Obstetric cholestasis

What is obstetric cholestasis?

Obstetric cholestasis is a disorder that affects your liver during pregnancy. This causes a build up of bile acids in your body.

Bile acids are made in your liver and help you to digest fat and fat-soluble vitamins. 

Obstetric cholestasis is uncommon. In the UK, it affects about 7 in 1,000 women (less than 1%). It is more common among women of Indian-Asian or Pakistani-Asian origin, with up to 15 in 1,000 women (1.5%) affected. It is often not clear why it develops in one pregnancy and not another.

Obstetric cholestasis can be a very uncomfortable condition. It does not have any serious consequences for your health during pregnancy but can be very distressing. If you experience anxiety or low mood because of ICP, please discuss this with your healthcare professional, who can arrange additional support.

What causes obstetric cholestasis?

The cause of obstetric cholestasis is not yet understood, but it is thought that hormones, genetic and environmental factors may be involved. 

What are the symptoms?

Itching

Itching is very common in pregnancy, affecting around 25% of women. Most women who have itching in pregnancy will not have ICP. However, itching can be the first sign of obstetric cholestasis and if you experience this, you should tell your healthcare professional.

The main symptom is itching of the skin, but with no rash. The itching is primarily on the soles of the feet and palms of the hands.

Itching can start at any time during pregnancy, but usually begins after 28 weeks. It can vary from mild to intense and persistent, and can be very distressing.

The itching tends to be worse at night and can disturb your sleep.

Jaundice

Women with obstetric cholestasis can develop jaundice, though this is rare.

Jaundice is where your skin and eyes become yellow because of changes in your liver. If you have jaundice due to ICP, this will get better after you have had your baby.

Pre-eclampsia

You may be more likely to develop pre-eclampsia (high blood pressure and protein in your urine during pregnancy) or to have gestational diabetes. Your healthcare professional will advise you what checks you may need for these conditions.

How is it diagnosed?

Examination of your skin

Your skin will be examined to check whether your itching is related to a skin condition, such as eczema or psoriasis. It is possible that you may have more than one condition.

Your doctor will check to rule out other possibilities. Skin can become sensitive during pregnancy so it is important to rule out any other possible causes of the itching. For example, this could be due to a change in washing powder or soap.

Blood tests

You will be offered blood tests to help diagnose obstetric cholestasis.

These include tests for the following: 

Liver function tests (LFTs)

These are blood tests that look at how well your liver is working. Levels of certain substances in the liver can be raised in women with obstetric cholestasis

Bile acid blood test

This is a blood test that measures the level of bile acids in your blood. Bile acids are raised in obstetric cholestasis. Your bile acid levels can be abnormal even if your liver function tests are normal. Bile acid levels can also be raised in conditions other than obstetric cholestasis

Some women may have itching for days or weeks before their blood tests become abnormal. If your itching persists and no other cause is found, your liver function tests and bile acids should be repeated within one to two weeks.

If your symptoms are unusual, start very early in your pregnancy or don’t get better after your baby is born, you may be offered further investigations, including more blood tests and a scan of your liver. You may also be referred to a liver specialist. This is to make sure that you don’t have another cause for your itching and raised bile acids.

What does obstetric cholestasis mean for my baby?

• There is an increased chance that your baby may pass meconium (open their bowels) before they are born. This makes the water around your baby a green or brown colour. Your baby can become unwell if meconium gets into their lungs during labour
• There is an increased chance of you having an early birth
• The chance of having your baby pre-term (earlier than 37 weeks) is higher if you have obstetric cholestasis. This may be because you go into labour naturally or because your doctor advises you to give birth early. At UHB we advise our women to deliver between 37 and 38 weeks
• There are no known long-term health risks to your baby
• However there is a small increased chance that your baby will need to go to the neonatal unit when they are born, especially if they have been born early

What about the chances of stillbirth?

Your chance of having a stillbirth depends on the level of bile acids found in your blood as well as any other pregnancy complications you may be experiencing.

• If your bile acid levels are between 19 and 39 micromol/L (mild) and you do not have any other risk factors, the chance of you having a stillbirth is no different to someone who doesn’t have obstetric cholestasis
• If your bile acid levels are between 40 and 99 micromol/L (moderate), and you do not have any other risk factors, the chance of you having a stillbirth is similar to someone who doesn’t have obstetric cholestasis until you are 38 – 39 weeks’ pregnant
• If your bile acid levels are 100 micromol/L or more (severe), your chance of having a stillbirth is higher than someone who doesn’t have obstetric cholestasis and is around 3%. Most of these stillbirths happen after 36 weeks of pregnancy
• If you have other factors (such as gestational diabetes and/or pre-eclampsia) or are having a multiple pregnancy (e.g. twins or triplets), you may have a higher chance of stillbirth, and this may affect when your healthcare team recommend that you give birth
• To ensure a good foetal and maternal outcome, UHB recommends delivery between 37 and 38 weeks

What extra care will I need?

Once you have been diagnosed with obstetric cholestasis, you should be under the care of an obstetrician. Your blood tests will be repeated regularly and you will be under the care of the Day Assessment Unit (DAU) at Heartlands Hospital or the Maternity Assessment Centre (MAC) at Good Hope Hospital.

The team will make an individualised plan of care for you depending on your circumstances.

• You should keep a close eye on your baby’s movements and if you are worried, you should go to your local maternity unit for a check-up straight away
• You do not need any additional scans of the baby because you have obstetric cholestasis
• You will be advised to have your baby in a consultant-led maternity unit with a neonatal unit

How do you treat obstetric cholestasis?

The obstetric cholestasis will get better when your baby is born.

Treatments to improve your itching during pregnancy are of limited benefit but might include:

• skin creams such as aqueous cream with 1% menthol or calamine lotion
  • If you have the aqueous cream, put it in the fridge and apply as required
• antihistamines, which may help you to sleep at night

Other treatments include the following:

• You will be advised to take a medication called ursodeoxycholic acid, often referred as Urso, three times a day. This medication may reduce your chance of giving birth prematurely but it does not prevent stillbirth
• At 36 weeks, we will prescribe a daily dose of vitamin K. This is because, in some rare cases, obstetric cholestasis may affect blood clotting

What follow up should I have?

Obstetric cholestasis symptoms will get better after birth. However, it can take several weeks for your blood tests to return to normal. 

At your six-week postnatal check, your healthcare professional should make sure that your itching has stopped and arrange blood tests to make sure that your liver blood tests and bile acids have returned to normal. If you still have symptoms or if your blood tests have not returned to normal by this time, you may be referred to a specialist for further investigations.

Is there anything else I should know?

• If you have obstetric cholestasis, there is an increased chance that you will have obstetric cholestasis again in future pregnancies
• Your liver function tests and bile acids should be checked at the start of any future pregnancies and you should tell your healthcare professional if you develop any symptoms
• Obstetric cholestasis does not affect your choice of contraception once your liver blood tests and bile acids have returned to normal. If you take an oestrogen-containing contraceptive, such as the combined pill, and develop itching you should see your healthcare professional immediately for review
• If you have had obstetric cholestasis, it is still possible for you take hormonal replacement therapy (HRT) in the future
• Obstetric cholestasis is not caused by drinking alcohol. However, it is sensible to avoid alcohol while pregnant