Obstructive Cholestasis Flashcards
What is obstetric cholestasis?
Intrahepatic cholestasis of pregnancy is a multifactorial condition specific to pregnancy. It is a reversible type of hormonally influenced cholestasis characterised by:
1) Pruritus without rash
2) Elevated bile acids
3) Typically resolves in the postpartum period.
Why does OC occur?
Affected individuals have a defect involving excretion of bile salts which leads to increased serum bile acids. These get deposited within the skin causing pruritis.
RFs for OC
South-Asian
Scandinavian, Chilean
3rd trimester
Genetics
Family Hx of OC
Prev Hx of OC
Complications of OC
PTB
IUFDemise 2-11%
Sudden fetal death
Meconium stained liqour
Admission to neonatal unit
Accumulation of bile acids in fetus
Mode of delivery in ICP
ICP does not change mode of delivery unless other co-morbidities.
Monitoring of labour in ICP
Only warranted in severe ICP due to risk of meconium stained liqour
What is the pathophysiology of stillbirth in OC?
Theory is bile acids may cause an acute fetal anoxic event due to arrhythmia or acute placental vessel spasm.
Classical symptoms of OC
Intense itching (worse at night)
Sleep disruption causing tiredness
Palms of hands and feet most affected
Skin breaks, bleeding and excoriations from scratching
Typically in 2nd or 3rd trimester.
Rare symptoms of OC
Jaundice
Dark Urine
Pale Stools
Steatorrhea
What would you ask someone regarding symptoms of itch?
Site of itch?
Any rash?
Change in stool/urine colour
Any self-care products/medications/diet that could explain itch?
PMH: Hx of liver or gallbladder disease?
Social Hx: Alcohol use
How would you investigate OC?
LFTs (HELLP, Hepatitis, AFLP)
FBC + U&Es (pre-eclampsia and HELLP)
Viral liver screen (Hep A, B, C, CMV, EBV)
Anti-mitochondrial antibodies (PBC)
Liver US (gallstones)
How is OC diagnosed?
Itching + raised fasting bile acids
Raised transaminases were previously used, however these have not been associated with increased risk of stillbirth.
Who should have further investigations completed?
Only if there is an atypical or uncertain picture of ICP. Such as,
1) Markedly elevated transaminases
2) Early onset ICP
3) Rapidly progressing biochemical picture
4) Liver failure features
5) Lack of improvement after birth
Possibility of identifying a viral, autoimmune or structural cause for itching and liver derangement is low, liver US and other tests not recommended.
What advice would you give someone with ICP to safety net them?
Monitor fetal movements + seek medical care if they have concerns.
More intensive fetal monitoring doesn’t reduce risk
Why is placental insufficiency not monitored?
Because ICP is not associated with fetal growth restriction or birth weight abnormalities and therefore unlikely to be beneficial.
Antenatal Management of OC
Medications:
- Topical emollients
- Anti-histamines (Chlorphenamine, Loratadine, Cetirizine)
- Ursodeoxycholic acid - only provides small reduction in itch
- Vit K (only if steatorrhea or abnormal PTT)
- Rifampicin
Weekly:
- Monitor LFTs + bile acids
Postnatal Management of ICP
4 weeks post birth - follow up to confirm resolution of ICP
If >6 weeks and itching or biochemical abnormalities persist - Refer to hepatologist for alternative diagnosis
Increased risk of ICP in subsequent pregnancies
Baseline bile acids and liver function tests measured at baseline in subsequent pregnancies.
Risk of stillbirth
Only increases above the general population when levels > 100 micromol/L
Delivery planning in OC
Mild ICP: 19-39 micromol/L - Deliver 40 weeks
Mod ICP: 40-99 micromol/L - Deliver 38-39
Severe ICP: >100 micromol/L - Deliver 35-36
If other factors are present like GDM - Individualise
Differential Diagnosis for Pruritis in Pregnancy
PIGSAP
ICP
Gestational pruritis (normal bile acids)
Pemphigoid Gestationis
Allergic reactions - drugs/atopy
Scabies
Pre-existing Liver Disease
Differentials for itchy skin, elevated LFTs and bile acids?
Urticaria
Allergic Reactions
Drug Reactions
Differential Diagnosis for Hepatic Impairment in Pregnancy
OC
Gallstones
AFLP
HELLP Syndrome
Viral Hepatitis
PBC or PSC
How would you differentiate OC from gallstones?
Gallstones:
- Pain
- Jaundice
- Pale stools
- Dark urine
- Cholecystitis (Vomiting, fever, severe abdo pain)
How would you differentiate OC from AFLP?
AFLP:
- Nausea
- Vomiting
- Abdo pain
- Polyuria/Polydipsia
- Hypoglycemia
- DIC
- Pre-eclampsia
How would you differentiate OC from PBC or PSC?
Symptoms of pruritis, jaundice, lethargy would pre-date the pregnancy
Maternal Complications of OC
