Is Cholestasis Of Pregnancy An Emergency & Can It Be Reversed?

Cholestasis of pregnancy is a complication of pregnancy, which mainly leads to increased perinatal mortality. There are obvious regional and ethnic differences in its onset. So far, there is no unified opinion on the diagnosis and treatment of cholestasis of pregnancy in the world.

During pregnancy, itching in the belly is frequent and not serious. But when they spread all over the body, they can be a sign of a liver disorder. In its most severe forms, cholestasis of pregnancy can be dangerous for the fetus. It must, therefore, be diagnosed and treated.(1)

Is Cholestasis Of Pregnancy An Emergency?

Cholestasis of pregnancy is not a medical emergency but it needs to be treated. What are the risks for mom and child? Is it a fatal condition? cholestasis of pregnancy most often has no impact on the mother’s health. The itching increases at night, so it can promote insomnia and fatigue. The disease typically does not present a danger to the safety of the mother but can cause major problems for the baby. Distress to the fetus, premature birth and stillbirth can happen in cholestasis of pregnancy.

The risks for the fetus are very real. Without knowing exactly why the high concentrations of bile acids are indeed toxic for the latter. Bile acids removal from the body of your baby takes place through the mother’s liver. Thus, excessive bile level in mother causes stress on the liver of your baby as well. Bile level over 40µmoles/L can have the fetal risk considerably increased. The frequency of in-utero fetal death at the end of pregnancy varies between 1 and 2% of cases. To limit their occurrence, premature deliveries are often necessary, with the associated risks.(5)

Can Cholestasis Of Pregnancy Be Reversed?

Treatment for cholestasis of pregnancy is based on taking ursodeoxycholic acid (AUDC) until delivery. This medicine is very well-tolerated by both the mom and the fetus. This molecule helps limit the concentration of bile acids in the blood, thus reducing fetal risks and maternal itching.

Because of the fetal risk, hospitalization is generally necessary from the 36th week of amenorrhea in order to ensure optimal monitoring (liver check-ups, monitoring, ultrasound, etc.). The decision to start childbirth from 37 weeks of gestation is discussed on a case-by-case basis. At 39 weeks of gestation, it is almost systematic.

Is There Any Possibility Of Recurrence Of Cholestasis Of Pregnancy?

The itching disappears spontaneously a few days after childbirth, but the risk of recurrence is high. The next pregnancy must, therefore, be closely monitored and may require immediate care in the maternity clinics.(6)

The recurrence of cholestasis in a subsequent pregnancy is 45 to 90% and often occurs earlier than the first time, sometimes even in the first trimester. You can also notice the reappearance of itching when taking oral contraceptive hormones, reaction linked to the presence of estrogen and progesterone.

The medical diagnosis is often made following blood tests (biochemical serum markers = bile salts and other laboratories), clinical examination, history, questionnaire and sometimes an ultrasound of the liver. However, it should be noted that symptoms may appear even before the changes in blood level.(2)

Cholestasis of pregnancy corresponds to the retention of bile in the liver. Instead of continuing in the digestive system, bile acids flow back into the blood where their concentration rises abnormally. This condition affects about 1% of pregnancies.(3)

Not all mechanisms of cholestasis of pregnancy are known. But this hepatic pathology would occur when the hormonal modifications of the pregnancy are added to a genetically predisposed ground. The age of the mother during pregnancy is also identified as risk factors.(1) (4)

Cholestasis of pregnancy causes intense itching, with no apparent eczema-like lesions. They most often appear in the 3rd trimester, first in the palms of the hands and feet, before spreading to the whole body. 1 in 10 times, they are associated with jaundice (jaundice).

All itching that occurs during pregnancy therefore imperatively requires medical advice. To look for possible pregnancy cholestasis, the doctor prescribes a blood test on an empty stomach to measure the transaminases and especially the serum bile acids. Cholestasis occurs if this hepatic assessment indicates a serum bile acid concentration greater than 10 µmoles/L. Above 14 µmoles/L, it is considered pathological and requires treatment.(4)

References:

  1. Ovadia C, Williamson C. Intrahepatic cholestasis of pregnancy: Recent advances. Clinics in dermatology. 2016;34(3):327-334.
  2. Williamson C, Geenes V. Intrahepatic cholestasis of pregnancy. Obstetrics & Gynecology. 2014;124(1):120-133.
  3. Gregory DS, Wu V, Tuladhar P, Wu V. The Pregnant Patient: Managing Common Acute Medical Problems. American family physician. 2018;98(9).
  4. Ozkan S, Ceylan Y, Ozkan OV, Yildirim S. Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy. World Journal of Gastroenterology: WJG. 2015;21(23):7134.
  5. Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clinics and research in hepatology and gastroenterology. 2016;40(2):141-153.
  6. Diken Z, Usta IM, Nassar AH. A clinical approach to intrahepatic cholestasis of pregnancy. American journal of perinatology. 2014;31(01):001-008.

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