Oxford University Hospitals

NHS Trust

Obstetric Cholestasis
(itching liver disorder)
Information for parents-to-be
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You have been given this leaflet because you have been diagnosed
with (or are suspected of having) a condition called obstetric
cholestasis (OC). In this leaflet we will give you information about
this condition. If you still have any questions after reading this
leaflet, please speak to your midwife, general practitioner or
obstetrician.

What is obstetric cholestasis or ‘itching liver

disorder’?
(also known as ‘intrahepatic cholestasis of pregnancy’)
Obstetric cholestasis is a condition that affects your liver during
pregnancy. The main symptom is itching of the skin but it doesn’t
cause a skin rash or spots. It most often affects the palms of the
hands and soles of the feet. In England, around 1 in every 160
women (less than 1% of all pregnant women) will develop OC.
During your pregnancy we can give you treatment to help relieve
the itching. The itching will then get better by itself after your baby
has been born.

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What causes obstetric cholestasis?
The causes of obstetric cholestasis are not yet fully understood. It is
thought that it could be caused by the different hormones that you
produce during pregnancy, or that genetic (inherited) factors may be
involved.
Hormones
Pregnancy-related hormones may affect the way your liver works
and cause obstetric cholestasis. A hormone called oestrogen
may have an effect on the way your liver deals with a number of
substances, including bile salts. Bile is a yellowish fluid that contains
waste products and chemicals (known as bile salts). Bile salts usually
flow from the liver into your gut, to help the digestion of food.
In obstetric cholestasis, the flow of bile is reduced. This causes a
build-up of bile salts in your body. It is thought that it is the effect
of this build-up that causes the itching during pregnancy.
One research study has suggested that one in five women with
obstetric cholestasis have very high levels of bile salts (more than
four times higher than normal) and that these women may be
more likely to have a premature birth. Because of this, we will have
checked the level of bile salts in your blood.
Genetic factors
Obstetric cholestasis is more common in women from certain ethnic
groups, particularly those from South American and Scandinavian
regions. Obstetric cholestasis has also been found to run in some
families. If you have obstetric cholestasis during one pregnancy,
there is a high risk that it may happen again in a future pregnancy.

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How is obstetric cholestasis diagnosed?
If you have symptoms that suggest a diagnosis of obstetric
cholestasis, you will have tests to check the function of your liver.
You may also be offered tests to check for other causes of abnormal
liver function.
Consultation
Tests do not always involve getting results from a laboratory.
Valuable information can be obtained from talking to you about
your family and medical history.
Inspection of your skin
Your skin will have been carefully examined to check that your itching
is not related to other skin conditions, such as eczema. However, it is
always possible that you may have more than one condition.
Blood tests
You may have been offered one or more blood tests for obstetric
cholestasis. These include:
Liver function test (LFT)
The liver function test involves a number of laboratory tests which
look at how your liver is working. This test is performed on a sample
of your blood. Specific liver enzymes (proteins that bring about
chemical reactions in the body) are checked.
Bile acid (or bile salt) test
This test measures the level of bile acids in your blood. The bile acid
level can be abnormal even if your liver function test is normal.
Further blood tests
Further tests on your blood will rule out other causes of
liver problems, including viral hepatitis, Epstein Barr virus,
cytomegalovirus, as well as a liver autoimmune screen for hepatitis.
Ultrasound scan
An ultrasound scan can check for liver abnormalities and gallstones.

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How soon can I expect to be given a diagnosis?
For some women with obstetric cholestasis, it can take several
weeks after the itching begins before a blood test can detect any
problem. In the meantime you can use creams (e.g. aqueous cream
with menthol or calamine lotion) to help with the itching.
If you have a normal liver function test (LFT) and you are still itching,
then you should be offered a repeat blood test every other week.

What does obstetric cholestasis mean for me

and my baby?
Obstetric cholestasis can be a very uncomfortable condition but it
does not have any serious consequences for your health. The main
symptoms are:
Itching
Itching can vary from mild to intense and is usually persistent. The
itching may start any time during pregnancy, but it usually starts
after 28 weeks. The itching may occur on the palms of your hands
and the soles of your feet. It may also spread over your arms and
legs and, less commonly, on your face, back and breasts. There is
no rash or spots with the itching. Many women have described the
itching as constant and, at times, unbearable. You may need to be
careful about scratching too hard as you may damage your skin.
The itching may be worse at night and might disturb your sleep. This
can make you feel tired and exhausted during the day.
Obstetric cholestasis and the itching will get completely better after
the birth of your baby and cause no long-term health problems.

