Obstetric Cholestasis

Obstetric cholestasis is a complication of pregnancy that can happen in any pregnancy. It is sometimes difficult to diagnose so the midwife or obstetrician needs to have a high index of suspicion for obstetric cholestasis during the pregnancy or immediately following the pregnancy. Another name for obstetric cholestasis is intrahepatic cholestasis of pregnancy or ICP. Doctors have just recently discovered how this particular condition occurs but the symptoms of intrahepatic cholestasis of pregnancy have been known for a long time. It used to be that women had symptoms but doctors either didn't diagnose it or diagnosed it as something else.

Statistically speaking, about seven out of every 1000 pregnancies are complicated by obstetric cholestasis. There are probably more women out there with the disease but it just isn't diagnosed. It is a condition of the liver that only happens during pregnancy. What happens is that bile does not flow correctly into the duodenum and bile acids tend to back up into the blood from within the liver. Digestion suffers greatly and there isn't enough fat absorption, leading to fatty stools. The main symptom is extreme itching because bile acids under the skin are very itchy. In severe situations, there is jaundice of the skin and eyes from bile acids. It is a situation usually found in the third trimester of pregnancy but it can occur as early as the first trimester of the pregnancy.

The aetiology of intrahepatic cholestasis of pregnancy is not known. There are some hereditary reasons behind getting the disease and about half of all women who have ICP have other family members who have liver problems. Women with ICP in pregnancy can have daughters with ICP during their pregnancies but because the disease is relatively rare, the exact mechanism of action is not clear.

Severe itching is the main complication of ICP. It tends to get progressively worse so that it disrupts all activities of daily living, including work, bathing, being comfortable in your house and sleeping. It is worse on the soles of the feet and on the palms of the hands but can affect any body part. Only around 20 percent of individuals with ICP will go on to have eye or skin jaundice. Other common symptoms seen in ICP include pale stools, loss of appetite, dark urine, tiredness and mild depression. Even things like severe depression, right upper quadrant abdominal pain and nausea or vomiting can occur. The biggest risk to the foetus is prematurity and about 44 percent of these women will end up having a baby before 37 weeks gestation. There can be uterine haemorrhage, foetal distress or still birth.

It is important to diagnose obstetric cholestasis as early as possible so the pregnancy can be surveilled and monitored closely for severe complications. Itching is a good way to pay attention to the severity of the disease as more itching means a more serious disease. Doctors can do blood tests to check for the presence of bilirubin in the blood or bile acids in the blood. The bile acid test isn't done by many laboratories so it may take a while to get the results back to help the patient. If a woman is past the 34 week mark, she should be managed as though she has disease if she has the symptoms because the results won't come back in time. Repeated liver enzyme testing should be done to see how much damage is going on to the liver.

Treatment does exist for ICP. Women are given Actigall, a medication usually given for patients with gall stones. It seems to reduce the risk of still birth and the symptoms of itching usually get better. Some women are given corticosteroids during the pregnancy so as to maximize the chances of the lung maturity of the infant if it happens to be born before 37 weeks gestation. Vitamin K therapy is given because it is not usually absorbed during ICP. Corticosteroids are also commonly given in order to reduce the degree of itching the woman has.