European Journal of Obstetrics & Gynecology and Reproductive Biology
Obstetric cholestasis: outcome with active management
Introduction
Obstetric cholestasis is the most common liver disease of pregnancy, and is characterized by intrahepatic cholestasis triggered by environmental, infectious and hormonal factors in genetically predisposed women. This disorder is associated with increased risk of stillbirth and perinatal death [1]. The mechanism underlying cholestasis-associated stillbirths is unknown and conventional monitoring of fetal well-being does not predict most cases of fetal death, which may occur within 24 h of a reactive non-stress test [2], [3], [4], [5]. Indeed, most stillbirths are not preceded by signs of chronic hypoxia, such as oligohydramnios or fetal growth restriction, or by acute fetal hypoxemia, as manifested by fetal heart rate changes. Interestingly, meconium passage has been reported in 86% of cholestasis-associated fetal deaths [3], [6], [7], [8], [9]. The mechanism underlying such association has not been elucidated. Most fetal deaths occur towards the end of pregnancy, and some series suggest an association between severity of maternal symptoms and poor fetal outcome [2].
The aim of this study was to evaluate whether a management strategy inclusive of search for presence of meconium and elective delivery at 37 weeks, in addition to standard monitoring of fetal well-being, could decrease the stillbirth rate in obstetric cholestasis compared with that of series published in the last 20 years.
Section snippets
Materials and methods
During the period January 1989 to December 1997 all pregnant women with a diagnosis of obstetric cholestasis at our Department of Obstetrics and Gynecology were prospectively followed with a consistent protocol. The diagnosis of obstetric cholestasis was made in the presence of severe generalized pruritus with onset during the second or third trimester of pregnancy, persisting up to the time of delivery and disappearing after delivery, without skin or medical conditions known to be associated
Results
During the study period, obstetric cholestasis was diagnosed in 206/20,815 pregnant women (1%), including 194 singleton and 12 twin pregnancies. Table 1 displays the demographic and obstetric characteristics of the study population. The median (range) highest serum aspartate aminotransferase after diagnosis was 87 mg/dl (11–1127, n.v. 8–41 mg/dl), serum alanine aminotransferase was 159 mg/dl (8–1734, n.v. 8–41 mg/dl), and bile acids level 16.5 μmol/l (0.6–200, n.v. <6 μmol/l). In 26 cases the serum
Comment
The risk of fetal mortality associated with gestational cholestasis is considerable [1] and traditional monitoring of fetal well-being has not been shown to prevent cholestasis-associated stillbirths. Even series in which patients with gestational cholestasis were hospitalized and underwent daily fetal monitoring reported cases of stillbirth with reassuring fetal testing as recently as 7 h before fetal death [4], [9]. Our experience represents one of the largest series ever published, and it
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