Leeds Maternity Care

nThe Leeds

Teaching HospitalsNHS Trust

Obstetric Cholestasis

Information for patients

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This leaflet is about obstetric cholestasis and how it affects the liver during pregnancy.

What is obstetric cholestasis?Obstetric cholestasis is a condition that affects the liver during pregnancy. This means that there is a build-up of bile acids (a substance made by the liver to breakdown dietary fats) in the blood. The main symptom is itching with no skin rash. The condition improves after you deliver the baby. Obstetric cholestasis does not have any serious consequences for your long term health.

Obstetric cholestasis is not common. It affects about 7 in 1000 women (less than 1%). Obstetric cholestasis is more common in women of Indian or Pakistani origin with 15 in 1000 (1.5%) women affected.

What causes obstetric cholestasis?The cause of obstetric cholestasis is poorly understood but it is thought that hormones and genetic factors may be involved.

Hormones such as oestrogen are much higher in pregnancy and may affect the way the liver works causing obstetric cholestasis.

Genetic factors are that obstetric cholestasis appears to run in some families. Also if you have had the condition once you are more likely to have it again in a future pregnancy.

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What are the symptoms of obstetric cholestasis? • Itching - is the most common symptom and can start at any

time during the pregnancy but more often, it begins after 28 weeks. It usually starts on the palms of the hands and the soles of the feet, however, it may spread over the arms and legs. It can vary from mild to intense and persistent. The itching tends to be worse at night which can disturb sleep. There is no rash with obstetric cholestasis, but some women can scratch so intensely that the skin breaks and bleeds.

• Jaundice - some women with obstetric cholestasis can develop jaundice (yellowing of the skin caused by build-up of bile acids in the blood). Some women feel unwell and lose their appetite. Jaundice can also cause the passage of pale stools and dark urine.

What does it mean for my baby? • Increased chance that your baby will be born early - one in

10 women with obstetric cholestasis will have their baby before 37 weeks of pregnancy. This includes women who have their labour induced.

• Increased chance that the baby will pass meconium (open its bowels) before being born - this makes the fluid around the baby a green or brown colour and means that closer monitoring of the labour will be required.

• Risk of stillbirth - some research conducted many years ago suggested that stillbirths may be more common in women with obstetric cholestasis. More recent research has shown that actually the risk of stillbirth is the same as women without obstetric cholestasis (1 in 200).

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It is difficult to know, however, if this is due to a general improvement in obstetric and neonatal care or early induction of labour.

How is obstetric cholestasis diagnosed?Women with unexplained itching in the last part of pregnancy (after 24 weeks) will be tested for obstetric cholestasis. The tests include blood tests (liver function and bile acids) and an ultrasound scan of the liver. The diagnosis of obstetric cholestasis is made once other causes of itching and abnormal liver function have been ruled out.

• Inspection of the skin - this is to check that your itching is not related to other skin conditions such as allergies or eczema. It is possible that you could have more than one condition.

• Blood tests

- Liver function tests to look at how the liver is working. - Bile acids to measure the level of the bile acids in your blood. This can be abnormal even if your liver function tests are normal. - Hepatitis B and C, CMV, EBV screen - these are viral infections that can affect the function of the liver. - Autoimmune antibody screen - there are some autoimmune conditions that can affect the function of the liver.

• Some women may have itching for days or weeks before their blood tests become abnormal. If itching persists and no cause found, the liver function tests should be repeated every 1 - 2 weeks.

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• Ultrasound scan - an ultrasound scan of the liver to check for liver abnormalities and gallstones.

What extra care will I need?Once diagnosed with obstetric cholestasis, you should be under the care of a consultant and have your baby in a consultant led maternity unit with a neonatal unit.

You will need to have your liver function checked usually once a week until you have had your baby.

You will also be offered ultrasound scans for growth and measuring the amount of fluid around the baby every 4 weeks.

During labour you will be offered continuous monitoring of the baby’s heart rate.

What is the treatment for obstetric cholestasis?There is no cure for obstetric cholestasis except the birth of your baby. Treatment may ease the symptoms for most women.

Treatments include:

• Skin creams and ointments to relieve the itching. These are safe in pregnancy and many provide temporary relief.

• Some women have found that having cool baths and wearing loose fitting clothing helps to reduce the itching.

• Antihistamines (chlorphenamine) may help the symptoms of itching but only take those prescribed by a doctor as not all anti-histamines are recommended in pregnancy.

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• Ursodeoxycholic acid reduces the level of bile acids in the blood and improves liver function. It may also help reduce the itching. There is not enough evidence to say whether ursodeoxycholic acid affects the chances of pregnancy loss and whilst there is not enough evidence that it is completely safe for your baby, it does not appear to be harmful to the baby and it is commonly prescribed for obstetric cholestasis.

• Vitamin K helps the clotting mechanisms in your blood, which can be affected by having obstetric cholestasis. If your blood clotting time is prolonged, it is recommended that you take a daily dose of vitamin K to prevent complications if you start to bleed.

• After birth, Vitamin K is also offered routinely to all babies.

When is the best time for delivery of my baby?You will have an opportunity to discuss the option of having your labour induced after 37 weeks of pregnancy, particularly if your symptoms are severe or your blood tests are very abnormal. Earlier induction of labour (before 37 weeks) may carry an increased risk of caesarean section and an increased chance of your baby being admitted to the special care baby unit for a time. It is difficult to predict the risk of stillbirth if your pregnancy continues beyond 37 weeks. Your obstetrician will discuss what is best for you and your baby so that you can make an informed choice.

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What will happen after the pregnancy? • Obstetric cholestasis gets better after the birth of your baby.

You will stop all your medication when the baby is born. You should have your liver function checked again 10 days after giving birth. This can be done by your GP. Continuing symptoms and abnormal liver function tests may suggest a different problem after all and you should then be referred to a liver specialist.

• If you have had obstetric cholestasis it is better to avoid oestrogen containing contraceptive pills and you will need to discuss alternative forms of contraception with your midwife or GP.

• There is a high chance that obstetric cholestasis may happen again in a future pregnancy; 45-90 in 100 (45-90%) of women who have had obstetric cholestasis will develop it again in future pregnancies.

Resources

• RCOG Green-top Guideline Obstetric Cholestasis April 2011

• RCOG Obstetric Cholestasis Patient Information Leaflet May 2012

LN004089Publication date

10/2017Review date

10/2020

© The Leeds Teaching Hospitals NHS Trust • 1st edition (Ver 1.0)

Developed by: Lydia Yusuf - ST5, Obstetrics and Gynecology

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