Obstetric Cholestasis Flashcards
What is obstetric cholestasis characterised by?
- Abnormal LFTs
- Intense pruritis in absence of skin rash
What LFTs in particular are abnormal in obstetric cholestasis?
AST and ALT elevation
What happens to the abnormal LFTs after delivery in obstetric cholestasis?
They resolve after delivery
What % of pregnancies are affected by obstetric cholestasis?
0.7%
What is the underlying cause of obstetric cholestasis?
Underlying cause not known, but likely to be a combination of genetic and environmental factors
What are the risk factors for obstetric cholestasis?
- Past history of OC
- Family history of OC
- Multiple pregnancy
- Presence of gallstones
- Hep C
When does OC typically present?
3rd trimester
How does OC present?
Intense pruritis
What part of the body is affected in OC?
Can affect any part of the body, but particularly the palms of hands and soles of feet
Why can OC be difficult to diagnose?
Because pruritis is common in pregnancy, and only a minority will have OC
Describe the pattern of symptoms in OC
They are worse at night
What is the result of the symptoms of OC being worse at night?
May interfere with sleep
What signs might a women with OC develop?
- Dark stool
- Dark urine
- Jaundice
- Generalised malaise and fatigue
What are the differential diagnoses of OC?
- Hyperemesis gravidum
- Pre-eclampsia
- HELLP syndrome
- Chronic liver disease
- Gallstones
- EBV
- Medications
What chronic liver diseases are differentials for OC?
- Cholestatic liver disease
- Acute fatty liver of pregnancy
- Autoimmune hepatitis
- Viral hepatitis
How is a diagnosis of OC be made?
If no other cause is found, a diagnosis can be based on symptoms and LFT abnormalities
What pattern of LFTs is typical with OC?
Raised transaminases and gamma-GT, bilirubin sometimes raised
What needs to be considered when interpreting LFTs to diagnose OC?
Interpretation should be made in light of pregnancy specific ranges
How does pregnancy change the ranges of LFTs?
The upper limit of normal is 20% lower than non-pregnant levels throughout pregnancy
What needs to be excluded when making a diagnosis of OC?
Other clinical conditions that affect the liver in pregnancy
What investigations may be done to exclude other conditions that affect the liver in pregnancy?
- Liver ultrasound scan
- Measurement of BP
- Further blood tests
What monitoring should be done in OC?
LFTs should be monitored weekly
What is being looked for when monitoring LFTs in OC?
To see if they return to normal or soar into the 100’s
What should be done if LFTs return to normal or soar into the 100’s in OC?
The diagnosis should be revised
When should LFTs be checked following delivery in OC?
Wait at least 10 days before re-checking
Why should you wait at least 10 days before re-checking LFTs after delivery in OC?
To avoid the confounding factor of normal fluctuations in LFTs during this time following normal pregnancy
What is the mainstay of medical management in OC?
Ursodeoxycholic acid (UDCA)
Why is UDCA used in OC?
Because it has positive effects on maternal and fetal outcomes, and on pruritis
What is the role of topical emollients in OC?
They are safe for the mother and baby, but of unknown efficacy
Describe the role of vitamin K in OC?
It may be offered, particularly if there is steatorrhoea or prolonged prothrombin time
At what point should induction of labour be considered in OC?
37 weeks onwards
Why should induction of labour be considered at 37 weeks onwards in OC?
Because perinatal and maternal mortality are increased from this point
When in particular is maternal and perinatal mortality increased from 37 weeks onwards in OC?
In those with more severe disease and higher levels of transaminases and bile acids
What are the complications of OC?
- Increased risk of feta distress and intrauterine death
- Increased risk of premature birth (spontaneous and iatrogenic)
- Maternal morbidity due to intense itching and lack of sleep
