based on rcog greentop guideline 43 january 2006 max brinsmead mb bs phd may 2015 cholestasis of...
TRANSCRIPT
Based on RCOG Greentop Guideline 43 January 2006
Max Brinsmead MB BS PhDMay 2015
Cholestasis of Pregnancy
Definition
A multifactorial obstetric condition characterised by... Pruritis without a skin rash and Abnormal liver function without other
cause That remits completely after delivery
Also known as “Benign obstetric cholestasis”
Incidence
1:150 pregnancies in a multi ethnic society
1:20 in Chilean Indians
It has a strong familial and ethnic component
Liver Function Tests in Pregnancy
Alkaline phosphatase is increased There is a placental contribution to the circulating
pool Normal range <260
GGT, Transaminases and Bilirubin are reduced
By a mean of 20% GGT <35 ALT < 30 AST < 45
Bile salts Should be fasting Normal range is <6 in pregnancy
Differential Diagnosis
40% of pregnant women develop a skin eruption of some sort during pregnancy
Many of which involve pruritis Pregnancy Urticarial Plaques and Papules
(PUPP) Typically begins in stretch marks on the abdomen In the final weeks of pregnancy Can pose a dilemma of management
Eczema and Psoriasis Typically has a past history Typical sites involved
Allergic skin reactions Scabies Preeclampsia, HELLP and acute yellow
atrophy liver
Abnormal Liver Function Tests?
Raised AST and ALT This is Hepatitis Viral or chronic active
Raised alkaline phosphatase and GGT This is cholestasis Typically due to gallstones
Raised GLT and ALT This is fatty liver
Raised GGT alone Typically a drug-induced liver effect
Raised ALT alone This arises from muscle damage
Raised Bilirubin but normal enzymes This is due to haemolysis or familial
hyperbilirubinaemia e.g. Gilberts
Maternal Consequences of Cholestasis
Pruritis and scratching Insomnia Skin damage
Some reports of increased risk of preeclampsia and urinary tract infection
Vitamin K dependent blood clotting factors may be reduced
Risk of APH and PPH Controversial
Fetal Consequences of Cholestasis
Increased risk of pre term delivery Controversial Some of this is iatrogenic
Increased risk of stillbirth Controversial Earlier studies suggested 2-3 fold increased risk Not substantiated by contemporary studies Is this a consequence of clinical awareness &
intervention? RCOG recommends “women with this condition should
be told that current rates of stillbirth are no higher than in the general obstetric population”
Increased risk of meconium liquor and CS
Pathogenesis of Fetal Risk
Still unknown There is evidence that risk of fetal
death, premature labour and meconium is related to the concentration of bile salts
Bile salts are oxytocic in vitro Fetal hypoxia (if it occurs) appears to
be acute and not chronic This makes monitoring difficult
Recommended Management
Weekly liver function tests Oral Vitamin K for mothers
Although prothrombin time is rarely checked Fetal monitoring
Umbilical Dopplers of no apparent value Waiting for CTG changes might be too late
Timing of Delivery should be decided on an individual basis
May depend on previous obstetric outcome Elective delivery after 37 weeks is common Any marked deterioration in LFT’s is regarded with
concern
Possible Interventions
Any simple skin emollient for pruritis Ursodeoxycholic acid
1.5 – 2.0 G/day Successfully lowers serum bile salts May assist with pruritis But fetal benefit lacking from RCT’s
Maternal Dexamethasone May have a role Acts by suppressing the fetal adrenals Which are the source of fetoplacental “liver toxic”
steroids May assist in fetal lung maturation
Recommended Followup
Follow liver function tests back to normal
Oestrogen-containing oral contraceptives are best avoided
Advice to relatives may be required Counselling and debriefing is required
when there has been an adverse obstetric outcome
There is a UK Support Group