Liver conditions causing itching in Pregnancy

There are several liver conditions that cause symptoms of generalized itching, be it in pregnancy or a non-pregnant state. A doctor has to be on the lookout for and always try to exclude the pregnancy-specific cholestasis. It is generally called "obstetric cholestasis". In the United States, it is also called ‘pruritus gravidarum’.

Its importance lies in the fact that, if unrecognized, it could lead to loss of the baby through stillbirth. It also makes the woman prone to premature labor. Some specific blood tests are required to establish the diagnosis, after which close monitoring of the disease and well-being of both the mother and the baby has to be maintained.

If cholestasis is seen to be progressive, delivery may have to be brought forward. Typically, apart from itching, the mother remains well. Obstetric cholestasis clears up soon after delivery.

Prevalence of obstetric cholestasis

The estimated incidence of obstetric cholestasis in the UK is five to seven in every 1000 pregnant women. Severity varies widely. It is relatively more common among Swedes and some native American tribes. In Chile for instance, one in every 40 pregnancies is affected and for women of some native tribes, the incidence is double that. For the Araucanian people of this country and Western Argentina, over 1 in 4 pregnancies are affected. This means there is almost certainly some genetic susceptibility.

Diagnosis of obstetric cholestasis

The condition is suspected from the symptoms. This will prompt blood tests based mainly on liver function. Some liver enzymes (transaminases) and specifically bile acids tend to be raised in this condition. The levels of the enzymes and bile acids will be monitored approximately every week to monitor the progression of the condition.

What makes it difficult is that these enzymes and chemicals aren’t always raised in cholestasis. That can make the management and decision making rather tricky. However, if the symptoms are typical and other itchy skin conditions have been conclusively excluded, it will be treated as obstetric cholestasis and managed accordingly.

Risks associated with obstetric cholestasis

Obstetric cholestasis is known to be associated with an increase in the risk of stillbirth the timing of which is very hard to predict. It is estimated that up to 2% of all affected pregnancies end up in stillbirth.

There is also a big increase in premature delivery. This could be spontaneous or through induction of labor or emergency caesarean section when there is significant concern about fetal wellbeing.

Treatment for obstetric cholestasis

There is no effective treatment for cholestasis. Nor is there any medication that has been shown to significantly alter the course of the condition.

Emollients such as calamine lotion, E45®, Diprobase® etc. are offered to try to relieve symptoms. Effectiveness is modest at best.

Ursodeoxycholic acid (UDCA) has been suggested as a possible treatment for relieving symptoms and possibly protecting the baby. The evidence to its effectiveness in this regard remains weak. Brand names of UDCA include Destolit®, Urdox®, and Ursogal® etc.

Vitamin K in obstetric cholestasis

Women with obstetric cholestasis may be offered daily Vitamin K tablets until delivery. This is to minimize the risk of postpartum haemorrhage and also fetal or neonatal haemorrhage. The condition is associated with a theoretical increase in the risk of these complications.

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