What is cholestasis of pregnancy, and how are symptoms and diagnosis found? Itching, treatment approach, birth planning and follow-up after birth.
Cholestasis of pregnancy is a condition that affects liver function and causes bile acids to build up in the body; it usually appears in the last part of pregnancy and settles after birth. Its main symptom is itching of the skin without a rash, felt especially on the palms and soles and worse at night. Because itching is a common complaint in pregnancy, the diagnosis is made not by the symptom alone but with a blood test; when cholestasis of pregnancy is suspected, monitoring is planned by the doctor and the timing of birth is assessed accordingly.
What is cholestasis of pregnancy?
Cholestasis of pregnancy (intrahepatic cholestasis) is the build-up of bile acids in the body as a result of the liver's function in producing and clearing bile being affected in pregnancy. It usually appears in the last period of pregnancy and settles with birth.
Why does cholestasis of pregnancy occur?
It is not clear why cholestasis of pregnancy appears in some pregnancies and not in others. Its occurrence is not related to anything you did or did not do; it is nobody's fault.
What are its symptoms?
Itching is a common complaint in pregnancy, and cholestasis is not found in most pregnant women who have itching. However, itching without a rash, felt especially on the palms and soles and worse at night, should be investigated; this kind of itching can be so intense that it disturbs sleep. Yellowing of the skin or eyes (jaundice) can rarely accompany it. Itching itself does not give a diagnosis; the diagnosis is made with a blood test.
How is cholestasis of pregnancy diagnosed?
The diagnosis is made with liver function tests and a bile acid blood test. The bile acid level can be high even if liver tests come out normal; for this reason, if the itching continues, the tests are repeated. If symptoms follow an unusual course, started early or do not go away after birth, a more detailed liver assessment and a specialist opinion may be requested.
What can it mean for the mother and baby?
Cholestasis of pregnancy can raise some likelihoods: the baby passing meconium before birth (in which case the colour of the amniotic fluid changes and the baby can become ill if it breathes this into the airway at birth) and a higher likelihood of preterm birth are among them. There is no known long-term health risk. In severe cholestasis the risk for the baby may increase; for this reason these cases are monitored more closely and the timing of birth is planned accordingly. Even so, most pregnancies diagnosed with cholestasis of pregnancy end healthily.
What can be done to ease the itching?
A moisturising cream, arrangements for sleeping comfortably at night, a cool bath and loose cotton clothes are among the measures for easing the itching; these may help to a limited extent and do not remove the condition itself.
When is medicine treatment considered?
If your doctor considers it necessary, medicine treatment may be added to the general measures. This kind of medicine treatment can reduce the itching a little in some people and may lower the likelihood of preterm birth, but it has not been shown to prevent the risk of losing the baby. The choice of medicine, when to start it and how long to use it are determined by the doctor; do not use any medicine or herbal product on your own.
How are blood tests and baby movements monitored?
The blood test is repeated a short time after diagnosis. It is important that you follow your baby's movements closely and report straight away when you notice a change in the usual pattern.
How is birth planned?
The timing and mode of birth are planned specifically for you by looking at your bile acid level and other risks such as gestational diabetes, high blood pressure or multiple pregnancy. The options include inducing labour, a planned caesarean or waiting for labour to start by itself. Cholestasis of pregnancy on its own does not require a caesarean; the decision is made together, according to the condition of you and your baby.
What happens after birth?
Itching and liver tests generally settle after birth; this settling can take some time. At a check-up some time after birth, it is confirmed that the tests have returned to normal. In later pregnancies the likelihood of cholestasis of pregnancy coming back is higher; for this reason liver tests are checked again at the start of a new pregnancy. After your tests have returned to normal, your choice of contraception is not affected by this; however, if itching occurs while you are using combined contraceptive pills containing oestrogen, you need to report it straight away. Having had cholestasis of pregnancy in the past does not prevent you from using hormone treatment in the future.
How can you support yourself?
- Do not miss your blood test check-ups.
- Get to know the usual pattern of your baby's movements; report if you notice a decrease or change.
- Report your itching to your doctor or midwife; do not dismiss it as unimportant.
- Do not use any medicine or herbal product on your own.
- Share your worries; ask for support if needed.
What can you ask your doctor about cholestasis?
- By which test can I find out whether my itching is related to cholestasis?
- If my tests come out normal, when will they be repeated?
- In what situation would medicine treatment be started if needed?
- How will the timing and mode of my birth be planned?
- Which check-ups will be needed after birth?
Frequently Asked Questions
When should I report my itching to my doctor or midwife?
When the itching started or how severe it is does not matter; if you notice itching without a rash, it is recommended that you report it without waiting for your next appointment. Early reporting allows the blood test to be done early too, if needed.
If medicine treatment is started, will my bile acid level always fall?
No. In some people the bile acid level can return to normal by itself without any medicine; for this reason, the decision to start and continue medicine treatment is assessed by your doctor with regular check-ups.
Will my pain relief options during birth be affected by cholestasis?
Your pain relief options are mostly not affected by cholestasis of pregnancy. But because cholestasis can affect blood clotting, some tests may be requested before birth; the health team decides which method is suitable for you according to the result of these tests.
What happens if my itching or tests do not return to normal after birth?
This generally settles after birth, but if your symptoms or tests last longer than expected, you may be referred for a detailed liver assessment.
Will my baby's heartbeat be monitored continuously during birth?
In severe cholestasis, or when there is an additional risk, continuous monitoring of the baby's heartbeat during birth (CTG) may be recommended; this is a practice decided according to the condition of you and your baby.
Does all itching in pregnancy mean cholestasis?
No. Cholestasis is not present in most pregnant women who have itching. Itching without a rash, especially on the palms and soles and worse at night, should be investigated.
If my liver tests are normal, is my bile acid necessarily normal too?
No. Bile acid can be high while liver tests are normal. If the itching continues, the tests are repeated.
Do a moisturiser and a cool bath remove cholestasis?
No. They may help the itching to a limited extent; they do not remove the condition itself.
Has medicine treatment been shown to prevent loss of the baby?
No. In some people it can reduce the itching a little and may lower the likelihood of preterm birth, but it has not been shown to prevent the risk of losing the baby.
Does a diagnosis of cholestasis necessarily require a caesarean?
No. It is not a reason for a caesarean on its own. The timing and mode of birth are planned specifically for you according to the bile acid level and other risks.
If my baby's movements change, should I report it straight away?
Yes. Report a change in the usual pattern of movement to your health team straight away. Do not miss your blood test check-ups either.
Should I mention an earlier cholestasis at the start of a new pregnancy?
Yes. The likelihood of it coming back in later pregnancies is higher. Liver tests are checked again at the start of the new pregnancy.
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