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What Is Obstetric Cholestasis?

From: "Natalie" <nataliedash@optusnet.com.au>
Date: Tue, 20 Nov 2001 11:23:34 +1100
To: "Oz Midwifery" <ozmidwifery@acegraphics.com.au>
Subject: Cholestasis Article (very long)

CHOLESTASIS is a liver condition that involves pruritis (itching) and increased bile acid levels in the last trimester of pregnancy. Approximately 1% of pregnant women have this condition, which continues until delivery. Babies have an increased chance of meconium stained amniotic fluid, foetal distress, spontaneous preterm delivery and a 1 in 4 chance of being stillborn. Subsequent pregnancies are usually affected, getting worse with each. Quite often symptoms go unrecognised in first pregnancies, increasing babies risks.

Cholestasis is caused by a blockage. When the liver has little capacity for absorption or excretion of bile, some of the normally excreted bile acids cause partial destruction of the liver cell membrane, allowing the toxins to enter the blood.

Little is known, but there is evidence to show that oestrogen plays a large role. Patients with increased oestrogen levels, such as those carrying twins, have an increased incidence of the disease.There is also a chance that cholestasis could be hereditary.

Symptoms may be difficult to diagnose until the patient is very sick., but if women and carers are aware of cholestasis it can be controlled. Pruritis usually starts on the soles of the feet and the palms, extending to the rest of the body. In some severe cases it can involve the face, ears, mouth and head. Itching is at its worst throughout the night, leading to sleep deprivation, exhaustion and physical and mental fatigue. Mild jaundice is shown in about 20% of patients and some babies are born jaundiced. Nausea and vomiting can be present throughout pregnancy, and 50% of mothers get urinary tract infections at the onset. In severe cases a cough may come on in the earlier stages before itching begins. Approximately 80% of patients show rises in liver levels after 30 weeks gestation. More severe cases come on earlier, last longer and have extreme symptoms, i.e. prickles, stinging, pain in the head and an increased chance of fatty liver disease, putting mother at risk.

Although the outcome is mostly good for mum, this disease frequently leads to malabsorption of vitamins, worsening maternal nutrition status. Cholestasis has about a 20% risk of postpartum haemorrhage and the tendency towards bleeding may be caused by inadequate absorption of vitamin K, which is needed for the blood to clot.

So far the treatments available to us are undesirable. We are only offered ways of suppressing the symptoms and the treatments only work if diagnosed early enough, or if it's a mild case and still side effects are not known. I was offered antihistamines and tranquillisers to supposedly help with pruritis, steroids to mature my baby's lungs and an induction or caesarean after establishment of foetal lung maturity at 34 wks.

Unknown are the effects of these drugs on our liver. It's possible that they could be actually making the problem worse for baby or subsequent pregnancies for the mother. I took this disease very seriously, but was unable to accept these options. After researching cholestasis this is how I decided to manage my condition.

Firstly I did the obvious and took out all fats from my diet, eating only fresh fruit and vegetables, preferably organic and drank 10 litres of purified water a day (the recommended amount of water is 2/3 litres per day) to flush the toxins out of my liver. I also drank fresh beetroot juice and vegetable soups. I took herbs to support my liver throughout my pregnancy and had a mix made up from my naturopath after cholestasis was confirmed, including Dandelion, St Mary's Thistle, Globe artichoke and Psyllium husks. I also did yoga and had Reiki to support my mind and body. Acupuncture was performed throughout my pregnancy for liver function, but more for use of induction in the final days before delivery. I had blood tests performed monthly until 20 weeks, every week from 30 weeks and every day from 32 weeks until birth. I also agreed to daily monitoring of baby's heartbeat. At 32 weeks I became aware of my liver cells dying and my levels indicated I was on my way to fatty liver disease, giving me a 20% chance of maternal mortality.

I knew I had to take full responsibility for myself and my baby and putting drugs into our bodies would only of done us more harm. Unfortunately there is not much information about this disease and many doctors and midwives are unaware of the symptoms, making it very difficult to diagnose.

Since my last baby was born, almost 3 yrs ago, I have continued to research this condition. There has been very little progress in the treatment offered from the medicos. Ursofalk acid is used in most cased, this relieves the itching by binding the bile acids in the blood. It's advisable NOT to stay on this medication longer than 2 or 3 wks as long term effects are unknown. Induction, or alternatively Caesarean is then advised once off the drug, so steroids are used to mature baby's lungs.

I have recently been back in touch with the Professor from my last pregnancy who sees approx 4 women per month with Cholestasis. He tells me that I'm still the only woman that he knows of that has actually decreased elevated liver results as high as mine were. He now suggests to all his clients to start drinking minimum 2 litres of water per day, along with dietary changes. Unfortunately most don't though.

All GP's, Midwives & GYN/OB's need to be made aware of how serious Cholestasis is, & how to reduce the risks after a diagnosis has been made. Preferably starting with natural alternatives.

Please feel free to pass on this information, or my details to any women who have in the past, or are now suffering. As well as any health professionals that come into contact with pregnant women.

Natalie Forbes Dash                                                                                   Homebirth Access Sydney                                                                                    Blue Mountains Homebirth Support                      nataliedash@optusnet.com.au