Obstetric Cholestasis: Guidelines and Management

Obstetric Cholestasis

(Intrahepatic Cholestasis of Pregnancy)

Dr Ramshar Rafiq

SHO Obstetrics and Gynaecology

George Eliot Hospital NHS Trust

Aims

To provide an overview of obstetric cholestasis in pregnancy.

To review diagnosis, maternal risks and fetal risks.

To discuss management according to current RCOG and international guidelines.

To highlight changes in practice based on recent evidence.

Why Obstetric Cholestasis Matters

One of the commonest pregnancy-related liver disorders

Associated with significant fetal risks — preterm birth, fetal distress and stillbirth

Early recognition and appropriate management improve pregnancy outcomes

Incidence

0.7%

of pregnancies in the UK are affected

Higher incidence in women of South Asian ethnicity

More common with a previous history of obstetric cholestasis

Definition

Obstetric cholestasis (Intrahepatic Cholestasis of Pregnancy) is a pregnancy-specific liver disorder. It is clinically defined by the presence of four key features:

Itching in pregnancy, particularly involving the palms and soles

Raised serum bile acids

No alternative explanation for liver dysfunction

Symptoms and abnormal blood tests usually resolve after delivery

Risk Factors

Previous obstetric cholestasis

Multiple pregnancy

Family history

Hepatitis C infection

Advanced maternal age

South Asian ethnicity

Pathophysiology

Hormonal, genetic and environmental factors

Pregnancy hormones impair bile transport

Accumulation of bile acids in maternal blood

May affect placental function and fetal wellbeing

Clinical Features

ITCHING

Often worse at night

Usually affects the palms and soles

Some women may also report:

Dark urine

Pale stools

Jaundice

Differential Diagnosis

Other conditions to exclude:

Viral hepatitis

Gallstones

Acute fatty liver of pregnancy

HELLP syndrome

Pregnancy dermatoses

Investigations

Serum bile acids

Liver function tests

Full blood count

Clotting profile

Classification According to Bile Acids

MILD

19 – 39 µmol/L

MODERATE

40 – 99 µmol/L

SEVERE

≥ 100 µmol/L

Fetal Risks

Preterm birth

Meconium-stained liquor

Fetal distress

Stillbirth

The risk increases with rising bile acid levels

Stillbirth Risk

Bile acids < 100 µmol/L

Low

risk of stillbirth

Bile acids ≥ 100 µmol/L

Significantly Increased

risk of stillbirth

This threshold is central to planning timing of delivery

Medical Management

Ursodeoxycholic Acid (UDCA)

May be offered to improve maternal symptoms, particularly itching

May improve liver function tests and reduce bile acid levels

Current evidence does NOT show clear proof that UDCA reduces the risk of stillbirth

Treatment decisions should be individualised — do not rely on medication alone

PITCHES Trial

(Pregnancy Intervention Trial of Ursodeoxycholic Acid in Cholestasis)

Large multicentre RCT — The Lancet, 2019

Compared UDCA vs placebo in ICP

Modest improvement in maternal itching

No clear reduction in adverse fetal outcomes

No proven reduction in stillbirth

This trial significantly changed modern management

Fetal Surveillance

Repeated bile acid measurements

Repeat liver function tests

Growth scans where indicated

Cardiotocography (CTG) if clinically required

⚠️

Surveillance has NOT been proven to reliably prevent sudden stillbirth

Timing of Delivery

One of the most important aspects of management — guided by bile acid levels (RCOG)

MILD DISEASE

Bile acids 19–39 µmol/L

Delivery at term

MODERATE DISEASE

Bile acids 40–99 µmol/L

Planned birth at 38–39 weeks

SEVERE DISEASE

Bile acids ≥ 100 µmol/L

Consider delivery at 35–36 weeks

Comparison of Guidelines

Management guided by bile acid levels

Recognises severe disease carries higher fetal risk

Recommends earlier delivery in severe OC

Management guided by bile acid levels

Recognises severe disease carries higher fetal risk

Recommends earlier delivery in severe OC

Both guidelines align on risk stratification and delivery planning

Mode of Delivery

Obstetric cholestasis alone is <span style="font-weight: 700; color: #ff6b6b; font-size: 1.05em; padding: 0 8px;">NOT</span> an indication for caesarean section

Mode of delivery should be based on obstetric indications

Management should be individualised

Case 1

34-week patient presents with itching

Bile acids: 32 µmol/L → MILD disease

Mild OC — Low risk

Management Options

Monitoring

Repeat bile acid testing

Plan delivery at term

Case 2

Case Presentation

35-week patient presents

Bile acids: 112 µmol/L →

SEVERE disease

⚠️ SEVERE Obstetric Cholestasis — Bile acids ≥ 100 µmol/L

Management

Early delivery should be considered

Consider delivery at 35–36 weeks per RCOG guidance

Postnatal Management

Symptoms usually resolve after delivery

Repeat LFTs and bile acids postnatally

Persistent abnormalities require further investigation

Counselling regarding recurrence in future pregnancies

Recurrence

45 – 90%

In Future Pregnancies

Women should be counselled about the significant risk of recurrence

Studies suggest recurrence rates between 45 and 90 percent

Important for future pregnancy counselling and planning

Potential Audit Opportunity

Are women diagnosed with OC managed according to RCOG Green-top Guideline 43?

Timing of delivery

Frequency of bile acid monitoring

Use of Ursodeoxycholic acid

Compliance with guideline recommendations

Summary

Obstetric cholestasis is diagnosed by symptoms and bile acids

Bile acid level determines fetal risk

Timing of delivery is central to management

Care should be individualised according to current guidelines

Thank You

Questions?

Dr Ramshar Rafiq

SHO Obstetrics and Gynaecology

George Eliot Hospital NHS Trust

References

Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 43. Obstetric Cholestasis.

Society for Maternal-Fetal Medicine. Consult Series No. 53. Intrahepatic Cholestasis of Pregnancy.

Chappell LC et al. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. The Lancet. 2019.

BJOG: An International Journal of Obstetrics and Gynaecology. Guidelines on Obstetric Cholestasis.