What is obstetric cholestasis?

The vast majority of women will experience some degree of itching during their pregnancy, thought mainly to be due to the increased levels of hormones circulating your body.  However, in some cases itching can be a sign of a more serious condition called Obstetric Cholestasis.

What is obstetric cholestasis?

Obstetric Cholestasis is sometimes referred to as Intrahepatic Cholestasis of Pregnancy (ICP).

ICP, or obstetric cholestasis, is a liver condition caused by a build up of bile acids that do not flow correctly in pregnancy and build up in the system.

In severe cases of ICP where the bile acid levels raise above 40µmol/L the risk of still birth is said to increase from 0.4 in every 100 births to 1 or 2 in every 100.

Given this increase, you may be offered induction of labour a little earlier and will be advised to have your baby in hospital.  During labour your baby would be continuously monitored on the Cardiotocograph (CTG) machine to ensure that all is well.

Signs and symptoms of obstetric cholestasis

Itching during pregnancy is often the only recognisable symptom of obstetric cholestasis. If you experience severe itching during pregnancy, you should contact your pregnancy care provider immediately and seek medical advice.

This itching will typically begin on arms, legs, hands and feet. It could also affect other parts of the body such as the face, back and breasts. Itching caused by obstetric cholestasis often won’t be accompanied with a rash. Though, women experiencing ICP-related itching could cause rashes or bleeding from severe scratching.

Symptoms of ICP also often seem heightened at night.

It’s worth mentioning that itching isn’t uncommon during pregnancy. Your body is changing and skin can become sensitive due to pregnancy. However, it is always best to check that your itching isn’t a sign of something more serious, such as ICP. If you are suffering from significant itching, please speak to your midwife.

When to call your midwife or doctor

If you are experiencing itching, you should speak to your midwife and doctor about getting an obstetric cholestasis diagnosis.

Your doctor will then likely ask about your medical and family history to aid diagnosis. If close female family members have also been affected by ICP in the past, you could be at increased risk. So, be sure to speak to your close family members to see if any of them had experienced ICP during pregnancy.

During the obstetric cholestasis diagnosis, your doctor should also be able to rule out any other potential causes of itching such as eczema or allergies

Your doctor will likely send you for liver blood tests and a serum bile salt test to diagnose the presence of ICP.

These tests will test how your liver is functioning and can help to rule out any other liver conditions. As part of a test for ICP, your doctor will be looking for abnormal levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). The levels of gamma-glutamyl transferase (GGT) may also be monitored and reported on during this diagnosis.

As ICP is caused by an increase in bile, tests measuring serum bile salt are also an important part of obstetric cholestasis diagnosis. However, this test isn’t available at all hospitals.

In most cases, both ALT and bile salt levels will be higher than normal levels. Sometimes, an initial test may only notice increases in one of these. If the liver blood tests are within the normal limits and you continue to experience itching, make sure you request repeat tests.

If ICP is confirmed you will be offered regular blood tests to check your liver function and bile acid levels.  If these levels become too high you may be advised to have an induction of labour.

Treatment

There is no cure for ICP. If you are diagnosed with ICP, you will have regular liver function tests to monitor your condition.

Weekly bile acid measurements can also help doctors advise when your baby should be born, and whether you may need to be induced early due to ICP.

There are some creams such as aqueous cream which can help relieve the itching symptoms.

You may be prescribed a drug called Ursodeoxycholic Acid (UDCA) which can help to reduce the itching and bile acid levels. However, such medications have not been properly tested in pregnancy so these should only be prescribed on an “informed consent” basis.