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13.10.16 GP notes

Obstetric cholestasis 
  • AKA intrahepatic cholestasis of pregnancy (ICP)
  • Most common in third trimester
  • Don't confuse with "normal" pregnancy itching
    • Affects palms and soles too
    • May be worse in evening
    • Does not respond to antihistamines
  • Mechanism pretty much unknown:
    • Oestrogens reduce hepatocyte bile acid uptake
  • Recurs in between 45% and 70% of subsequent pregnancies
  • Management
    • Ursodeoxycholic acid (secondary bile acid) to reduce bile acid reabsorption
    • Cholestyramine
    • Early delivery (by 37 weeks)
    • Correct clotting
Vitamin K deficiency bleeding (VKDB) 
  • AKA haemorrhagic disease of the newborn (HDN)
    • Due to deficiency of clotting factors as a result of vitamin K deficiency
  • Onset
    • Early VKDB occurs within 24 hours of birth (rare)
      • Mostly due to drugs during pregnancy
    • Classic VKDB happens between day 1 and day 7 of life (44%)
    • Late VKDB occurs between week 2 and week 12 of life (56%)
      • Can result in significant morbidity and mortality due to intracranial haemorrhage
  • Risk factors
    • Children who are entirely breast-fed have a 20 times greater risk of developing VKDB 
      • Low levels of vitamin K in breast milk
      • Low levels of bacteria which help to synthesize vitamin K in the guts of breast-fed babies
    • Medications: Isoniazid, rifampicin, anticoagulants, anticonvulsant agents
    • Warm environmental temperatures 
    • Unsuspected liver disease, especially alpha-one-antitrypsin deficiency
    • Malabsorption of fat-soluble vitamins due to diarrhoea, coeliac disease or cystic fibrosis
  • Management
    • Vitamin K (1 mg IM normally given to everyone at birth)
      • Or 1 mg PO weekly
    • FFP if already bleeding

Anti-D (Rho) immunoglobulin
  • Indications (for non-sensitised RhD-negative women )
    • Miscarriage 
      • Threatened, spontaneous complete or incomplete miscarriage at or after 12+0 weeks of gestation
        • Not required for spontaneous miscarriage before 12+0 weeks of gestation, unless there is instrumentation or medical evacuation of the uterus
      • If the woman continues to bleed intermittently after 12+0 weeks of gestation, anti-D Ig should be given at 6-weekly intervals
    • Ectopic pregnancy / TOP
      • All women who have an ectopic pregnancy or termination of pregnancy, regardless of method of management
    • Sensitising events
      • Prenatal diagnosis, other intrauterine procedures, antepartum haemorrhage, ECV, any abdominal trauma, fetal death
    • Recurrent vaginal bleeding after 20+0 weeks of gestation
      • Anti-D Ig should be given at a minimum of 6-weekly intervals
    • Routine antenatal anti-D prophylaxis (RAADP) programme
      • Not uniformly offered
      • Protects against "silent" sensitisation (? common in third trimester)
    • Postnatal prophylaxis
      • Give within 72 hours of delivering a rhesus positive infant
      • No universally accepted postnatal dose
  • Dose
    • Take an anticoagulated blood sample is taken from the susceptible mother as soon as possible (within two hours)
    • Kleihauer screening quantifies extent of fetal-maternal haemorrhage
      • 500 IU anti-D immunoglobulin (anti-D Ig) intramuscularly will neutralise an FMH of up to 4 ml (99% of women).
      • For each millilitre above 4 ml, 125 micrograms of extra anti-D Ig are required.
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