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Cholestasis of Pregnancy

Antenatal Obstetrics 

Cholestasis of pregnancy is a condition which develops in the second and third trimester of pregnancy.

It typically presents with an intense itch, especially on the palms of the hands and the soles of the feet, but it can be anywhere. It is usually worse at night. There is no rash but a rash can develop secondary to intense itching.

Risk factors:

  • South American Indians
  • Multiple pregnancy (twins, triplets)
  • Previous cholestasis in a previous pregnancy
  • Family history
  • Liver disease e.g hepatitis

Clinical features:

  • Itching – palms and soles especially, worse at night
  • Scabs from intense itching
  • Jaundice (yellow eyes) may occur

Diagnosis

The diagnosis is usually made on clinical grounds which can be confirmed with blood tests. The best test is a fasting bile acid level, as well as liver function tests. Sometimes the blood tests can be normal and the diagnosis is made on clinical grounds alone. Coagulation studies may be done, but are rarely affected. An ultrasound of the liver is not routinely done in this scenario.

Risks of Cholestasis

The mum may develop Vitamin K deficiency either from the disease or the treatment. This can cause clotting abnormalities and may lead to haemorrhage after the birth. There are some significant risks for babies of mothers with this condition:

  • Preterm delivery in up to 40% (higher in twins)
  • Meconium stained liquor at delivery
  • Fetal distress in labour
  • Stillbirth 3 – 4% risk – this rarely occurs before 36 weeks
  • Bleeding complications

Treatment

Treatment of this condition involves treating the intense itching which can be done with over the counter medications such as calamine lotion and anti-histamines. Topical steroids and various prescription medications such as Ursofalk or oral steroids can be used for more sever itching. Vitamin K can be given to the mum to reduce the risk of bleeding complications and vitamin K is strongly recommended to all babies whose mothers have this condition.

The mum and baby need more intense monitoring than normal. The mum may require regular blood tests to check her liver function, and the baby may need more regular checks with ultrasounds and heart rate monitoring.

Delivery of the baby will depend on variable factors such as the stage of the pregnancy, the severity of the cholestasis and the monitoring of the mum and baby. Natural birth can be achieved with this condition – caesarean is not usually necessary unless other factors come into play.

The risk of cholestasis in another pregnancy is 75%. Any oestrogen containing contraceptives need to be used with caution following a pregnancy affected by cholestasis.

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