Overview

• Obstetric Cholestasis → reduced outflow of bile acids from the liver. Resolves after delivery of baby.
  • Common complication, occuring in 1% of pregnant women. Usually develops later in pregnancy (>28 weeks gestation).
  • Increases risk of stillbirth.
• Acute Fatty Liver of Pregnancy → rare condition occuring in third trimester. Rapid accumulation of fat within hepatocytes, causing acute hepatitis.
  • Due to impaired processing of fatty acids in the placenta.
  • Most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency (MITOCHONDRIAL DISORDER AFFECTING FATTY ACID OXIDATION). Autosomal recessive condition. LCHAD enzyme is important in fatty acid oxidation. Fetus and placenta are unable to break down fatty acids, which then enter maternal circulation and accumulate in liver.

Making Diagnosis

Clinical Features

• Obstetric Cholestasis → typically presents in third trimester.
  • Itching (pruritus) of the palms of the hands and soles of the feet. NO RASH.
  • Other symptoms related to cholestasis and outflow obstruction in bile ducts → fatigue, dark urine, pale + greasy stools, jaundice.
• Acute Fatty Liver → malaise, fatigue, N&V, jaundice, RUQ abdominal pain, lack of appetite, ascites. Hypoglycaemia and coagulopathy. NO PRURITUS.

Investigations

• Women presenting with pruritus → LFTs and bile acids. (MEASURE WEEKLY IN SOMEONE WITH OC UNTIL DELIVERY).
• Acute Fatty Liver → raised ALT and AST. Prolonged PT and raised bilirubin.
  • Steatosis on imaging.

Management Plan

• Obstetric Cholestasis ⇒
  • Monitoring
    • Consultant led antenatal care, advise to give birth on labour ward.
    • Weekly LFTs (incl. bile acids) until delivery. Twice-Weekly Doppler and CTG.
    • Pay attention to foetal movements (SAFETY NET).
  • Symptoms Management
    • For Itching → wear cool/loose clothing, soak in a cool bath, appy ice packs to affected areas, topical emolients.
    • Ursodeoxycholic Acid → improves pruritus and LFTs, but no protection against stillbirth.
    • Sedating Antihistamines (Chlorphenamine) → improves sleep, but no impact on pruritus.
    • Vitamin K → give if clotting (PT) is deranged.
  • Delivery
    • Induction of labour at 37 → deliver on labour ward with continuous foetal (CTG) monitoring.
  • Follow-Up → measure LFTs 6 weeks postnatally to ensure resolution.
• Acute Fatty Liver → obstetric emergency. Requires prompt admission and expidite delivery of the baby.

Complications → OC: high recurrence rate (up to 90%).

Prognosis →