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

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