Management

Management

• requires specialist advice
• serial measurements of maternal serum concentrations of bile acids, albumin, and alkaline phosphatase are essential
• close monitoring of fetal wellbeing is essential, although no single test reliably predicts the risk of intrauterine death
  • raised serum concentrations of maternal bile acids correlate with the severity of pruritus and risk of fetal distress
  • "... Stillbirths in obstetric cholestasis have been reported across all gestations.As gestation advances, the risk of delivery (prematurity, respiratory distress, failed induction) versus the uncertain fetal risk of continuing the 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 be stronger in those with more severe biochemical abnormality..." (2)
• vitamin K may be required if prolonged prothrombin time. Vitamin K is given to the baby at birth
• ursodeoxycholic acid, though not licensed for use in pregnancy, is increasingly used in patients with obstetric cholestasis (1,2)
• in affected mothers the symptoms classically disappear within a day to two after delivery, with rapid normalisation of liver function values and serum bile acid concentrations. Persistent abnormalities should prompt a search for underlying liver disease (2)
  

Following pregnancy (2):

• as a minimum,healthcare practitioners must ensure that LFTs return to normal,pruritus resolves,all investigations carried out during the pregnancy have been reviewed and the mother has fully understood the implications of obstetric cholestasis
  • the latter will include reassurance about the lack of long-term sequelae for mother and baby and discussion of the high recurrence rate (45–90%), contraceptive choices (usually avoiding estrogen-containing methods) and the increased incidence of obstetric cholestasis in family members
  • LFTs at 6 weeks after delivery and an appointment at 8 weeks is a suggested model
  • appropriate follow-up should be arranged by a medical practitioner with appropriate skills

Reference:

1. Walker KF et al. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD000493. DOI: 10.1002/14651858.CD000493.pub3.
2. Royal College of Obstetricians and Gynaecologists (April 2011). Guideline No. 43 - Obstetric cholestasis.