Why does it occur
In the second half of pregnancy, the level of estrogen and progesterone increases sharply. In women with a hereditary characteristic of carrier proteins in liver cells, these hormones disrupt the excretion of bile. Bile acids do not exit into the ducts, but enter the blood and are deposited in the skin, irritating the nerve endings - hence the debilitating itching. An additional contribution is made by a deficiency of certain microelements and seasonality: the condition is more common in winter. It is the hormonal nature that explains why everything goes away in the first days after childbirth and why it often repeats during the next pregnancy.
- Hereditary characteristics of bile carrier proteins
- High levels of estrogen and progesterone
- Multiple pregnancy
- Pregnancy after assisted reproductive technologies
- Chronic diseases of the liver and biliary tract
- Cholestasis in previous pregnancies
Symptoms
Usually it all starts after 28 weeks, less often earlier. Itching appears on the palms and soles, then can spread to the stomach, back and entire body. It intensifies in the evening and at night, interferes with sleep, and only scratches are visible on the skin, but there is no primary rash - this is an important difference from skin diseases of pregnant women. In approximately one to two weeks after the itching, some women develop slight jaundice, urine darkens, and stool becomes lighter. Nausea, loss of appetite, discomfort in the right hypochondrium, and increased fatigue are possible.
- Itching of palms and soles, worse at night
- Spread of itching throughout the body
- Scratching without primary rash
- Sleep disturbance due to itching
- Dark urine and light-colored stool
- Mild yellowing of the skin and sclera
- Nausea, fatigue, discomfort on the right side
How dangerous it is for a child
For the mother, cholestasis, as a rule, leaves no consequences, but for the fetus it increases the risks. Bile acids cross the placenta and can affect the baby's heart rate and uterine contractility. This is associated with an increase in the frequency of premature births, meconium entering the amniotic fluid, respiratory disorders in the newborn, and with very high values of bile acids - rare but severe outcomes. The risk depends on the level of bile acids in the blood, so it is this indicator that determines the tactics and timing of delivery.
- Premature birth
- Meconium in amniotic fluid
- Respiratory disorders in a newborn
- Dependence of risk on bile acid levels
- The need for more frequent monitoring of the fetus
- Vitamin K deficiency and increased bleeding
Survey
The main test is to determine the level of bile acids in the blood: it confirms the diagnosis and determines the degree of risk. Additionally, the liver enzymes ALT and AST, which are usually moderately elevated, as well as bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase, are assessed. A coagulogram is required, since with prolonged cholestasis vitamin K is less absorbed. An ultrasound of the liver and bile ducts is performed to exclude stones and other causes. It is important to exclude viral hepatitis, autoimmune liver diseases and skin diseases of pregnant women. The child is monitored using CTG and ultrasound.
- Serum bile acids
- ALT and AST
- Total and direct bilirubin
- Alkaline phosphatase
- Coagulogram and prothrombin
- Ultrasound of the liver and gallbladder
- Tests for viral hepatitis
- CTG and ultrasound of the fetus with Doppler ultrasound
Treatment and childbirth
Ursodeoxycholic acid is considered the main drug: it improves the flow of bile and in most women noticeably reduces itching and normalizes blood tests. It is prescribed only by a doctor, the dose is selected individually. To relieve itching, a cool shower, light clothing made from natural fabrics, moisturizers, and a cool bedroom can help; Antihistamines are usually ineffective, but are sometimes used to improve sleep as prescribed by a doctor. For severe cholestasis, vitamin K is added. The timing and method of delivery are planned in advance, based on the level of bile acids and the condition of the child.
- Ursodeoxycholic acid as prescribed by a doctor
- Monitoring bile acids and liver tests over time
- Vitamin K for clotting disorders
- Cool shower, moisturize skin, light clothes
- Regular CTG and ultrasound of the fetus
- Planning your due date with your obstetrician
- Control of tests a few weeks after birth
- Discussion of contraceptive methods without estrogen
