obstetric cholestasis, obesity, GDM

What is obstetric cholestasis?

reduced outflow of bile acids from the liver

this condition resolves after delivery of the baby

What is the epidemiology of obstetric cholestasis?

common complication occurring in 1% of pregnant women

Why does obstetric cholestasis cause pruritis?

bile acids are produced in the liver from breakdown of cholesterol, bile acids flow from the liver through hepatic duct into the intestines

when outflow is reduced, bile acids build up in the blood causing pruritis

What are risk factors for obstetric cholestasis?

personal or family history

South Asian ethnicity

multiple pregnancies

hepatitis C

gallstones

How does obstetric cholestasis present?

• usually occurs in third trimester/after 28 weeks

• no rash

• pruritis, especially on palms and soles of feet

• fatigue

• dark urine

• pale, greasy stool

• jaundice

• excoriation- skin picking

What investigations are done for obstetric cholestasis?

LFTs:

• increased ALT

• increased ALP

• increased bile acids

ALP increases during pregnancy anyway, as it is released via the placenta, so a rise in ALP with no other abnormal results can be due to pregnancy rather than pathology

Clotting factors

If a rash is present what are alternative diagnosis?

polymorphic eruption of pregnancy

pemphigoid gestationis

What are differentials of obstetric cholestasis?

hepatitis

HELLP syndrome

cholecystitis

acute fatty liver

How is obstetric cholestasis managed?

1. emolliants can be used to help itching (calamine lotion)

2. antihistamines can be used to help sleep

3. monitor LFTs and bile acids weekly

4. water soluble vitamin K if clotting times are deranged

5. ursodeoxycholic acid

may require planned/early delivery

What is Ursodeoxycholic acid?

a secondary bile acid used to treat bile/liver duct pathologies

Why may water-soluble vitamin K be needed?

vitamin K is a fat soluble vitamin, which means that bile acids are important for the absorption of vitamin K in the intestines

lack of bile acids can lead to vitamin K deficiency which can lead to impaired clotting

What complications can obesity increase prevalence of?

• miscarriage

• pre-eclampsia

• gestational diabetes

• thromboembolism

• cardiac disease

• induced labour

• C-section

• infection

• maternal mortality

• feeding by bottle

• post-partum haemorrhage

How can maternal obesity impact foetus?

increases adult risk of: heart disease, diabetes, metabolic syndrome, and due to epigenetics, can influence future generations

risk of macrosomia and meconium aspiration

What is recommended pre-pregnancy for obese women?

weight loss before pregnancy has been shown to improve pregnancy outcomes, and reduce medical co-morbidities (diabetes, HTN)

as weight loss during pregnancy correlates with lighter babies prone to post-natal problems

What can be given to improve pregnancy outcomes in obese women?

higher risk of neural tube defects so give 5mg folic acid 1 month before conception

10mcg of vitamin D supplements as more prone to vit D deficiency

>30 BMI screen for gestational diabetes at 24-28 weeks

consider 7 day VTE prophylaxis with heparin if one other risk factor postnatally, all women BMI >40 have 7 day prophylaxis

What is gestational diabetes?

glucose intolerance triggered by pregnancy, caused by reduced insulin sensitivity during pregnancy, that resolves after birth

What are risk factors for gestational diabetes?

previous pregnancy with GDM

previous macrosomia (>4,5kg)

BMI >30

1st degree relative with DM

minority ethnic origin (black Caribbean, middle eastern, south Asian)

• these warrant testing for GDM

What are the main complications from gestational diabetes?

large foetus and macrosomia - this has implication for birth posing risk for shoulder dystocia

in the long term women are at higher risk of developing T2DM

How does gestational DM present?

asymptomatic

polyuria

polydipsia

large for gestational age foetus

When is an oral glucose tolerance test carried out?

24-28 weeks for high risk women

may be soon after booking clinic in women with history of previous gestational diabetes

What is an oral glucose tolerance test?

• fast from midnight

• take fasting capillary blood glucose

• give 75g fast release glucose

• repeat capillary glucose after 2 hours

What are normal results of an oral glucose tolerance test?

<5.6mmol/L if fasting

<7.8mmol/L after 2 hours

(5678 rule)

results higher than this diagnose gestational DM

When is oral glucose tolerance testing carried out?

when high risk features or features suggestive of GDM:

• large for gestational age foetus

• polyhydramnios (increased amniotic fluid)

• glucose on urine dipstick

How are patients monitored for gestational DM?

USS every 4 weeks from 28-36 to monitor growth and guide delivery planning

How is gestational diabetes managed?

1. lifestyle advice including trial of diet and exercise if fasting glucose <7mmol/L

2. If target’s not met after 1-2 weeks add metformin

3. if have fasting glucose >7mmol offer metformin and insulin immediately

4. if above 6mmol/L with other complications (macrosomia) start insulin and metformin

5. induce labour 37-39 weeks

offer glibenclamide (sulfonylurea) is metformin not tolerate or insulin/metformin declines

What are target blood sugar levels in gestational DM?

• fasting 5.3mmol/L

• 1 hour post meal 7.8mmol/L

• 2 hours post meal 6.4mmol/L

• avoid going below 4mmol/L

How are diabetic women prepared pre-conception?

aim for good glucose control and take 5mg folic acid from preconception until 12 weeks gestation

How is pre-existing diabetes managed in pregnancy?

T1/2DM should aim for same levels as women with GDM.

T2DM managed using metformin and insulin other medications should be stopped

When should retinopathy screening be carried out in women with pre-existing diabetes?

shortly after booking and at 28 weeks gestation as diabetes carries a risk of rapid progression of retinopathy

How is gestational diabetes managed after birth?

medication can be stopped immediately after birth but need follow up test to their fasting glycose after at least 6 weeks

How are women with pre-existing diabetes managed after birth?

lower their insulin and be wary of hypoglycaemia in the postnatal period as insulin sensitivity increases after birth and with breastfeeding

What are babies of mothers with diabetes at risk of?

• neonatal hypoglycaemia (need close monitoring with regular blood glucose checks to maintain blood sugar >2mmol?L)

• polycythaemia (raised Hb)

• jaundice

• congenital heart disease

• cardiomyopathy

Why do babies get neonatal hypoglycaemia?

Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

they may need IV dextrose if drops below 2mmol/L

What are complications of gestational diabetes?

macrosomia and neonatal hypoglycaemia