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Other effects
A few women with obstetric cholestasis develop jaundice (yellowing
of the skin due to liver changes). Some women feel unwell and lose
their appetite. Other signs of obstetric cholestasis are dark urine and
pale bowel movements.
Your baby
There is uncertainty about how this disorder may affect your baby.
There may be an increased risk of stillbirth, though this risk is likely
to be very low.
A recent study looked at all women in the UK diagnosed with severe
obstetric cholestasis (women who had very high bile acid levels of
more than 40micromol/L). Such high bile acid levels are seen in only
1 in 7 cases of women diagnosed with obstetric cholestasis. This
study showed a slightly increased risk of stillbirth in severe obstetric
cholestasis when compared with women without this condition.
However, the majority of the women in the study who suffered
a stillbirth also had other medical complications. Further research
is needed before we can be clear about the effects of obstetric
cholestasis on the health of your baby.
A Swedish study has shown that with active management (that is,
monitoring and induction of labour at the appropriate time), women
with obstetric cholestasis have no greater risk of stillbirth when
compared with women without this condition.
Women with obstetric cholestasis are more likely to have a preterm
birth (have their baby early). This is due partly to the decision to
induce labour early and also due to an increased risk of going into
labour prematurely (this happens to 1 in 10 women).
Depending on the level of bile acids in your blood and your response
to treatment you may be offered an induction of labour at around
38-40 weeks (occasionally earlier in very severe cases). There are
risks when inducing labour and the advantages and disadvantages
of early delivery will be discussed with you.

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Will I need extra antenatal care?
Depending upon your circumstances, you may be advised to have
additional antenatal checks to monitor your baby. Additional checks
may include monitoring your baby’s heart rate and an ultrasound
scan to check for growth and fluid volume around your baby. None
of these monitoring tests can predict whether your baby is at risk of
stillbirth.
Your healthcare professional will have a full discussion with you so
that you can decide together what is best for you and your baby.

What treatment can I get?

Unfortunately, there is no cure for obstetric cholestasis except
the birth of your baby. However, we can offer you a choice of
treatments to help ease the symptoms. These might include:
• skin creams, ointments and drugs to relieve the itching
• a drug to reduce the build-up of bile salts in your liver –
ursodeoxycholic acid helps to reduce itching and reduces the level
of bile salts. There have only been a few large trials and it is not
licensed for treatment in pregnancy, however, it has been used
for a number of years and there is little evidence of any harmful
effects.
• a daily supplement of vitamin K – obstetric cholestasis can reduce
how well you absorb vitamin K from your diet. Vitamin K is
needed to help your blood to clot. This means you may have an
increased chance of bleeding after birth. Vitamin K is also offered
to all babies shortly after birth – this is especially important if they
are born prematurely or their mothers have obstetric cholestasis.

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When is the best time for my baby to be born?
There is considerable debate about the best time for a baby to
be delivered if you have obstetric cholestasis. Being induced early
means that you have an increased chance of needing a forceps
delivery or a caesarean section. There is also an increased chance of
your baby being admitted to the special care baby unit because they
are a few weeks early. However, each pregnancy is unique. Your
options will be explained and discussed with you so that you can
make an informed choice about what to do.

Why do I need to come to follow-up

appointment(s)?
After the birth of your baby it is important to have a follow-up visit
with your GP. This is to make sure your itching has gone away and
your liver is working normally. The follow-up appointment should be
at about six weeks after your baby is born. If you have continuing
symptoms and abnormal liver function tests this might suggest a
different problem and you should be referred to a specialist.
At your follow-up appointment your GP should:
• check that the itching has stopped
• take a blood test to check your liver function to confirm that your
liver is working normally
• discuss the high chance that obstetric cholestasis may happen
again in a future pregnancy
• discuss contraceptive options with you. As you have had
obstetric cholestasis in your pregnancy, the oestrogen-containing
contraceptive pill may affect your liver function test.

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Is there anything else I should know?
• Little is known about how obstetric cholestasis affects a baby’s
development in the womb. There is no scientific evidence that
obstetric cholestasis affects your baby’s growth or causes disability.
• Some women have found that having cool baths and wearing
loose-fitting cotton clothing helps to reduce the itching.
• Drinking alcohol does not cause obstetric cholestasis. However, it
is sensible to avoid alcohol intake when pregnant, especially when
there is evidence of any liver disease.
• Some women have found that high stress situations increase the
itching. There are a number of ways you can help avoid stress,
including relaxation classes, counselling, support groups and
complementary medicine. You can discuss these options with your
healthcare professional, who should be able to help.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and
Gynaecologists’ (RCOG) guideline on obstetric cholestasis and their
patient information leaflet. Both of these documents are available at
www.rcog.org.
Wikstrom Shemer et al. (2013) Intrahepatic cholestasis of pregnancy
and associated adverse pregnancy and fetal outcomes: a 12 year
population based study. BJOG 120 (6) p717-723

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Other organisations
Obstetric Cholestasis Support and information
Website: www.ocsupport.org.uk
Tel: 07549 667 011 (9am - 9pm, Monday, Thursday, Friday)
07843 660 349 (10am - 8pm, Monday to Friday)
Email: [email protected]

The British Liver Trust

Website: www.britishlivertrust.org.uk/liver-information/liver-
conditions/obstetric-cholestasis/

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If you have a specific requirement, need an interpreter,
a document in Easy Read, another language, large print,
Braille or audio version, please call 01865 221 473
or email [email protected]

Sujay Chakravarti, Consultant Obstetrician

September 2014
Review: September 2017
Oxford University Hospitals NHS Trust
Oxford OX3 9DU
www.ouh.nhs.uk/patient-guide/leaflets/library.aspx

OMI 11028P