Cholestasis of Pregnancy (also known as Pruritus gravidarum or Cholestatic Jaundice of Pregnancy or Intrahepatic Cholestasis of Pregnancy) is the occurrence of Jaundice in Pregnancy due to the obstruction of flow of bile or slow movement of bile leading to yellowish discoloration of the eyes and skin (in those with fair skin). Cholestasis of Pregnancy is also known as Cholestatic hepatosis or Icterus gravidarum and it is triggered by pregnancy and usually resolves after delivery. It occurs commonly in 2nd trimester of pregnancy.

Cholestasis of Pregnancy is the most common liver condition affecting pregnancy. This occurs because the gallbladder increases in size and empties more slowly during pregnancy while the secretion of bile remains unchanged. Cholestasis is almost physiological in pregnancy and may be associated with generalized pruritus but only rarely produces jaundice. When it produces Jaundice in late cases, it is called Cholestatic Jaundice of Pregnancy.

Cholestasis of Pregnancy Epidemiology

Cholestatic Jaundice of Pregnancy occurs in about 1 in every 2000 pregnancies worldwide and it is common in South American countries such as Chile. Jaundice (yellow discoloration of the eyes) presents in late cases.

Cholestasis of Pregnancy Symptoms and Signs

1. Generalize itching of the body (pruritus) especially around the sole
2. Upper abdominal pain
3. Dark urine
4. Lack of sleep
5. Skin excoriations from scratching
6. Jaundice in some women
7. Steatorrhea (excess fat in feces or stool)
8. Pale bulky stool that is foul smelling

Cholestasis of Pregnancy Causes/Risk Factors

The risk of developing Cholestatic Jaundice of Pregnancy includes:

1. Inheritance: the risk is increased in a woman whose mother had cholestatic jaundice in pregnancy.
2. Contraceptive drugs are a risk factor due to high circulating levels of estrogen, which inhibit intraductal transport of bile acids.

Cholestasis of Pregnancy Diagnosis

Laboratory investigations include liver function tests and assay of serum bile acids. It is currently uncertain whether the bile acids themselves may be directly responsible for fetal demise.

Laboratory Findings in Cholestatic Jaundice of Pregnancy

1. There is elevated level of bilirubin in the blood (Conjugated hyperbilirubinemia). Total plasma bilirubin rarely exceeds 4 to 5 mg/dL.
2. Elevated alkaline phosphatase level above normal pregnancy
3. Liver biopsy will show mild cholestasis with bile plugs in the hepatocytes and canaliculi of the centrilobular region without necrosis or inflammation
4. Raised transaminases (ALT and AST elevated; may be normal)

Cholestasis of Pregnancy Treatment

1. The use of Ursodeoxycholic Acid (UDCA) in the treatment of Cholestatic Jaundice in Pregnancy is the mainstay of treatment.
2. Timely delivery (pregnancy should not exceed 38 weeks gestation)
3. Use of antihistamines or cool aqueous menthol cream to relieve the body itching
4. Vitamin K due to decreased absorption of fat soluble vitamins (should be given a week before delivery to prevent bleeding)

Cholestasis of Pregnancy Complications

1. Intrauterine Growth Restriction (IUGR ) occurs in the fetus
2. Meconium staining liquor
3. Intrauterine Fetal Death (IUFD) may occur when not treated
4. Increased risk of premature delivery
5. Fetal Coagulopathy
6. Hemorrhage especially during delivery without prior treatment with Vitamin K

The mechanism of intrauterine death of the fetus in Cholestasis of Pregnancy is uncertain but is likely to be related to the toxic effect of bilirubin on the fetus. There is no major maternal complication; However, Cholestasis of Pregnancy has a high likelihood of recurrence of about 80%. Some women who present with this condition may be having underlying liver disease; in such conditions, it can be differentiated when cholestatic jaundice occurs early in pregnancy or inability of liver function to return to normal after delivery.