Women and Children’s Division

Maternity Services

Guideline: Cholestasis (Obstetric) - Suspected and Confirmed

1.Introduction

The clinical importance of obstetric Cholestasis lies in the potential fetal risks, which may includespontaneous preterm birth, iatrogenic preterm birth and fetal death.There can also be maternal morbidityin association with the intense pruritus and consequent sleep deprivation (RCOG 2011)It tends to get worse over time unless treated or the baby is delivered. After delivery the condition resolves

Obstetric Cholestasis characteristically presents itself with itching. This is the most common symptom - it can be ‘all over’ but is often worse on the palms of hands and soles of the feet, and is generally worse at night. It presents with NO rash, although the skin may appear inflamed from repeated scratching.

In England, obstetric Cholestasis affects 0.7% of pregnancies in multi-ethnic populations and 1.2 – 1.5 % of women of Indian-Asian or Pakistani-Asian origin.

N.B. Pruritus in pregnancy is common, affecting 23 % of pregnancies of which a small proportion will have Obstetric Cholestasis. (RCOG 2011)

2.Aims and Objectives:

  • To diagnose Obstetric Cholestasis (OC)
  • To monitor and maintain maternal and fetal wellbeing and plan timely intervention

3.Definition:

Obstetric cholestasis is a multifactorial condition of pregnancy characterised by pruritus in the absenceof a skin rash with abnormal liver function tests (LFTs),neither of which has an alternative cause and bothof which resolve after birth. Diagnosis is based on elevationof LFTs beyondpregnancy-specific limits, particularly ALT and bile acids, after exclusion of other causes of pruritus and of abnormal LFTs.

4.Duties and Responsibilities:

  • To ensure safety of mother and baby.
  • To follow guidelines and monitor the pregnancy and clinical picture.
  • To support the woman and provide as much information as possible.

5.Management

  • Establish history including: gestation, extent and location of itching.
  • Maternal baseline observations – Blood pressure, Pulse, Temperature. Respirations (record the results on the MPAR chart), and presence of normal fetal movements.
  • Discuss the diagnosis with the woman and her partner and provide written information see appendix one.
  • Obtain blood samples with consent for:
  • FBC
  • LFTs
  • Bile Acids.
  • clotting screen (If Platelet count is below 100)
  • If these results are within normal limits, but itching persists, bloods should be repeated weekly-fortnightly as itching may be present before blood results are affected. (RCOG 2011)

NB; Bile Acids result may take up to 2 weeks (sample currently sent to Basildon for analysis).

  • Organise Liver Ultrasound scan (to exclude other reasons for the blood results &/or symptoms
  • Send blood for Auto-immune antibodies, including Anti-Smooth Muscle antibody and Anti-mitochondrial antibody; Hepatitis A,B,C, Ebstein Barr Virus (EB) Cyto Megla Virus (CMV) viral screen (to exclude other reasons for the blood results &/or symptoms.

6. Ongoing management

There is no evidence that any specific treatment improves maternal symptoms or neonatal outcomes. All therapies should be discussed with the individual woman with this in mind. Women with obstetric cholestasis should be offered consultant-led care and give birth in the consultant unit(RCOG 2011).

6.1Further investigations:

  • Repeat bloods weekly, LFTs, FBC, Clotting and Bile acids
  • Discuss with the woman the importance of her monitoring the Fetal movements and to report any changes (although there is no robust evidence to support this).
  • Ultra sound* for growth and liquor volume may be advised, depending on clinical picture

*NB: Ultrasound and CTG are not reliable methods for preventing fetal deathin obstetric cholestasis. (RCOG 2011)

