Flashcards in Obstetric cholestasis Deck (15)
In UK estimated to be 0.7% of pregnancies
Higher in women of south asian ethnicity
Pruritus in the absence of a skin rash with abnormal liver function tests (LFTs),neither of which has an alternative cause and both of which resolve after birth
What to do with women who have persistant pruritus and normal LFTs?
Repeat LFTs in 1-2/52
Typical symptoms of obstetric cholestasis?
Pruritus in hands and feet/all over
Worse at night
Investigation of cholestasis?
Diagnosis- symptoms + abnormal LFTs/bile acids
Coagulation screen- may need to give vitamin K
Diagnosis of exclusion, so also need to do:
- Viral hepatitis screen
- Consider Liver USS
- Liver autoimmune screen for primary biliary cirrhosis (anti-smooth muscle and anti-mitochondrial antibodies)
- Exclude PET and acute fatty liver of pregnancy
Monitoring of cholestasis
- Weekly LFTs +/- coag screen depending on severity
- Check PN LFTs 10/7 later
- Sx and bloods should return to normal by 6/52 - if not then an alternative cause should be considered
- Discussion re:
- Risk of recurrence in future pregnancies (45-90%)
- Contraceptive advice- avoid COCP
- Stillbirth - current obstetric management suggests that still birth rate is now closer to the rate for the general population
- Prematurity- iatrogenic and idiopathic
- Meconium liqour
- Fetal distress in labour
- CS for fetal distress
How to class severity of OC?
Severe = bile salts >40
Mild = bile salts <20
Can fetal death be predicted and prevented?
- In vitro evidence that level of bile salts may play a role in fetal demise
- In real life- difficult to know exactly how this affects the fetus. May be due to maternal serum bile salt level or fetal bile salt level.
- Link found with bile salts >40 and: passage of meconium, abnormal CTG, non-fatal fetal asphyxia events, prematurity
- CTG and growth scans do not identify babies at risk of stillbirth as fetal death is usually sudden
Timing of delivery
- Consider IOL from 37+0/40
- No clear evidence regarding still birth risk, may be increased fetal risk from IOL at 37/40
- Women with higher bile salts levels and more deranged LFTs may benefit more from IOL around 37/40
Treatment for OC
Definitive treatment is delivery
- UDCA found to reduce itching although results variable in studies. No proven benefit to outcome for fetus.
- Women may benefit from emollient
- Vitamin K if PT prolonged (5-10mg a day)
Physiological rationale for the use of vitamin K?
In OC there is a decreased absorption of fats from GI tract due to reduction in excretion of bile salts
Leads to reduction in absorption of fat soluble vitamins eg. vitamin K
Vitamin K required for the manufacture of coagulation factors 11,V11, 1X and X
In a small study, PPH found to be more common in those who didn't take vitamin K than those who did
Oral vitamin K is in a water soluble form