Obstetric cholestasis (OC) or intrahepatic cholestasis of pregnancy (ICP) is a rare liver condition that affects 0.5% to 2% of pregnant women (1). The condition is more commonly seen in Araucanian Indians and females of Scandinavian ancestry (2). Women dealing with ICP have reduced bile flow in the intestine, which eventually accumulates bile salts in the blood, causing itchy skin and other symptoms. ICP can occur due to several reasons, but the symptoms disappear after delivery in most cases. This post informs you about ICP, including its causes, symptoms, diagnosis, treatment options, and recommended dietary changes to manage it.
What Is Obstetric Cholestasis?
Obstetric cholestasis is a condition that reduces the normal outflow of bile from the liver. Normally, the liver produces bile, which flows through the bile ducts into the intestine, where it helps in digesting the food. But in the case of obstetric cholestasis, the bile flow into the intestines is reduced. This builds up the bile salts, which leaks into the bloodstream and increases the amount of bile salts in the blood. The excess salts make your skin very itchy, causing a condition called pruritus. This usually occurs in the last three months of pregnancy, and sometimes even sooner. But the good thing is that raised bile salts and pruritus disappear after delivery, and do not cause any long-term complications for the mother or the baby (3).
What Causes Obstetric Cholestasis?
The exact cause of cholestasis during pregnancy is not known. However, it is known to be affected by the following factors (4): Whatever is the cause, this condition occurs only during pregnancy.
What Are The Symptoms and Signs Of Intrahepatic Cholestasis Of Pregnancy/ Obstetric Cholestasis?
The most common symptom of obstetric cholestasis is itching, which usually develops without a rash. It may start after 24 weeks of pregnancy, when the hormone levels are at their peak. However, most women may have severe itching during last trimester of pregnancy. The following characteristics of itching can be seen during cholestasis of pregnancy.
It occurs on the palms and soles, but it can also affect other areas of the body. The itching gets worse at night and tends to worsen, until you have your baby. The itch can be mild to severe. Severe itching can affect your sleep pattern, your mood, and concentration.
Other symptoms, although rare, include (5) :
Tiredness Feeling sick or ill Dark urine color Pale stools Food aversions Mild jaundice, characterized by yellow urine, skin, or whites of the eye Pain around the liver, usually in the right upper quadrant Nausea Depression Fatigue
Occasional, mild itching is normal. But if you develop a constant itch that turns worse in combination with the above symptoms, you should see your doctor immediately.
How Is Obstetric Cholestasis Diagnosed?
Obstetric cholestasis is diagnosed through blood tests. Your doctor will discuss your symptoms, your family history, and medical history, and recommend some tests to measure the bile acids and liver enzymes. These tests will check for obstetric cholestasis and also detect other causes of itching. Sometimes bile acid levels rise while the ALT and AST remain normal. In other cases, the liver enzymes will rise, and bile acids remain normal. In both cases, your bile acids are tested if there is recurrent itching (7).
What Are The Risks Of Obstetric Cholestasis?
For the mother-to-be Obstetric cholestasis can lead to vitamin K deficiency and affect the body’s ability to clot blood. There is an increased risk of bleeding as it takes a longer time to stop. However, the research behind this is indefinite. Your doctor will suggest vitamin K supplements to treat the clotting problem (8). You may undergo more antenatal appointments so that the doctor can examine you carefully. The medical tests involve:
Tracking the baby’s movements Listening to the baby’s heartbeat Ultrasound scans to monitor the growth and well-being of the baby
For the unborn baby
Your baby may pass their first stool (meconium) while still in the womb. It could, therefore, cause breathing problems post birth. You may go into preterm labor if your doctor advises an early delivery. There is an increased risk of stillbirth, which is why the doctor suggests induced labor at around 37 to 38 weeks (9).
Your doctor will decide about the induced labor depending upon the blood tests and bile acid levels in the blood. If obstetric cholestasis is too severe, you may have to induce your labor before 37 weeks (10).
How Is Obstetric Cholestasis Treated?
The primary goal of the treatment is to relieve itching. The following measures may help to alleviate itching associated with obstetric cholestasis (11):
Cold water baths Soaking feet and hands in ice water Applying calamine lotion on itchy regions Image: Shutterstock Applying creams containing extracts of calendula and chamomile. These are said to reduce itching and redness caused during pregnancy. Using mild soaps and detergents Choosing mild bath shower gels instead of heavy, perfumed ones containing harsh formulations Avoiding hot water baths Wearing loose-fitting and cotton clothes Following a healthy balanced diet (cut down on oily and fatty foods) Resting whenever you get tired Avoiding hot and humid weather conditions Avoiding alcohol and drugs as they are toxic to the liver and cause irreversible damage to it
The above measures can offer temporary relief, especially before bedtime, so that the itch may ease and allow you to have a good night’s sleep.
Medical Treatment For Managing Cholestasis During Pregnancy
Medication is usually aimed at decreasing the bile salt levels, relieving itching, and protecting the baby. Your doctor is likely to prescribe the following medications for obstetric cholestasis.
Ursodeoxycholic acid (ursodiol), which eliminates the itching, and normalizes the liver and bile acids (11). Steroids (dexamethasone) with careful management. They aid in the maturity of the baby’s lungs (12). Vitamin K supplements to help with blood-clotting (6).
Note: Do not use antihistamines, aveeno, and oatmeal baths.
Diet For Intrahepatic Cholestasis
The primary goal of the pregnancy cholestasis diet is to place less strain on the liver, and for that, you should be taking foods containing lecithin, which is unsaturated fat that helps absorb fats in the bile. A low-fat diet may make it easy for the intestine to absorb vitamins and minerals from the food. Include:
A mix of organic fruits and vegetables with colorful pigments such as carrots, beets, potatoes, pumpkin, red cabbage, and cauliflower for easy digestion. Foods containing omega-3 fatty acids (tuna, salmon, mackerel, sardines, shrimp, oysters, linseed, and cod liver oils) and omega-6 fatty acids (leafy greens, nuts, fish, and soybeans) to combat illnesses. High protein foods including, nuts, beans, fish, and eggs. A low-fat diet of rice, wheat, corn, oats, and rye. Virgin olive oil, sunflower oil, and canola oil. Healthy alternatives such as honey spread, hummus, and fruit jams. More water to flush away toxins from the system. Fresh lemon juice in warm water to neutralize the bile acids.
This diet helps minimize bile production in the liver and promotes liver health. Besides a healthy diet, other natural remedies can be used to deal with obstetric cholestasis.
Natural Remedies For Obstetric Cholestasis
Before going for medical treatment options, you can try the following measures to lower the discomfort associated with obstetric cholestasis. These remedies also reduce the chances of developing the condition. Do check with your doctor about them. While taking these measures helps manage the condition better, medical supervision is necessary for a few weeks to months, even after delivery.
Obstetric Cholestasis Or Intrahepatic Cholestasis Of Pregnancy After Delivery
A follow-up check-up is done around six to eight weeks after the baby is born. Your doctor will check if the itch is still there and if the liver is working normally.
If you are using birth control pills, you may be told to stop them as the estrogen in them can trigger the cholestasis again. The doctor may suggest an alternative contraceptive. You may be at risk of developing chronic liver disease and gallstones in later life. There is a 45-70% chance that obstetric cholestasis recurs during subsequent pregnancies (4).
Foods with a high amount of sugar or artificial sweeteners White flour and soy products Processed meats Eat dairy products in small portions and avoid full-fat milk, cream, and cheese Foods with high caffeine content
