Obstetric Cholestasis

Reduced outflow of bile acids from the liver which resolves after delivery of the baby

Aetiology

  • Underlying cause not known, thought to be the result of increased oestrogen and progesterone levels
  • There seems to be a genetic component

Risk factors

  • More common in women of South Asian ethnicity
  • Past history of obstetric cholestasis
  • Family history of obstetric cholestasis
  • Multiple pregnancy
  • Presence of gallstones
  • Hep. C

Clinical presentation

  • Usually develops later in pregnancy, particularly in the third trimester
  • Itching (pruritis)) is the main symptom, particularly affecting the palms of the hands and soles of the feet
  • Rarely - dark urine, anorexia, steatorrhoea

Investigations

  • Abnormal LFTs, mainly ALT, AST and GGT
  • Raised bile acids
  • Diagnosis of exclusion - other tests used to rule out other causes (should be normal)
    • Liver USS
    • Viral serology
    • Liver autoantibodies

Management

  • Ursodeoxycholic acid improves LFTs, bile acids, and symptoms
  • Symptoms of itching can be managed with:
    • Emollients e.g. calamine lotion to soothe the skin
    • Antihistamines e.g. chlorphenamine can help sleeping
  • Water-soluble vitamin K can be given if PT is deranged
  • Monitoring of LFTs is required weekly during pregnancy and for at least 10 days after delivery
  • Planned delivery after 37 weeks may be considered, particularly when the LFTs and bile acids are severely deranged
    • Stillbirth in obstetric cholestasis is difficult to predict, and early delivery aims to reduce the risk

Complications

  • Increased risk of fetal distress at term
  • Amniotic fluid meconium aspiration
  • Intrauterine fetal death
  • Need for preterm delivery (and risks of preterm delivery)