What is cholestasis of pregnancy? What is obstetric cholestasis?

Cholestasis of pregnancy, also known as obstetric cholestasis or intrahepatic cholestasis of pregnancy, usually occurs during the last trimester of pregnancy, and triggers severe itching, especially on the hands and feet. On rare occasions symptoms may appear before the third trimester. The condition is rarely of concern for the mother's long-term health, but may cause severe complications for the fetus baby. 

Cholestasis is when the excretion of bile (from the liver) is interrupted. Bile is a fluid that helps the body process fat. 

There are two main types of cholestasis:

§  Short and long term cholestasis (acute and chronic)

§  The one that comes on suddenly is known as acute cholestasis.

§  Long-term interruption in the excretion of bile is called chronic cholestasis.

§  Cholestasis outside and inside the liver

§  Extrahepatic cholestasis occurs outside the liver.

§  Intrahepatic cholestasis occurs inside the liver.

The term "cholestasis" comes from the Greek word chole meaning "bile" and the Greek word stasis meaning still. 

Pregnancy is a possible cause of intrahepatic cholestasis. Apart from giving the patient intense itching, it does not usually cause any serious problems for the mother. However, it can be potentially dangerous for the fetus (developing baby inside the mother).

What are the signs and symptoms of cholestasis of pregnancy?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. 

The following signs and symptoms may be present when the mother has cholestasis of pregnancy:

§  Very intense itching, especially on the palms of the hands and soles of the feet.

§  Dark urine.

§  Light-colored feces (stools, bowel movements).

§  Jaundice - whites of the eyes, skin and tongue may take on a yellowish/orangey tinge.

It is not uncommon for the itchiness to be the only symptom, which tends to become much worse during the night. 

Pregnant mothers who have any of the signs or symptoms mentioned above should tell a health care professional as soon as possible.

What causes cholestasis of pregnancy?

Experts believe that pregnancy hormones trigger the condition; but they are not sure. 

What is bile? Bile is a yellow-green fluid that helps to digest fat. It is produced by the liver and stored in the gallbladder. From the gallbladder it passes through the common bile duct, into the duodenum. 

Bile mainly consists of cholesterol, bile salts, and the pigment bilirubin. 

Pregnancy hormones - these can affect the proper functioning of the gallbladder. On some occasions pregnancy can slow or even completely block the flow of bile. If the excess bile enters the bloodstream the condition is called cholestasis of pregnancy.

What are the risk factors for cholestasis of pregnancy?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. 

We do not really know how many women globally develop cholestasis of pregnancy. According to The Mayo Clinic, USA, estimates vary from 1% to 15%. In Chile and Scandinavia records indicate that the risk of cholestasis of pregnancy is higher during the winter months. 

The following factors may increase a woman's risk of developing cholestasis of pregnancy:

§  Having a close relative who had cholestasis of pregnancy.

§  Having had cholestasis of pregnancy before (up to70% risk of recurrence during the subsequent pregnancies).

§  Carrying multiple babies (twins, triplets, etc).

§  Having a history of liver damage.

§  Being pregnant as a result of in-vitro fertilization (IVF).

What are the possible complications of cholestasis of pregnancy?

The mother

§  The pregnant mother may have some problems with absorbing fat-soluble vitamins (vitamins A, D, E and K), as well as intense itching. However, within a few days after giving birth the problems resolve with hardly ever any subsequent liver problems.

§  The greatest complication for the mother is a very high risk of recurrence in subsequent pregnancies.

The baby

§  The risk of being born prematurely is significantly greater if the mother has cholestasis of pregnancy. Experts are not sure why.

§  There is also a risk of the baby inhaling meconium during childbirth, resulting in breathing difficulties.

§  The risk of fetal death during late pregnancy is also higher if the mother has the condition.

Doctors often induce labor early if the mother has cholestasis of pregnancy because of the potential serious complications for the baby.

How is cholestasis of pregnancy diagnosed?

The doctor will ask the patient questions related to potential signs and symptoms, such as urine and stool color, itchiness, etc. The mother will also be asked about her personal and family medical histories. A physical exam will also be performed.

§  Blood test - this may reveal how well the patient's liver is functioning. Blood levels of bile may also be measured.

§  Ultrasound scan - the aim here is to check the mother's liver (not the baby) for any abnormalities.

What are the treatment options for cholestasis of pregnancy?

There are two aims when treating a mother with this conditions: 1. To relieve the symptoms, mainly of itching. 2. To prevent potential complications. 

Relief of symptoms

§  Ursodeoxycholic acid is a drug which helps relieve itching as well as increasing bile flow.

§  Corticosteroids - these will be in the form of anti-itching creams or lotions.

§  If the patient soaks the affected areas of skin in lukewarm water there may be some temporary relief.

Preventing potential complications

§  Blood tests - the patient's liver function and blood levels of bile will be closely monitored.

§  Ultrasound scans - these will occur more frequently to monitor the baby's health and development.

§  Non-stress test - the aim here is to check how often the baby moves in a given period. The baby's heartbeat in relation to body movements is also measured.

§  Induced labor - in most cases the health care professional will recommend inducing labor at about 38 weeks. If cholestasis is severe induction may occur earlier.