Patient's question:
Patient Gender:Patient Age:
Description of Symptoms:
Doctor's answer:
Cholestasis of pregnancy is a special condition that only occurs in pregnant women, affecting 2.3 to 3.4 out of every 100 pregnant women. Pruritus is the first symptom to appear, usually occurring between weeks 28 and 30 of pregnancy, but it can start as early as week 12. As the pregnancy progresses, the itching intensifies, primarily on the trunk and lower limbs, and in severe cases, it can affect the entire body, especially at night, disrupting sleep. The itching becomes unbearable, leaving numerous scratch marks. After delivery, the itching typically disappears within 1 to 2 days, though it may persist for up to a week in some cases.Within a few weeks of the itching starting, about 50% of pregnant women develop jaundice, though it is usually mild, affecting only the sclera of the eyes. Some women may also experience a reduced appetite, diarrhea, fatigue, and abdominal bloating, but these symptoms are generally mild.
Laboratory tests show elevated levels of conjugated bile acids in the serum. In 1/5 to 2/3 of cases, serum bilirubin levels are mildly elevated, and in more than 80% of cases, serum alanine aminotransferase (ALT) levels are mildly elevated. This condition can recur in subsequent pregnancies. Patients often have a family history, with their mothers and sisters frequently having similar symptoms, suggesting a link to autosomal genetic disorders.
Cholestasis of pregnancy is more common than viral hepatitis during pregnancy. Due to similarities in symptoms, it is sometimes misdiagnosed as hepatitis, so differentiation is important. Key characteristics of this condition include:
1. The pregnant woman generally remains in good overall health, with no significant digestive system symptoms.
2. Pruritus is prominent, accompanied by jaundice.
3. Liver function is only mildly impaired.
4. The condition does not worsen postpartum, and symptoms and jaundice resolve quickly.
This condition poses significant risks to the fetus, increasing the likelihood of premature birth, low birth weight, fetal intrauterine distress, and neonatal asphyxia. If a pregnant woman develops skin itching, she should seek immediate medical evaluation. A reliable early diagnostic indicator is the elevation of conjugated bile acids in the serum before or shortly before the rise in ALT levels.
Currently, there is no specific treatment for this condition. Cholestyramine may provide some relief from itching; ursodeoxycholic acid and dexamethasone may also be effective. Phenobarbital not only alleviates itching but also helps improve sleep at night. To prevent postpartum hemorrhage, vitamin K should be supplemented before delivery. If jaundice occurs or fetal distress is suspected, hospitalization should be arranged promptly, and delivery may need to be terminated if necessary. Postpartum, the risk of severe bleeding must be monitored.
Diagnostic Criteria:
1. Generalized pruritus, more severe at night, without specific skin rashes during the second and third trimesters.
2. No history of hepatitis or exposure, often without digestive symptoms or hepatomegaly, and no tenderness or percussion pain.
3. Jaundice occurs only during pregnancy and resolves after delivery; pruritus precedes jaundice, and jaundice is usually mild to moderate, far less severe than the itching.
Management:
1. Rest and Monitoring:
- Manage as high-risk pregnancy.
- Conduct systematic monitoring.
- Provide symptomatic and liver-protective treatment.
- Terminate pregnancy at the appropriate time.
2. Medication:
(1) Chinese herbal medicine for soothing the liver, stabilizing fetal development, and promoting bile flow.
(2) Cholestyramine, taken 2–3 times orally.
(3) Phenobarbital 0.03g, taken orally.
(4) Supplement vitamin C, vitamin B6, and vitamin K1, administered intravenously in glucose solution to prevent postpartum hemorrhage.
(5) Liver-protective drugs, such as livertabs.
3. Obstetric Management:
(1) Enhanced monitoring, including NST for fetal assessment at least once weekly.
(2) Induction of labor after 37 weeks, but not beyond the due date.
(3) Cesarean delivery is often necessary if fetal heart abnormalities or suspected intrauterine distress are detected during pregnancy or labor.
(4) Estrogen should not be used in cases of induced labor or postpartum lactation.