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Obstetric Cholestasis

The itch you shouldn't ignore

Itching is very common in pregnancy, affecting around 23 in 100 women (23%). Only a small proportion of those women will have obstetric cholestasis — a liver condition specific to pregnancy. But because the itching is often the first sign, it’s important to tell your midwife or obstetrician about it.

What is obstetric cholestasis?

Obstetric cholestasis (also called intrahepatic cholestasis of pregnancy (ICP)) is a liver disorder in which the normal flow of bile out of the liver is reduced. Chemicals in the bile, called bile acids, build up in your bloodstream and cause itching.

The classic features are:

  • Itching — often worse at night, and frequently involving the palms of the hands and soles of the feet, although it can occur anywhere on the body
  • No rash in most cases — the itch is on intact skin
  • Sometimes additional symptoms such as pale stools, dark urine, jaundice (yellowing of the skin and eyes), or pain under the right rib cage

Symptoms most often start from around 30 weeks of pregnancy, but it can develop earlier.

Why it matters

For most women, obstetric cholestasis is uncomfortable but settles after birth. The reason we screen for it carefully is that, when bile acid levels are very high, ICP is associated with an increased risk of:

  • Premature birth
  • The baby passing meconium during labour
  • Stillbirth, particularly when bile acid levels are very high

These risks can be reduced by careful monitoring and, in some cases, planning to deliver your baby a little earlier than 40 weeks. Your obstetric team will discuss the right plan for you based on your individual blood test results.

How is it diagnosed?

Your skin will be carefully examined to check that your itching is not related to other skin conditions, such as eczema. It is possible to have more than one condition.

You may be offered one or more blood tests:

  • Liver function tests (LFTs) — a number of blood tests that look at how the liver is working.
  • Bile acid test — measures the level of bile acids in your blood. The bile acid level can be abnormal even if your LFTs are normal.

Other causes of itching and liver changes will also be considered. Sometimes the tests are repeated to confirm the diagnosis.

Treatment and what to expect

Can obstetric cholestasis be treated?

There is no cure for obstetric cholestasis except the birth of your baby. Treatment is aimed at easing your symptoms and reducing risk.

Treatments may include cool baths, loose cotton clothing, and skin creams or ointments to relieve itching. Your doctor or midwife will advise on what may help you.

Obstetric cholestasis may cause a problem with the clotting mechanism of your blood, making you more prone to bleed for longer than usual. Vitamin K can help with this change. If your blood clotting time is prolonged, a daily dose of vitamin K is recommended to prevent complications if you start to bleed. Even if your blood clotting is not affected, there may be a small benefit from vitamin K.

You’ll have more frequent blood tests and consultant-led appointments. Your baby’s wellbeing will be closely monitored, and a delivery plan will be agreed with you.

Depending on your bile acid levels and how the pregnancy is progressing, your team may recommend an earlier delivery. This is a shared decision — you’ll have time to ask questions and weigh the options.

Symptoms typically settle within a few days of delivery, and liver function returns to normal. You should have follow-up blood tests to confirm this.

Obstetric cholestasis is likely to recur in future pregnancies. Let your team know early so they can plan your care.