Obsteric cholestasis (Complete)

Question 1

Define obstetric cholestasis

Answer 1

Pregnancy-related hepatobilliary disorder characterised by accumulation of bile salts due to impaired bile flow

Question 2

Obstetric cholestasis typically occurs during which stage of pregnancy?

Answer 2

> 24 weeks gestation

Question 3

Obstetric cholestasis is alternatively known as?

Answer 3

Intra-hepatic cholestasis of pregnancy (ICP)

Question 4

What is the aetiology of obstetric cholestatis?

Answer 4

Unknown however associtaed with environmental, hormonal and genetic factors

Question 5

What are the main risk factors of obstetric cholestasis?

Answer 5

Genetic:

Previous family history or previous pregnancy

Indian-asian, pakistani-asian or south american ethnicity

Maternal factors:

Advanced maternal age

Multiple pregnancies

IVF

Hepatobilliary predisposition:

History of gallstones

History of liver disease (e.g. hepatitis C)

Environmental factors:

Selenium deficiency (needs more research)

Winter season

Question 6

What are the main clinical features of obstetric cholestasis?

Answer 6

Pruritis (due to bile acid deposits in skin)

• Severe and intense
• Mainly affecting hands and feet
• Worse at night
• No rash (may see excoriations)

Fatigue/malaise

RUQ abdominal pain

Nausea and anorexia

Mild jaundice (in some cases)

• Dark urine
• Pale stools

Question 7

What are the features of pruritis caused by bile acid buildup?

Answer 7

Severe and intense (moresoe on hands and feet)

Worse at night

Absence of rash but may see excoriations from intense itching

Question 8

What complications are associated with obstetric cholestasis?

Answer 8

Maternal:

PPH (due to vit K deficiency)

High risk of recurrence in future pregnancies

Foetal:

Preterm labour

Foetal distress

Meconium aspiration

Stillbirth

Foetal uterine growth restriction

Question 9

What differentials should be considred alongside obsteric cholestasis?

Answer 9

Pruritus gravidarum

• Generalised itching with no obvious cause in prgenancy
• Normal lab findings

Hepatobilliary disorders (e.g. viral hepatitis, gallstones)

• Abnormal LFTs and positive serology

Prurigo of pregnancy

• Small itchy bumps during pregnancy

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

• Itchy red bumps and hives

Question 10

What investigations should be conducted in patient with suspected obstetric cholestasis?

Answer 10

Bedside:

Abdominal examination: Check for excoriations

CTG: Check for signs of foetal distress

Bloods:

Bile acids: Raised

LFTs: Raised billirubin

Coagulation screen: Check clotting due to vit K deficiency

Fasting serum cholesterol: Raised

Hepatitis C serology: Increases risk of obsteric cholestasis

Question 11

What investigation findings are suggestive of obstetric cholestasis?

Answer 11

Raised bile salts

Raised billirubin

Impaired clotting

Question 12

What is the management plan for patients with obstetric cholestasis

Answer 12

Conservative:

Topical emollients

Loose clothing

Medicine:

Sedating antihistamines: Chlorphenamine, promethazine

Vitamin K: If impaired clotting factors

Antenatal care + monitoring:

Weekly LFTs until delivery

Twice weekly CTG and doppler until delivery

Induction of labour at 37 weeks

Follow-up LFT post-natally until normal findings

Question 13

Name examples of antihistamines used in obsteric cholestasis

Answer 13

Chlorphenamine

Promethazine

Question 14

What medication should be given in cases of impaired clotting?

Answer 14

Vitamin K

Question 15

How are women with obstetric cholestasis monitored during and after pregnancy?

Answer 15

Weekly LFTs until delivery

Bi-weekly dopper and CTGs until delivery

Follow-up LFTs postnatally until normal findings

Question 16

What is the delivery management in patients with obstetric cholestasis?

Answer 16

Consultant led induction of labour at 37 weeks