Cholestasis of Pregnancy

What is Cholestasis of Pregnancy?

Bile is a fluid made by the liver that helps to digest  fats. Cholestasis of pregnancy is a liver disorder in which the release of bile from the liver is  blocked by high levels of the  hormones estrogen and progesterone during pregnancy. The bile  builds up in the blood causing itching. Cholestasis of pregnancy usually occurs in the second half of pregnancy, and  affects about one in 200 pregnancies. Cholestasis of pregnancy is also called intrahepatic cholestasis of pregnancy (ICP) and obstetric cholestasis.

Symptoms

Most women complain of itching. The itching usually begins on the palms of the hands and soles of the feet. The itching tends to be worse at night. Although there is no rash  as is seen with pruritic urticarial papules and plaques of pregnancy (PUPPP), intense scratching may leave multiple scrapes or abrasions. About 10% of  women with cholestasis of pregnancy may also develop  jaundice (yellowing of the skin or whites of the eyes). Dark urine and light colored stool (bowel movements) are uncommon symptoms.

Risk Factors

If you have any of the following you are at increased risk for cholestasis of pregnancy

  • A family history of cholestasis
  • A history of cholestasis in a prior pregnancy
  • A history of cholestasis  with use of oral contraceptives
  • You are presently carrying more than one baby (twins or triplets)
  • This pregnancy is the result of in-vitro fertilization (IVF)
  • You have hepatitis C


Diagnosis

Contact your doctor if you develop intense  itching or signs of cholestasis of pregnancy.

Cholestasis of pregnancy is diagnosed by physical examination, reviewing your history, and performing blood tests to evaluate how well your liver is working. Some blood tests that might be ordered to evaluate your liver function include serum bile acids, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and prothrombin time (PT) .

There are many medications and health conditions besides cholestasis of pregnancy that can cause itching and abnormal liver function tests. So make sure to take any medication you have been using,  and any medical records your doctor may not have  to your doctor's appointment.

The diagnosis of cholestasis of pregnancy is usually made if the following are present:

  • Itching
  • Elevated fasting bile acids  greater 10 μmol/L (or other liver function test).

Because some women may have itching for weeks before abnormal liver function tests develop, your doctor will often repeat the  tests every 1 to 2 weeks if your tests are normal.

Cholestasis of pregnancy can occur together with other diseases that cause similar symptoms. Your doctor may order more tests if there is chance you might have another disorder of pregnancy  such as pre-eclampsia or HELLP syndrome.


Effect On Pregnancy

Cholestasis of pregnancy increases the risk for premature delivery and stillbirth.  Some studies have found an increased chance for having  a low birth weight baby if the mother has cholestasis of pregnancy. In addition, bleeding in the mother may occur due to poor absorption of  vitamin K from the gut due to the lack of bile. The likelihood of having a complication appears to greatest for women with very high levels of bile acids.

Treatment

  • Ursodeoxycholic acid (Actigall, Urso); Usually 1000 mg or 15 mg /kg  per day in three divided doses is given to improve liver function and decrease itching

  • Calamine lotion and  Diprobase® cream  may help soothe your skin

  • Vitamin K , 5 mg orally once daily or Parenteral vitamin K (phytonadione; AquaMephyton) 5 to 10 mg/d IM QD may be prescribed in patients with an abnormal prothrombin time (PT)

  • Dandelion Root and Milk Thistle are natural substances that are thought by some to be  beneficial to the liver . However, there is not enough scientific evidence to support the safe use of Dandelion Root or Milk Thistle during pregnancy or breastfeeding at this time.

Management

  • Your baby's heart rate and movement will be monitored two times per week or more using an electronic monitor  starting at the time cholestasis of pregnancy is diagnosed. This test is called the Nonstress Test.  The fluid around the baby is often measured at the same time of the nonstress test.
  • Early  delivery at about 37 weeks' is recommended by some experts, especially in severe cases of cholestasis, in order to decrease the chances of a stillbirth.
  • After delivery you should be seen by your doctor to make sure the itching has gone away and your liver tests have return to their normal values.
  • The risk of developing cholestasis again in a future pregnancy is as high as 70 percent.

Support Groups

 

REFERENCES
http://obfocus.com/high-risk/Cholestasis/Cholestasis.htm
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