Obstetric cholestasis

Question 1

What is obstetric cholestasis?

Answer 1

• unexplained itching (pruritus) in pregnancy and abnormal liver function tests (LFTs) and/or bile acid accumulation that resolves postpartum
• most common liver related disorder in pregnancy

Question 2

Describe typical features of itching (pruritus) in obstetric cholestasis

Answer 2

• widespread
• often worse at night
• particularly common to affect palms of hands and soles of feet
• no rash
• often trauma from intense scratching

Question 3

Apart from pruritus, what are some other symptoms/signs of obstetric cholestasis?

Answer 3

• pale stools
• dark urine
• jaundice

Question 4

What are risk factors for obstetric cholestasis?

Answer 4

• personal or family history of obstetric cholestasis
• multiple pregnancy
• hepatitis B
• gallstones

Question 5

What is the pathophysiology of obstetric cholestasis?

Answer 5

• disturbance of enterohepatic circulation results in accumulation of bile salts in blood as well as reduction of bile products from liver and subsequent flow to small intestine
• possible reaction to increased estrogen
• increased histamine release causes intense itching

Question 6

What are the associated risks of obstetric cholestasis?

Answer 6

• often offered induction after 37/40
• increased rate of birth by c/s
• iatrogenic preterm birth
• excess bile acids can cause FDIU/stillbirth (fetal mortality 11-20% if untreated)
• small increased risk of preterm labour
• fetal distress
• meconium liquor and aspiration
• intracranial haemorrhage due to low vit K
• PPH (low absorption of vit K)

Question 7

How is obstetric cholestasis diagnosed?

Answer 7

• care should be managed by multi-disciplinary team in tertiary setting
• pruritus
• abnormal liver function tests (LFTs) using pregnancy specific reference ranges
• excluding other causes of itching and liver dysfunction
• confirmation of postnatal resolution

Question 8

What treatments are available for obstetric cholestasis?

Answer 8

• topical emollients
• advice about comfort measures (wearing loose cotton clothing, moisturising, cool baths/showers)
• low fat diet
• increased water intake
• vitamin k supplementation
• antihistamines at night
• UDCA (ursodeoxycholic acid)