- What is obstetric cholestasis?
- What causes obstetric cholestasis?
- What are the symptoms of intrahepatic cholestasis of pregnancy/ obstetric cholestasis?
- How is obstetric cholestasis diagnosed?
- What are the risks of Obstetric Cholestasis?
- How is obstetric cholestasis treated?
- Diet for intrahepatic cholestasis
- Natural remedies for obstetric cholestasis
- Obstetric cholestasis or intrahepatic cholestasis of pregnancy after delivery
- What is the correct ICD-10 code for obstetric cholestasis?
Obstetric cholestasis (OC), also known as intrahepatic cholestasis of pregnancy (ICP), is a rare liver disorder that affects 0.5% to 2% pregnancies (1). It is common among certain ethnic groups such as the Araucanian Indians and women of Scandinavian ancestry (2). If it is so rare, should you worry about it?
What Is Obstetric Cholestasis?
Obstetric cholestasis is a condition that reduces the normal outflow of bile from the liver.
Normally, the liver produces bile, which flows through the bile ducts, into the intestine where it helps in digesting the food.
But in the case of OC, the bile flow into the intestines is reduced. This builds up the bile salts, which leak into the bloodstream and increase the amount of bile salts in the blood.
The excess salts make your skin very itchy, causing a condition called pruritus. This usually occurs in the last three months of pregnancy, and sometimes even sooner. But the good thing is that raised bile salts and pruritus disappear after delivery, and do not cause any long-term complications for the mother or the baby (3).
What Causes Obstetric Cholestasis?
The exact cause of OC is not known. However, it is known to be affected by the following factors (4):
- Hormonal: An increase in the pregnancy hormones, estrogen and progesterone, can affect liver function. Studies show that OC usually occurs in the last trimester when the estrogen levels are higher. OC is also common in twin and triplet pregnancies when the hormonal levels are high.
- Genetic: In some cases, OC runs in families (but can skip some generations). Those with a genetic predisposition to OC can also inherit a problem associated with bile production and passage through the bile ducts. OC may not be a major concern unless you are pregnant, as an increase in the hormonal activity during pregnancy can alter the hormonal balance.
- Environmental factors: OC is more common during winters, and the incidence is high when combined with nutritional factors like selenium deficiency (5).
Whatever is the cause, this condition occurs only during pregnancy.
What Are The Symptoms Of Intrahepatic Cholestasis Of Pregnancy/ Obstetric Cholestasis?
The most common symptom of obstetric cholestasis is itching, which usually develops without a rash. It starts after 24 weeks of pregnancy when the hormone levels are at their peak (6).
- It occurs on the palms and soles, but it can also affect other areas of the body.
- The itching gets worse at night and tends to worsen, until you have your baby.
- The itch can be mild to severe.
- Severe itching can affect your sleep pattern, your mood, and concentration.
- Your urine will be dark.
Other symptoms, although rare, include:
- Feeling sick or ill
- Pale stools
- Food aversions
- Mild jaundice, characterized by yellow urine, skin or whites of the eye
- Pain around the liver, usually in the right upper quadrant
Occasional, mild itching is normal. But if you develop a constant itch that turns worse in combination with the above symptoms, you should see your doctor immediately.
How Is Obstetric Cholestasis Diagnosed?
Obstetric cholestasis is diagnosed through blood tests. Your doctor will discuss your symptoms, your family history, and medical history, and recommend some tests to measure the bile acids and liver enzymes. These tests will check for OC and also detect other causes of itching.
- Bile acid test: This is the most specific test for OC. It measures the levels of bile acids in the bloodstream. The normal range is 0-10 micromol/L, and any reading above this range detects the presence of OC (7).
- Liver function test (LFT): It checks the functioning of the liver by measuring the different enzyme levels. The primary enzymes including alanine transaminase (ALT) and aspartate transaminase (AST) will rise abnormally in the case of OC.
Sometimes bile acid levels rise while the ALT and AST remain normal. In other cases, the liver enzymes will rise, and bile acids remain normal. In both cases, your bile acids are tested if there is recurrent itching (8).
What Are The Risks Of Obstetric Cholestasis?
For the mother-to-be
Obstetric cholestasis can lead to vitamin K deficiency and affect the body’s ability to clot blood. There is an increased risk of bleeding as it takes a longer time to stop. However, the research behind this is indefinite. Your doctor will suggest vitamin K supplements to treat the clotting problem (9).
You will more antenatal appointments so that the doctor can examine you carefully. The medical tests involve:
- Tracking the baby’s movements
- Listening to the baby’s heartbeat
- Ultrasound scans to monitor the growth and well being of the baby
For the unborn baby
- Your baby may pass her first stool (meconium) while still in the womb. It will, therefore, cause breathing problems post birth.
- You may go into preterm labor because your doctor will advise an early delivery.
- There is an increased risk of stillbirth, which is why the doctor suggests induced labor at around 37 to 38 weeks (10).
Your doctor will decide about the induced labor depending upon the blood tests and the bile acid levels in the blood. If OC is too severe, you may have to induce your labor before 37 weeks (11).
