Obstetric Cholestasis: Itching to Know the Reason?

If there is any milestone in a woman’s life that brings a string of changes, it is pregnancy.  However, the entire experience is not all rosy for women. Morning sickness, bloating, and weight gain are just some of the side effects that open your eyes to the unglamorous side of pregnancy. However, aside from the usual complaints, conditions like Intrahepatic Cholestasis of Pregnancy is one that must be taken seriously. Besides the disruptive itch, it also poses serious risks, so read more to protect you and your baby. 

What is Intrahepatic Cholestasis of Pregnancy (ICP)?

Intrahepatic cholestasis of pregnancy, which is also known as Obstetric Cholestasis, is a liver condition where the normal flow of bile slows down or is blocked. Instead of leaving the liver, it builds up in the organ resulting in bile salts leaking into the bloodstream and causing severe itching.

…bile salts leaking into the bloodstream…cause severe itching Click To Tweet

For expectant moms, severe itching unaccompanied by spots or rashes is the main red flag.  You can either experience the itch localized to your palms and the soles of your feet, while others get generalized body itching. Itching usually worsens at night where it can impair your sleeping pattern.

Other less common signs and symptoms of obstetric cholestasis include:

• Yellowing of the skin and the whites of the eyes (jaundice)
• Nausea
• Dark urine
• Light-colored stool
• Fatigue
• Pain in the upper right side of your belly
• Decreased appetite

The symptoms may appear earlier for some women, and worsen during the third trimester or as your due date approaches. The reason is that pregnancy hormones are at their peak during this stage.

What causes cholestasis of pregnancy?

This condition is thought to be caused by a combination of hormonal, genetic, and environmental influences.

Bile produced by the liver is supposedly stored in the gallbladder. However, additional estrogen hormones during pregnancy can change the way these two organs function. Hormonal changes slow down the normal flow of bile, which triggers a cascade of events that lead to itching.

Evidence shows that this condition tends to run in families. It is also common in certain ethnic groups in the South Asian, South American, Nordic, and Scandinavian regions. It can also be expected to reappear during subsequent pregnancies, with a 45-90% recurrence rate.

How is intrahepatic cholestasis of pregnancy diagnosed?

An accurate diagnosis relies on a high index of suspicion supported by abnormal liver function tests and raised bile acid levels. The doctor makes this conclusion after organic causes of liver disease has been ruled out.

Other lab tests include prothrombin time to check how well your blood clots. An ultrasound exam may even be done to assess the tubes that carry bile (bile ducts) for liver abnormalities and gallstones.

Is intrahepatic cholestasis of pregnancy dangerous?

Obstetric cholestasis runs a serious risk of complications to your developing baby. These include:

• Preterm birth/Stillbirth. An early delivery improves a baby’s chance to thrive when they are exposed to the risks associated with intrahepatic cholestasis while in the womb.
• Fetal distress. This results when your developing baby is not thriving well.
• Meconium in the amniotic fluid. While in the womb, your baby’s gut normally collects a sticky, green substance in their intestines called meconium which may be expelled into the amniotic fluid if a mother develops cholestasis.
• Respiratory problems. Meconium in the amniotic fluid can potentially be aspirated by the baby which can cause respiratory problems in a newborn or stillbirth. Steroids may be given at 34 weeks to help the baby’s lungs mature, especially with preterm births.

On the maternal end, obstetric cholestasis reduces your ability to absorb fat-soluble vitamins (A, D, and K). This effect puts you at risk for vitamin K deficiency, which can result in postpartum hemorrhage. It explains why you need to have your clotting time checked so that you get proper treatment before giving birth. Otherwise, you’ll run the risk of excessive bleeding during delivery.

What extra care do I need if diagnosed with ICP?

After a diagnosis, you’ll be advised to have additional antenatal checks. This will include liver function tests which is done as often as once or twice a week until you deliver. Additionally, your baby will also be closely monitored. This involves fetal heart monitoring and ultrasound scans to measure growth and the fluid around your baby.

While these efforts may not guarantee the prevention of stillbirth, they can still help you and your doctor be on top of your baby’s well-being inside the belly.

Does cholestasis go away after pregnancy?

You may continue to itch for some time after delivery, especially in prolonged cases, or if you have several pregnancies over a short period of time. It is fortunate that this condition typically goes away after your baby is born.

…this condition typically goes away after your baby is born. Click To Tweet

How is intrahepatic cholestasis of pregnancy treated?

The goal of treatment is to relieve itching and prevent complications. Aside from the seemingly unbearable itching, it is the fear of not knowing how the condition is affecting your baby that increases your anxiety. To ensure your baby’s safety, treatment may include:

• Home remedies. Cold or ice baths slows down blood circulation, which can help relieve itching, and wearing loose-fitting cotton garments help minimise it.
• Skin creams and ointments. These products help relieve the itching temporarily and are considered safe interventions for pregnant women.
• Proper assessment. Your doctor will carefully examine your skin to check if the itch is related to other skin conditions. 
• Fetal monitoring. Management may vary with each OB, but it may often include recommendations increased antenatal monitoring for women with ICP. This will include fetal heart monitoring and contraction recordings.
• Medicine. Drug treatment may include corticosteroids and ursodeoxycholic acid (drug that can decrease the concentration of bile acids). Antihistamines will be given but not so much for the itch, but only to help you sleep. While histamines cause the common itch, ICP is directly or indirectly caused by bile salts in your bloodstream.
• Early delivery. The benefits of delivering the baby at 37-38 weeks outweigh the risks associated with early delivery. This is a necessary step to protect the baby from the complications attached to cholestasis.

What follow-up should I have during the postpartum period?

It is advised that you get a follow-up appointment with your doctor 6-8 weeks after giving birth. This visit is necessary to assess your symptoms and liver function thoroughly. Persistent symptoms and abnormal liver function test results suggest a different problem which calls for a referral to a specialist. It is generally not advisable to be on the oral contraceptive pill after such a condition.

This may not be a common condition, but it’s essential that you are aware of how obstetric cholestasis poses a real threat to your baby. Having this knowledge will help you adopt proper health-seeking behaviors if ever you experience this condition.

Therefore, if you are experiencing a rashless itch or other unusual symptoms, bring your concerns to a certified obstetrician. In Singapore, you can schedule your appointment with Dr. Pamela Tan.