Obstetric Cholestasis

Introduction

Pregnancy is a transformative journey for a woman's body, marked by a cascade of changes and challenges. Among these challenges is the potential for liver-related conditions, such as obstetric cholestasis (OC), also known as intrahepatic cholestasis of pregnancy (ICP). ¹ Obstetric cholestasis is a liver disease during pregnancy which causes a disruption of the flow of bile out of the liver, and it can cause severe complications if not treated promptly. ^1,2,3 In this comprehensive article, we will delve into the various facets of obstetric cholestasis, from its underlying causes to its management and implications for both mothers and their babies. 

Understanding Obstetric Cholestasis

The liver, a remarkable organ responsible for detoxification and metabolism, is pivotal in maintaining overall health. Obstetric cholestasis disrupts the liver's harmony by impeding the normal flow of bile, a digestive fluid essential for fat absorption.^1,2,3 As a result, bile accumulates in the body, leading to itching and potentially affecting various bodily functions, known as cholestasis.^1,2,3 This condition's hallmark is persistent itching, predominantly on the palms and soles.^1,2,3 Obstetric cholestasis is when cholestasis occurs during pregnancy. While the exact cause remains elusive, factors such as hormonal shifts and genetic predisposition are believed to contribute to its onset.^1,2,3

Obstetric cholestasis also typically happens between the end of the second trimester and the beginning of the third, although it could also happen at other times. ^1,2,3 

Exploring Underlying Causes

Although uncertain, a mix of genetic susceptibility, hormonal changes and environmental factors appear to cause obstetric cholestasis.^1,2 Certain genes, including ABCB4 and ATP8B1, have been linked to this condition.^1,2 It has also been found that first-degree relatives of women affected by OC are more likely to get it themselves, and women who have had OC previously are more likely to be affected again in subsequent pregnancies.¹ OC is influenced by environmental and seasonal factors as well. It has been observed that the condition is more common in women with lower levels of selenium and vitamin D.^1,2 Additionally, it tends to be more prevalent in certain countries during the winter months, when selenium and vitamin D levels may also be lower.^1,2

Furthermore, it has been shown that high levels of oestrogen also play a role in causing OC.^1,2 For this reason, genetically predisposed women taking an oestrogen-containing contraceptive pill are at a high risk of developing OC.¹ These genes, environmental influences, along with hormonal factors like oestrogen and possibly progesterone, create a complex interplay that can lead to the development of cholestasis.^1,2,3

Recognising Symptoms and Seeking Help

Persistent itching, medically known as pruritus, is a cardinal sign associated with obstetric cholestasis (OC).^1,2,3 Itching is usually worst on the palms and soles and may spread to other body parts.^1,2,3 The intensity of the itching could range from slightly inconvenient to debilitating.^1,2,3 While you might think of itching as a mild inconvenience, it's crucial to recognise that it can signify an underlying condition requiring medical attention. If you experience such symptoms, seeking prompt medical help is essential to ensure timely intervention.

Another symptom of OC, although less common, is the yellowing of the skin and the whites of the eyes - also known as jaundice.^1,2 This typically presents at the late stages of the disease, and you should seek medical help immediately if you notice this yellowing.¹

Other symptoms of OC include^1,2,3: 

• Dark urine
• Light grey or light brown-coloured stool
• Stool that floats 
• Extreme tiredness
• Nausea  
• Abdominal pain (rare) 

Understanding Risks and Complications

Obstetric cholestasis (OC) extends its impact beyond only the mother, posing risks to the baby as well. This is because the bile that is accumulating in the mother's body can cross the placenta and get to the baby, potentially causing several problems.^1,3 The foetus can experience premature birth, respiratory distress syndrome, meconium passage while still in utero (potentially leading to aspiration), stillbirth, and foetal death.^1,2,3 It should be noted that stillbirth is rare in mothers who have a bile acid concentration < 100 micromol/L, with the risks increasing as the bile acid concentration increases.^1,4 Therefore, prenatal care encompassing vigilant monitoring and medical guidance is pivotal in managing these potential risks effectively.

