Obstetric cholestasis is not a common pregnancy condition. Obstetric cholestasis is a liver disease of pregnancy that usually appears in the last trimester with a complex aetiology including different elements such as genetic, environmental and endocrinological factors.
It is characterised by itching skin without the presence of rash and elevated concentrations of serum bile acids and serum transaminases, in the absence of other liver pathology. It usually disappears after birth.
The incidence varies widely, advising a geographical and seasonal environmental influence in some populations. This condition occurs in 0.5 – 0.8% of pregnant women in South Australian Aboriginal Culture. It has a recently recognised relationship with gestational diabetes and gallstones in women and their affected families. It has an increased incidence in women who are seropositive for hepatitis C, linked with early-onset disease
What causes obstetric cholestasis?
The exact cause is unknown.
Obstetric cholestasis has a genetic predisposition. This condition has a higher sensitivity to certain hormonal and environmental factors in the last trimester of pregnancy
Oestrogen is the most critical hormonal precipitant. Obstetric cholestasis usually develops when placental oestrogen synthesis is at its highest level and solves soon after birth
Severe obstetric cholestasis is defined when the serum bile acids are greater than 40 micromoles /L) and may be associated with increased fetal morbidity and mortality.
Symptoms of obstetric cholestasis
The main symptom of OC is itching, often on the palms of the hands and soles of the feet. It usually happens from around 28 weeks, more commonly in multiple pregnancies.
Other symptoms are sleep disturbance, dark urine, pale stools, jaundice (rare), malaise and anorexia. It is common to have excoriations (scratch marks) on physical examination, while the presence of a rash is unusual. When it is present the doctor will consider other conditions.
The diagnosis is made by a health practitioner taking into consideration the symptoms, signs and physical examination. Also, it will be necessary to perform some laboratory test with the aim to identify the cause. Some of the laboratory tests are the following
– Serum bile acids. This blood component is increase
– Other blood test disturbances include abnormalities in liver function tests, such as aminotransferases [ALT, AST], gamma-glutamyl transferase [γGT] and bilirubin. Prothrombin time (INR) can be prolonged in severe cases
The management of this condition involves the antenatal period, the intrapartum period and the postpartum period.
Generally, pregnant women do not need to be admitted to the hospital except in cases of severe elevation of the concentration of serum bile acids in the blood.
If the diagnosis was made about 37 weeks, delivery should be considered. If the diagnosis is made before the 37 weeks, then close monitoring of clinical symptoms, liver function and fetal wellbeing is commenced and preparations made for possible early delivery.
The baby should be monitored continuously. Any decrease/absence of fetal movements should be reported.
Ursodeoxycholic acid (UDCA) has been proved to reduce itching. It has also shown benefit in small studies to improve liver function in obstetric cholestasis.
Some agents (including activated charcoal and cholestyramine) have been used to bind bile acids in the intestine and thus get rid of them. These agents have potential adverse effects for mothers due to the depletion of vitamin K, required for blood clotting; as a result, parenteral Vitamin K may be necessary
Antihistamines are useful in relieving pruritus
The itching or pruritus will usually disappear 1-2 days after birth and serum bile acid concentrations should become normal within the first week.
A general practitioner will review at one month postnatal to check bile acids and liver function. Then the woman should be evaluated after six weeks postpartum to assess if any biochemical abnormalities persist. The likelihood of recurrence in a subsequent pregnancy is of the order of 70-90%. Estrogen containing contraceptives should be avoided.
You can make an appointment with Dr Kenny on 07 3188 5000.
This article is written to be informative and does not substitute seeking a professional consultation from a medical professional.
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