6.2Pharmacological options

  • Suggest ways to reduce skin temperature, itching is generally worse the warmer the skin, hence worse at night under duvets etc. Cold flannels, cold water bottles, showers etc have all been anecdotally reported as beneficial in relieving itching
  • Topical emollients such as Diprobase, Calamine Lotion, Aqueous cream with calamine or Levomenthol.
  • Chlorphenramine (Piriton) 4mg from once daily up to 6 hourly
  • Ursodeoxycholic acid (UDCA) Dose 8-12mg/kg Dailytoimprove pruritus and liver function in women with obstetric cholestasis.Women should be informed of the lack of robust data concerning protection againststillbirth and safety to the fetus or neonate. (RCOG 2011)
  • If Liver function and Bile Acids continue to rise Consultant review is essential to discuss alternative medication. (Dexamethasone/Rifampicin Orally or others)
  • Where the prothrombin time is prolonged, the use ofwater-soluble vitamin K (menadiol sodium phosphate) in doses of 10 mg is indicateddaily.
  • In all women Vit K 10mgsDaily should be consideredat or after 32/52 gestation

NB: Erythromycin and Co-amoxiclav should be avoided as they have the potential to cause cholestasis

7Planning the delivery

  • Delivery can be considered if Bile Acids are > 40 micrormol/L with increasing trend; this needs to be carefully balanced against iatrogenic prematurity, and should be consultant decision.
  • Women should be informed of the increased risk of perinatal morbidity from early
  • A discussion should take place with women regarding induction of labour 37+0-38 weeks of gestation.
  • Women should be informed that the case for intervention (37+0 -38 weeks of

gestation) may be stronger in those with more severe biochemical abnormality

(transaminase, Gamma GT and bile acids).

  • Women should be informed of the increased risk of maternal morbidity from

intervention at 37+0-38 weeks of gestation.

  • Women should be informed of the inability to predict stillbirth if the pregnancy

continues.

Stillbirths in obstetric cholestasis have been reported across all gestations.As gestation advances, the riskof delivery (prematurity, respiratory distress, failed induction) versus the uncertain fetal risk of continuingthe pregnancy (stillbirth) may justify offering women induction of labour after 37+0 weeks of pregnancy.

The decision should be made after careful counselling.The case for intervention at this gestation may bestronger in those with more severe biochemical abnormality. The consultant will decide together with discussions involving the woman when delivery should be planned.

Poor outcome cannot currently be predicted by biochemical results and deliverydecisions should not be based on results alone

7.1During labour

Continuous fetal monitoring in labour should be offered.

Active management of the third stage should be encouraged, due to the increased risk of PPH.

7.2Postnatal

  • Postnatal vitamin K must be offered to the babiesin the usual way
  • The General Practitioner (GP) should be advised (via the discharge summary) to ensure that LFTs return to normal.
  • Prior to discharge following the birth the woman should be given a completed blood request form and advised to have this test at 6 weeks, prior to her postnatal review with her GP.
  • Ensure the woman has a copy of the RCOG information leaflet (appendix One) for further information
  • Combined Oral Contraception usually avoided toprevent further hepatic cholestasis.
  • Discuss recurrence of Cholestasis - 45% in future pregnancies.

8.Monitoring compliance

Audit of cases will be undertaken to inform future practice.

9.References

C Nelson-Piercy, I A Greer & B Walters, ( 2007)Maternal Medecine, Medical Problems in Pregnancy.Churchill Livingtsone,Elsevier.

RoyalCollege of Obstetrics and Gynaecology (RCOG), ‘Obstetric Cholestasis’, Green-top Guideline No.43 May2011.

………………………………………… ………..……………………….

Dymphna Sexton-BradshawAban Kadva

Associate Director of Women & Consultant Obstetrician

Children's/ Head of MidwiferyLead Delivery Suite

Women & Children’s Division

------

Anne Regan

Lead Pharmacist

Version / Author (s) / Date / Circulation / Comments
One / Mervyn Jarritt
Antenatal Ward Manager
Anne lines
Student Midwife / 2008 / Obstetric Division
Two / LynnEverritt
AAU Midwife
Judy Evans
ANC & AAU Sister
Sally Price
Consultant Obstetrician & Gynaecologist / 2012 / AAU & ANC Staff
Obstetric Consultants
Supervisors of Midwives / Reviewed and Revised

Appendix One

RCOG Information to give to women

Date of Original document;November 2008 Cholestasis (Obstetric) -Suspected and ConfirmedDate AmendedMay 2012Version2 Guideline No: 2.5

Review date; May 2015

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