Obstetric cholestasis and Acute fatty liver of pregnancy

Question 1

Pathophysiology of obstetric cholestasis

Answer 1

Reduced outflow of bile acids from the liver, thought to be the result of increased oestrogen and progesterone levels

Question 2

Presentation of obstetric cholestasis

Answer 2

Itching - particularly the palms and soles of feet
Fatigue
Dark urine
Pale, greasy stools
Jaundice

Question 3

Differential of obstetric cholestasis

Answer 3

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

Question 4

Investigations in suspected obstetric cholestasis

Answer 4

LFTs - abnormal tests ALT, AST, GGT (it is normal for ALP to increase in pregnancy)

Bile acids - raised

Question 5

Management of obstetric cholestasis

Answer 5

Ursodeoxycholic acid

Symptoms of itching can be managed with Calamine lotion, antihistamines (can help sleeping but doesn’t improve itching)

Planned delivery after 37 weeks may be considered - to reduce risk of stillbirth

Water soluble vitamin K can be given if clotting is deranged (increased prothrombin time)

Question 6

Possible complications of obstetric cholestasis

Answer 6

Stillbirth

Vitamin K deficiency leading to clotting disorder

Question 7

Presentation of acute fatty liver of pregnancy

Answer 7

General malaise and fatigue
N+V
Jaundice
Abdominal pain
Ascites
Loss of appetite

Question 8

Investigations in suspected acute fatty liver of pregnancy

Answer 8

Bloods - LFTs - will be elevated, clotting (may be deranged - raised PT and INR), FBC (may have raised WBC and low platelets)

NB - Elevated liver enzymes much more commonly caused by HELLP syndrome but acute fatty liver in pregnancy is a potential differential

Question 9

Management of acute fatty liver of pregnancy

Answer 9

It is an obstetric emergency
Admit the patient
Prompt delivery of the baby

Most patients will recover after delivery but may need to consider a liver transplant