[CG] Obstetric Cholestasis : revised guideline during the COVID 19 Pandemic

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If a pregnant woman presents with itching, and no other red flag symptoms or signs, offer a non-fasting blood sample for liver transaminases and bile acids, which could be done in the community.

Assess fetal wellbeing by asking the woman about fetal movements.

Additional fetal scans or cardiotocographs (CTGs) are not indicated by OC alone.

  1. If serum bile acids are in the normal range, reassure the woman that itch is not caused by OC at the next antenatal appointment (which may be by telephone/videoconference). Offer repeat LFTs/ bile acids at any subsequent face to face appointments if symptoms of itch continue.

  2. If serum bile acids are above the normal range, explain the diagnosis of OC (this can be done by telephone/videoconference):
  • Advise that no treatments are currently proven to reduce adverse perinatal outcomes, but that aqueous cream (with or without menthol) and chlorphenamine (both available over the counter) may provide some symptomatic relief.
  • Offer review in 1-2 weeks by telephone/videoconference, with safety netting that if symptoms worsen, the woman should contact the maternity unit sooner for telephone advice.
  • Women should be advised to report dark urine, pale stools, yellow conjunctivae, reduced fetal movements, or any other causes for concern.

If bile acids are <60 μmol/litre, offer repeat bile acid testing at any face-to-face appointments held in person from 34 weeks, or at 37 weeks as a minimum, in order to guide delivery timing. If bile acids remain <60 μmol/litre, consider planned birth at 39 weeks.

If bile acids are >60 μmol/litre, offer a repeat blood test for ALT and serum bile acids at 34 weeks’ gestation. If they remain raised, discuss the benefits and risks of planned birth at 35-36 weeks’ gestation.

If bile acid concentrations rise and then fall (without treatment), explain that it is uncertain whether any further intervention is needed.

Bile Acid Levels

10-60 - mild/mod cholestasis  - Deliver 39-40 

>+60 severe cholestasis – deliver 35-36 weeks

 

Note:  with current GG&C Abbott Bile Acid assay (introduced 2018), 60micromol/l is equivalent to 100micromol/l quoted in RCOG guidance.

  • A recent (2019) Systematic review and Meta-analysis found that stillbirth rates in women with OC were not significantly different when compared to women without OC.
  • OC is associated with an increase in preterm birth, passage of meconium in labour and need for admission to the Neonatal Unit.
  • OC is not associated with an increase in rates of postpartum haemorrhage
  • Delivery after 37 weeks and before 39 weeks does not appear to increase stillbirth risk in women with Bile Acids <60mmol/l or a normal ALT*
  • Delivery before 37 weeks is associated with increased problems for the baby
  • Mutually agreed individualized management plans are required for women:
    • With persistently raised Bile Acids >60 µmol/litre and/or transaminitis (offer IOL 35-36 weeks)
    • Those seeking to prolong their pregnancy further require documentation that SB can occur but there is uncertainty as to whether OC is a cause

Last reviewed: 18 May 2020

Next review: 18 May 2021

Author(s): J Murphy & F Mackenzie

Version: Updated 18/5/20