cholestatic disease in pregnancy

8/8/2019 Cholestatic Disease in Pregnancy

1/25

Cholestatic disease in

pregnancy

Mohd Arif

071303044

Melaka Manipal Medical College


2/25

Cholestatic disease in pregnancy

Obstetric cholestasis

Acute cholecystitis & Cholelithiasis in pregnancy


3/25

Obstetric cholestasis


4/25

Background Previously referred to as intrahepatic cholestasis of

pregnancy.

Affects 0.7% of pregnancies in multi-ethnic populations

and 1.21.5% of women of Indian-Asian or Pakistani-Asian origin.

More common in Asian women.

1/3 of patients have positive family history ofthe

condition Usually occurs in 3rd trimester of pregnancy

Resolvesspontaneously after delivery


5/25

Definition

Obstetric cholestasis is a multifactorial condition

of pregnancy characterisedbyintensepruritus in the absence of a skin rash, withabnormal liver function tests (LFTs),neither of which have an alternative cause and

both of which remit following delivery


6/25

Pathogenesis

Unknown Presence ofsome distinctive features1. Cholestasis & pruritus in 2nd half of pregnancy

without other major liver dysfunction2. Tendencyto recur in each pregnancy3. Associations with OCP& multiple gestations4. Benign course with no maternal hepatic

sequelae5. Increase rate of meconium stain amniotic fluid

and fetal demise


7/25

Clinical importance

Potential fetal risks spontaneous prematurity iatrogenic prematurity intrauterine death

Significant

maternal mor

bidity in a

ssocia

tion wi

th intense pruritus and consequentsleep

deprivation vitamin K deficiency : fetal intracranial

haemorrhage&PPH


8/25

Clinical Features

Pruritis ofthe trunk and limbs, withoutskin

rash, (often worsen at night) Anorexia & malaise

Epigastric discomfort, jaundice, steatorrhea &dark urine (uncommon)


9/25

Investigations

LFTs

- 2-3 fold increase in ALT,AST,

GT or ALP- use pregnancyspecific referrance ranges

Clotting screen

Bile acids

USG liver &biliarytree Viral serology (Hep A,B,C, CMV,EBV)

Autoimmune screen (anti-smooth muscle andantimitochondrial antibodies)


10/25

Diagnosis

Diagnosis of exclusion

Based on History

Abnormal LFT :

Raisedbile acids in absence of any cause for

hepatic dysfunction


11/25

DDx

Gallstones

Acute or chronic viral hepatitis : Hepatitis A, B,C, Epstein Barr and cytomegalovirus

Chronic active hepatitis (anti-smooth muscleantibodies)

primarybiliary cirrhosis (antimitochondrialantibodies)


12/25

Monitoring

Measure LFTs weekly

Postnatal LFTsshouldbe deferred for at least 10days


13/25

Managements

1. Send Ix for all women came with prurituswith no rash2. If normal, repeat every 1-2 weeks ifsymptoms persists

3. Exclude other causes4. Water soluble vitamin-K commenced on diagnosis :

TAB 10 mg daily5. Topical ellomients to alleviate symptoms.6. Ursodeoxycholic acid : 8-12 mg/kg daily in two divided

doses7. Fetal surveillance : CTG & USS..8. Establish postnatal resolution ofsymptoms and

pruritus9. Next pregnancy : Recurrance(45-70%)


14/25

Drugs used

Topical emollients eg. calamine lotion &

aqueous cream with menthol Cholestyramine

Antihistamines eg. Piriton (CPM)

S adenosyl methionine

Ursodeoxycholic acid Dexamethasone

Vitamin K

piriton


15/25

Acute Cholecystitis & Cholelithiasis


16/25

Background

2nd most common surgical condition in

pregnancy Incidence

- gallstones : 7%(nulliparous)

: 19%(multiparous)

- Acute cholecystitis : 1-8 in 10 000- hospitalization : 1-2%

- Surgery : 1 in 2000

Gallstone composition : crystallized cholesterol


17/25

Organism

Aerobic

i. Escherichia coliii. Klebsiella sp.

iii. Enterococci

iv. Proteussp.

Anaerobici. Bacteroides sp.

ii. Clostridium sp.

iii. Anaerobic cocci


18/25

During pregnancy..

Increase in serum cholesterol & lipid levels

Biliarystasis : Progesterone diminishessmoothmuscle tone

Increase saturation of cholesterol inbile : Highlevels of estrogen


19/25

Signs & symptoms

Colicky epigastric/RUQ pain

Nausea &Vomiting Murphyssign

Jaundice

Infection : Fever &tachycardia

Peritoneal signs : guarding,rigidity, reboundtenderness


20/25

Investigations

FBC,LFT,CRP- Increase of WBC count- Elevated ALP&bilirubin- Increase AST & ALT (>200U/L)without

leukocytosis suggestsViral hepatitis

USG ofbiliarytract- calculi- dilatation ofbiliarytree- increase thickness of gallbladder wall


21/25

Managements

Canbe managed medically in pregnancy:

Parenteral fluidsGastric decompression

Dietary measures

Analgesics

Anti-emeticAntibiotics


22/25

ERCP

Endoscopic retrogradecholangiopancreatography

Diagnostic + Therapeutic

Indication : Cholangitis or Pancreatitis due tocommonbile ductstone

Canbe safely performed in pregnancy with

little ionizing radiation exposure to the fetus


23/25

Cholecystectomy

Preferably : laparoscopic

Emergency (in pregnancy) ifsymptoms&signspersists with progressive peritonitis despitemedical management and ERCP.

Elective (after delivery)

i. Recurrentbiliary colicii. Acute cholecystitis

iii. Obstructive cholelithiasis


24/25

Referrances

Hacker & Moore Essentials of obstetrics&

gynaecology 5

th

edition 2010 Oxford handbook of obstetrics& gynaecology 2nd

edition 2009

http://www.rcog.org.uk/files/rcog-

corp/uploaded-files/GT43ObstetricCholestasis2006.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364506/pdf/IDOG-04-303.pdf


25/25

cholestatic disease in pregnancy

Documents