Cholestasis of pregnancy, also known as obstetric cholestasis or intrahepatic cholestasis of pregnancy, can cause severe itching, especially on the hands and feet. It usually occurs during the last trimester of pregnancy.
The condition does not usually pose a serious risk for the mother's long-term health, but it may cause severe complications for the infant.
The term "cholestasis" comes from the Greek words "chole" meaning "bile" and "stasis," meaning "still."
Cholestasis happens when the liver cannot excrete bile properly. Bile is a fluid that helps the body process fat.
Contents of this article:
Itching and other symptoms
Itchy hands and feet are the most common symptom.
The following signs and symptoms may be present in cases of cholestasis of pregnancy:
- Intense itching, especially on the palms of the hands and soles of the feet
- Dark urine
- Light-colored feces
- Jaundice, giving the whites of the eyes, skin and tongue a yellowish or orangey tinge
The itchiness may be the only symptom, and it often becomes worse during the night.
A pregnant woman who has any of the signs or symptoms mentioned above should tell a health care professional as soon as possible, because they could indicate a risk for her unborn baby.
Causes and risk factors
Bile is a yellow-green fluid that helps to digest fat. It mainly consists of cholesterol, bile salts, and the pigment bilirubin.
It is produced by the liver and stored in the gallbladder. From the gallbladder it passes through the common bile duct, into the duodenum.
Sometimes, a blockage outside the liver prevents the bile from leaving the liver, leading to a condition known as extrahepatic cholestasis.
Intrahepatic cholestasis happens when there is a problem with eliminating bile salts from the liver. This is the kind of cholestasis that happens during pregnancy.
The prevalence of cholestasis of pregnancy is not known. One estimate suggests that it affects 1 to 2 pregnancies in every 1,000 in the U.S. Other figures suggest that up to 1 in 50 women may develop it, depending on the population.
According to the United Kingdom's Royal College of Obstetricians, women of Indian or Pakistani origin have a higher risk, with 1.5 percent of women affected.
Factors that may increase a woman's risk of developing cholestasis of pregnancy include:
- Having a close relative who had cholestasis of pregnancy
- Having had cholestasis of pregnancy before, as the risk of recurrence during the subsequent pregnancies is between 45 and 90 percent
- Carrying multiple babies, such as twins or triplets
- A history of liver damage
- Being pregnant as a result of in-vitro fertilization (IVF)
Complications and effects on the fetus
As well as intense itching, the mother may have some problems with absorbing fat-soluble vitamins, which are vitamins A, D, E and K. However, within a few days after giving birth, the problems should resolve and there are not usually any further liver problems.
Cholestasis during pregnancy increases the risk of a preterm birth.
For the fetus, there is a significantly higher risk of preterm birth if the mother has cholestasis of pregnancy, although the reasons are unclear.
An infant who is born preterm may have breathing difficulties, if the lungs are not yet fully developed.
The risk of fetal death is also higher.
During gestation, the fetus depends on the mother's liver to remove bile acids from the blood. If the mother has too much bile acid, this can be passed onto the fetus.
The neonate also has a higher risk of inhaling meconium during childbirth, resulting in breathing difficulties.
Doctors often induce labor early if the mother has cholestasis of pregnancy, because of the potentially serious complications for the baby.
Diagnosis and treatment
The doctor will consider the patient's signs and symptoms, such as urine and stool color, and itchiness. The mother will also be asked about her personal and family medical histories, and there will be a physical examination.
Blood tests may reveal how well the patient's liver is functioning. Blood levels of bile will also be measured.
Ultrasound scans can detect abnormalities in the mother's liver, but not in the fetus.
Treatment may not be necessary if cholestatis is mild and occurs late in pregnancy. Treatment normally aims to relieve symptoms, mainly the itching, and to prevent potential complications.
The following medications may be prescribed:
- Ursodeoxycholic acid, to relieve itching and increase bile flow
- Menthol creams may help soothe the itching, and there is no evidence that they cause harm during pregnancy
Soaking the affected areas of skin in lukewarm water may provide some temporary relief. Dabbing the affected areas with baking soda or apple cider vinegar may help, or applying coconut oil after a bath.
Patients with cholestasis will have low levels of vitamin K, increasing the chance of hemorrhage, so a mother will often need Vitamin K supplements before and after delivery.
According to the American Pregnancy Association, natural remedies for liver health include and dandelion root and milk thistle, and calamine lotion may help with itching, but any supplements or alternative treatments should be discussed first with a physician, as the effects during pregnancy may be unknown.
Some sources recommend oatmeal baths, but the American Pregnancy Association says the use of Aveeno or oatmeal baths should be avoided. They also warn against the use of antihistamines.
Many women choose to take herbs, creams, baths, and tinctures instead of medication. Some herbs are difficult to break down, especially when the liver is already compromised.
It is very important to check with the doctor beforehand, to make sure a natural remedy is safe, and to consult the doctor if symptoms get worse.
Preventing potential complications
Blood tests will monitor the patient's liver function and blood levels of bile.
Ultrasound scans may become more frequent, to monitor fetal health and development.
A non-stress test may be ordered to check how often the fetus moves in a given period, and the fetal heartbeat in relation to body movements is also measured.
Induced labor is often recommended at about 38 weeks. If cholestasis is severe, induction may occur earlier.
While drinking alcohol will not cause cholestasis in pregnancy, alcohol should be avoided during pregnancy, as it can lead to a number of complications, including other types of liver disease.