How Is Obstetric Cholestasis Treated?
There is no cure for OC. As said, the condition is not serious but can be distressing. So the primary goal of the treatment is to relieve itching.
General measures to alleviate itching associated with obstetric cholestasis (12):
- Having cold water baths
- Soaking feet and hands in ice water
- Applying calamine lotion on itchy regions
- Applying creams containing extracts of calendula and chamomile. These are said to reduce itching and redness caused during OC
- Using mild soaps and detergents
- Choosing mild bath shower gels instead of heavy, perfumed ones containing harsh formulations
- Avoiding hot water baths
- Wearing loose fitting and cotton clothes
- Following a healthy balanced diet (cut down on oily and fatty foods)
- Resting whenever you get tired
- Avoiding hot and humid weather conditions
- Avoiding alcohol and drugs as they are toxic to the liver and cause irreversible damage to it
The above measures can offer temporary relief, especially before bedtime, so that the itch may ease and allow you to have a good night’s sleep.
Medical treatment for managing OC:
Medication is usually aimed at decreasing the bile salt levels, relieving itching and protecting the baby. Your doctor is likely to prescribe the following medications for OC.
- Ursodeoxycholic acid (ursodiol), which eliminates the itching, and normalizes the liver and bile acids (13).
- Steroids (dexamethasone) with careful management. They aid in the maturity of the baby’s lungs (14).
- Vitamin K supplements to help with blood-clotting (15).
Note: Do not use antihistamines and oatmeal baths.
Diet For Intrahepatic Cholestasis
The primary goal of the pregnancy cholestasis diet is to place less strain on the liver, and for that, you should be taking foods containing lecithin, which is an unsaturated fat that helps absorb fats in the bile. A low-fat diet makes it easy for the intestine to absorb vitamins and minerals from the food. Include:
- A mix of organic fruits and vegetables with colorful pigments such as carrots, beets, potatoes, pumpkin, red cabbage and cauliflower for easy digestion.
- Foods containing omega 3 fatty acid (tuna, salmon, mackerel, sardines, shrimp, oysters, linseed, and cod liver oils) and omega 6 fatty acids (leafy greens, nuts, fish, and soybeans) to combat illnesses.
- High protein foods including nuts, beans, fish, and eggs.
- A low-fat diet of rice, wheat, corn, oats, and rye.
- Virgin olive oil, sunflower oil, and canola oil.
- Healthy alternatives such as honey spread, hummus, and fruit jams.
- More water to flush away the toxins from the system.
- Fresh lemon juice in warm water to neutralize the bile acids.
This diet helps minimize the bile production in the liver and promotes liver health. Besides a healthy diet, other natural remedies can be used to deal with OC.
Natural Remedies For Obstetric Cholestasis
Before going for medical treatment options, you can try the following measures to lower the discomfort associated with obstetric cholestasis. These remedies also reduce the chances of developing the condition.
- Guar gum: Guar gum is a fiber component of the seed of the guar plant. Research shows that oral intake of guar gum relieves cholestasis. It binds to the bile, therefore, preventing an increase in serum bile levels (16).
- Activated charcoal: This is a potent treatment method where activated charcoal traps chemicals and toxins in the body allowing them to flush out before they get absorbed. In a study, it was found that an eight-day treatment of activated charcoal reduced bile concentrations in pregnant women with ICP (17).
- Dandelion root: It is a safe remedy for gallstones, one of the significant causes of cholestasis. The vitamins and nutrients in dandelions aid in cleansing the liver and stimulating proper bile flow (18).
- Vitamin D and calcium: Research findings show that metabolic bone diseases are a complication of cholestatic liver disease (19). Therefore, it is also essential that you consume calcium-rich foods and calcium supplements. Vitamin D, which you can get by spending some time outdoors, also plays a key role in absorbing calcium (20).
While taking these measures helps manage the condition better, medical supervision is necessary for a few weeks to months even after delivery.
Obstetric Cholestasis or Intrahepatic Cholestasis Of Pregnancy After Delivery
- If you are using birth control pills, you may be told to stop them as the estrogen in them can trigger the OC again. The doctor may suggest an alternative contraceptive.
- You may be at the risk of developing chronic liver disease and gallstones in later life.
- There is a 45-70% chance that OC recurs during subsequent pregnancies (21).
What Is The Correct ICD-10 Code For Obstetric Cholestasis?
The correct ICD-10 code for obstetric cholestasis is O26.6, which falls under liver disorders in pregnancy, childbirth, and puerperium (22).
ICD-10 is a coding system proposed by the WHO (World Health Organization) to interpret the written description of health and medical information into standardized codes. ICD-10 represents International Classification of Diseases and Related Health Problems (10th revision).
Dealing with obstetric cholestasis can be exhausting, scary and troublesome. But the condition is not dangerous and is easily manageable. Though there are no preventable therapies and interventions, you will be able to pull yourself and your baby out of the issues associated with OC. It is important to be happy while you are pregnant, as your anxieties may affect your growing baby. Talk to your doctor, family, and friends to share your concerns and stay healthy.
Have tips to manage OC better? Share them in the comments section.