

What vitamin should the baby be given following birth?

1 - vitamin D
2 - vitamin B
3 - vitamin A
4 - vitamin K

Answer 17

4 - vitamin K
- important for clotting factors