Objective: To determine the effects of obstetric cholestasis on the mother and fetus.
Study Design: A descriptive Cross-sectional survey based on sample of convenience.
Place & Duration: The study was conducted at Mother & Child Health Center (MCH) Pakistan Institute of Medical Sciences (PIMS), Islamabad from 1st January 2007 to 30th June 2008.
Materials & Methods: 30 pregnant women presenting with pruritus and having deranged liver functions tests were interviewed.
Result: The total number of patients, who delivered at MCH Center, Unit-II, PIMS, during the study duration were 6964. Among them, 30 women all with singleton pregnancies were diagnosed as having obstetric Cholestasis. Therefore, the incidence of the disease was 0.4%. The mean gestational age of clinical presentation of symptoms was 32 weeks + 2.02. Pruritus was the only symptom in 16 (53.3%) patients, whereas 14 (46.7%) patients presented with both pruritus and jaundice. The liver function tests were deranged in 22 (73.3%) patients, while 8 (26.7%) had normal laboratory findings. Medical treatment was given to 24 (80%) patients, whereas 6 (20%) of them received no treatment. Onset of labor was spontaneous in 22 (73%) patients, whereas labor was induced in 7 (23.3%) women at term. Intrapartum complications of obstetric Cholestasis were seen in 26 (86.7%) patients. Regarding mode of delivery, 24 (80%) women had a spontaneous vaginal delivery, whereas 5 (16.7%) underwent emergency cesarean section due to fetal distress and 1 (3.3%) had an elective cesarean section. There were 18 (60%) neonates who required admission to neonatal unit. Among these admissions, 17 (56.7%) had meconium aspiration syndrome. No perinatal mortality occurred. Postnatal resolution of pruritus and liver function tests occurred within 5-14 days with a mean of 8 days + 2.52.
Conclusion: Obstetric Cholestasis is stressful, primarily affecting the mother with discomfort from pruritus and jaundice. Intrahepatic Cholestasis of pregnancy increased the need for special neonatal care.
Key Words: Pruritus, Jaundice, Obstetric Cholestasis.

Introduction

Intrahepatic Cholestasis of pregnancy (ICP) predominately occurs during the third trimester of pregnancy1 which seldom exhibits before 25 weeks gestation. Obstetric Cholestasis is a rare disease and rates vary dramatically, with overall prevalence estimated as 1 in 1000 to 1 in 10,000 pregnancies in North America, Asia and Australia.¹ The incidence of obstetric Cholestasis varies from 0.1% to 1.5% of pregnancies in Europe.² The highest prevalence is in Chile (14%) and Scandinavian countries (2%).¹ The etiology of obstetric Cholestasis is multifactorial, and genetic, environmental and hormonal factors have important roles.2 The condition worsens as pregnancy proceeds and resolves completely after delivery.3 The main cause of fetal death is acute anoxia.¹
Intrahepatic Cholestasis of pregnancy can have devastating consequences for the fetus with perinatal mortality reaching upto 11% to 20% in untreated cases1. Obstetric cholestasis clusters within some families and is under strong genetic influence, although the precise genetic pattern remains obscure.⁴At least 16% of ICP cases are familial1 and therefore likely to be caused by an inherited predisposition.
Obstetric cholestasis classically manifests itself in the second or third trimester of pregnancy, with generalized pruritus but without any skin rash⁵, being the main complaint2. It begins in the palms and soles with progression to the arms and legs, eventually reaching the trunk and face. Jaundice is relatively uncommon, complicating only the most severe and prolonged cases2. The biochemical hallmark of cholestasis from any cause is an elevation in the SBAs, predominately the conjugated fraction.¹
The objective of pharmacologic treatment in ICP is to decrease maternal symptomatology and enhance fetal outcome. Ursodeoxycholic acid (UDCA) is considered to be a safe treatment option in the third trimester.6 No matter what medication course is chosen for ICP, vitamin K therapy is suggested as a supplemental treatment.1 Control of symptoms may be achieved with combination of antihistamines and topical emollients, or if these are insufficient, then UDCA and dexamethasone.⁷The major therapeutic objectives in the care of ICP patients are relief of pruritus and prevention of fetal death.
Conservative management of intrahepatic obstetric cholestasis is associated with a high stillbirth rate despite monitoring of fetal well-being with non-stress test and amniotic fluid volume assessment. Evidence supports delivery at approximately 38 weeks, after the evaluation of both sequential estimations of fetal lung maturity and maternal serum concentrations of total bile acids have shown indication for delivery.¹ Postpartum SBA and liver function testing are suggested for ICP patients to assure that no other underlying disease exists, such as hepatitis, AIDS, benign recurrent intrahepatic cholestasis, or bile duct obstruction. Intrahepatic Cholestasis of pregnancy can also reoccur in 80% to 90% of subsequent pregnancies with variances in severity.⁸ Symptoms and abnormal liver functions may resolve within 2 weeks of delivery.⁹

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