Cholestasis of pregnancy

Cholestasis is a condition in which the flow of bile from the liver is slowed, causing a build-up of bile acids in the bloodstream. It may occur in the later parts of pregnancy and tends to be characterised by intense itching.

While it can be very unpleasant, cholestasis of pregnancy does not generally pose a significant health risk for expectant mothers. However, it is a serious condition that requires monitoring, because it can slightly increase the risk of a number of complications for the baby.

Cholestasis is known by a number of other names, including:

• Intrahepatic cholestasis of pregnancy (ICP);
• Obstetric cholestasis, and;
• Pruritus gravidarum.

Causes

The liver produces bile, a yellow-green fluid that passes through bile ducts in the liver to be stored in the gall bladder. During digestion, bile passes into the upper intestine where it helps to break down fats from food.

Bile contains chemicals called bile acids. If the flow of bile in the bile ducts is slowed or impeded, these bile acids can pass into the blood vessels of the liver and begin to circulate around the body via the bloodstream, and so cause the symptoms of cholestasis.

Exactly why cholestasis occurs in pregnancy is not known. It is thought that genetics may play a role. Hormones produced in pregnancy, such as oestrogen and progesterone, may also play a role by affecting the flow of bile in the liver.

It is possible that environmental factors also contribute to the condition. Cholestasis of pregnancy may be more common during the colder winter months.

 

Signs and symptoms

The most common symptom of cholestasis of pregnancy is a persistent, intense itch that:

• Is not associated with a rash;
• Most often affects the palms of the hands and soles of the feet;
• Can affect the whole body;
• Is often worse at night and may interrupt sleep;
• Generally does not begin until the third trimester of pregnancy, but may occur earlier, and;
• Stops within days of giving birth.

Itching (sometimes called pruritus) is common during pregnancy. It is usually due to conditions such as eczema and dry skin. However, these conditions do not generally cause itching on the palms or soles. Although cholestasis of pregnancy does not cause a rash, the skin may be irritated and red from damage caused by scratching.

Other symptoms can include:

• Reduced appetite;
• Fatigue;
• Feeling sick in the stomach (nausea);
• Light stools and dark urine;
• Diarrhoea, and;
• Yellowing of the skin and eyes, consistent with mild jaundice.

Methods for diagnosis

Cholestasis of pregnancy is diagnosed when no other explanation can be found for the itching, and blood tests show:

• Raised levels of bile acids, and;
• Abnormal liver function.

Symptoms can sometimes occur before raised levels of bile acids are detectable by blood tests. Repeat blood tests every 1-2 weeks may be recommended to monitor liver function throughout the pregnancy.

A physical examination, blood tests (for example, a screening for viruses that may affect the liver, such as hepatitis A, B and C) and a liver ultrasound may also be recommended to rule out other liver problems or medical conditions.

To confirm the diagnosis, further blood tests can be done a few weeks after birth to make sure that bile acid levels and liver function have returned to normal.

Types of treatment

If the condition is mild, particularly if it begins late in the pregnancy, no treatment may be required. In other situations, treatment options may include:

Medications

Topical ointments such as calamine lotion are safe for use in pregnancy, but they generally offer only some relief from the itching. It is important to be examined by a doctor before using any medications to treat itching during pregnancy, so that the cause of the symptoms can be identified.

Ursodeoxycholic acid (UDCA), which works by increasing bile flow, has been shown to improve itching and liver function for the mother during pregnancy. It is commonly prescribed for the treatment of cholestasis of pregnancy, but there is limited evidence as to whether it reduces the risk of complications for the baby.

Antihistamines such as promethazine may be prescribed at night to help with sleep and partially reduce itching.

Vitamin K

Vitamin K is important in the clotting of blood and can be reduced in people with decreased liver function. A low-dose supplement may be recommended, particularly if the cholestasis is severe, or develops relatively early in the pregnancy.

Management of symptoms

There are a number of things you can do to help manage symptoms, such as:

• Avoiding exposure to hot water. Cool to warm baths or showers may be helpful;
• Keeping cool generally, by using air conditioning and not overheating the house;
• Leaving skin uncovered at night;
• Not scratching or rubbing your skin, and;
• Using an icepack or bathing the hands and feet in cool water to temporarily numb the skin and reduce the itching.

Monitoring the baby

An ultrasound may be recommended to assess the baby's growth and rule out pre-eclampsia. More frequent antenatal checks may be recommended during pregnancy to monitor the baby's health.

Potential complications

Cholestasis of pregnancy has been associated with an increased risk of a number of serious complications for the baby. For this reason, it is generally recommended that women who are diagnosed with the condition give birth in a hospital.

Premature birth

Women who experience cholestasis of pregnancy are at increased risk of premature birth, which can carry a number of complications for the baby, including breathing difficulties, feeding problems and anaemia.

Meconium

Meconium is a waste product produced by the foetus (similar to faeces or stool) while it is developing in the uterus. Cholestasis of pregnancy may increase the risk of meconium passing into the amniotic fluid during birth. This can cause problems with the baby's breathing after birth.

Stillbirth

Cholestasis of pregnancy may be associated with an increased risk of death of the baby before birth, usually in the last few weeks of pregnancy. Because of these risks, your obstetrician may recommend continuous monitoring of the baby during labour.

Prognosis

The symptoms of cholestasis of pregnancy for the mother usually go away a few days after birth, with liver function returning to normal within weeks. Women who have had the condition in one pregnancy are highly likely to be affected in future pregnancies.

Risks for the baby are likely to be small, but can be serious. There is much that is still not well understood about this condition; research into how it affects the health of the baby and the best management for it is ongoing.

Prevention

Cholestasis of pregnancy cannot be prevented. It is important to seek prompt and appropriate antenatal care if:

• You have itching that is persistent;
• You have had the condition in previous pregnancies, and/or;
• You have family members who have had the condition.