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Clinical Skills Blogspot

Obstetric Cholestasis

Title

Ñ    Obstetric Cholestasis

Definition

Ñ    Pregnancy specific liver condition

Ñ    Presents with pruritus in the absence of a rash

Ñ    Associated with raised serum bile acids

Aetiology

Ñ    Unknown

Ñ    Prevalence higher in Scandinavia, Chile, Bolivia

Ñ    Being recognised as a common obstetric problem

Pathogenesis

Ñ    Not clear

Cholestasis may be due to:

Ñ    Metabolite of oestrogen or progesterone

Or

Ñ    Increased sensitivity to the effects of oestrogen and progesterone

Cholestasis may result in:

Ñ    Direct toxic effect on the foetus

Or

Ñ    Vasospastic effect on the placental circulation

Clinical Features

History

IS

Ñ    Pruritus 30-36 weeks of gestation

Ñ    Affects palms and soles of feet:

Especially

Ñ    Increased at night

GIT

Ñ    Right upper quadrant pain:

Unusual

Family history

Ñ    30%

Complications

Ñ    Prematurity

Ñ    Foetal distress

Ñ    Meconium staining

Ñ    Stillbirth

Ñ    Perinatal death

Investigations

Fluids

Blood

Haematology

Ñ    Prothrombin time

May be raised:

·          Vitamin K deficiency

Biochemistry

Ñ    Aminotransferases:

Elevated

Ñ    Alkaline phosphatase:

Difficult to evaluate as placental and bone alkaline phosphatase are elevated, not usually greatly elevated

Ñ    Serum bilirubin:

Slightly raised

Jaundice in about 60%

Ñ    Serum bile acids:

Elevated

Management

Symptom Relief

Drugs

Ñ    Ursodexoycholic acid:

Symptomatic relief

Ñ    Cholestyramine:

        Alternative

Prevention

Ñ    Delivery:

Deliver between 36-38 weeks to prevent stillbirth and decrease risk of prematurity

Prognosis

Ñ    Does not cause significant liver damage

Ñ    Resolves after delivery

Ñ    May recur in subsequent pregnancies or with ingestion of oestrogen containing contraceptives

 

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