Obstetric Cholestasis (Cholestasis of Pregnancy)

Last updated 03.11.12

Definition

-  Pruritus wo rash in presence of abnormal LFTs in pregnancy wo alternative cause which resolves after delivery

 

Features

-  Australian incidence 0.1-0.2%

-  x5 incidence in multple pregnancies (twins..) 

-  May recurr in subsequent pregnancies, risk up to 70%

-  Multifactorial aetiology

-  Oestrogen most important hormonal precipitant

-  Perinatal mortality 11/1000 pts

 

Risk Factors

-  Personal or family Hx of obstetric cholestasis

-  Liver disease

-  Twin pregnancy

-  IVF

 

Associated S/S

-  Pruritus

-  Usually after 28/40

-  Hands, soles of feet

-  Progressess to extremeties then trunk

-  Worse at night

-  +/- Dermatographia artefacta

-  +/- Pale stools & dark urine (uncommon)

-  +/- Jaundice (rare) &/or steatorrhoea

-  Malaise

-  Anorexia

 

DDx

-  Hepatitis, PBC

-  Pre-eclampsia

-  Acute fatty liver of pregnancy

-  Cholelithiasis/choledocolithiasis: Abdo US

-  PUPPS: rash

-  Eczema, atopic eruption of pregnancy

 

Complications

-  Increased risk of

-  +/- PPH

-  Preterm Delivery (largely iatrogenic)

-  MSL

-  Fetal distress, stillbirth

-  LUSCS rate

-  Intrauterine death (poor detection rates)

-  Insomnia, Depression from pruritus & lack of sleep

 

Ix

-  LFTs

-  May go into several hundreds

-  ALP expected to rise in normal pregnancy

-  +/- hyperbilirubinaemia

-  Bile acids

-  Normal levels do not exclude Dx

-  +/- post prandial level elevation

-  Can use random levels

-  Abdo US

-  Cholelithiasis/choledocolithiasis, hepatitis

-  Hepatitis Serology: HBV, HCV, HAV

-  Serology: CMV, EBV

-  Autoimmume Hepatitis screen: Anti-sm Ab, Anti-mitochondrial Ab

-  +/- INR

 

Mx

-  Symptomatic Mx

-  Emolients

-  Sorbolene, Calamine lotion

-  0.5% menthol + 0.5% phenol in aqueous cream

-  Ursodeoxycholic Acid (UDCA)

-  10-20mg/kg PO Daily or divided dose

-   250mg TDS PO up to 750mg TDS/QID

-  Improves pruritus & LFTs

-  Expensive, not on PBS

-  Antihistamines

-  Particularly useful at night (sedation)

-  Cetirizine 10mg PO Daily/BD

-  OR Promethazine 10mg PO TDS

-  +/- Dexamethasone

-  Not first line Mx

-  Cautious use (D/W Consultant)

-  Vitamin K 5-10mg PO Daily

-  Commence in late pregnancy

-  Esp if increased INR

-  Poor GIT absorption in cholestasis

-  Consultant opinion on Mx in pregnancy

-  Out-Pt Mx if ALT <200 & Bile acids <40 else admission

-  Monitor for RFM

-  Ongoing LFTs & Bile acids

-  Prutitus wo LFT elevation: 1-2 weekly

-  Once Dx weekly until delivery

-  If levels normalise Obstetric cholestasis unlikely

-  If levels elevate extrememly or very rapidly consider alt Dx

-  Labour Mx

-  IOL at 37/40

-  Ergometrine in 3rd stage of labour

-  Vitamin K1 to infant at delivery

-  Continous CTG

-  Postnatal resolution of pruritus & LFTs should be confirmed (10/7+)

-  Contraception

-  Once Dx w need to avoid COC due to oestrogen effect on cholestasis

 

 

 

References

 

RANZCOG

RCOG – Green Top Guideline 43: Obstetric Cholestasis, April 2011

SA DoH: Obstetric Cholestasis, 18/12/2007

eTG: Cholestasis of Pregnancy, Feb 2011