Cholestasis of pregnancy 

BMJs Best Practice – search Cholestasis of pregnancy 

Diagnosis of cholestasis in pregnancy is confirmed by:

1. clinical features
2. exclusion of other forms of liver disease or cholestasis
3. laboratory findings

Clinical features

• Pruritis without a rash
  • itching is classically on the palms and soles of the feet although it may be more widespread. 
  • The pruritis is worst at night and women may exhibit dermatographia artefacts ( skin trauma from intense scratching)
• malaise
• steatorrhea with fat malabsorption
• Jaundice – uncommon  but can occur in 10-15% of cases

• Exclude other causes
  • Autoimmune hepatitis
  • Hepatitis A,B, C2, 3 or E1
  • Epstein Barr
  • Cytomegalovirus
  • Gall bladder disease
  • Liver disease e.g. cirrhosis, acute fatty liver
  • Early HELLP syndrome or preeclampsia
  • Skin conditions e.g. eczema, pruritic eruption of pregnancy, scabies

Investigations

• Fasting Serum Bile Acids – to make the diagnosis
• LFTs –weekly once obstetric cholestasis is diagnosed
• Full blood picture
• Coagulation studies – may be ordered by the obstetric team if abnormal LFTs.
• Prolonged prothrombin times may reflect Vitamin K deficiency
• Viral screen for hepatitis A, B and C, Epstein Barr and cytomegalovirus.
• Liver autoimmune screen for chronic hepatitis and primary biliary cirrhosis.
• Liver ultrasound

Fetal surveillance

• Antenatal visits should be arranged 2nd weekly.
• Timing of birth
• Aim to deliver the woman between 37weeks  and 38 weeks gestation, or earlier if there is sufficient risk for maternal morbidity or fetal compromise detected.

Treatment of maternal pruritis

• The use of topical emollients e.g. calamine lotion may provide temporary relief of itching.
• skin moisturised, cool baths/showers for comfort, use of cotton material where possible (e.g. bed linen).
• Anti-histamines at night (beneficial for their sedative effect)
• Ursodeoxycholic acid (UDCA or URAO).
  • Dosage required to attain effect on maternal pruritis and serum bile acids is from 10 to 15 mg/kg/day
• Vitamin K supplementation
  • Recommend daily supplementation of water soluble 5-10mg of Vitamin K orally to reduce the risk of post-partum haemorrhage (PPH).
• Nutritional supplementation
  • Steatorrhea and fat malabsorption may lead to nutritional deficiency.