Obstetric Cholestasis - GT 43 +TOG: Intrahepatic Cholestasis of Pregnancy Flashcards
What % of pregnancies are affected by obstetric cholestasis?
- 7%
1. 2-1.5% of women of Indian/Pakistani descent
What are the perinatal risks of obstetric cholestasis?
- Spontaneous/iatrogenic preterm birth
- Increased risk CS
fetal distress in labour - Fetal Death - likely small; risk above background not determined
- Increase risk meconium passage proportional to bile acids
What % of women with obstetric cholestasis suffer with pruritis?
23%
What are the differential diagnoses of pruritis in pregnancy?
Eczema
Atopic eruption of pregnancy
Dermatographia artefacta (excoriations)
If rash - consider PEP/pemphigoid
What are the risk factors for obstetric cholestasis?
Personal/family history Multiple pregnancy Hepatitis C Gallstones IVF older women
What should be ruled out before diagnosing obstetric cholestasis?
- Viral screen - Hep A, B, C, EBV, CMV
- Liver autoimmune screen - Chronic active hepatitis and
PBC (i.e. anti-smooth muscle, antimitochondrial
What should be considered in atypical/early cases of obstetric cholestasis?
PET
Acute fatty liver of pregnancy
What is the recommended monitoring for women diagnosed with obstetric cholestasis?
- LFTs weekly until delivery (consider coag screen if rapid elevation as atypical)
- Defer LFTs until 10 days postnatal
What is the treatment for obstetric cholestasis?
- Topical emolients
- Antihistamines for sedation
- Ursodeoxycholic acid
When should Vitamin K be used in treatment of obstetric cholestasis?
If PT prolonged needs 5-10mg Vitamin K daily, or woman has steatorrhoea
What is the recurrence rate of obstetric cholestasis?
45-90%
What is the contraceptive advice for women who have had obstetric cholestasis?
Best to avoid oestrogenic compounds
What environemntal factors are thought to influence risk of ICP (intrahepatic cholestasis of Pregnancy)
dietary selenium & vitamin D, seasonal cariation- more cases diagnosed in winter
in what percentage of women does obs chole present after 30/40?
80%
what percentage of women suffer with jaundice associated with obs chole?
10%
what is the most sensitive and specific marker for diagnosing and monitoring obs chole?
bile acids
if a woman who is 30/40 pregnant presents with itching suggestive of obstetric cholestasis, but bile acids and LFT’s are normal and itching continues, what suggestion has been made about how she should be managed?
if >24/40- weekly bile acids & LFTs until delivery
if <24/40- fortnightly bile acids &LFT’s
if woman with obs chole presents with steatorrhoea, what blood test should be considered and why
coag screen- risk of malabsorption of fats and fat-soluble vitamins.
what level of bile acid is associated with particular concern for adverse perinatal outcomes?
bile acid >40
how does UDCA affect bile acids?
decreases level of bile acids in maternal and umbilical cord serum. Also causes qualitative changes in serum bile acid pool- consequent reduction of hydrophobicity of the pool
what protective effects does UDCA have?
reduced risks preterm labour, reduced fetal distress during labour, reduced NNU admission
what is a possible second line treatment for obstetric cholestasis
rifampicin- reduced pruritis and enhances bile acid secretion in primary biliary cirrhosis
in what percentage of women treated with dual therapy- UDCA and rifampicin for obs chole, did the bile acid level reduce?
50% of women treated had reduced bile acid levels
what are the future health risks for women with obstetric cholestasis?
increased incidence hepato-biliary disease (hepatitis, chronic hepatitis, hepatic fibrosis) in women with ICP
what other diseases have been associated with women who have history of ICP
increased risk of liver cancer, cardiovascular disease, maternal diabetes
children of women with ICP are also at risk of metabolic disease later in life
