Obstetric cholestasis or itchy skin in pregnancy

Here we explain what you need to know about obstetric cholestasis (OC), how to know if you might have it, and how it might affect you and your baby during pregnancy and after your little one is born.

What is obstetric cholestasis?

OC is an uncommon condition that can affect your liver when you’re pregnant; the main symptom is itchy skin. In the UK, OC affects about 7 in 1000 women; however it’s more common in women of Indian/Asian or Pakistani/Asian origin, affecting 15 in 1000 women.

You may find that your doctor or midwife uses a different name for OC – intrahepatic cholestasis of pregnancy or ICP.

What causes OC?

Your liver produces bile which flows into the gut to help you digest food. In OC the flow of bile out of the liver is reduced and the levels of bile acids rises in the blood stream”

We’re not certain why some mums-to-be develop OC during pregnancy, while others don’t, but we know you’re more likely to be affected by OC if:

• You have hepatitis C.
• Other women in your family developed OC when they were pregnant; this is because there may be a genetic link for some women.
• You had OC in a previous pregnancy; you have a high chance of developing it again.
• You’re expecting twins or more

What are the symptoms of OC?

The main, and often only, symptom is unexplained itching, which can start any time during pregnancy but usually after 28 weeks. Often the palms of your hands and soles of your feet are first affected, with the itching occasionally spreading to your arms, legs and body. More rarely, it can affect your whole body.

Some women have quite mild itching, while for other mums-to-be the itching is intense and persistent; it tends to be worse at night, and may disturb your sleep.

There’s no rash with OC, however some women scratch so hard that their skin becomes damaged and bleeds.

A few women feel unwell and lose their appetite and about 1 in 10 women develop jaundice. The signs of jaundice are yellowing of the skin and whites of the eyes, dark urine and pale bowel movements (poo).

The good news is that once your baby is born, the itching usually disappears quite quickly.

Is itching in pregnancy always caused by OC?

No, definitely not: about a quarter of women experience itching in pregnancy, but only a few will have OC. If you have itching at any time, talk to your midwife or GP; while the cause may turn out to be OC, it’s more likely that you’ll simply have a skin condition, such as eczema.

Your doctor or midwife may recommend you have some simple blood tests to see if you have OC, including:

• Liver function tests, to check how your liver is working.
• A bile acid test to measure the level of bile acids in your blood.

You might also have an ultrasound scan to inspect your liver and check for gallstones.

How will OC affect me and my baby?

If you are diagnosed with OC, you’ll have weekly or twice-weekly liver function and blood clotting tests for the rest of your pregnancy until your little one is born. You’ll also receive consultant-led care and be advised to give birth in a hospital unit.

This is because there’s a 1 in 10 chance that your baby will be born prematurely (possibly by having your labour induced early) and in some cases there may be an increased risk of stillbirth. Also, some babies born to mums with OC pass meconium before being born. In order to minimise these risks your consultant will monitor your blood test results closely; they may recommend you have an induced labour at about 37-38 weeks or earlier if your bile acid levels are very high.

Try not to worry though; it’s important to remember that most babies are born completely healthy and on time.

Treatment of OC

While there’s no actual cure for OC, except for the birth of your child, you can get some relief from:

• Wearing loose clothes made of natural fibres, or having a cool bath.
• Moisturising skin creams and ointments.
• The antihistamine chlorphenamine, which may help you sleep at night; it’s safe to use in later pregnancy.
• A medicine called ursodeoxycholic acid (UDCA), which may reduce your itching.
• Other medicines that may be suggested if these treatments don’t help.

You may need a daily vitamin K supplement. OC can cause vitamin K deficiency, which is needed for normal blood clotting.

Are there any long-term effects?

About 6-8 weeks after your baby is born, your doctor will check that your blood test results are back to normal. It can take up to 12 weeks for things to settle down completely, but if you’re still feeling itchy after 6 months they may refer you to a liver specialist or gastroenterologist to rule out any underlying liver conditions.

Your doctor may recommend that you avoid the oestrogen-containing contraceptive pill and certain antibiotics (co-amoxiclav and erythromycin) as the condition may make your liver more sensitive to their effects.

Rest assured that for most women, OC is not believed to cause any lasting liver damage. It’s not known to cause any developmental problems for babies or increase their chances of having jaundice after they’re born.