Title:
CLINICAL GUIDELINES ID TAG
Obstetric Cholestasis
management
Author:
Dr Foteini Verani
Designation:
Specialist Doctor
Speciality / Division:
Obstetrics-IMWH
Directorate:
Acute Services
Date:
April 2017
Consulted upon:
Authorised by
Yes
Mr David Sim
Ms Joanne McGlade
Approved by:
Dr Martina Hogan
(Name of AMD)
Dept./Division Only: YES-IMWH
Applicable to:
Directorate Only: NO
(delete Yes / No as
appropriate)
Trust-wide: NO
Review Date (Every
3 years or sooner if April 2020
required):
Clinical Guideline ID:
CG0429
Obstetric Cholestasis Management
Aim
To improve the quality of care for the women presenting with pruritus in
pregnancy and to provide guidance on the different management choices and
the options available for the treatment of obstetric cholestasis.
Definitions
Pruritus (itch) is described as an unpleasant sensation that triggers a desire
to scratch.
Obstetric Cholestasis, OC (or Intrahepatic Cholestasis of Pregnancy, ICP) is
a multifactorial condition of pregnancy characterised by pruritus (especially
the palms and soles of the feet) in the absence of skin rash with abnormal
liver function tests (LFTs or Bile acids or both) neither of which has an
alternative cause and both resolve after birth.
Background
Pruritus in pregnancy: 23% (almost 1:4)
Obstetric Cholestasis: 1:135; 0.7% of pregnancies in multiethnic populations
and 1.2-1.5% of women of Indian-Asian or Pakistani-Asian population
The clinical importance of OC lies in the potential fetal risks, which may
include preterm birth, passage of meconium, fetal distress or unexplained
fetal death. There can also be maternal morbidity in association with the
intense pruritus and consequent sleep deprivation, higher incidence of
cesarean section and postpartum haemorrhage.
Diagnosis
Symptoms/ History
• Unexplained pruritus especially if it involves palms and soles and typically
worse at night
• No rash unless skin irritation and excoriation due to scratching may
resemble a rash
• Pale stool, Dark urine, Jaundice
• Personal or family history of OC
• Multiple pregnancy
• Carriage of Hep C
• Presence of gallstones
• Drug history (herbal remedies or recent antibiotics)
Differential diagnosis
• Eczema, atopic eruption of pregnancy, polymorphic eruption, pemphigoid
gestations if rush is present
• Hep A, B, C or chronic active hepatitis (viral and autoimmune screen)
• Epstein- Barr (viral screen)
• Cytomegalovirus (CMV) - (viral screen)
• Primary biliary cirrhosis (anti-smooth muscle and antimitochondrial
antibodies, US liver)
• Pre-eclampsia and Acute fatty liver (FBC, LFTs, U+E, Coag screen, US
liver)
Blood science
• All pregnant women above 24w presenting with pruritus should LFTs
checked. If pruritus persists with normal biochemistry, LFTs should be
repeated every 1-2 weeks
• Fasting bile acids (normal levels do not exclude the diagnosis)
• FBC
• Clotting screen only if already suspected low platelets, bleeding tendencies
or highly deranged LFTs (ALT>200)
Normal biochemistry in pregnancy (20% lower than non-pregnant)
Test
Normal level
Bile Acid
<14 mmol/L
ALT
<32 iu/L
Further investigations when deranged LFTs
• Virology screen for Hep A, B, C, Epstein Barr, CMV
• Liver autoimmune screen for chronic active hepatitis and primary biliary
cirrhosis
• US liver
• Investigations for pre-eclampsia or acute fatty liver
Management of OC
General advice
• Low fat intake
• Frequent tepid baths
• Avoid warm areas and clothes
• Wear loose cotton clothing
• Scratch skin with baby’s soft hairbrush if necessary
Management
• Consultant led care
• Measure LFTs weekly until delivery. Postnatally resolution should be
confirmed by measuring LFTs at least 10 days post delivery
• Consider corticosteroids to improve fetal lung maturity in case preterm
delivery occurs before 36weeks but not for the management of OC
• Fetal biometry with US and CTG are not reliable methods for preventing
fatal death nor biochemical results can predict poor outcome
• Drugs that can commonly cause cholestasis should be avoided e.g.
Erythromycin, Augmentin, Fluoxetine unless benefit outweigh risk
• Women should be given written information to support verbal advice (patient
information
leaflets
from:
https://www.rcog.org.uk/globalassets/documents/patients/patientinformation-leaflets/pregnancy/pi-obstetric-cholestasis.pdf
or
www.britishlivertrust.org.uk
• In severe cases of sleep deprivation and anxiety support networks may be
offered e.g. British Liver Trust
• The widely adopted practice of offering delivery at 37 weeks or at diagnosis
if this is after 37 weeks is not evidence based. The decision of delivery
should be individualised based on:
Lung maturity
Bile acid levels especially if >40 mmol/L
Gestational age at onset of pruritus
Informed patient’s choice
• Continuous fetal monitoring in labour should be offered
• Vaginal delivery is preferable unless there there is other obstetric indication
for cesarean section
Treatment
• Bland topical emollients such as Diprobase, Calamine lotion, Aqueous
menthol cream PRN may provide temporary relief of pruritus
• Chloremphinamine (Piriton) 4mg TDS may provide some sedation at night
with no significant impact on pruritus
• Vitamin K (water soluble) 10mg daily from the time of diagnosis, especially
where the prothrombin time is prolonged, to reduce the risk of maternal and
fatal haemorrhage
• Postnatal vitamin K should be offered to neonates in the usual way
• Ursodeoxycholic acid (UDCA) to improve pruritus and LFTs
Not licensed to use in pregnancy but commonly prescribed
10-15mg/Kg in 2-3 divided doses.
75% respond.
Should be taken with meal or immediately after.
Postnatal management
• Repeat LFTs in 2 weeks in community to confirm resolution
• There is 10% risk of developing pruritus or hepatic impairment or both with
oestrogen containing contraception
• The recurrence rate is 40-90%
• There are no known developmental problems with the baby and no
increased risk of developing neonatal jaundice
References
• NICE .Itch in Pregnancy. July 2015
• RCOG Green Top Guideline No 43. Obstetric Cholestasis. April 2011
• Royal Cornwall Hospitals NHS. Obstetric Cholestasis. February 2014
Flow Chart
Itching without rash
Personal or family history
Detailed history and examination
LFTs and bile acids
Normal but persisted itch
Repeat 1-2 weekly
Abnormal LFTs and/or
fasting Bile acids
Rule out pre-eclampsia
Obstetric cholestasis
Intrapartum
Antenatal
Postnatal
Topical
emollients
Antihistamines
UDCA
Vitamin K
Discuss
delivery after
37weeks
1-2 Weekly
LFTs and or
fasting Bile
acids
Continuous
monitoring
LFTs in 2 weeks in
community