Ellen Knox, West Midlands Perinatal Insitute, October
2001
Why is it important?
The fetus of the mother with cholestasis is at risk
of premature delivery, meconium in the liquor, antepartum
stillbirth, intrapartum fetal distress ( 1,2)
and intracranial haemorrhage (2).
Presentation
Obstetric cholestasis presents with maternal itching,
without rash, predominantly on the palms and soles
of the feet. However the itching may become generalised
and excoriations may be present. It typically occurs
in the third trimester but has been recorded as early
as the first trimester (3).
In a few cases jaundice, pale stools dark urine, steatorrhoea
and anorexia may occur but ITCHING IS USUALLY THE
ONLY SYMPTOM.
Any woman presenting with itching in pregnancy
should have her bile acids and liver function checked.
Raised bile acids with or without abnormal liver
function (see diagnosis) suggest a diagnosis of cholestasis.
If these bloods are normal but the itching persists
they should be repeated at regular intervals until
they either become abnormal or she delivers.
Our October Perinatal Forum on obstetric cholestasis
focused on incidence, pathophysiology, diagnosis and
management.
Incidence
There is worldwide variation. The highest reported
rates are in Chile (12-22%) (4),
with Scandinavia reporting rates of 2% (5).
European rates are 0.2% (6).
A retrospective analysis in the South Birmingham area
found a prevalence of 0.7% overall (7).
There is some evidence that the incidence is increasing
but this is likely to represent increased awareness.
References
1.Reid R, Ivey KJ, Rencoret RH, Storey B. Fetal complications
of obstetric cholestasis. Br Med Journal 1976;1:870-2, Abstract
2. Fisk NM, Storey GNB. Fetal outcome in obstetric
cholestasis. Br J Obstet Gynaecol 1988; 95:1137-43, Abstract
3. Midgley DY, Khalaf Y, Braude PR, Nelson-Piercy
C. Recurrent cholestasis following ovarian hyperstimulation
syndrome. Human Reproduction. 1999; 14(9): 2249-2251, Abstract
4. Reyes H, Gonzales MC, Ribalta J. Prevalence of
intrahepatic cholestasis of pregnancy in Chile. Ann
Intern Med 1978; 88: 487-93, Abstract
5. Berg B, Helm G, Petersohn I et al. Cholestasis
of pregnancy. Clinical and laboratory studies. Acta
Obstet Gynecol Scand 1986; 65:107-13, Abstract
6. Waine C. Beware of itching during late pregnancy.
Practitioner 1995;239:97-100, Abstract
7. Abedin P, Weaver J, Egginton E. Intrahepatic cholestasis
of pregnancy: Prevalence and ethnic distribution. Ethnicity
and Health. 1999; 4(1-2): 35-37, Abstract
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