Document Detail


Obstetric cholestasis: outcome with active management.
MedLine Citation:
PMID:  11750958     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: Conservative management of intrahepatic obstetric cholestasis is associated with a high stillbirth rate despite monitoring of fetal well-being with non-stress test and amniotic fluid volume assessment. Most cases of stillbirth are associated with meconium passage. We prospectively evaluated the effect of a management protocol inclusive of surveillance for presence of meconium and induction of labor at 37 weeks. STUDY DESIGN: Between January 1989 and December 1997, all women with obstetric cholestasis underwent transcervical amnioscopy after 36 weeks for assessment of amniotic fluid color, in addition to standard monitoring of fetal well-being (semi-weekly non-stress test and amniotic fluid volume determinations). Amniocentesis for fetal lung maturity and amniotic fluid color assessment was performed before 36 weeks in severe cases. Labor was induced at 37 weeks or earlier in the presence of non-reassuring fetal testing, meconium, or severe maternal symptoms unresponsive to therapy with mature fetal lungs. The obstetric outcome of the group with cholestasis was compared with that of the general obstetric population at our Institution during the study period. The rate of fetal death in the study group was compared with that of series published within the last 20 years, which used expectancy and conventional monitoring of fetal well-being. Statistical analysis utilized Fisher's exact test, Chi-square, and Student's t-test with P value <0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. RESULTS: Obstetric cholestasis was diagnosed in 206/20,815 pregnant women (1%) at a median gestational age of 34 weeks (range 20-40). Delivery was prompted by non-reassuring fetal testing in four cases (2%). Meconium passage was documented in 33 cases (16%), in 11 of which before onset of labor and in 10 before 37 weeks. The rate of meconium passage before 37 weeks (17.9 versus 2.9%, OR=7.3; 95% CI 3.3, 16.0) was significantly higher in obstetric cholestasis than in the general obstetric population, whereas the cesarean section rate was similar in the two groups (15.1 versus 16.0%, OR=0.9; 95% CI 0.6, 1.4). The fetal death rate was significantly lower in the group managed with the current strategy than in the published series of obstetric cholestasis (0/218 versus 14/888, P=0.045). CONCLUSION: In pregnancies complicated by obstetric cholestasis, a protocol inclusive of search for meconium and elective delivery at 37 weeks, in addition to standard monitoring of fetal well-being, can significantly reduce the stillbirth rate without increasing the cesarean delivery rate.
Authors:
Nadia Roncaglia; Alessandra Arreghini; Anna Locatelli; Primula Bellini; Camilla Andreotti; Alessandro Ghidini
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  European journal of obstetrics, gynecology, and reproductive biology     Volume:  100     ISSN:  0301-2115     ISO Abbreviation:  Eur. J. Obstet. Gynecol. Reprod. Biol.     Publication Date:  2002 Jan 
Date Detail:
Created Date:  2001-12-25     Completed Date:  2002-03-26     Revised Date:  2009-11-19    
Medline Journal Info:
Nlm Unique ID:  0375672     Medline TA:  Eur J Obstet Gynecol Reprod Biol     Country:  Ireland    
Other Details:
Languages:  eng     Pagination:  167-70     Citation Subset:  IM    
Affiliation:
Department of Obstetrics and Gynecology, Divisione di Ostetricia e Ginecologia, Ospedale San Gerardo, I.S.B.M. San Gerado, University of Milano-Bicocca, Via Solferino 16, 20052, Monza, Italy. pvergan@tin.it
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MeSH Terms
Descriptor/Qualifier:
Adult
Alanine Transaminase / blood
Amniotic Fluid
Aspartate Aminotransferases / blood
Bile Acids and Salts / blood
Bilirubin / blood
Cholagogues and Choleretics / therapeutic use
Cholestasis, Intrahepatic / complications,  diagnosis,  drug therapy*
Cholestyramine Resin / therapeutic use
Female
Fetal Death / etiology
Fetal Monitoring
Fetoscopy
Gestational Age
Humans
Labor, Induced
Meconium
Middle Aged
Odds Ratio
Pregnancy
Pregnancy Complications / drug therapy*
S-Adenosylmethionine / therapeutic use
Ursodeoxycholic Acid / therapeutic use
Chemical
Reg. No./Substance:
0/Bile Acids and Salts; 0/Cholagogues and Choleretics; 11041-12-6/Cholestyramine Resin; 128-13-2/Ursodeoxycholic Acid; 29908-03-0/S-Adenosylmethionine; 635-65-4/Bilirubin; EC 2.6.1.1/Aspartate Aminotransferases; EC 2.6.1.2/Alanine Transaminase

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