Obstetric cholestasis during pregnancy

MOST pregnant women will experience some amount of itching, especially in the abdominal area, when their bump grows. And while some amount of itchiness is normal during pregnancy, consultant obstetrician-gynaecologist Dr Anna-Kay Taylor Christmas said that severe itchiness during pregnancy could be a sign of a more serious condition referred to as cholestasis of pregnancy or obstetric cholestasis.

“Pruritus or itching in pregnancy is common, affecting about 23 per cent of pregnancies, but of that number, only a small proportion will have it due to cholestasis. Cholestasis in pregnancy (otherwise called obstetric cholestasis) is a fairly rare condition of the liver that affects an average one in 100 pregnancies, depending on the country,” Dr Taylor Christmas said.

She pointed out that the condition, which usually happens late in the second or third trimester of pregnancy, develops when there is significant liver dysfunction. She explains that what happens is that pregnancy hormones affect liver function resulting in an obstruction of the natural flow of the bile from your liver to your gut, causing a build-up in your body. This leads to severe itching and abnormal liver function blood test results, which occur solely because of pregnancy, and without another identifiable underlying cause.

“It has to be differentiated from other common causes of itching in pregnancy, such as eczema or other skin conditions. We always look out for other signs of the bile duct being obstructed in the liver, including pale stool, dark urine and jaundice (yellowing of the eyes). When we talk to patients, we also ask about personal or family history of obstetric cholestasis, multiple pregnancies, carriage of hepatitis C and presence of gallstones,” Dr Taylor Christmas shared.

She said that the condition, which is typically worse at night, is often widespread and may involve the palms of the hands and/or the soles of the feet.

Complications of obstetric cholestasis may occur in both mom and the developing baby; the clinical importance, according to Dr Taylor Christmas, lies in the potential foetal risks because these are often severe.

“Most of the risks of obstetric cholestasis is to the baby. There are complications such as pre-term birth, and an increase in incidence of the passage of meconium (foetal stool) which may trigger lung problems since the child, in this case, will pass the stool into the amniotic fluid then breathe it in. There are also incidences of foetal distress and foetal death,” Dr Taylor Christmas outlined.

In the mother, there is an increased chance of maternal morbidity. Other issues include intense itching and consequent loss of baby, delivery by Caesarean section, and postpartum haemorrhaging. For these reasons, Dr Taylor-Christmas says that women with obstetric cholestasis should be booked under consultant-led, team-based care and give birth in a hospital unit.

“If we can’t find another cause for the itching and the abnormal liver blood results, then we monitor both mother and baby regularly by measuring blood results weekly until delivery.

“Our major concern for the baby is the risk of premature delivery and stillbirth. To decrease the risk to the baby, steroids are given antenatally to promote lung maturity and give the baby a better chance at survival if delivery has to be early,” Dr Taylor-Christmas said.

She acknowledged that there is no specific method of antenatal foetal monitoring for the prediction of foetal death, and because of this, doctors often opt to deliver the baby as soon they are satisfied that there is good lung maturity and all relevant results are stable.

“This means that we usually induce labour at 37 weeks gestation or deliver by Caesarean section. If results are worsening or the tests on the baby are not looking good, then delivery is done more urgently. When a vaginal delivery is planned, we offer continuous monitoring of the foetus during the labour. Women with this condition, however, have a higher risk of ending up with a Caesarean section,” Dr Taylor-Christmas advised.

To treat the itching, Dr Taylor-Christmas said that topical creams are usually prescribed. However, in instances when the cases are severe, she said there may be a need for oral systemic therapy. She said that vitamin K supplementation may also be required in some women who have abnormal results.

While the condition usually resolves following childbirth, a test is usually carried out sometime after delivering to confirm same.

“We usually wait about 10 days before repeating the blood tests and then continue to test them regularly until they return to normal levels. In addition, we advise women about the high risk of recurrence in subsequent pregnancies (45–90 per cent), and advise against using oestrogen-containing contraceptives due to the interaction with liver metabolism.”