1. Cholestasis of Pregnancy
Based on RCOG Greentop Guideline 43 January 2006
Max Brinsmead MB BS PhD
May 2015

2. 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”

3. Incidence 1:150 pregnancies in a multi ethnic society
1:20 in Chilean Indians
It has a strong familial and ethnic component

4. 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

5. 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

6. 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

7. 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

8. Fetal Consequences of Cholestasis
Increased risk of pre term delivery
Controversial
Some of this is iatrogenic
Increased risk of stillbirth
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

9. 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

10. 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

11. 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

12. 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

13. Any Questions or Comments?
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