Cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy, commonly known as cholestasis of pregnancy, is a liver condition that can occur in late pregnancy. The condition triggers intense itching, but without a rash. Itching is usually on the hands and feet but also can occur on other parts of the body.

Cholestasis of pregnancy can make you very uncomfortable. But more worrisome are the potential complications, especially for your baby. Because of the risk of complications, your pregnancy care provider may recommend early term delivery around 37 weeks.

Intense itching is the main symptom of cholestasis of pregnancy. But there is no rash. Typically, you feel itchy on the palms of your hands or the soles of your feet, but you may feel itchy everywhere. The itching is often worse at night and may bother you so much that you can't sleep.

The itching is most common during the third trimester of pregnancy but sometimes begins earlier. It may feel worse as your due date gets near. But once your baby arrives, the itchiness usually goes away within a few days.

Other less common signs and symptoms of cholestasis of pregnancy may include:

• Yellowing of the skin and whites of the eyes, called jaundice
• Nausea
• Loss of appetite
• Oily, foul-smelling stools

When to see a doctor

Contact your pregnancy care provider right away if you begin to feel constant or extreme itchiness.

The exact cause of cholestasis of pregnancy is unclear. Cholestasis is reduced or stopped bile flow. Bile is the digestive fluid made in the liver that helps break down fats. Instead of leaving the liver for the small intestine, bile builds up in the liver. As a result, bile acids eventually enter the bloodstream. High levels of bile acids appear to cause the symptoms and complications of cholestasis of pregnancy.

Pregnancy hormones, genetics and the environment may all play a role.

• Hormones. Pregnancy hormones rise the closer you get to your due date. This may slow the flow of bile.
• Genes. Sometimes, the condition runs in families. Certain gene changes have been identified that may be linked to cholestasis of pregnancy.
• Environment. Although the exact environmental factors aren't clear, risk varies by geographic location and season.

Some factors that may increase your risk of developing cholestasis of pregnancy include:

• Personal or family history of cholestasis of pregnancy
• History of liver damage or disease, including hepatitis C and gallbladder stones
• Being pregnant with multiple babies
• Pregnancy at an older age, such as 35 years or older

If you have a history of cholestasis in a prior pregnancy, your risk of developing it during another pregnancy is high. About 60% to 70% of females have it happen again. This is called a recurrence. In severe cases, the risk of recurrence may be as high as 90%.

Complications from cholestasis of pregnancy appear to be due to high bile acid levels in the blood. Complications may occur in the mom, but the developing baby is especially at risk.

In moms, the condition may temporarily affect the way the body absorbs fat. Poor absorption of fat could result in decreased levels of vitamin K-dependent factors involved with blood clotting. But this complication is rare. Future liver problems may occur but are uncommon.

Also, cholestasis of pregnancy increases the risk of complications during pregnancy such as preeclampsia and gestational diabetes.

In babies, the complications of cholestasis of pregnancy can be severe. They may include:

• Being born too early, also called preterm birth.
• Lung problems from breathing in meconium. Meconium is the sticky, green substance that typically collects in the developing baby's intestines. Meconium may pass into the amniotic fluid if a mom has cholestasis.
• Death of the baby late in pregnancy before delivery, also called stillbirth.

Because complications can be very dangerous for your baby, your pregnancy care provider may consider inducing labor before your due date.

There is no known way to prevent cholestasis of pregnancy.

To diagnose cholestasis of pregnancy, your pregnancy care provider usually will:

• Ask questions about your symptoms and medical history
• Do a physical exam
• Order blood tests to measure the level of bile acids in your blood and to check how well your liver is working

The goals of treatment for cholestasis of pregnancy are to ease itching and prevent complications in your baby.

Ease itching

To soothe intense itching, your pregnancy care provider may recommend:

• Taking a prescription medicine called ursodiol (Actigall, Urso, Urso Forte). This medicine helps to lower the level of bile acids in your blood. Other medicines to relieve itching also may be an option.
• Soaking itchy areas in cool or lukewarm water.

It's best to talk to your pregnancy care provider before you start any medicines for treating itching.

Monitoring your baby's health

Cholestasis of pregnancy can potentially cause complications to your pregnancy. Your pregnancy care provider may recommend close monitoring of your baby while you're pregnant.

Monitoring may include:

• Nonstress testing. During a nonstress test, your pregnancy care provider will check your baby's heart rate, and how much the heart rate increases with activity.
• Fetal biophysical profile (BPP). This series of tests helps monitor your baby's well-being. It provides information about your baby's heart rate, movement, muscle tone, breathing movements and amount of amniotic fluid.

While the results of these tests can be reassuring, they can't predict the risk of preterm birth or other complications associated with cholestasis of pregnancy.

Early delivery

Even if prenatal tests are within standard limits, your pregnancy care provider may suggest inducing labor before your due date. Early term delivery, around 37 weeks, may lower the risk of stillbirth. Vaginal delivery is recommended by induction of labor unless there are other reasons a cesarean section is needed.

Future birth control

A history of cholestasis of pregnancy may increase the risk of symptoms returning with contraceptives that contain estrogen, so other methods of birth control are generally recommended. These include progestin-containing contraceptives, intrauterine devices (IUDs) or barrier methods, such as condoms or diaphragms.

Home remedies may not offer much relief for itching due to cholestasis of pregnancy. But it doesn't hurt to try these soothing tips:

• Cool baths, which may make the itching feel less intense
• Oatmeal baths, creams or lotions, which may soothe the skin
• Icing a particularly itchy patch of skin, which may briefly reduce the itch

Research into effective alternative therapies for treating cholestasis of pregnancy is lacking, so pregnancy care providers generally don't recommend them for this condition.

Several studies have looked at whether the supplement S-adenosyl-L-methionine (SAMe) might ease itching related to cholestasis of pregnancy. But data are conflicting. When compared with ursodiol in early trials, SAMe didn't work as well. It may be safe when used for a short time during the third trimester. But the risks to mother and baby aren't well known. Often, this medicine isn't recommended.

The safety of other alternative therapies hasn't been confirmed. Always check with your health care provider before trying an alternative therapy, especially if you're pregnant.

It's a good idea to be prepared for your appointment with your obstetrician or pregnancy care provider. Here's some information to help you get ready for your appointment, and what to expect.

What you can do

To prepare for your appointment:

• Make a list of any symptoms you have. Include all of your symptoms, even if you don't think they're related.
• Make a list of any medicines, vitamins, herbs and other supplements you take. Make note of doses and how often you take them.
• Have a family member or close friend go with you, if possible. You may be given a lot of information at your visit.
• Take a notebook with you. Use it to make notes of important information during your visit.
• Make a list of questions you'll ask. This can help you remember important points you want to cover.

Some questions to ask may include:

• What is likely causing my symptoms?
• Is my condition mild or severe?
• How does my condition affect my baby?
• What is the best course of action?
• What kinds of tests do I need?
• Are there any alternatives to the treatment that you're suggesting?
• Are there any restrictions that I need to follow?
• Will I need to have labor induced early?
• Do you have any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment or if you don't understand something.

What to expect from your doctor

To better understand your condition, your pregnancy care provider might ask questions, such as:

• What symptoms do you have?
• How long have you had symptoms?
• How bad are your symptoms?
• Can you feel your baby moving?
• Does anything seem to improve your symptoms?
• What makes your symptoms worse?
• Have you been diagnosed with cholestasis during any previous pregnancies?

Cholestasis of pregnancy can be a worrisome diagnosis. Work with your pregnancy care provider to make sure that you and your baby receive the best possible care for this condition.