When itchy skin means choleostasis

Itchy skin is common in the first trimester, but, while most itches fall into the category of dry skin syndrome, there is a rare condition called choleostasis of pregnancy, of which itching is a symptom.

Known as intrahepatic choleostasis of pregnancy (ICP), mild choleostasis could go undetected during a first pregnancy, but may recur the second time around, with serious outcomes for mother and baby.

What is choleostasis?

Choleostasis may cause skin colour changes. A jaundiced (yellow) look mirrors an unhappy liver. Choleostasis occurs when there is too much bile salt in the blood. This comes from the gall bladder, found immediately underneath the liver. It’s a reservoir that also concentrates bile.

Pregnancy can block this draining duct causing an overload of bile salts. ICP could also be caused by an overworked liver or disease.

The risk choleostasis poses for a pregnant woman

Choleostasis depletes a mother’s vitamin K and iron stores, which can interfere with blood-clotting mechanisms. This puts her at risk for anaemia and even haemorrhaging after the birth. Her baby risks prematurity, stained amniotic fluid and sometimes even death (this, however, is very rare).

Choleostasis can be hereditary

Choleostasis runs in families with an incidence of one in 146 to 1 203 pregnancies in the US. Occasionally it could be unrelated to pregnancy because there may have been undetected gallstones before pregnancy.

Choleostasis usually clears up after birth

Although the symptoms can be distressing and monitoring may ring alarm bells, choleostasis resolves on its own after the birth. If it continues post delivery, there may well be gallstones, which will have to be removed.

Signs and symptoms

Initially a mother will complain of itchy skin. Some describe it as extremely severe, while others have not itch. It seems to be worse at night and may cause sleeplessness. Some women complain that their palms and the soles of their feet itch most.

Other symptoms include

• Pale stools
• Dark urine
• Feeling tired and listless
• Sometimes depression.

Treatment

Tests to monitor levels of bile salts and amniotic fluid

Your doctor will want to see you at least weekly for blood tests to monitor the levels of bile salts. As long as these levels are stable and less than 8mcg/ml, your pregnancy will be allowed to continue. Induction (from 37 weeks) may be necessary if these levels become higher. The doctor may also want to monitor the amniotic fluid index (AFI) because lower fluid levels indicate problems for the baby.

Non-stress tests

Non-stress tests to monitor baby should be done twice weekly, and continuous foetal heart monitoring during labour is unavoidable.

Antihistamines and medication

Antihistamine tablets may be given to help relieve itching. Sometimes medication for the treatment of gallstones may help. These work by changing bile into a form that’s not toxic (poisonous) to the liver.

Preventing constipation

Some naturopaths encourage healthy liver function by preventing constipation. This can be quite simply done by drinking warm water and lemon juice in the morning, adding one tablespoon of olive oil to vegetables and salads, exercising daily (especially walking), increasing natural fibre in the diet and taking lecithin capsules.

Regular antenatal visits

Antenatal visits are important, particularly in the last three months of your pregnancy. Never dismiss symptoms as unimportant; they could be telltale signs of an avoidable problem. Choleostasis could be mild and easily resolved, but on the other hand, it could be acute and necessitate immediate delivery. Only your doctor will know the difference.