What is it?
Obstetric cholestasis is a complication of pregnancy where pregnancy hormones (particularly oestrogen) affect the liver by preventing the flow of bile into the intestines. Bile usually aids with the breakdown and absorption of food after digestion, but when a women has obstetric cholestasis, bile and other toxins accumulate in the bloodstream.
Obstetric cholestasis usually begins in the final trimester in the last 10 weeks of pregnancy, although it can begin earlier. In Australia it affects less than 1 per cent of women. As it is seen in higher numbers in certain South American and Asian countries, it’s thought it is a genetic condition - especially considering that women are more likely to develop it if a family member, such as the mother or a sister, have also had it in their pregnancies.
Other people more susceptible to obstetric cholestasis include women who are expecting more than one baby, women with a history of alcohol abuse, and women who have had infections such as hepatitis or other conditions that affect the liver.
Women who had obstetric cholestasis in a previous pregnancy are also very likely to have it again in a subsequent pregnancy, and will be monitored carefully if they have more children.
What are the symptoms?
• The main symptom is itching. The itching usually occurs on the palms of the hands and the soles of the feet, but it can affect other areas of the body. It’s usually worse at night. It won’t cause a rash, as the itching is under the skin.
• Some women may also experience jaundice, a yellowing of the skin and the whites of the eyes, due to a build-up of a pigment called bilirubin. This can cause vitamin deficiency in both the pregnant woman and her unborn baby.
• Women may notice dark urine or pale stools, which are caused by the absence of bile that contributes to their usual colour.
• Sufferers may have urinary tract infections, caused by a build-up of liver enzymes.
• Although it can often be overlooked as a typical side effect of pregnancy, women with obstetric cholestasis can suffer from exhaustion and sluggishness, which can sometimes lead to depression.
How is it diagnosed?
Women should report any itching to their midwife or obstetrician, who can run tests to check for obstetric cholestasis. The tests will include blood samples to run a bile acid test and a liver function test.
Sometimes the tests will show a negative result, but if the itching doesn’t subside or if any other symptoms of are still present, or suddenly begin, the tests will need to be conducted again.
Some pregnant women will also need an ultrasound to check for gallstones. This condition can mirror many of the symptoms of obstetric cholestasis, as it blocks the flow of bile.
Keep in mind that itching is very common in pregnancy, due to the stretching of the skin and the extra production of oestrogen, so it is normal to be a little itchy.
What's the treatment?
Doctors may prescribe ursodeoxycholic acid – this boosts liver function and diminishes the itching. Steroids are also sometimes used, but aren’t as safe.
However, the only way for the condition to end completely is for the woman to give birth.
Does it affect the baby?
Obstetric cholestasis affects the baby because there is an increased risk of foetal distress and stillbirth. This could be due to several reasons:
• The bile acids crossing the placenta could causing the it to malfunction, and the baby could experience oxygen deprivation
• There’s a higher chance of the baby passing meconium (its first bowel movement) while still in the womb. This can lead to meconium aspiration, where the baby’s airways are blocked when the meconium leaks into the amniotic fluid.
For this reason pregnant women with obstetric cholestasis will usually deliver around 35-38 weeks of pregnancy. If the doctor deems the baby’s lungs to be strong enough, it can be induced around 37 weeks.
Frequent scans and foetal heart monitoring will be used to check on the progress of the baby, helping to prevent stillbirth.
Babies born to women with obstetric cholestasis may have a low birth weight if born premature, and may also be jaundiced. They can require a longer hospital stay so their health can be monitored.
Women who have had obstetric cholestasis have a slight risk of excessive bleeding and post-partum haemorrhaging during and immediately after childbirth. This is because vitamin K isn’t absorbed properly from the bile into the intestines during pregnancy, so the blood isn’t able to clot as well. For this reason, women with obstetric cholestasis will usually be given vitamin K on a regular basis while pregnant.
Vitamin K will also be given to the baby just after the birth, to help them build up their stores.
Syntocinon may also be given during the birth to help keep bleeding under control, particularly in the third stage of labour, when the placenta is delivered.
During pregnancy, women with obstetric cholestasis can benefit from maintaining a diet that doesn’t place any additional strain on their liver. This means avoiding foods that are high in fat, as well as alcohol (although pregnant women are advised to avoid these anyway). Drinking water can also help to flush out toxins.
Although the symptoms of obstetric cholestasis will usually disappear immediately or very soon after giving birth, additional tests may be ordered for women 6-12 weeks after giving birth. This is to check that obstetric cholestasis was in fact the cause of the problem, and that there are no other issues with the liver.
Women may be advised against taking contraceptives or other medications containing oestrogen in the future, as it increases the risk of obstetric cholestasis recurring in later pregnancies.
Facts verified by Dr Andrew Zuschmann. Dr Andrew Zuschmann is a Miranda-based fertility specialist, obstetrician and gynaecologist.