obstetric cholestasis

Question 1

description

Answer 1

also known as intrahepatic cholestasis of pregnancy
multifactorial condition affecting 0.7% of pregnancies
more common in indian/paki descent
characterised by abnormal LFTs (particularly AST and ALT) - resolve following delivery
also intense pruritus in the absence of rash

Question 2

cause

Answer 2

underlying cause unknown

likely consists of genetic and environmental factors

Question 3

risks of the condition

Answer 3

increased risk of fetal distress (due to increased likelihood of meconium passage) and intrauterine death
increased risk of prematurity
increased risk of maternal morbidity due to intense itching and lack of sleep
no evidence linking it to PPH or risk of C-section

Question 4

risk factors

Answer 4

past history of obstetric cholestasis
family history of obstetric cholestasis
multiple pregnancy
presence of gallstones
hep C

Question 5

presentation

Answer 5

typically in the 3rd trimester
intense pruritus +/- excoriation, particularly palms of hands and soles of feet (pruritus is common in pregnancy, only a few will have cholestasis)
often worse at night, may interfere with sleep
other Sx ass. w/ cholestasis eg pale stool, dark urine, jaundice
malaise and fatigue
itching may precede LFT abnormalities by days or weeks

Question 6

diagnosis

Answer 6

should be consultant led management, delivery should be in hospital
exclude other causes of liver dysfunction and itching eg gallstones, hep, EBV, CMV, medications
organise liver USS
rule out pre-eclampsia and fatty liver of pregnancy

diagnosis made on the basis of Sx and deranged LFTs once all other causes have been ruled out

Question 7

DDx

Answer 7

hyperemesis gravidarum
pre-eclampsia
HELLP syndrome
chronic liver diseases eg cholestatic liver disease, autoimmune hep, Wilson’s, viral hep

Question 8

management

Answer 8

monitor LFTs weekly - if they return to normal or soar (into the 100s), revise diagnosis
recheck 10 days after delivery
Tx:
topical emollients are safe, but little evidence for efficacy
ursodeoxycholic acid (UDCA) is the mainstay
vit K, particularly if there is steatorrhoea or prolonged prothrombin time
perinatal and maternal morbidity increases from 37 weeks gestation, so consider induction