Cholestasis of pregnancy

Cholestasis of pregnancy occurs in late pregnancy and triggers intense itching, usually on the hands and feet but often on many other parts of the body.

Cholestasis of pregnancy can make you intensely uncomfortable but poses no long-term risk to an expectant mother. For a developing baby, however, cholestasis of pregnancy can be dangerous. Doctors usually recommend early delivery.

The term “cholestasis” refers to any condition that impairs the flow of bile — a digestive fluid — from the liver. Pregnancy is one of many possible causes of cholestasis. Other names for cholestasis of pregnancy include obstetric cholestasis and intrahepatic cholestasis of pregnancy.

Intense itching is the predominant symptom of cholestasis of pregnancy. Most women feel itchy on the palms of their hands or the soles of their feet, but some women feel itchy everywhere. The itching is often worse at night and may be distressing enough that you can’t sleep.

The itching is most common during the third trimester of pregnancy, but sometimes begins earlier. It may feel worse as your due date approaches. Once your baby arrives, however, the itchiness usually goes away within a few days.

Other less common signs and symptoms of cholestasis of pregnancy may include:

• Yellowing of the skin and whites of the eyes (jaundice)
• Nausea
• Loss of appetite

When to see a doctor

Contact your pregnancy care provider promptly if you begin to feel persistent or extreme itchiness.

What causes cholestasis of pregnancy is unclear. There may be a genetic component, as the condition sometimes runs in families and certain genetic variants have been associated with it.

Pregnancy hormones also may play a role. Bile is a digestive fluid produced in the liver that helps the digestive system break down fats. It’s possible that the increase in pregnancy hormones — such as occurs in the third trimester — may slow the normal flow of bile out of the liver. Eventually, the buildup of bile in the liver allows bile acids to enter the blood stream. Bile acids deposited in the mother’s tissues can lead to itching.

Factors that increase the risk of developing cholestasis of pregnancy include:

• A personal or family history of cholestasis of pregnancy
• A history of liver disease
• A twin pregnancy

Some of these factors may have to do with heredity, and all probably have to do with increased levels of pregnancy hormones. After you’ve had the condition once, the risk of developing it during a subsequent pregnancy is high. About half to two-thirds of women experience recurrence of cholestasis of pregnancy.

For mothers, cholestasis of pregnancy may temporarily affect the way the body absorbs fat-soluble vitamins, but this rarely impacts overall nutrition. Itching usually resolves within a few days of delivery, and subsequent liver problems are uncommon — although cholestasis is likely to recur with other pregnancies.

For babies, the complications of cholestasis of pregnancy can be more severe. For reasons not well-understood, cholestasis of pregnancy increases the risk of the baby being born too early (preterm birth). It also increases the risk of meconium — the substance that accumulates in the baby’s intestines — getting into the amniotic fluid that surrounds the baby. If a baby inhales meconium during delivery, he or she may have trouble breathing. There’s also a risk of fetal death late in pregnancy. Because of the potentially severe complications, your doctor may consider inducing labor around the 37th week of pregnancy.

It’s a good idea to be well-prepared for your appointment with your obstetrician or pregnancy care provider. Here’s some information to help you get ready for your appointment, and what to expect from your pregnancy care provider.

What you can do

To prepare for your appointment:

• Write down any symptoms you’re experiencing. Include all of your symptoms, even if you don’t think they’re related.
• Make a list of any medications, vitamins and other supplements you take. Write down doses and how often you take them.
• Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
• Take a notebook or notepad with you. Use it to write down important information during your visit.
• Think about what questions you’ll ask. Write them down so you won’t forget important points you want to cover.

For cholestasis of pregnancy, some basic questions to ask your pregnancy care provider include:

• What is likely causing my symptoms?
• Is my condition mild or severe?
• Is it safe to continue the pregnancy?
• How does my condition affect the baby?
• What is the best course of action?
• What kinds of tests do I need?
• What are the alternatives to the primary approach that you’re suggesting?
• Are there any restrictions that I need to follow?
• Will it be necessary to induce early labor?
• Do you have any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you’ve prepared, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor

To better understand your condition, your pregnancy care provider might ask several questions, such as:

• What symptoms are you experiencing?
• How long have you been experiencing symptoms?
• How severe are your symptoms?
• Has your baby been active?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you been diagnosed with cholestasis during any previous pregnancies?

To diagnose cholestasis of pregnancy, your pregnancy care provider may:

• Ask questions about your symptoms and medical history
• Perform a physical exam
• Send blood samples for lab testing to evaluate how well your liver is working and measure the amount of bile salts in your blood.

Treatment for cholestasis of pregnancy aims to relieve itching and prevent complications.

Relieving itching

To soothe intense itching, your pregnancy care provider may recommend:

• Taking the prescription medication ursodiol (Actigall, Urso), which helps decrease the level of bile in the mother’s bloodstream, relieves itchiness and may reduce complications for the baby
• Soaking itchy areas in lukewarm water

You might be tempted to take an antihistamine or use an anti-itch (corticosteroid) cream to relieve the intense itching associated with this condition. Antihistamines are often ineffective and may pose risks to your developing baby. And if they do work, you may not feel the need to see your pregnancy care provider, delaying effective diagnosis and treatment. Corticosteroid creams and lotions don’t work to relieve the itching of cholestasis of pregnancy. In addition, using too much corticosteroid cream may pose a risk to the baby.

Preventing complications

Because complications related to the baby’s health can be serious, your pregnancy care provider may recommend close monitoring of your baby during pregnancy. Measures your pregnancy care provider might take include:

• Nonstress tests and biophysical profile scores. These tests help monitor your baby’s well-being. During a nonstress test, your pregnancy care provider will check how often your baby moves in a certain period of time and how much his or her heart rate increases with movement. The biophysical profile provides information regarding the volume of amniotic fluid, as well as fetal muscle tone and activity. While these tests can be reassuring, they can’t really predict the risk of preterm birth or other complications associated with cholestasis of pregnancy.
• Early induction of labor. Even if the prenatal tests appear normal, your pregnancy care provider may suggest inducing labor early — around 37 weeks or so. Because it’s hard to predict when fetal death might occur, early delivery is sometimes the best and only way to prevent complications.

Unfortunately, itching due to cholestasis of pregnancy isn’t very responsive to home remedies. To relieve itching, you might try:

• Warm baths, which seem to lower the intensity of the itching for some women
• Icing a particularly itchy patch of skin, which may temporarily reduce the itch

Research into effective alternative therapies for treating cholestasis of pregnancy is lacking, so doctors and other pregnancy care providers generally don’t recommend alternative therapies.

One alternative therapy being studied for cholestasis of pregnancy is S-adenosyl-L-methionine (SAMe), a naturally occurring substance. You can get it through an injection into your muscle or through a vein (intravenously). Some evidence suggests that it may help relieve itching, though the risks to mother and baby of such an approach aren’t well known. When compared with ursodiol in preliminary trials, SAMe wasn’t as effective. Given that the way you take the medicine can be uncomfortable and inconvenient, its safety is unknown, and it doesn’t appear to work as well as other more established medicines, doctors are hesitant to recommend it as a treatment.

Other alternative therapies, including guar gum, activated charcoal, milk thistle and dandelion root, are also being studied, but there’s no evidence that these therapies work or are safe for pregnant women to take.

Always check with your doctor or health care provider before trying an alternative therapy, especially if you’re pregnant.

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