Cholestasis of pregnancy

Definition

Cholestasis of pregnancy occurs in late pregnancy and triggers intense itching, usually on the hands and feet but sometimes on other parts of the body. Cholestasis of pregnancy can be intensely uncomfortable but poses no long-term risk to the mother. Cholestasis of pregnancy can be dangerous for a developing baby, however. Early delivery is usually recommended.

The term "cholestasis" refers to any condition in which the flow of bile, a digestive fluid from the liver, slows or stops. Pregnancy is one of many possible causes of cholestasis. Other names for cholestasis of pregnancy include obstetric cholestasis and intrahepatic cholestasis of pregnancy.

Symptoms

Signs and symptoms of cholestasis of pregnancy may include:

• Intense itching
• Dark-colored urine
• Light-colored bowel movements
• Yellow eyes or skin

Often, however, intense itching — particularly on the palms of the hands and the soles of the feet — is the only symptom of cholestasis of pregnancy. The itching may be worse, even intolerable, at night. The itching is most common during the third trimester of pregnancy, but sometimes begins earlier.

When to see a doctor
Contact your health care provider if you develop any signs or symptoms of cholestasis of pregnancy.

Causes

The cause of cholestasis of pregnancy is unknown. However, the condition may be related to pregnancy hormones.

Bile — a digestive fluid that helps the body break down fats — is produced in the liver and stored in the gallbladder. Pregnancy hormones can affect how well the gallbladder functions. Sometimes, pregnancy hormones slow or even stop the flow of bile. Eventually, this excess bile may enter the bloodstream. This is cholestasis of pregnancy.

Risk factors

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

• A personal or family history of cholestasis of pregnancy
• A history of liver damage
• A twin pregnancy
• A pregnancy achieved by in vitro fertilization

After you've had the condition once, the risk of developing it during a subsequent pregnancy may be as high as 70 percent.

Complications

For mothers, cholestasis of pregnancy may temporarily hinder the absorption of fat-soluble vitamins. 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 much more severe. For reasons not well understood, cholestasis of pregnancy increases the risk of preterm birth and meconium — a substance that lines the baby's intestines during pregnancy — in the amniotic fluid. 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, labor is typically induced early.

Preparing for your appointment

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; list the most important questions first, in case time runs out.

For cholestasis of pregnancy, some basic questions to ask your doctor or 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 doctor or 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?

Tests and diagnosis

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

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

Rarely, an ultrasound exam may be done. This test uses high-frequency sound waves to create images of your internal organs. For cholestasis of pregnancy, your doctor might use ultrasound to check your liver for abnormalities.

Treatments and drugs

Treatment for cholestasis of pregnancy has two goals: relieve itching and prevent complications.

Relieving itching
To soothe intense itching, your health care provider may recommend:

• Taking a prescription medication, such as ursodiol (Actigall, Urso), to relieve itching and decrease the absorption of bile
• Using anti-itch creams or lotions that contain corticosteroids
• Soaking itchy areas in lukewarm water

Using too much corticosteroid cream — as you might be tempted to do to relieve the intense itching associated with this condition — may pose a risk to your developing baby. Follow your doctor's instructions for using over-the-counter anti-itch creams, if he or she recommends that you use them.

Preventing complications
To make sure your condition doesn't lead to complications with your pregnancy, your health care provider may recommend:

• Regular blood tests to monitor how well your liver is working and measure the amount of bile in your blood.
• Periodic ultrasounds and nonstress tests to monitor your baby's well-being. During an ultrasound, high-frequency sound waves are translated into a pattern of light and dark areas — creating an image of your baby on a monitor. During a nonstress test, your health 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.
• Early induction of labor. Even if the prenatal tests appear normal, your health care provider may suggest inducing labor early — at or near 38 weeks, or even earlier if cholestasis is severe — which is sometimes the best and only way to prevent complications.

Lifestyle and home remedies

To relieve intense itching, you might try:

• Applying an anti-itch cream to small areas
• Taking a cool bath with cornstarch added to the water

If you have extensive itching, check with your doctor before applying anti-itch cream or any other over-the-counter product to large portions of your body.

Alternative medicine

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

One alternative therapy being studied as a treatment for cholestasis of pregnancy is S-adenosylmethionine (SAMe), a naturally occurring substance. In two small studies, women in their third trimesters who had cholestasis of pregnancy were given SAMe intravenously — through a vein — and experienced relief from intense itching with no adverse effects to them or their babies. These results suggest that SAMe therapy might be safe for short-term use during the third trimester of pregnancy, but more research is needed before doctors can recommend this therapy.

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.