Pregnancy / 19 July, 2021 / Dr Ellie Rayner
Intrahepatic cholestasis of pregnancy (ICP), also more commonly known as Obstetric Cholestasis is an uncommon liver disorder that can occur during pregnancy. It is caused by a build-up of bile acids in your body. Normally, bile passes down the bile ducts in the liver aiding with digestion. In Obstetric Cholestasis there a reduced flow, causing the bile acids to leak out into your bloodstream.
In the UK around 7 in every 1000 women experience the condition, which is less than 1%. It can run in families and it is seen twice as commonly in women of Indian- Asian or Pakistani-Asian origin, affecting around 15 in every 1000 women. We don’t yet fully understand the cause, but there is thought to be genetic, hormonal and environmental factors that increase the chance of the condition occurring.
It is most common for obstetric cholestasis to develop after 28 weeks of pregnancy, with the main symptom being itching, without a rash. Itching can occur for many reasons in pregnancy, but in obstetric cholestasis, although it can be anywhere on the body, it is more common on the palms of the hands and soles of the feet. It tends to be worse at night and because it varies from mild to very severe it can disturb your sleep, resulting in you feeling tired during the day. The itching usually is not associated with a rash, although it can be so intense, that you skin may break and bleed from scratching.
Some women may also develop a yellowing of the skin called jaundice. This can cause you to feel unwell, lose your appetite and may even cause your urine to be very dark and your bowel movements to be very pale. You may also notice pain and discomfort in the upper right side of your tummy or radiating to your back.
If you notice any of these symptoms it is important you speak to your midwife or doctor. They will have a look at the area of skin you are finding itchy to ensure this isn’t related to any other skin conditions. Obstetric Cholestasis is diagnosed after your healthcare professional rules out any other causes of itching. They will usually recommend blood tests to look at the function of your liver and to measure the level of bile acids within your blood. Depending on your history, they may also recommend further blood tests or scans to look for other causes such as infection or underlying pre-existing liver problems. If your bile acid level or liver function tests are abnormal your midwife or doctor will arrange an appointment to discuss the condition in full and make a plan for the rest of your pregnancy with you.
It can take time for the results to become abnormal, so even if your results are normal initially, if you continue to have symptoms you should mention this to your midwife, and they should recheck your blood tests every week or two.
Once obstetric cholestasis has been diagnosed, if your pregnancy has been previously low-risk under midwifery-led care, you will be transferred to consultant-led care and be seen by an obstetrician, a doctor who specialises in pregnancy, labour and birth.
They will recommend additional monitoring of your pregnancy which may include extra antenatal appointments and ultrasound scans for fetal growth and measuring the amount of amniotic fluid around your baby. They will also recommend you have your baby at your local maternity hospital consultant-led unit, often called a labour ward or delivery suite and that during your labour your baby’s heart rate is listened to using continuous fetal monitoring using a CTG (cardiotocography) machine. This is because unfortunately, obstetric cholestasis can cause increased risks to your baby during pregnancy. These include an increased chance your baby could pass meconium (their first poo), during your pregnancy before they are born which can lead to complications with breathing after birth and may increase the chance of needing to go to the neonatal unit. An increased risk of a premature birth of around 1 in 10 women before 37 weeks.This may be a spontaneous preterm labour, or because you are recommended to be induced.
Previous research also showed there was a higher risk of having a stillbirth if you were diagnosed with obstetric cholestasis however, more recent studies have suggested the risk is only increased if your bile acids are at much higher levels than previously thought/used. Your midwife and obstetrician will monitor your pregnancy closely and may offer you an induction of labour to reduce the chance of this happening depending on your circumstances.
There is no cure for obstetric cholestasis, but it should go once you’ve had your baby. Treatment is designed to improve your symptoms until your baby is born. Loose-fitting clothes, cool baths and showers may help. Your doctor may offer you conservative treatment initially such as skin creams and ointments to help relieve the itching. If this doesn’t work, some women may be recommended to take an antihistamine to help them sleep at night. Urosdeoxycholic Acid (UDCA) is often prescribed as this sometimes improves your itching, liver function and bile acid levels. This is commonly prescribed in pregnancy, although it is unlicenced, and research is ongoing as to whether this will help reduce the chance of stillbirth. You may also be recommended to take vitamin K tablets daily as obstetric cholestasis may cause a problem with the clotting mechanism in your blood and vitamin K can treat this.
After birth you will be recommended to have your liver function checked with your GP to ensure it has returned/is returning to normal. In a future pregnancy, there is a 45-90% chance of obstetric cholestasis occurring again.
If you would like any more information check out the Royal College of Obsteticians and Gynaecologists patient information section.
Dr Ellie Rayner is a practicing Obstetrician and Gynaecologist and founder of The Maternity Collective. She is the only Obstetrician to offer private and group, expert-led Antenatal and Hypnobirthing Classes both Online and face-to-face. She is passionate about providing parent-centred, evidence-based care for all pregnancies and supports all methods of birth.
Follow Dr Ellie Rayner @maternitymedic for the latest evidence-based information on pregnancy, birth and women’s health issues.
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