Intrahepatic Cholestasis of Pregnancy

What is obstetric cholestasis (intrahepatic cholestasis of pregnancy – ICP)?


Obstetric cholestasis (sometimes called "cholestasis of pregnancy", "OC", "intrahepatic cholestasis of pregnancy", "ICP") affects the liver, which in some women seems to be oversensitive to pregnancy hormones. Bile is produced in the liver and normally it flows down the bile ducts into the intestines where it helps with the digestion of food. If you have OC, the flow of bile into the intestines is reduced and so bile salts build up in your blood.


What are the symptoms of Cholestasis of pregnancy?

• Itching, particularly on the hands and feet (often is the only symptom noticed)
• Dark urine color
• Light coloring of bowel movements
• Fatigue or exhaustion
• Loss of appetite
• Depression

Less common symptoms include:

• Jaundice (yellow coloring of skin, eyes, and mucous membranes)
• Upper-Right Quadrant Pain
• Nausea

Who is at risk for Cholestasis of pregnancy?
1 to 2 pregnancies in 1000 are affected by cholestasis. The following women have a higher risk of getting cholestasis during pregnancy:

• Women carrying multiples
• Women who have previous liver damage
• Women whose mother or sisters had Cholestasis

How is OC identified?
A diagnosis of cholestasis can be made by doing a complete medical history, physical examination, and blood tests that evaluate liver function, bile acids, and bilirubin.


Will OC harm my baby?
The risk of having a stillborn baby is 15 per cent greater for women who have OC than for other women. Nobody is quite sure why. The baby may die because of the bile acids, which are known to cross the placenta, or as a result of being suddenly deprived of oxygen, perhaps because of placental problems.


ICP/OC has been reported to be associated with an increased risk of spontaneous premature birth, fetal distress and stillbirth. With active management (which usually means treatment and choosing to deliver early) the risk of stillbirth in an ICP/OC pregnancy is believed to be the same as that for a normal pregnancy (1%). Most hospitals chose to monitor women with ICP/OC more closely and to deliver the babies early in order to minimize any risk to your baby.


How is OC managed?
The treatment goals for cholestasis of pregnancy are to relieve itching. Some treatment options include:

• Topical anti-itch medications or medication with corticosteroids
• Medication to decrease the concentration of bile acids such as ursodeoxycholic acid
• Cold baths and ice water slow down the flow of blood in the body by decreasing it’s temperature
• Dexamethansone is a steroid that increases the maturity of the baby’s lungs
• Vitamin K supplements administered to the mother before delivery and again once the baby is born to prevent intracranial hemorrhaging
• Dandelion Root and Milk Thistle are natural substances that are beneficial to the liver
• Bi-weekly non-stress tests which involve fetal heart monitoring and contraction recordings
• Regular blood tests monitoring both bile serum levels and liver function

Treatment for cholestasis of pregnancy needs to be determined by your physician who will take the following criteria into consideration:

• Your pregnancy, overall health, and medical history
• The extent of the disease
• Your tolerance of specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference

Treatments that should not be used for Cholestasis include:

• Antihistamines
• Aveeno and Oatmeal Bath

*There are conflicting views on using the medication Cholestyramine for treatment of cholestasis. In the past, this medication was readily used to treat this condition, but some studies have shown that Cholestyramine may not be as effective as other treatments and potentially has some adverse side effects such as blocking essential vitamins like Vitamin K (a vitamin that is already deficient in women with cholestasis).


Will the itching go away after delivery?
ICP is believed to be a condition caused by a gene mutation resulting in the liver's inability to cope with high levels of estrogen present in the body. However, ICP is sometimes a result of an underlying liver disorder. It is normal for patients to continue itching for some time after delivery, particularly with cases that have been prolonged or in cases where a patient has had several pregnancies in a short time frame, but special attention should be given to patients whose itching intensifies after delivery or does not go away at all. Postpartum Serum Bile Acid testing and Liver Function testing are suggested for ICP patients to ensure overall health. A differential diagnosis may include Primary Bilary Cirrhosis, Hepatitis, AIDS, anemia, Benign Recurrent Intra-hepatic Cholestasis, and bile duct obstruction.

I found this information posted by Full Circle Doulas on Facebook and americanpregnancy.org.

Preeclampsia, Toximia, HELLP Syndrome & Pregnancy-Induced Hypertension

Pregnancy-Induced Hypertension or PIH is a diagnosis which includes the complications of: toximia, preeclampsia, eclampsia (which indicates that a seizure has occured) and the HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, which indicates blood and liver complications. The term PIH can be used to refer to any or all of the above complications.

Sustained high blood pressure or Hypertension can increase an expectant woman's risk of reduced placental blood flow to the baby, placental abruption, and possible internal organ damage to the mother. Blood pressure can vary according to activity level, emotional state and body position. If you are at rest and free of emotional stress, your blood pressure is more likely to be low, whereas if you are active and/or stressed your blood pressure is more likely to be elevated. Blood pressure readings can vary depending on the instrumentation used and the skill of the person taking the reading, so it's a good idea to request that the same person with the same equipment take your blood pressure reading each time you have it checked.

PIH can be prevented and/or reversed through a healthy diet. 80 to 100 milligrams of protein daily can reverse the symptoms of PIH. Good sources of protein include:

• Meat, poultry and fish
• Eggs
  
• Dried beans and peas
• Cheese (cottage cheese is especially high in protein)
  
• Milk
• Whole grains
• Peanut butter
• Nuts

For more information about a health pregnancy diet, please see my post about Staying Healthy and Low-Risk

Mild PIH consists of the following symptoms:

• Blood pressure over 140/90
  
• Edema (fluid retention and swelling)
• Protein in the urine

Mild PIH is generally treated with bed rest (the best position to rest is on your side), regular blood pressure checks, and close medical supervision to watch for signs of a more serious problem.

Severe PIH is characterized by any or all of the following symptoms:

• Blood pressure over 160/110
• Headaches
• Blurred vision
• Spots before the eyes
• Pain in the upper abdomen
• Decreased urine output
• Increased knee and ankle reflexes
• Changes in blood chemistry that indicate problems with the liver, kidney and blood platelet levels
• In the most severe cases, seizures or coma or death of the mother and baby can occur, which is why PIH is treated very aggressively

Severe PIH may be treated with hospitalization and medication such as magnesium sulfate to decrease the risk of seizures.

If signs of severe PIH persist after treatment, an induction of labor or cesarean section may be planned. Blood pressure generally normalizes within days or weeks after birth, and with early diagnosis and treatment, complications from PIH are usually minimal and a healthy outcome is achieved.

The causes of PIH are unknown, but it has been found to be more common in first time mothers, those pregnant with twins, teenagers, women over the age of 35, obese women, those with poor diets, and women in high stressful living conditions. Expectant mothers with a personal or family history of chronic hypertension, kidney or liver disease, diabetes mellitus, or a past pregnancy with PIH are also more likely to develop PIH.

Information paraphrased from Pregnancy, Childbirth and the Newborn by Simkin, Whalley & Keppler.