Obstetric Cholestasis

Question 1

How is obstetric cholestasis diagnosed?

Answer 1

• Obstetric cholestasis is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal liver function tests (LFTs) and/or raised bile acids occur in the pregnant woman and both resolve after delivery. Pruritus that involves the palms and soles of the feet is particularly suggestive.
• Pregnancy-specific reference ranges for LFTs should be used.
• Other causes of itching and of liver dysfunction should be excluded.
• Women with persistent pruritus and normal biochemistry should have LFTs repeated every 1–2 weeks.
• Postnatal resolution of pruritus and abnormal LFTs should be confirmed.

Question 2

How should obstetric cholestasis be monitored?

Answer 2

• Once obstetric cholestasis is diagnosed, it is reasonable to measure LFTs weekly until delivery.
• Postnatally, LFTs should be deferred for at least 10 days.

Question 3

What is the risk of stillbirth for pregnancies complicated by obstetric cholestasis?

Answer 3

• In a hospital setting, the current additional risk of stillbirth in obstetric cholestasis above that of the general population has not been determined but is likely to be small.

Question 4

What additional risks are associated with pregnancies complicated by obstetric cholestasis?

Answer 4

• Obstetricians should be aware (and should advise women) that the incidence of premature birth, especially iatrogenic, is increased.
• Women should be advised of the increased likelihood of meconium passage in pregnancies affected by obstetric cholestasis.
• Women with obstetric cholestasis should be booked in under consultant-led, teambased care and give birth in a hospital unit

Question 5

Can fetal death be predicted and prevented?

Answer 5

• Poor outcome cannot currently be predicted by biochemical results and delivery decisions should not be based on results alone.
• No specific method of antenatal fetal monitoring for the prediction of fetal death can be recommended.
• Ultrasound and cardiotocography are not reliable methods for preventing fetal death in obstetric cholestasis.
• Continuous fetal monitoring in labour should be offered.

Question 6

Should women with obstetric cholestasis be offered elective early delivery?

Answer 6

• A discussion should take place with women regarding induction of labour after 37+0 weeks of gestation.
• Women should be informed of the increased risk of perinatal morbidity from early intervention (after 37+0 weeks of gestation).
• Women should be informed that the case for intervention (after 37+0 weeks of gestation) may be stronger in those with more severe biochemical abnormality (transaminases and bile acids).
• Women should be informed of the increased risk of maternal morbidity from intervention at 37+0 weeks of gestation.
• Women should be informed of the inability to predict stillbirth if the pregnancy continues.

Question 7

What treatment, if any, should be used to treat obstetric cholestasis and what benefit
can be expected?

Answer 7

• Topical emollients are safe but their efficacy is unknown
• S-adenosyl methionine
  There is insufficient evidence to demonstrate whether S-adenosyl methionine (SAMe) is effective for either control of maternal symptoms or for improving fetal outcome,and it is not recommended.

Ursodeoxycholic acid

• Ursodeoxycholic acid (UDCA) improves pruritus and liver function in women with obstetric cholestasis.
• Women should be informed of the lack of robust data concerning protection against stillbirth and safety to the fetus or neonate.
• Dexamethasone
  Dexamethasone should not be first-line therapy for treatment of obstetric cholestasis, nor should it be used outside of a randomised controlled trial without a thorough consultation with the woman

Question 8

What is the role of vitamin K?

Answer 8

• A discussion should take place with the woman regarding the use of vitamin K.
• Women should be advised that where the prothrombin time is prolonged, the use of water-soluble vitamin K (menadiol sodium phosphate) in doses of 5–10 mg daily is indicated.
• Women should be advised that when prothrombin time is normal, water-soluble vitamin K (menadiol sodium phosphate) in low doses should be used only after
  careful counselling about the likely benefits but small theoretical risk

Question 9

What follow-up should be offered to women who have had a pregnancy affected by obstetric cholestasis?

Answer 9

• Women should be offered follow-up with a healthcare professional with the necessary skills and expertise to provide appropriate counselling and to ensure that LFTs have returned to normal.