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Obstetric Cholestasis – Everything You Need To Know

Mild itching during pregnancy is quite common and is usually due to increased blood flow to the skin. As your baby grows, you might also notice the skin on your belly becomes itchy as the skin stretches. In most cases, mild itching is nothing to be concerned about. However some women experience mild to severe itching all over the body and this can be a sign of be a sign of a liver condition called obstetric cholestasis.

This pregnancy related condition can be potentially very serious, so it’s important to know as much about it as possible.

What Is Obstetric Cholestasis?

Obstetric cholestasis is a liver disorder that occurs in pregnant women. Normally, the liver produces bile, which then flows down the bile ducts into the intestines, where it helps with food digestion. If obstetric cholestasis develops, the flow of bile into the intestines is reduced, and bile salts begin to build up in the bloodstream.

Obstetric Cholestasis Symptoms

The signs of obstetric cholestasis usually develop around the end of the second trimester, although the disorder can develop earlier in pregnancy. The most common symptom is continuous itchiness without a rash. Often the palms of the hands and soles of the feet are the worst affected. The itching can increase in severity as the pregnancy progresses, and this can interfere with sleep, concentration and mood.

You might have other, less common symptoms of obstetric cholestasis:

  • Fatigue
  • Feeling nauseous
  • Having little appetite
  • Mild jaundice (yellowing of skin, dark urine and pale stools)

How Is It Diagnosed?

In most cases women who have obstetric cholestasis begin to experience severe itching without a rash. If your symptoms suggest you might have obstetric cholestasis, your care provider will request blood tests that will determine whether you have raised levels of liver enzymes and bile acids. You might also have liver function tests to make sure there are no other causes of liver problems, such as hepatitis. Your care provider might also want you to have an ultrasound to check for gallstones, as this can sometimes be a problem during pregnancy.

If the results of these tests are normal but you are still itching, your care provider should have the test repeated after a week. In some cases the itch develops a week or two before the blood levels change. Not all women experience severe itchiness and their care providers might not consider obstetric cholestasis. A blood test should be arranged, however, if the itching is continuous and not caused by a rash.

If your blood shows high levels of liver enzymes and bile salts that are not due to any other liver disease, obstetric cholestasis will be the diagnosis.

What Are The Treatment Options for Obstetric Cholestasis?

There is no cure for obstetric cholestasis. The condition is rarely serious but it can be distressing. Most women are willing to try almost anything to relieve the itching; these things might help:

  • Wear light, loose clothes; avoid anything tight, or fabrics which might increase itching, such as wool.
  • Use creams containing chamomile or calendula. Calamine lotion is often recommended but can be drying, which might increase itching.
  • Milk thistle and dandelion root are herbs used for liver support; check with a herbalist or care provider who works with natural medicines before use.
  • Avoid hot and humid conditions, and check your heater thermostat, especially overnight when itching can be worse.

There are two medication treatment options available to women with obstetric cholestasis:

  • Ursodeoxycholic acid is used most often. It’s a naturally occurring bile acid which eliminates or reduces the itching and can result in the liver function and bile acid results returning to normal.
  • Steroids (particularly dexamethasone) can also be considered but need careful management due to lack of research on their effects on mothers and babies.

You might also be offered a vitamin K supplement. Obstetric cholestasis can affect your absorption of vitamin K, which is important for healthy blood clotting.

Who Is At Risk?

The exact cause of obstetric cholestasis is not clear but it’s believed hormones and genes might be responsible. Obstetric cholestasis occurs in about 1 in 100 pregnancies in the UK and Australia, and is more common in women who are pregnant with multiples.  A woman who has had obstetric cholestasis is more likely to have it again in future pregnancies.

During pregnancy your body experiences an increase in estrogen and progesterone. These hormones can affect the liver, slowing down the flow of bile. Some women are more sensitive to these hormonal changes.

There seems to be a genetic link with obstetric cholestasis although it can skip some generations. It’s thought that some women might inherit a problem with the way bile is made and passed down the bile ducts. When they become pregnant, the higher hormone levels reduce the flow of bile.

Women in certain parts of the world are also more likely to have obstetric cholestasis. In South America up to 1 in 20 women will develop the condition.

What Are The Effects On The Baby?

Prevailing medical opinion is that there is an increased risk of stillbirth with obstetric cholestasis. However the evidence is not still not clear on the link. One theory is the increased levels of bile acid cause irregular heart rates in unborn babies, leading to higher risk of fetal distress, premature birth, and stillbirth.

Due to this increased risk, many care providers will recommend labour induction at 37 weeks. There are risks of having your baby early and it’s important you are provided with as much information as possible to make an informed decision about your care.

The effects of obstetric cholestasis should subside immediately or not long after the birth of your baby. Usually you will have another liver function test about 6-12 weeks after the birth, to make sure your levels are back to normal. This is also to check that obstetric cholestasis was in fact the correct diagnosis and will help you be aware for future pregnancies.

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