Obstetric cholestasis is a disorder that affects your liver during pregnancy. This causes a build-up of bile acids in your body. The main symptom is itching of the skin but there is no skin rash. The symptoms get better when your baby has been born. Obstetric cholestasis is uncommon. In the UK, it affects about 7 in 1000 women (less than 1%). Obstetric cholestasis is more common among women of Indian- Asian or Pakistani-Asian origin, with 15 in 1000 women (1.5%) affected.
Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis.
Mild itching is common in pregnancy because of the increased blood supply to the skin. Later on, as your bump grows, the skin of your abdomen is stretched and this may also feel itchy. Mild itching is usually nothing to worry about, however, itching can also sometimes be a symptom of a liver condition called intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis.
The cause of obstetric cholestasis is not yet understood, but it is thought that hormones and genetic and environmental factors (for example diet) may be involved.
Hormones such as estrogens, levels of which are higher in pregnancy, may affect the way your liver works and cause obstetric cholestasis.
• Genetic and environmental factors
Obstetric cholestasis is more common in women from certain ethnic groups. Further evidence for a genetic component is that obstetric cholestasis appears to run in some families. If you have suffered 2 from obstetric cholestasis, there is a risk of recurrence in a future pregnancy (see below: ‘Is there anything else I should know?’). What does it mean for me? Obstetric cholestasis can be a very uncomfortable condition, but it does not have any serious consequences for your health.
Itching can start any time during pregnancy, but usually begins after 28 weeks. Although it often starts on the palms of your hands and the soles of your feet, it may spread over your arms and legs and, less commonly, may occur on your face, back and breasts. It can vary from mild to intense and persistent, such that it can be very distressing. The itching tends to be worse at night and can disturb sleep, often making you feel tired and exhausted during the day. There is no rash, but some women scratch so intensely that their skin breaks and bleeds. The itching gets better after birth and causes no long-term health problems.
A few women with obstetric cholestasis develop jaundice (yellowing of the skin owing to liver changes). Some women feel unwell and lose their appetite. Jaundice can also cause dark urine and pale bowel movements.
You may be diagnosed with obstetric cholestasis if you have unexplained itching in pregnancy with abnormal blood tests (liver function and bile acid tests), both of which get better after your baby is born. It is a diagnosis that is made once other causes of itching and abnormal liver function have been ruled out.
Itching is very common in pregnancy, affecting 23 in 100 women (23%), but only a small proportion of those women will have obstetric cholestasis. However, itching is often the first sign of obstetric cholestasis, 3 often being worse at night and involving the palms of the hands and soles of the feet. Therefore, if you do have itching, it is important you tell your midwife or obstetrician.
Inspection of the skin
Your skin will be carefully examined to check that your itching is not related to other skin conditions, such as eczema. It is possible that you may have more than one condition.
You may be offered one or more blood tests to help diagnose obstetric cholestasis.
• Liver function tests (LFTs). These involve a number of blood tests that look at how the liver is working.
• Bile acid test. This measures the level of bile acids in your blood. The bile acid level can be abnormal even if your LFTs are normal.
• Blood tests to rule out causes of other liver problems. Some women may have itching for days or weeks before their blood tests become abnormal. If itching persists and no cause is found, the LFTs should be repeated every 1–2weeks.
If you are diagnosed with ICP, you will have regular liver function tests so that your condition can be monitored.
There is no cure for obstetric cholestasis except the birth of your baby. Treatment may ease symptoms for most women. None of the treatments offered affects the outcome for your baby.
Treatments might include:
Skin creams and ointments to relieve the itching. These are safe in pregnancy and may provide temporary relief.
Antihistamines may help you sleep at night but don’t appear to have much success in helping itching.
Ursodeoxycholic acid often known as ‘Urso’ reduces the level of bile acids in your blood and improves LFTs. It may also help reduce the itching. There is not enough evidence to say whether ursodeoxycholic acid reduces the small chance of a stillbirth or whether it is completely safe for your baby, but it is a commonly prescribed medication for obstetric cholestasis.
Some women have found that having cool baths and wearing loose-fitting cotton clothing helps to reduce the itching.
Obstetric cholestasis may cause a problem with the clotting mechanism of your blood, making you prone to bleed for longer than usual. Vitamin K can help with this change. If your blood clotting time is prolonged, it is recommended that you take a daily dose of vitamin K to prevent complications if you start to bleed.
Even if your blood clotting is not affected, there may be a small benefit from vitamin K. There is very little up-to-date information that vitamin K is harmful for your baby in pregnancy. Therefore, you may wish to have a discussion with your doctor about whether you wish to take vitamin K or not.
Shortly after birth, your baby should be offered vitamin K, as are all babies.