What is obstetric cholestasis?
Obstetric cholestasis is a liver condition that only occurs in pregnancy. It is not known what causes it but it is believed to be related to the high levels of oestrogen that circulate in the blood stream during pregnancy. It is suggested that the oestrogen levels trigger a reduction in the flow of bile salts within the liver. This stagnation of flow or stasis results in an increase in the amounts of bile acids circulating in the blood which in turn creates the main symptom, which is itching of the skin. In some cases the amounts of bile acid in the blood stream can give rise to jaundice.
'The flow of bile salts within the liver is reduced'.
The principle concern with the condition is the impact that high bile acid levels might have on the developing foetus. High levels of bile acid could affect the foetus resulting in premature delivery. In very rare instances obstetric cholestasis could result in stillbirth. Even though this sad outcome is rare any woman with cholestasis would continue to be monitored throughout the pregnancy in order to establish that the foetus was developing normally.
What are the symptoms?
The most prominent symptom is itching. This usually affects the arms, hands, legs and feet. The itching usually disappears within a couple of weeks of the actual delivery and does not have any long-term effect on the mother's health.
In a normal pregnancy itching is quite common. However, with obstetric cholestasis the itching is usually confined to the limbs and is frequently worse at night. This can give rise to an ongoing disturbance of sleep, which can result in exhaustion for the mother. In some cases the high levels of bile acids may make some women feel generally unwell. Some may also feel nauseous and lose their appetite.
How is it detected?
Cholestasis can be detected by a blood test. The usual tests that are performed are a measurement of liver enzymes and bile acids. The liver enzymes indicate that actual damage to the liver cells has taken place but this is not a common outcome. Any elevation of liver enzymes usually reverses itself after the delivery.
The most important test is the measurement of serum bile acid. This may be elevated without the liver enzymes being affected. It is usually measured every few weeks to monitor trends and detect if the level is rising, falling or stabilising.
As part of the ongoing monitoring the blood clotting times are measured. Some women may have low vitamin k levels, which may require supplementation. Low vitamin k levels can result in prolonged clotting times with a resulting increased risk of bleeding at the time of the delivery.
How is it treated?
There are no specific licensed products available for the reversal of the stasis of bile acids during pregnancy. Research is being undertaken with certain drugs to establish if they can be used safely.
Steroids are sometimes used if delivery has to take place in advance of the expected date of delivery. They are primarily used for the baby's benefit since prematurely delivered babies can experience difficulties with their breathing. Steroids help to counteract this difficulty. Steroids also help to suppress the production of the hormones, which contribute to cholestasis and may help to relieve itching.
Some mothers have found that the following measures help to alleviate the itching associated with cholestasis:
- cold baths
- liberal application of calamine lotion to the itchy areas
- wearing loose fitting cotton clothing
Alcohol has no effect on obstetric cholestasis however it is wise to reduce alcohol intake during pregnancy or perhaps better still to avoid it altogether. Excessive alcohol consumption can have a damaging effect on the developing foetus.
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