ANSC January Update: St George and Sutherland Hospitals

Obstetric Cholestasis

Obstetric Cholestasis (OC) is a multifactorial condition of pregnancy characterised by pruritus in the absence of a skin rash, with abnormal liver function tests (LFTs), neither of which has an alternative cause and both of which resolve after birth.

OC is a complication in 0.1% to 2% of pregnancies and is often associated with an increase in perinatal morbidity and mortality, including higher incidence of spontaneous and iatrogenic preterm birth, meconium-stained liquor, fetal asphyxia and stillbirth. 

DIAGNOSIS 

Women who have unexplained persistent and generalised itch (involving palms and soles of feet is particularly suggestive) require bile acids and liver function tests (LFTs). Blood tests may be fasting or non-fasting. 

The diagnosis is made with: 

  • Serum bile acids >10 and/or deranged LFT. 
  • May also have an unexplained persistent generalised itch in the absence of a visible rash 

If results are abnormal, refer woman to the Delivery Suite/Birth Unit for antenatal assessment as soon as possible. 

ANTENATAL SURVEILLANCE 

Ongoing assessment in the Day Assessment Unit or Antenatal Assessment Unit is required. 

Other tests including coagulation studies, preeclampsia screen, hepatitis screen (including liver USS) to screen for high risk or atypical cholestasis are at the discretion of the obstetric team. 

Women with abnormal coagulation studies should have the levels repeated weekly and be given Vitamin K 10mg orally. 

An ultrasound scan to assess growth is performed initially and repeated at the discretion of the consultant. 

For severe OC (serum bile acids > 100), the frequency of monitoring should be increased to three time per week. 

TREATMENT

Medication will be considered initially and dosage titrated depending on blood results and symptoms.

Ongoing monitoring of LFTs is required. 


TIMING OF BIRTH 

Birth should be undertaken at: 

  • 39 weeks gestation if bile acids < 40 

  • Earlier than 39 weeks gestation if there are: 

    • Other obstetric indications for earlier delivery

    • Worsening maternal liver function 

    • Bile acids > 40 despite maximum medical therapy. 

The risk of stillbirth increases with increases in bile acid and advancing gestation.

The timing of birth should be a shared decision with the woman, acknowledging the uncertainty in stillbirth risks with the known risks of preterm birth.

 

POSTNATAL CARE

Medical therapies can be ceased in the immediate postpartum period unless pruritic symptoms persist. 

If abnormal LFTs, a review with GP at 6 weeks postpartum is arranged to assess for resolution of pruritus and repeat LFTs.                                                                         

If LFTs remain abnormal 6 weeks postpartum, arrange for screening for other causes (hepatitis, autoimmune) with liver/abdomen ultrasound and specialist referral if clinically indicated. 

There are no contraindications to breastfeeding.

 

EDUCATIONAL NOTES 

  • Women with OC are also more likely to have other pregnancy complications including pre-eclampsia and gestational diabetes. 
  • There is high risk of recurrence of OC (40 to 60%) in subsequent pregnancies. 
  • Women with pre-existing liver disease (especially gallstones, chronic hepatitis) are at higher risk of OC during pregnancy.
  • Risk of OC is increased by five-fold in multiple pregnancies.
  • OC is multifactorial in aetiology, including genetic, hormonal (oestrogen and progesterone) and environmental factors (vitamin D and selenium) thought to be the causes that contribute.
  • Pruritis (involving palms and soles of feet is particularly suggestive) in the absence of a visible rash is the most common symptom; other symptoms include fatigue, anorexia, malaise, insomnia, epigastric discomfort, steatorrhea and weight loss. 
  • Other causes of itching and liver dysfunction should be excluded (hepatitis, autoimmune).
  • Fetal death is often sudden in well-grown baby with normal USS and normal CTG, with little or no warning prior. Hence, daily external fetal monitoring is of no proven benefit.
  • Women should be advised and reminded to monitor any changes to fetal movements and report to the hospital promptly. 
  • Women can be reassured that there are no long-term sequelae to her or baby.
New Birth Unit at St George Hospital 

St George Hospital will be opening the new Birth Unit (previously named Delivery Suite) on 30 January 2020.

Location:Level 2, Ward Tower Block (previously level 1) Gray St, Kogarah

The Birth unit has 8 birthing rooms and 2 antenatal observation beds. Each room has a bath and double-headed shower, picture wall and individual temperature control.

The Pregnancy Care Unit (previously Antenatal Assessment) has 4 antenatal assessment bays, 1 consult room and a bathroom.

Telephone numbers remains the same: 9113 2126 / 9113 2125

Ward tours are available by booking on Saturdays at 2:30pm.                                               

Ph 9113 2162. Numbers are limited.

There is a waiting area for family at the entrance to 2 South ward. Support people only are allowed entry to the Birth Unit.