Pregnant women with OC might be at a greater risk of experiencing conditions like preeclampsia or gestational diabetes.⁴ To ensure their well-being, they need to have their blood pressure and urine regularly checked, and they should also undergo tests for gestational diabetes as recommended by national guidelines.⁴ This monitoring helps to keep them and their baby safe throughout the pregnancy journey.⁴

It should also be mentioned that mothers affected by OC in one pregnancy are more likely to be affected again in subsequent pregnancies.¹  Furthermore, OC is associated with other chronic liver diseases, but this relationship is unclear.¹  

Diagnosis and Management

Medical Management 

 Diagnosing obstetric cholestasis (OC) often involves liver function tests and assessment of bile acid levels.^1,2,3 Ursodeoxycholic acid (UDCA), a bile acid supplement, is a common therapeutic approach to managing the condition. UDCA helps alleviate itching and reduces the risk of complications.^1,2,3 UDCA is generally considered safe for use during pregnancy, although it's prescribed under "informed consent" as it hasn't been thoroughly tested in pregnancy. Typically, hospital doctors are the ones who prescribe it. If UDCA does not work, there are other options in doctors' medical arsenals, namely rifampin, cholestyramine, and S-adenosyl-L-methionine.¹

During pregnancy, using creams like aqueous cream with menthol is safe and can provide relief from itching.^1,3 If nighttime itchiness is a problem, an alternative to consider is antihistamine medication, like chlorphenamine.^1,3 This medication can also help with sleep issues because it tends to induce drowsiness.¹ It's important not to drive or operate machinery if you feel drowsy.

You might also be offered a vitamin K supplement. This is because OC can affect your ability to absorb vitamin K, which is essential for healthy blood clotting. Vitamin K supplements are usually suggested if you have pale-coloured stool, a known blood clotting disorder, or experience severe OC early in pregnancy. Under the guidance of healthcare professionals, regular monitoring ensures that the treatment plan remains tailored to the individual's needs.

Delivery and Postpartum Care

Determining the optimal timing for delivery is a delicate decision for women with obstetric cholestasis (OC).¹ Doctors might recommend early delivery in severe cases to mitigate the potential complications for the baby and mother.^1,3 However, there are also risks associated with premature birth, which should also be considered.^1,3 Different health boards have differing recommendations around timing for delivery in OC, so this decision should be made based on individual bases.^1,3 After childbirth, symptoms typically resolve, and no further treatment is necessary.^1,3  However, this is not always the case, so postpartum monitoring of liver function and bile acid levels ensures that any residual effects of the condition are promptly addressed.^1,3

Lifestyle and Home Management

Supplementing medical treatment with a health-conscious lifestyle can amplify the management of obstetric cholestasis (OC). Some mothers find that drinking plenty of water, as well as eating foods that are whole, fresh and unprocessed, reduces the severity of the itching.

Building a Support System

Coping with obstetric cholestasis (OC) can be a multifaceted challenge, impacting not only physical health but also emotional well-being. Partners play a pivotal role in offering emotional and practical support during this time. Engaging with support groups and connecting with fellow mothers who have navigated similar challenges can foster a sense of community and shared understanding. Employing strategies to manage stress and anxiety contributes to overall well-being.

Summary

Obstetric cholestasis (OC) is a liver disorder that occurs during pregnancy and causes blockage of normal bile flow out of the liver. OC serves as a reminder that while pregnancy is a beautiful journey, it can also present unexpected health concerns. By staying informed, seeking professional guidance, and fostering a robust support network, you empower yourself to make informed decisions that contribute to a safe and healthy pregnancy journey.
If you experience symptoms of OC, such as itching or jaundice, remember to contact a healthcare professional. OC can cause serious complications, but early intervention and medication would go a long way.^1,3,4 Creams, supplements and antihistamines could provide symptomatic relief, but it is important to consult your doctor before starting any medications while pregnant.^1,4 By prioritising your health and your baby's well-being, you can navigate OC with confidence, resilience, and hope.