 Otherwise unexplained pruritus

 and abnormal liver function tests (LFTs)

 and/or raised bile acids occur in the
pregnant woman
 and both resolve after delivery.
 Pruritus that involves the palms and soles
of the feet is particularly suggestive.
 0.7% in multi ethnic
 1.2-1.5% Indian–Asian or Pakistani–Asian
 Prevalence influenced by genetic and
environmental factors
 Varies between populations worldwide.
 In Chile,2.4% , a 5% prevalence in women
of Araucanian–Indian origin
The aim of this
Obstetric
audit was to
Cholestasis
look at the
before and
diagnosis,
after the
management
update of
and outcomes
guideline
of patients with
 • To assess if
the diagnosis of • Tofind the
OC was
gestational
identified and
other diagnoses age at time of
excluded by diagnosis
arranging all
the appropriate
investigations. • To ascertain
the gestation at
delivery of
•Has new those
guideline
impacted on the
diagnosed with
gestational age at OC and
delivery adherence with
depending on the new
bile acid level? guideline
proposed time
of delivery
“however, in light of recent evidence elective
early delivery is recommended as follows:
• lf bile acids are ≥40µmol/l delivery should be
between 37-38 weeks
• If bile acids are <40µmol/l delivery may be
postponed but not beyond 40 weeks
• If bile acids return to &lt;40µmol/l after
treatment then delivery should be by 40
weeks”
 Data collected:
Electronic notes

Before
guideline
Retrospective
update:
audit
March 2018-
March2019
No. of Pt. 48

After guideline
update:
April 2019-
March2020
No. of Pt. 44
 0%

16, 36% 16, 33%

28, 64%
32, 67%

Primi
Multip Primi
Multip
 2, 5%
8, 21% 3, 6%
8, 20% 24-28 24-28
15, 33% 10, 22%
29-33 29-33
34-36 34-36
>37 >37

21, 54% 18, 39%

2019-2020 2018-2019
 BA Levels

2019-2020 2018-2019
7
15%
17, 39% BA<40 No
BA>40 Yes
27, 61%
41
85%
 Deranged LFTs

12, 27% 18, 37%

Yes No
30, 63% Yes
No
32, 73%

2019-2020 2018-2019
 Growth Scan

25%
11, 25%
Yes No
No 75% Yes

33, 75%

2019-2020 2018-2019
 Liver USS

20%

20, 42%
Yes 28, 58% No
No Yes
35, 80%

2018-2019
2019-2020
 Autoimmune Screen

2019-2020 2018-2019

12, 27%
11, 23%

Yes No
No Yes

37, 77%
32, 73%
 Viral Screen

12, 27%
10, 21%
Yes No
No Yes

32, 73%
38, 79%

2019-2020
2018-2019
 Multiple levels/Tests

2019-2020

8, 18% 9, 19%

Yes No
No Yes

36, 82% 39 81%

 Weekly DAU

18%
13, 28%

Yes No
No Yes

33, 72%
2019-2020 36, 82%
 Medical Treatment

10, 21%
11, 25%
URSO + Vit K UCDA + Vit K
No treatment No treatment

33, 75% 38, 79%

LFTs/BA improved after treatment

29%

Yes
No

71%
 2, 4%
3, 7%
6, 14% <37 5, 10%
wks <37
11, 25% 37 wks 7, 15% 13, 27% 37

38 wks 38
15, 34% 39
39 wks
9, 20% >40
40 wks 21, 44%

2019-2020 2018-2019
 Onset of Labour

2019-2020 2018-2019

7
7, 16%
1 15%
Induced 2% Induced
Spontaneous Spontaneous
11, 25% 26, 59% No Labour No labour
40
83%
 IOL in pts. With BA<40

<39

Induced

0 2 4 6 8 10 12 14 16 18
 Mode of Delivery

1, 2% 4 5
ELLSCS
10, 23% 8% 11% ELLSCS
EMCS 7 EMCS
15%
Forceps Forceps
3, 7% 3
24, 54% SVD SVD
6%
6, 14% 29 Ventouse
Ventouse
60%

2019-2020 2018-2019
 GA @ Diagnosis

25

20

15

10

5
2019-2020

0
24-28 29-33 34-36 >37 2018-2019
GA @onset of labour or delivery

25
21
20

15
15 13
11
10 9
7
6
5
5 3
2

0
GA 37 wks 38 wks 39 wks 40 wks
<37 wks

2019-2020 20182019
 Mode of Delivery

2019-2020 2019-2020
35

30

25

20

15

10

0
EMCS ELCS Forceps Ventouse SVD
 Onset of Labour

40

35

30

25
2019-2020
20
2018-2019
15

10

0
Induced Spontaneous No Labour
Antenatal Complications

45

40

35

30

25

20

15

10

5 2019-2020
0
PTD I PTD S NONE RFM 2018-2019
Documented evidence of risks
and benefits of URSO
Zero

Trust Guideline
Women should be informed of
the lack of robust data
concerning protection against
stillbirth and safety to the fetus
or neonate
 Conclusion

There was a
significant
reduction in Spontaneous No clear
IOL rate • All patients
had bile
• Over 90% • There was preterm differenc
between two patients no delivery rate
acids/LFTs e noted
were intrauterine was 2%, not
years. 25% tests to help
confirm delivered death in the greater than on the
less induced ≥37 weeks. 92 cases the general mode of
diagnosis
population. delivery
labours in
2019-2020.
 Recommendation

•Counsel patients • Continue to

postnatally about Fully investigate
check LFT’s in the patients for other
the need of repeat
presence of itch, causes of
LFTs and symptoms
to look for. even if initial results deranged LFT’s.
are normal.

• Treatment with
• Considerdelivery UDCA should be
around 40 weeks if BA < considered to
40mmol/L Counsel patients
improve itch and
about the risks and
benefits of URSO LFT’s.
and document
accordingly. (This is
one of RCOG
auditable standard)
Interpretation The risk of stillbirth is increased
in women with intrahepatic cholestasis of
pregnancy and singleton pregnancies when
serum bile acids concentrations are of 100
µmol/L or more. Because most women with
intrahepatic cholestasis of pregnancy have
bile acids below this concentration, they
can probably be reassured that the risk of
stillbirth is similar to that of pregnant women
in the general population, provided repeat
bile acid testing is done until delivery