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Cholestasis of Pregnancy
Obstetrics 

 

Obstetric cholestasis is not a common pregnancy condition.  Obstetric cholestasis is a liver disease of pregnancy that usually appears in the last trimester with a complex aetiology including different elements such as genetic, environmental and endocrinological factors.

 

It is characterised by itching skin without the presence of rash and elevated concentrations of serum bile acids and serum transaminases, in the absence of other liver pathology. It usually disappears after birth.

 

The incidence varies widely, advising a geographical and seasonal environmental influence in some populations. This condition occurs in 0.5 – 0.8% of pregnant women in South Australian Aboriginal Culture. It has a recently recognised relationship with gestational diabetes and gallstones in women and their affected families. It has an increased incidence in women who are seropositive for hepatitis C, linked with early-onset disease

 

What causes obstetric cholestasis?

 

The exact cause is unknown.

Obstetric cholestasis has a genetic predisposition. This condition has a higher sensitivity to certain hormonal and environmental factors in the last trimester of pregnancy

Oestrogen is the most critical hormonal precipitant. Obstetric cholestasis usually develops when placental oestrogen synthesis is at its highest level and solves soon after birth

Severe obstetric cholestasis is defined when the serum bile acids are greater than 40 micromoles /L) and may be associated with increased fetal morbidity and mortality.

Symptoms of obstetric cholestasis

The main symptom of OC is itching, often on the palms of the hands and soles of the feet. It usually happens from around 28 weeks, more commonly in multiple pregnancies.

Other symptoms are sleep disturbance, dark urine, pale stools, jaundice (rare), malaise and anorexia. It is common to have excoriations (scratch marks) on physical examination, while the presence of a rash is unusual. When it is present the doctor will consider other conditions.

 

Diagnosis

 

The diagnosis is made by a health practitioner taking into consideration the symptoms, signs and physical examination.  Also, it will be necessary to perform some laboratory test with the aim to identify the cause. Some of the laboratory tests are the following

–       Serum bile acids.  This blood component is increase

–     Other blood test disturbances include abnormalities in liver function tests, such as aminotransferases [ALT, AST], gamma-glutamyl transferase [γGT]  and bilirubin. Prothrombin time (INR) can be prolonged in severe cases

 

Management

 

The management of this condition involves the antenatal period, the intrapartum period and the postpartum period.

 

Antenatal management

Generally, pregnant women do not need to be admitted to the hospital except in cases of severe elevation of the concentration of serum bile acids in the blood.

If the diagnosis was made about 37 weeks, delivery should be considered. If the diagnosis is made before the 37 weeks, then close monitoring of clinical symptoms, liver function and fetal wellbeing is commenced and preparations made for possible early delivery.

The baby should be monitored continuously. Any decrease/absence of fetal movements should be reported.

 

Pharmacological management

Ursodeoxycholic acid (UDCA) has been proved to reduce itching. It has also shown benefit in small studies to improve liver function in obstetric cholestasis.

Some agents (including activated charcoal and cholestyramine) have been used to bind bile acids in the intestine and thus get rid of them. These agents have potential adverse effects for mothers due to the depletion of vitamin K, required for blood clotting; as a result, parenteral Vitamin K may be necessary

Antihistamines are  useful in relieving pruritus

 

Postnatal management

The itching or pruritus will usually disappear 1-2 days after birth and serum bile acid concentrations should become normal within the first week.

A general practitioner will review at one month postnatal to check bile acids and liver function. Then the woman should be evaluated after six weeks postpartum to assess if any biochemical abnormalities persist. The likelihood of recurrence in a subsequent pregnancy is of the order of 70-90%. Estrogen containing contraceptives should be avoided.

 

You can make an appointment with Dr Kenny on 07 3188 5000.

This article is written to be informative and does not substitute seeking a professional consultation from a medical professional.

 

References

1.Geenes V, Williamson C. Intrahepatic cholestasis of pregnancy. World J

Gastroenterol 2009; 15: 2049-66.

2.Reyes H. Sex hormones and bile acids in intrahepatic cholestasis of pregnancy. Hepatology 2008; 47: 376-79.

3.Wikström Shemer C, Marschall HU, Ludvigssun JF, Stephansson O. Intrahepatic cholestasis of pregnancy and associated adverse pregnancy and fetal outcomes: a 12-year population-based cohort study. BJOG 2013; 120: 717-23.

4.Palmer DG, Eads J. Obstetric cholestasis of pregnancy: A critical review. J Perinat Neonat Nurs 2000; 14: 39-52.

5.Williamson C, Girling J. Obstetric cholestasis. In: James DK, Steer PJ, Weiner CP, Gonik B, Crowther C, Robson SC editors. High risk pregnancy. Fourthed.

Philadelphia: Elsevier; 2011. p. 843-846

6.Martineau M, Raker C, Powrie R, Williamson C. Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes. Eur J  bstet Gynecol Reprod Biol 2014; 176: 80-85.

7.Walker IAL, Nelson-Piercy C, Williamson C. Role of bile acid measurement in pregnancy. Anals Clin Biochem 2002; 39: 105-14.

8.Williamson C, Hems LM, Goulis DG, Walker I, Chambers J, et al. Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group. BJOG 2004; 111: 676-81.

9.Paternoster DM, Fabris F, Palù G, Santarossa C, Bracciante R, et al. Intrahepatic cholestasis of pregnancy in hepatitis C virus infection. Acta Obs Gyn Scan 2002; 81: 99-103.

10.Geenes V, Chappell LC, Seed PT, Steer PJ, Knight M, Williamson C. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population -based case-control study. Hepatology 2014; 59:148291.

11.Royal College of Obstetricians and Gynaecologists (RCOG). Obstetric Cholestasis. RCOG Guideline No. 43; April 2011.

12.Saleh MM, Abdo KR. Consensus on the management of obstetric cholestasis: National UK survey. BJOG 2007; 114: 99-103.

13.Glantz A, Marschall H-U, Lammert F, Matteson L-A. Intrahepatic cholestasis of pregnancy: a randomized controlled trial comparing dexamethasone and

ursodeoxycholic acid. Hepatology 2005; 42: 1399-1405

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